Safety culture and work systems influence safety, but it is unclear whether safety improvement efforts should focus on one or both factors. This study sought to improve adherence to the WHO surgical safety checklist and to enhance technical and nontechnical team performance using several safety interventions. One intervention focused on improving safety culture, while another was directed at the work system. Investigators also tested a combined approach. Although both team training and system redesign individually demonstrated improvement, the combined approach was more successful than either individual approach. This finding suggests that in order to truly enhance surgical safety, organizations must invest in both systems and culture interventions.

The effectiveness of safety checklists depends mostly on how well they are implemented and performed—a recent study found no improvements in surgical outcomes with their adoption. This study created reliable observation tools for measuring surgical safety checklist performance and teamwork in the operating room.

Operating room briefings or time-outs are mandated by The Joint Commission as a strategy to prevent wrong-site surgery. This commentary explores the use of briefings both before and after surgery, evidence regarding their impact, and how a comprehensive unit-based safety program (CUSP) initiative designed and implemented a briefing and debriefing process.

Error disclosure is receiving increased attention as a strategy to improve communication and patient safety. This review discusses elements of surgical care that hinder disclosure, including frequency of adverse events, teamwork and hierarchy, and lack of surgery-specific guidelines.

Communication failures are a common cause of patient harm in surgical settings. This commentary reviews safety challenges in this setting and describes how models used by NASA and the FAA can be applied in health care to improve safety culture, education, and surgeon leadership.

This scientific statement from the American Heart Association (AHA) reviews the current state of knowledge on safety issues in the operating room (OR) and provides detailed recommendations for hospitals to implement to improve safety and patient outcomes. These recommendations include using checklists and formal handoff protocols for every procedure, teamwork training and other approaches to enhance safety culture, applying human factors engineering principles to optimize OR design and minimize fatigue, and taking steps to discourage disruptive behavior by clinicians. AHA scientific statements, which are considered the standard of care for cardiac patients, have traditionally focused on clinical issues, but this article (and an earlier statement on medication error prevention) illustrates the critical importance of ensuring safety in this complex group of patients.

This commentary reveals how implementing perioperative checklists in conjunction with the Safe Surgery 2015 initiative can promote a culture of safety in surgical care.

This study found that wrong-site surgeries continued to occur despite adoption of "Sign Your Site" initiatives and implementation of a Universal Protocol. The most common errors reported were related to wrong-level spine surgery.

This commentary discusses retained surgical objects as a systems issue and provides suggestions to prevent such incidents.

After several episodes of incorrect surgical procedures, a medical center conducted individual root cause analyses and summarized the findings to identify common causes of each individual error. These findings were used to implement systematic prevention measures.

This study noted a 6% error rate for patients admitted to a surgical ward with nearly 70% having little or no clinical consequence. The authors advocate for systematic evaluation of near miss events as key learning opportunities.

This commentary describes one hospital's successful use of a dry-erase board to facilitate teamwork and communication in the operating room to prevent retained foreign objects.

Preventing surgical instruments from being retained in the patient after surgery has traditionally relied on nurses manually counting instruments used during the procedure. However, this method is not foolproof, and this qualitative study used interviews with operating room personnel to explore reasons for incorrect instrument counts. Not surprisingly, the issues identified are known contributors to safety issues in the operating room, including production pressures, poor communication between physicians and nurses, and overt disruptive behavior. In light of these findings, the authors argue that addressing the persistent problem of retained surgical instruments will require an improvement approach based on safety culture principles.

This case study discusses errors that contributed to transplantation of infected organs and provides recommendations to improve test result communication and organizational safety culture.

The so-called July phenomenon, in which errors are supposedly more common in July due to an influx of inexperienced residents and students, has long been a source of gallows humor in hospitals. Although prior studies have reached mixed conclusions, this Australian study of anesthesia errors did find a significant increase in preventable adverse events for procedures performed by trainees during the first 4 months of the academic year. Interestingly, error rates were higher for trainees at all levels, not just first-year residents. This finding implies that underlying systems issues as well as clinical inexperience resulted in adverse events. An accompanying editorial calls for revising training models in order to provide adequate supervision and support for new trainees. A case of inadvertent hypoglycemia resulting from an intern's lack of familiarity with insulin ordering at his new hospital is discussed in an AHRQ WebM&M commentary.

This analysis of wrong-site surgery cases and near misses reported to the Pennsylvania Patient Safety Authority found that many cases involved failure to follow The Joint Commission's Universal Protocol for preventing such errors.

Disruptive behaviors are a growing concern in patient safety and system-level solutions remain a challenge. This study adds to those concerns by finding that failures in behavioral practice occurred in nearly 80% of examined closed cases with poor communication accounting for the majority of patient complications.