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Defining and studying errors in surgical care: a systematic review.

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Marsh KM, Turrentine FE, Knight K, et al. Ann Surg. 2022;275:1067-1073.

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.

Fast tracking in cardiac surgery: is it safe?

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MacLeod JB, D’Souza K, Aguiar C, et al. J Cardiothorac Surg. 2022;17:69.

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.

APSF endorsed statement on revising recommendations for patient monitoring during anesthesia.

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The APSF Committee on Technology. APSF Newsletter. 2022;37(1):7–8.

Variation across standards and processes can result in misunderstandings that disrupt care safety. This guidance applied expert consensus to examine existing anesthesia monitoring standards worldwide. Recommendations are provided for organizations and providers to guide anesthesia practice in a variety of environments to address patient safety issues including accidental patient awareness during surgery.

Intraosseous Line Extravasation in a Pediatric Trauma Patient

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April 27, 2022

An 18-month-old girl presented to the Emergency Department (ED) after being attacked by a dog and sustaining multiple penetrating injuries to her head and neck. After multiple unsuccessful attempts to establish intravenous access, an intraosseous (IO) line was placed in the patient’s proximal left tibia to facilitate administration of fluids, blood products, vasopressors, and antibiotics. In the operating room, peripheral intravenous (IV) access was eventually obtained after which intraoperative use of the IO line was restricted to a low-rate fluid infusion.

Performance variability in perioperative sentinel events: report on a nationwide data set.

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Reijmerink IM, Bos K, Leistikow IP, et al. Br J Surg. 2022;109:573-575.

Organizational, environmental, and work-related factors can contribute to performance variations and human error during healthcare delivery. This study examined perioperative sentinel events reported to a Dutch database over a one-year period. It found that although performance variability continued in almost all events, it was rarely explicitly mentioned in incident reports or represented in resulting improvement measures. The authors suggest that explicitly addressing performance variability in sentinel event analyses can lead to more effective improvement measures that account for human performance in healthcare.

Increased adherence to perioperative safety guidelines associated with improved patient safety outcomes: a stepped-wedge, cluster-randomised multicentre trial.

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Emond YEJJM, Calsbeek H, Peters YAS, et al. Br J Anaesth. 2022;128:562-573.

A necessary part of successful implementation of new guidelines is ensuring continued adherence. Nine Dutch hospitals implemented a multifaceted program (IMPlementatie Richtlijnen Operatieve VEiligheid [IMPROVE]) to support application of surgical guidelines. Results of guideline use were mixed.

ISMP Medication Safety Self Assessment® for Perioperative Settings.

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Institute for Safe Medication Practices

The perioperative setting is a high-risk area for medication errors, should they occur. This assessment provides hospitals and outpatient surgical providers a tool to examine their medication use processes and share data nationwide for comparison. Organizational participation can identify strengths and gaps in their systems to design opportunities that prevent patient harm.

Perioperative Safety Collaborative.

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ECRI and Institute for Safe Medication Practices. January 2022 through May 2022.

Collaboratives provide teams with active learning and improvement opportunities based on the experiences of others working toward a collective goal. This collaborative will target safety during surgical procedures. The discussions protected under the sponsors’ Patient Safety Organization status will explore improvement topics such as medication errors and surgical site infections.

Awareness of human factors in the operating theatres during the COVID-19 pandemic

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October 27, 2021

Understanding the ways in which human factors, such as non-technical skills, influence individual and team performance can ultimately improve patient safety, particularly in high-intensity settings such as operating rooms.

Decreased incidence of cesarean surgical site infection rate with hospital-wide perioperative bundle.

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Sood N, Lee RE, To JK, et al. Birth. 2022;49:141-146.

Cesarean delivery can contribute to increased maternal morbidity. This retrospective study found that the introduction of a hospital-wide perioperative bundle significantly reduced surgical site infection rates. The perioperative bundle consisted of five elements (1) an antibiotic protocol, (2) preoperative warming and intraoperative maintenance of normal temperature, (3) standardized surgical preparation for each patient, (4) use of standardized fascial closure trays, and (5) standardized intraoperative application of wound dressing.

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Maternal Safety

Local Anesthesia-Induced Coma During Total Knee Arthroplasty.

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July 28, 2021

A 61-year-old male was admitted for a right total knee replacement under regional anesthesia. The surgeon – unaware that the anesthesiologist had already performed a right femoral nerve block with 20 ml (100mg) of 0.5% racemic bupivacaine for postoperative analgesia – also infiltrated the arthroplasty wound with 200 mg of ropivacaine. The patient was sedated with an infusion of propofol throughout the procedure.

Ethical considerations and patient safety concerns for cancelling non-urgent surgeries during the COVID-19 pandemic: a review.

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Brown NJ, Wilson B, Szabadi S, et al. Patient Saf Surg. 2021;15:19.

At the start of the COVID-19 pandemic, many elective surgical procedures were canceled or postponed due to limited resources (e.g., personal protective equipment, diagnostic tests, redeployment of healthcare personnel). This commentary discusses the implications of rationed non-urgent surgical care within the context of medical ethics: beneficence, non-maleficence, justice, and autonomy. The authors developed an algorithm to guide surgical teams through the decision-making process of delaying non-urgent surgical procedures, if necessary, in the future.

Each Baby Counts.

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Royal College of Obstetricians and Gynaecologists.

This organization highlights the importance of in-depth reporting and investigation of adverse events in labor and delivery, involving parents in the analysis, engaging external experts to gain broader perspectives about what occurred, and focusing on system factors that contribute to failures. A WebM&M commentary discusses how lapses in fetal monitoring can miss signs of distress that result in harm. The reporting initiative closed in 2021 after presenting its final report. Investigations in this area will now be undertaken by the Healthcare Safety Investigation Branch in England.

The burden of opioid-related adverse drug events on hospitalized previously opioid-free surgical patients.

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Urman RD, Seger DL, Fiskio JM, et al. J Patient Saf. 2021;17:e76-e83.

Harm from opioids is a widely recognized patient safety issue, and potential harm associated with short-term use is a growing area of concern. This analysis of a previously opioid-free surgical population identified a high rate of potential opioid-related adverse drug events (ORADEs); risk was strongly associated with route and duration of post-operative opioid administration. The presence of an ORADE was associated with longer postoperative length of stay, higher hospitalization costs, lower odds of discharge home, and higher odds of death.

Incidence of accidental awareness during general anaesthesia in obstetrics: a multicentre, prospective cohort study.

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Odor PM, Bampoe S, Lucas DN, et al the Pan-London Peri-operative Audit and Research Network (PLAN), for the DREAMY Investigators Group. Anaesthesia. 2021;76(6):759-776.

Accidental patient awareness during anesthesia can result in significant patient distress and harm. This prospective cohort study, including 3,115 patients, identified high rates of accidental awareness during general anesthesia for obstetric surgery. In some patients, accidental awareness resulted in distressing experiences, paralysis, or a provisional diagnosis of post-traumatic stress disorder.

Outcomes from Wake Up Safe, the pediatric anesthesia quality improvement initiative.

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Haché M, Sun LS, Gadi G, et al. Paediatr Anaesth. 2020;30:1348-1354.

The Wake Up Safe initiative includes a registry of serious adverse events occurring in pediatric anesthesia. This study analyzed events reported between 2010 and 2015. The most common anesthesia-related events were medication events, respiratory complications, and cardiac events. Approximately 85% of these events were considered to be preventable.

Bundle interventions including nontechnical skills for surgeons can reduce operative time and improve patient safety.

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Koike D, Nomura Y, Nagai M, et al. Int J Qual Health Care. 2020;32:522-530.

Nontechnical skills are gaining interest as one way to enhance surgical team performance and patient safety. In this single-center study, the authors found that a perioperative bundle that introduced nontechnical skills to the surgical team was effective in reducing operative time.

Real-time debriefing after critical events: exploring the gap between principle and reality.

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Arriaga AF, Szyld D, Pian-Smith MCM. Anesthesiol Clin. 2020;38:801-820.

Debriefing is an established strategy teams use to learn from critical events, reduce event occurrence, and improve failure response. This review examines how debriefing principles can be embedded for use of the practice in real time, rather than developed in simulated circumstances, to improve anesthesia safety.

Cognitive bias impact on management of postoperative complications, medical error, and standard of care.

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Antonacci AC, Dechario SP, Antonacci C, et al. J Surg Res. 2021;258:47-53.

Cognitive bias is an important source of medical error. In this analysis of over 700 general surgical cases with complications, the authors attributed cognitive bias in one-third of all cases. These cases were also associated with an increase in management errors (e.g., diagnostic, communication, or therapeutic errors) and a lower standard of care.

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