Obstetric and gynecologic (OB/GYN) physicians are frequently involved in malpractice lawsuits, some of which result in catastrophic payouts. This study categorized malpractice claims involving OB/GYN trainees (students, residents, and fellows) between 1986 and 2020. Cases are categorized by type of injury, patient outcome, category of error, outcome of lawsuit, and amount of settlement.

A 2009 CMS Condition of Participation (CoP) requires that a director of anesthesia services assume overall responsibility for anesthesia administered in the hospital, including procedural sedation provided by nonanesthesiologists. This article reviews the CoP as it relates to procedural sedation, lays out a framework for implementing this role, and describes challenges of implementation in a large health system.

Hospitals are increasingly creating and updating their emergency disaster response plans. This guide assists hospital executives, quality & safety professionals, and risk managers by assessing potential hazards or failures in radiology departments in the event of disaster. Disaster planning tools, checklists, and other recommendations are described.  

Wrong-site surgeries can lead to serious patient harm and are considered never events by the National Quality Forum. Based on events reported to the Pennsylvania Patient Safety Reporting System between 2015 and 2019, the authors identified an average of 1.42 wrong-site surgery events per week and found that three-quarters of events resulted in temporary or permanent patient harm. The authors present several evidence-based strategies to reduce the likelihood of wrong-site surgery, including preoperative and intraoperative verification, site marking, and timeouts.  

In this retrospective review of root cause analysis (RCA) reports of select gastrointestinal procedures, researchers identified 27 adverse events 30-month period. Nearly half (48%) of events caused major or catastrophic harm. The most frequently reported adverse events were attributable to human factors (22%), medication errors (22%) or retained items; retained items were associated with the most harm.

The rise in maternal morbidity and mortality is one of the most pressing patient safety issues in the United States. Formal debriefing after adverse events is an important method for analyzing and improving safety. In this study, an academic hospital adopted a systems-based morbidity and mortality conference model to review cases of serious maternal harm and implemented several safety measures (including teamwork training) to address issues that were identified through structured review.

Maternal mortality is a sentinel event that affects mothers and families across a wide range of socioeconomic characteristics. This commentary explores how data collection gaps, medical errors, ineffective treatments, and care coordination weaknesses contribute to preventable maternal death. The author highlights efforts to improve safety in maternity care such as best practice bundles to ensure teams and clinicians are prepared for certain complications.

Maternal harm is a sentinel event that is gaining increased attention in both policy and clinical environments. In this commentary, the author relates her family history of maternal morbidity and mortality and advocates for enhancements in collecting data on maternal health outcomes, access to care, understanding of racial disparities, accountability, and listening to patients and families who have been impacted by unsafe maternal care.

The Joint Commission and National Quality Forum both consider wrong-site, wrong-procedure, and wrong-patient surgeries to be never events. Despite improvement approaches ranging from the Universal Protocol to nonpayment for the procedures themselves and any consequent care, these serious surgical errors continue to occur. This study measured the incidence of incorrect surgeries in Veterans Health Administration medical centers from 2010 to 2017. Surgical patient safety events resulting in harm were rare and declined by more than two-thirds from 2000 to 2017. Dentistry, ophthalmology, and neurosurgery had the highest incidence of in–operating room adverse events. Root cause analysis revealed that 29% of events could have been prevented with a correctly performed time-out. A WebM&M commentary examined an incident involving a wrong-side surgery.

Vital signs remain a mainstay of monitoring for deterioration, and early identification of and rapid response to clinical deterioration is critical to preventing patient harm. This observational study used an automated technique to characterize vital sign measurement for nearly 50,000 intensive care unit stays. Investigators found that omission of vital sign recording occurred more than one third of the time. The analysis identified logically inconsistent blood pressure measurements, which suggested data-entry error. The data included a significant proportion of unusual, outlier vital sign values. Taken together, these results demonstrate important inaccuracy in vital sign documentation in the intensive care unit. The authors recommend seeking alternatives to hourly vital sign monitoring in order to optimize safety. A previous WebM&M commmentary discussed challenges in monitoring vital signs.

The weekend effect, in which adverse events occur more commonly outside of normal working hours, has been noted across multiple health care settings. In this retrospective observational study, investigators examined maternal and neonatal quality measures for deliveries occurring on Tuesdays compared with deliveries during the weekend. They found that four of seven performance measures studied were worse during the weekend, but staffing levels did not seem to explain the higher complication rate on weekends. This study is consistent with prior work suggesting patient safety vulnerabilities during the weekend, but further investigation of the weekend effect is required.

This study found that one-third of critically ill patients experienced an adverse event related to an invasive procedure. Infectious adverse events, namely ventilator-associated pneumonia, were more frequent than mechanical ones.

Interdisciplinary teamwork training in obstetrics units helped identify discrepancies between institutional policies and day-to-day clinical practice.