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Chaudhry H, Nadeem S, Mundi R. Clin Orthop Relat Res. 2021;479:47-56.
The COVID-19 pandemic has dramatically increased the use of telehealth across various medical specialties.This systematic review did not identify any differences in patient or surgeon satisfaction or patient-reported outcomes with telehealth for orthopedic care delivery as compared to in-person visits.However, the authors note that the included studies did not adequately capture or report safety endpoints, such as complications or missed diagnoses.
Kannampallil T, Lew D, Pfeifer EE, et al. BMJ Qual Saf. 2021;30:755-763.
Prior research has found that intraoperative anesthesia handovers can increase patient morbidity and mortality. However, this retrospective cohort study, focused on pediatric surgical patients treated, found that intraoperative anesthesia handovers were not associated with adverse postoperative outcomes.  
Farnborough, UK; Healthcare Safety Investigation Branch; December 18, 2019.
Maternal care during and after childbirth is at risk for never events including retained foreign objects. This analysis of a sentinel event involving a retained surgical tampon after childbirth discusses communication, fatigue, and process factors that contributed to the incident. The report suggests improved handoffs as one improvement strategy.
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.

GMS J Med Educ. 2019;36:Doc11-Doc22.

Patient safety has been described as an unmet need in physician training. This special issue covers areas of focus for a patient safety curriculum drawn from experience in the German medical education system. Topics covered include human error, blame, and responsibility. Articles also review the epidemiology of common problems such as medication safety, organizational contributors to failure, and diagnostic error.
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.
Randmaa M, Swenne CL, Mårtensson G, et al. Eur J Anaesthesiol. 2016;33:172-8.
The SBAR (situation-background-assessment-recommendation) method is commonly used to ensure high-quality communication between clinicians in acute situations. However, this study found that use of SBAR did not improve recall of critical communications during handover from the operating room to the postanesthesia care unit.
Pucher PH, Johnston MJ, Aggarwal R, et al. Surgery. 2015;158:85-95.
The Joint Commission and the Accreditation Council for Graduate Medical Education have called for institutions to implement standardized handoff strategies. This systematic review found indications that checklists can improve the quality of care transitions for surgical patients, but the quality of published evidence is low.
Tscholl DW, Weiss M, Kolbe M, et al. Anesth Analg. 2015;121:948-956.
This pre-post study demonstrated increases in teamwork after introduction of an anesthesia checklist. Although evidence for checklists in real-world settings is mixed, this work demonstrates their efficacy as part of an intervention study, which is consistent with prior work.
Jammer I, Ahmad T, Aldecoa C, et al. Br J Anaesth. 2015;114:801-807.
The initial evidence supporting the impact of the World Health Organization's surgical safety checklist was a cohort study that found a significant reduction in mortality associated with the use of the checklist. More recently, the mandated adoption of surgical checklists in Canada failed to show any benefits on surgical outcomes. This retrospective point prevalence study evaluated checklist use in 426 hospitals across 28 European nations, involving more than 45,000 patients undergoing noncardiac inpatient surgery. Notably, there was striking variation in surgical checklist exposure, with checklists used for 0% to 99.6% of patients, depending on the nation. The use of surgical checklists was associated with lower hospital mortality, even after adjusting for risk factors. However, it is unclear from this study whether this improvement is due to the checklist or rather checklist usage is a process measure indicating higher overall perioperative quality. A prior AHRQ WebM&M perspective reviewed best practices for creating effective checklists.

J Health Serv Res Policy. 2015;20(suppl 1):S1-S60.

Articles in this special supplement explore research commissioned by National Institute for Health Research in the United Kingdom to address four patient safety research gaps: how organizational culture and context influence evaluations of interventions, organizational boundaries that affect handovers and other aspects of care, the role of the patient in safety improvement, and the economic costs and benefits of safety interventions.
Nagpal K, Vats A, Lamb B, et al. Ann Surg. 2010;252:225-39.
This systematic review of 38 published studies identified communication failures in all phases of surgical care, including intraoperatively and during postoperative care. Such breakdowns in information transfer, particularly during handoffs, have been linked to adverse events in prior studies. A number of interventions have been proposed to address this issue, including standardized checklists—which were remarkably successful at reducing postoperative complications in a classic study—and incorporation of handoff techniques from other industries. An AHRQ WebM&M commentary discusses the disastrous consequences of an intraoperative communication breakdown.
Nagpal K, Arora S, Abboudi M, et al. Ann Surg. 2010;252:171-6.
This qualitative study interviewed 18 providers and found that postoperative handovers are informal, unstructured, and fraught with inconsistent and incomplete information transfer. These data were used to develop and validate a formal handover protocol. Prior studies have used insights from Formula One auto racing to inform improvement strategies for postoperative handoffs, and the World Health Organization's Surgical Safety Checklist explicitly emphasizes structured handoffs at the time of patient transfer from the operating room to the postoperative area.
Reynard J, Reynolds J, Stevenson P. Oxford, UK: Oxford University Press; 2009. ISBN: 9780199239931.
This book provides an introduction to key patient safety topics and includes a set of 20 case studies to demonstrate opportunities for error prevention.
Sixth Report of Session 2008–09. House of Commons Health Committee. London, England: The Stationery Office; July 3, 2009. Publication HC 151-I.
This government report analyzes the National Health Service's efforts to enhance patient safety and recommends improving certain areas, such as adopting technology, analyzing failure, and ensuring both practitioner education and adequate staffing.
Intern J Health Care Qual Assur. 2007;20(7):555-632.
This special issue includes articles by authors from Australia, Israel, France, Iran, and Belgium that explore ideas such as building a culture of safety, replacing medical equipment, and measuring safety improvements.