Anesthesiologists often must oversee multiple surgeries. This study evaluated adult patients from 23 US academic and private hospitals who underwent major surgery between 2010, and 2017, to examine anesthesiologist staffing ratios against patient morbidity and mortality. The authors categorized the staffing into four groups based on the number of operations the anesthesiologist was covering. The study found that increased anesthesiologist coverage was associated with greater risk-adjusted morbidity and mortality of surgical patients. Hospitals should consider evaluating anesthesiology staffing to determine potential increased risks.
Zhang D, Gu D, Rao C, et al. BMJ Qual Saf. 2022;Epub Jun 1.
Clinician workload has been linked with poor patient outcomes. This retrospective cohort study assessed the outcomes for patients undergoing coronary artery bypass graft (CABG) performed as a surgeons’ first versus non-first procedure of the day. Findings suggest that prior workload adversely affected outcomes for patients undergoing CABG surgery, with increases in adverse events, myocardial infarction, and stroke compared to first procedures.
Sun EC, Mello MM, Vaughn MT, et al. JAMA Intern Med. 2022;182:720-728.
Physician fatigue can inhibit decision-making and contribute to poor performance. This cross-sectional study examined surgical procedures performed between January 2010 and August 2020 across 20 high-volume hospitals in the United States to determine the association between surgeon fatigue, operating overnight and outcomes for operations performed by the same surgeon the next day. No significant associations were found between overnight surgeries and surgical outcomes for procedures performed the next day.
Operating room fires are never events that, while rare, still harbor great potential for harm. This review discusses settings prone to surgical fire events, prevention strategies, and care management steps should patients be harmed by an operating room fire.
Lohmeyer Q, Schiess C, Wendel Garcia PD, et al. BMJ Qual Saf. 2022;Epub Mar 8.
Tall Man lettering (TML) is a recommended strategy to reduce look-alike or sound-alike medication errors. This simulation study used eye tracking to investigate how of ‘tall man lettering’ impacts medication administration tasks. The researchers found that TML of prelabeled syringes led to a significant decrease in misidentified syringes and improved visual attention.
Bernstein SL, Catchpole K, Kelechi TJ, et al. Jt Comm J Qual Patient Saf. 2022;48:309-318.
Maternal morbidity and mortality continues to be a significant patient safety problem. This mixed-methods study identified system-level factors affecting registered nurses during care of people in labor experiencing clinical deterioration. Task overload, missing or inadequate tools and technology, and a crowded physical environment were all identified as performance obstacles. Improving nurse workload and involving nurses in the redesign of tools and technology could provide a meaningful way to reduce maternal morbidity.
Messing EG, Abraham RS, Quinn NJ, et al. Am J Nurs. 2022;122.
When hospitals began to fill up with COVID-19 patients, new strategies had to be developed and implemented quickly to reduce the spread of the virus. This article describes one strategy implemented by a New York hospital: relocating smart intravenous (iv) infusion pumps outside of patient rooms. Challenges, facilitators, and lessons learned are discussed.
Lyndon A, Simpson KR, Spetz J, et al. Appl Nurs Res. 2022;63:151516.
Missed nursing care appears to be associated with higher rates of adverse events. More than 3,600 registered nurses (RNs) were surveyed about missed care during labor and birth in the United States. Three aspects of nursing care were reported missing by respondents: thorough review of prenatal records, missed timely documentation of maternal-fetal assessments, and failure to monitor input and output.
Hennus MP, Young JQ, Hennessy M, et al. ATS Sch. 2021;2:397-414.
The surge of patients during the COVID-19 pandemic forced the redeployment of non-intensive care certified staff into intensive care units (ICU). This study surveyed both intensive care (IC)-certified and non-IC-certified healthcare providers who were working in ICUs at the beginning of the pandemic. Qualitative synthesis identified five themes related to supervision; quality and safety of care; collaboration, communication, and climate; recruitment, scheduling and team composition, and; organization and facilities. The authors provide recommendations for future deployments.
Designated safety leadership roles are situated to direct and sustain organizational safety progress. This commentary describes an anesthesiology safety officer function and how it is positioned to motivate staff safety behaviors and support engagement during project challenges.
Awan M, Zagales I, McKenney M, et al. J Surg Educ. 2021;78:e35-e46.
In 2011, the Accreditation Council for Graduate Medical Education (ACGME) updated the duty hour restrictions (DHR) for medical residents to increase resident well-being. This review focused on surgical patient outcomes, resident case volume, and resident quality of life following the implementation of the 2011 update. Results showed DHR did not improve patient safety or surgical resident quality of life. The authors suggest future revisions meant to improve resident well-being not focus solely on hours worked in a single shift or week.
Marang-van de Mheen PJ, Vincent CA. BMJ Qual Saf. 2021;30:525-528.
Research has shown that patients admitted to the hospital on the weekend may experience worse outcomes compared to those admitted on weekdays (the ‘weekend effect’). This editorial highlights the challenges to empirically evaluate the underlying mechanisms contributing to the weekend effect. The authors propose viewing the weekend effect as a proxy for staffing levels and the influence of other factors influencing outcomes for patients admitted on weekends, such as patient acuity, clinician skill-mix and access to diagnostic tests or other ancillary services.
Rahman SA, Sullivan JP, Barger LK, et al. Pediatrics. 2021;147:e2020009936.
Reducing resident shift duration can improve resident health and patient safety. This study found that resident shifts limited to 16 hours can reduce performance impairment and medical errors, compared to extended work shifts (24+hours).
Hedsköld M, Sachs MA, Rosander T, et al. BMC Health Serv Res. 2021;21:48.
Intensive care units (ICUs) are complex environments that carry high risk for medical errors. This qualitative study characterized the role of front-line ICU managers in organizing for safe care and creating a culture of safety.
Pryce A, Unwin M, Kinsman L, et al. Int Emerg Nurs. 2020;54:100956.
Emergency department (ED) overcrowding and prolonged ED stays can lead to adverse patient outcomes. This study examined patient flow bottlenecks in the ED and several factors posing risks to patient safety, such as prolonged time to triage and use of makeshift spaces (which may have inadequate staffing allocations or lack necessary equipment).
Hillman E, Paul J, Neustadt M, et al. Acad Med. 2020;95:1864-1873.
Quality improvement and patient safety (QIPS) programs are intended to increase patient safety competency during graduate medical education. This article describes the development and implementation of a consortium aimed to improve QIPS education at a large academic health center. Primary goals of the consortium include to (1) expand learner-driven, interprofessional opportunities, (2) leverage simulation training, and (3) engage and collaborate with community stakeholders.
Butler CR, Wong SPY, Wightman AG, et al. JAMA Netw Open. 2020;3:e2027315.
The COVID-19 pandemic has led to wide-ranging changes to health care delivery. This qualitative study with clinicians in the United States identified three emerging themes describing clinicians’ experience providing care in settings of resource limitations - planning for crisis capacity, adapting to resource limitations, and unprecedented barriers to care delivery.
Althoff FC, Wachtendorf LJ, Rostin P, et al. BMJ Qual Saf. 2020;30:678-688.
Prior research suggests that patients undergoing surgery at night are at greater risk for intraoperative adverse events. This retrospective cohort study including over 350,000 adult patients undergoing non-cardiac surgery found that night surgery was associated with an increased risk of postoperative mortality and morbidity. The effect was mediated by potentially preventable factors, including higher blood transfusion rates and more frequent provider handovers.
Please select your preferred way to submit a case. Note that even if you have an account, you can still choose to submit a case as a guest. And if you do choose to submit as a logged-in user, your name will not be publicly associated with the case. Learn more information here.