Root cause analysis (RCA) may not be an ideal process, but it still creates opportunities for learning and improvement after a sentinel event. This article posits why perioperative nurses may not report problems to avoid engagement in RCA activities. Increasing nurse awareness of RCA as a multidisciplinary and systems-focused improvement method is a suggested educational tactic to increase nurse RCA participation.

Intraoperative deaths are rare, catastrophic events. This retrospective review of 154 intraoperative deaths occurring between March 2010 and August 2022 at one academic medical center found that most deaths occurred during emergency procedures. Common contributing factors included coordination challenges, skill-based errors, and environmental factors.

Prior research has asked surgeons how they cope with intraoperative errors, but this study asks operating room personnel how they perceive surgeons' coping strategies. Positive response strategies included announcing that an error has occurred and the plan for managing it. Negative responses include the surgeon becoming visibly upset, raising their voice, and blaming others. The authors suggest additional education on positive strategies to cope with errors during medical education and residency.

The American Geriatrics Society (AGS) Beers Criteria serves as a guideline for prescribers to avoid potentially inappropriate medications (PIM) in geriatric patients (age 65 years and older). In this retrospective cohort study, nearly 70% of geriatric patients undergoing elective surgery received at least one PIM identified by the Beers Criteria. Patients, including cognitively impaired and frail patients, who received at least one PIM, had longer length of hospital stay after surgery.

Post-operative complications can lead to increased length of hospital stay, cost, and resource utilization. This retrospective study compared “fast track” patients (patients extubated and transferred from ICU to a step-down unit the same day as their procedure) and patients who were not fast tracked. Results showed fast track pathways led to a reduction in ICU and overall hospital length of stay and similar post-operative outcomes.

The perioperative setting is a high-risk environment. This continuing education model discusses safety threats and evidence-based best practices to deliver nursing care in perioperative settings and promote a culture of safety.

The anesthesia community has been a leader in patient safety innovation for over four decades. This conference summary highlights presented content related to the conference theme of “preventing, detecting, and mitigating clinical deterioration in the perioperative period.” The results of a human-centered design analysis exploring tactics to reduce failure to rescue were summarized.

This commentary discusses the harms of opioid overprescribing, particularly among opioid-naïve patients. The authors suggest that opioid dependence, abuse, or overdose in an opioid-naïve patient undergoing surgery should be considered a “never event” and discuss strategies for appropriate prescribing by surgeons.

This thematic analysis identified 123 events comprising malpractice claims in the closed claims database of the American Association of Nurse Anesthetists (AANA) Foundation that the investigators determined could have been prevented by the Certified Registered Nurse Anesthetist involved. Among the factors identified as being associated with preventable events were communication failures, violations of the AANA Standards for Nurse Anesthesia Practice, and errors in judgment.

This integrative review examined the factors contributing to perioperative adverse events resulting from anesthesia. Researchers found that both active errors, such as medication errors or inattention, and latent errors, such as communication failures, contributed to adverse events.

Pharmacists working with surgical teams bring distinct safety context, expertise, and process awareness to perioperative care. These guidelines outline how pharmacists can help reduce medication errors before, during, and after surgery. Perioperative pharmacists can enhance communication, medication histories, and process reliability.

Surgeon technical skill, real-time problem solving, and communication quality are essential for avoiding harm during surgery. This study found that those types of human errors were responsible for 51.6% of 188 surgical adverse events at 3 hospitals. A past PSNet perspective delineates the evolution of surgical patient safety.

This pre–post study found that color-coded head coverings in the operating room significantly decreased misidentification of attending physicians versus medical students. The authors recommend implementation of this highly feasible solution to enhance proper role identification in the surgical setting.

This randomized simulation study examined the use of checklists during simulated pediatric cardiac arrests in the surgical setting. Despite low uptake of the checklists, their availability during the simulations was associated with better performance. The authors recommend use of these checklists to enhance performance in rare critical situations.

Nontechnical skills, such as teamwork, communication, and leadership, are essential human-centered components of safe surgical practice. This commentary discusses contextual characteristics needed to support nontechnical skill development to improve health care outcomes. The authors recommend a cultural shift away from focusing on technical performance to one that incorporates training in nontechnical skills.

Physicians who behave unprofessionally toward other health care workers compromise both safety culture and patient health. Hostile behavior among surgeons is particularly harmful because surgical care is both teamwork-dependent and has high stakes. Although many have reported anecdotally that disrespectful surgeon behavior has led to patient harm, it is challenging to study systematically. Investigators sought to determine whether patients whose surgeons had coworker reports of unprofessional behavior experienced more harm. Surgeons at two academic medical centers who had coworker reports of unprofessional behavior in the 3 years before a surgery were more likely to have patients experience both medical and surgical complications after the surgery. These findings highlight the importance of empowering team members to report unprofessional behavior so that it can be remediated. Two WebM&M commentaries describe different approaches to addressing unprofessional physician behavior.

Prior research has shown that including errors in training may result in improved retention of knowledge and skills. In this study, first-year anesthesia residents participated in a simulation involving hyperkalemia management. Half received support from an attending physician while the other half participated in the scenario independently. The groups were further split so that half of those practicing independently and half of those working with an attending experienced simulated mortality of the patient. The residents participated in another hyperkalemia simulation 6 months later without attending assistance. Residents who had practiced independently and experienced simulated mortality in the initial hyperkalemia scenario achieved the lowest mortality rate compared to the other groups during the follow-up simulation activity.