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Arshad SA, Ferguson DM, Garcia EI, et al. J Surg Res. 2021;257:455-461.
Engaging patients and families is an important strategy in ensuring safe health care delivery. In this prospective, observational study, use of a parent-centered script did not improve parent engagement during the preinduction checklist and resulted in an expected decline in checklist adherence.  
O'Reilly-Shah VN, Melanson VG, Sullivan CL, et al. BMC Anesthesiol. 2019;19:182.
Utilizing American College of Surgeons National Surgical Quality Improvement Project  (ACS NSQIP) data, the authors looked at the effects of intraoperative handoffs  involving anesthesia personnel in two hospitals. Initial findings of higher rates of adverse outcomes were no longer statistically significant when confounding variables were added to the analysis.
This Primer provides an overview of the history and current status of the patient safety field and key definitions and concepts. It links to other Patient Safety Primers that discuss the concepts in more detail.
National Pharmacy Association; NPA.
This website for independent community pharmacy owners across the United Kingdom features both free and members-only guidance, reporting platforms, and document templates to support patient safety. It includes reporting tools and incident analysis reports for providers in England, Scotland, and Northern Ireland. Topics covered in the communications include look-alike and sound-alike drugs, patient safety audits, and safe dispensing of liquid medications.
Following surgery under general anesthesia, a boy was extubated and brought to postanesthesia care unit (PACU). Due to the patient's age and length of the surgery, the PACU anesthesiologist ordered continuous pulse-oximetry monitoring for 24 hours. Deemed stable to leave the PACU, the boy was transported to the regular floor. When the nurse went to place the patient on pulse oximetry, she realized he was markedly hypoxic. She administered oxygen by face mask, but he became bradycardic and hypotensive and a code blue was called.
When patients in two cases did not receive complete preanesthetic evaluation, problems with intubation ensued. In the first case, an anesthesiologist went to evaluate a morbidly obese patient scheduled for hysteroscopy. As the patient was donning her hospital gown behind a closed curtain, he waited but left without performing the preoperative assessment because the morning surgery list was overbooked and he had many other patients to see. Once in the operating room, he discovered on chart review that the woman had a history of gastroesophageal reflux.
Ball JE, Bruyneel L, Aiken LH, et al. Int J Nurs Stud. 2018;78:10-15.
Missed nursing care may result from inadequate nurse staffing and explain the relationship between nurse-to-patient ratios and patient outcomes. Research has shown that higher nurse staffing levels are associated with lower inpatient mortality and that reduced staffing increases the risk for postoperative complications. In this study, investigators examined data from more than 400,000 surgical patients from 300 hospitals in 9 countries as well as survey responses from 26,516 nurses. They found a significant association between nurse staffing and missed nursing care with 30-day risk-adjusted postoperative mortality. The authors conclude that measuring missed nursing care may help identify patients at greater risk for adverse outcomes earlier in their course. A past WebM&M commentary highlighted important issues associated with nurse staffing ratios.
Rose M, Newman SD. AANA J. 2016;84:329-338.
Patient handoffs between care teams are vulnerable to error. This scoping review explored the literature to identify factors that affect the safety of handoffs from anesthesia providers to the postanesthesia care unit. Individual communication styles, team dynamics, and policy were described as elements that influence information transfers. A past PSNet perspective discussed the importance of safe inpatient handovers.
A woman with a history of chronic obstructive pulmonary disease underwent hip surgery and experienced shortness of breath postoperatively. A chest radiograph showed a pneumothorax, but the radiologist was unable to locate the first call physician to page about this critical finding.
Robinson NL. J Perianesth Nurs. 2016;31:245-53.
Handoffs are comprised of a multitude of steps that are prone to communication error. This commentary describes how a hospital drew from Lean Six Sigma concepts to develop and implement a standardized handoff process. The effort achieved improvements and established a concrete method for nurses to apply safe communication and data sharing principles in the perioperative environment.
Guglielmi CL, Canacari EG, DuPree ES, et al. AORN J. 2014;99:783-794.
The Universal Protocol has been widely adopted in the decade since its release. Successful utilization of the protocol to prevent wrong-site surgery has been determined to extend beyond checklist use. This commentary features insights from a multidisciplinary panel on their experiences with time outs and why are still needed to ensure safety in surgery.
Treadwell JR, Lucas S, Tsou AY. BMJ Qual Saf. 2014;23:299-318.
Checklists have been responsible for some of the most remarkable successes of the patient safety era, particularly in improving safety for patients undergoing surgery. However, recent studies have raised concern that surgical checklists may not realize their promise in real-world settings. This systematic review, performed originally for the AHRQ Making Healthcare Safer II report, found broad evidence that surgical safety checklists (including the SURPASS checklist and the World Health Organization checklist) are effective at preventing intraoperative and postoperative complications. The review also identifies factors associated with successful implementation of the checklists, information that is essential in order to translate research findings into daily clinical practice.
After changing the type of knee repair being done mid-procedure, a surgeon verbally informed the patient of drastically different discharge instructions in the post-anesthesia care unit but did not provide specific written instructions of the changed procedure or recovery plan to her or her husband.
Minnesota Hospital Association; MHA.
This Web site provides access to materials for patient safety improvement efforts in Minnesota, including initiatives to reduce adverse drug events and hospital collaboratives to implement best practices.
Following spinal anesthesia for an outpatient procedure, a patient is discharged and instructed to take sitz baths with tepid water. The patient misunderstood the instructions, using scalding water instead, and residual anesthesia blunted his response to the hot water.
Following surgery for hip fracture, an elderly man with a history of chronic obstructive pulmonary disease developed worsening shortness of breath. At this hospital, the orthopedic surgery service has hospitalists comanage its patients. Inadequate communication between the services led to a delay in diagnosing the patient with pneumonia and initiating treatment.
Based on preoperative discussions, a patient undergoing knee replacement expected to receive spinal anesthesia; however, general anesthesia was administered, and the records did not note or explain this change. The patient suffered an unusual complication.
On the day of a patient's scheduled electroconvulsive therapy, the clinic anesthesiologist called in sick. Unprepared for such an absence, the staff asked the very busy OR anesthesiologist to fill in on the case. Because the wrong drug was administered, the patient did not wake up as quickly as expected.
Several days after a patient’s surgery, preliminary wound cultures grew Staphylococcus aureus. Although the final sensitivity profile for the cultures showed resistance to the antibiotic that the patient was receiving, the care team was not notified and the patient died of sepsis.