Surgical safety checklists (SCC) are utilized around the world, but checklist completion at the operating room level remains inconsistent. This review summarizes facilitators and barriers to completion. Resistance or endorsement at the individual surgeon level remains a significant factor in SSC completion. Early inclusion of frontline staff in evaluation and implementation supported increased use.

Provider bias may impact the pain management patients receive post-operatively. This review presents recent findings on the types and amounts of pain management patients receive. Results suggest women and people of color receive less pain medication despite reporting higher pain scores. Results regarding socio-economic status and English language proficiency bias are mixed. Implicit bias training, prescribing guidelines for all patients, and culturally competent pain management scales have all been suggested as ways to reduce provider bias and improve pain management.

Effective implementation of the WHO Surgical Safety Checklist remains challenging. This qualitative synthesis of 34 studies identified several factors that influence uptake and compliance with the Surgical Safety Checklist, including effective leadership and use of audit and feedback.

Blood management errors can lead to serious patient harm. This article highlights five patient safety risks during pediatric perioperative blood management (failure to recognize and treat preoperative anemia, failure to obtain informed consent regarding perioperative blood management, failure to consider specific intraoperative blood conservation techniques in children, failure to recognize massive hemorrhage, failure to prevent unnecessary transfusion). The authors discuss potential solutions to address these safety risks.

Hospital-acquired venous thromboembolism (VTE) remains a significant source of preventable patient harm. This study of 4,252 high-risk general surgery patients found that only one-third received care in compliance with VTE prophylaxis guidelines. Patients receiving guideline-compliant care experienced shorter lengths of stay (LOS), fewer blood transfusions, and decreased odds of having a VTE, emphasizing the importance of initiating VTE chemoprophylaxis in high-risk general surgery patients.

Perioperative and anesthesia care present unique patient safety challenges. This article describes the development and implementation of the Anesthesia Risk Alert (ARA) program, which promotes collaborative clinical decision-making and recommends risk mitigation strategies to address specific high-risk clinical scenarios. Since implementation began in 2019, ARA compliance has exceeded 90% and has reduced the rate of adverse events among certain high-risk patients, such as those with a high body mass index.

Human factors influence how humans and systems interact to make processes more reliable or more error-prone during both normal and unexpected circumstances. This guideline provides recommendations centered on elements of communication, the organization, the work environment, and training to guide the consideration of human factors in improvement actions during critical anesthesia or intensive care situations.

Retained surgical items (RSIs) can lead to serious patient harm. Survey findings from 21 clinicians and stakeholders in Switzerland emphasized the importance of addressing production pressures, encouraging a culture of safety and teamwork, and implementation of effective counting procedures to reduce the incidence of retained surgical items.

Preventing surgical site infections remains a persistent challenge to patient safety. This article outlines strategies to prevent surgical site infections during the perioperative period and the roles that infection surveillance, infection prevention bundles, and a culture of safety play a substantial role in decreasing the rate of surgical site infections.

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.

Interprofessional huddles and voluntary reporting of incidents and near-misses are ways to improve patient safety and safety culture. This Norwegian post-anesthesia care unit (PACU) implemented a voluntary incident reporting method, Green Cross (GC), that includes daily team huddles to discuss reports from the previous 24 hours. Three years after implementation, staff reported GC was still active, but use has declined, particularly during the COVID-19 pandemic. They also reported a desire for increased follow up and physician involvement.

Safety-II is a proactive approach to improving patient safety by focusing on what goes right in healthcare. This study describes the use of a novel tool and activity, One Safe Act (OSA), to capture activities performed by perioperative staff that keep patients safe. Eight themes emerged, with the most common theme being routines the staff “always” performed, followed by confirming resource availability.

Identifying and classifying adverse events is an important, yet often challenging, component of incident reporting. This article describes the development and testing of a novel Quality Improvement Classification System (QICS) designed to incorporate adverse events in both inpatient and outpatient settings across medical and surgical specialties in order to capture a broader range of outcomes related to patient care, including organizational issues, near-miss events, and expected deviations from ideal outcomes of surgery.

A 2022 study found that non-first off-pump coronary artery bypass graft (CABG) had a higher risk of complications than first cases, proposing prior workload as a contributing cause. This commentary responds to that study, proposing system and organizational factors, not just the individual surgeon, be taken into consideration as contributing causes.

Retained surgical items (RSI) are a never event, a serious and preventable event. After experiencing a high rate of RSIs, this United States health system implemented a bundle to reduce RSI, improve near-miss reporting, and increase process reliability in operating rooms. The bundle consisted of five elements: surgical stop, surgical debrief, visual counters, imaging, and reporting.

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.

The patient safety field frequently adapts safety methods from aviation, such as checklists and crew resource management. Drawn from fieldwork, interviews with aviation safety experts, and focus groups with patient safety experts, this study adapted interventions from aviation crisis recovery for use in surgical error recovery. Twelve tools were developed based on three broad strategies: situational awareness and workload management; checklists for non-normal situations; decision making and problem solving.

Having standardized definitions and classifications of errors allows researchers to better understand potential causes and interventions for improvement. This systematic review identified six broad error categories, 13 definitions of error, and 14 study methods in the surgical error literature. Development and use of a common definition and taxonomy of errors will provide a more accurate indication of the prevalence of surgical error rates.