Skip to main content

All Content

Search Tips
Save
Selection
Format
Download
Published Date
Original Publication Date
Original Publication Date
PSNet Publication Date
Narrow Results By
Additional Filters
1 - 20 of 113
Sujan M, Bilbro N, Ross A, et al. Appl Ergon. 2022;98:103608.
Failure to rescue refers to delayed or missed recognition of a potentially fatal complication that results in a patient’s death. This single-center study sought to more effectively manage deteriorating patients after emergency surgery and reduce failure to rescue rates. Researchers used the functional resonance analysis method (FRAM) to develop recommendations for strengthening organizational resilience. Recommendations included improving team communication, organizational learning, and relationships.
Brenner MJ, Boothman RC, Rushton CH, et al. Otolaryngol Clin North Am. 2021;55.
This three-part series offers an in-depth look into the core values of honesty, transparency, and trust. Part 1, Promoting Professionalism, introduces interventions to increase provider professionalism. Part 2, Communication and Transparency, describes the commitment to honesty and transparency across the continuum of the patient-provider relationship. Part 3, Health Professional Wellness, describes the impact of harm on providers and offers recommendations for restoring wellness and joy in work.
Sotto KT, Burian BK, Brindle ME. J Am Coll Surg. 2021;233:794-809.e8.
The World Health Organization (WHO) Surgical Safety Checklist has been implemented in healthcare systems around the world. This systematic review and thematic analysis concluded that the surgical safety checklist positively impacts clinical outcomes (surgical outcomes and mortality), process measures, team dynamics, and communication, as well as safety culture. The authors note that the checklist was negatively associated with efficiency and workload; included studies often noted that checklist users felt the checklist slowed down processes within the operating room
Gabrysz-Forget F, Zahabi S, Young M, et al. J Surg Educ. 2021;78:2020-2029.
An essential part of resident training is error recovery- recognizing an error has occurred and strategizing how to correct the error to maximize patient safety. Through interviews with surgical residents, barriers and facilitators to experience error recovery were supervision, self, surgical context, and situation safeness. Focusing on these factors may enhance residents’ ability to develop their error recovery skills.
Wright MI, Polivka B, Abusalem S. AORN J. 2021;113:465-475.
Prior research identified variability in perioperative safety culture by provider type and experience. This study found that perioperative nurse engagement (e.g., energy, dedication, resilience) and perioperative nurse certification were significantly associated with self-reported safety culture in the operating room, but length of perioperative nurse experience was not.
Weinger MB. BMJ Qual Saf. 2021;30:613-617.
Checklists are widely used strategies for error reduction and improved communication. This editorial discusses the limitations of checklists for perioperative safety (i.e., when used in isolation or implemented incorrectly) and suggests that safety initiatives taking a systems-oriented approach and organizational buy-in can lead to both perioperative and general safety improvements.
Aaberg OR, Hall-Lord ML, Husebø SIE, et al. BMC Health Serv Res. 2021;21:114.
TeamSTEPPS is a patient safety intervention designed to improve teamwork and communication in healthcare settings. One Norwegian hospital utilized TeamSTEPPS to improve professional and organizational outcomes in the urology and gastrointestinal surgery ward. Twelve months after implementation, researchers observed sustained improvements in three patient safety culture dimensions and three teamwork dimensions. Further studies with larger same size and stronger study designs are warranted.

Preckel B, ed. Best Pract Res Clin Anaesthesiol. 2021;35(1):1-154.

The field of anesthesiology has realized impressive improvements in safety, yet challenges still exist in its practice. This special issue provides discussions on a variety of concerns that require continued effort, including use of early warning scores, differences associated with sex and gender, and use of incident reporting systems.

Cornelissen C, Call RC, Harbell MW, et al. APSF Newsletter. February 202136(1);25-27

Error disclosure is supported by a robust safety culture and a defined communication and management approach. This article discusses the engagement of anesthesiologists in the disclosure processes to ensure learning, patient centeredness, and care improvement.

After a failed induction at 36 weeks, a 26-year-old woman underwent cesarean delivery which was complicated by significant postpartum hemorrhage. The next day, the patient complained of severe perineal and abdominal pain, which the obstetric team attributed to prolonged pushing during labor. The team was primarily concerned about hypotension, which was thought to be due to hypovolemia from peri-operative blood loss. After several hours, the patient was transferred to the medical intensive care unit (ICU) with persistent hypotension and severe abdominal and perineal pain. She underwent surge

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.
Lin DM, Peden CJ, Langness SM, et al. Anesth Analg. 2020;131:e155-1159.
The anesthesia community has been a leader in patient safety innovation for over four decades. This conference summary highlights presented content related to the conference theme of “preventing, detecting, and mitigating clinical deterioration in the perioperative period.” The results of a human-centered design analysis exploring tactics to reduce failure to rescue were summarized.
Duffy CC, Bass GA, Duncan JR, et al. J Patient Saf. 2022;18:16-25.
Incident reporting systems are central to most patient safety programs, but studies have identified barriers to effective use. This study used clinical vignettes describing a medication error or near miss to explore error awareness and attitudes towards reporting and disclosure among anesthesiologists. Approximately one-third of anesthesiologists recalled having had medication safety training. Perioperative medication error awareness and assessment of potential harm were variable, and the likelihood of patient disclosure and incident reporting was low. Education programs utilizing vignettes should be utilized to raise awareness about error reporting and disclosure behaviors.  
Leveson N, Samost A, Dekker SWA, et al. J Patient Saf. 2020;16:162-167.
This article describes the use of a new accident analysis technique (CAST, or Causal Analysis based on Systems Theory), an alternative approach to root cause analysis. The CAST approach is based on the principle that accidents are not only the result of individual system component failures or errors but more generally result due to inadequate enforcement of constraints on the behavior of the system components (i.e., safety constraints enforced by controls, such as checklists).  Many adverse events (AEs) appear to be related to the design of the system involved and not attributable to unsafe individual behavior. This technique can be useful in identifying causal factors to help health care systems learn from mistakes and design systems-level changes to prevent future AEs.
Trinchero E, Kominis G, Dudau A, et al. Public Manag Rev. 2020;22.
Employing a mixed-methods approach, this study found that teamwork (directly and indirectly) positively impacted professionals’ safety behavior. Teamwork indirectly impacted safety behavior by increasing individual’s positive psychological capital, thereby increasing their self-efficacy and resilience. These findings emphasize the role of hospital leadership and middle management in creating an organizational culture of safety
Lemos C de S, Poveda V de B. J Perianesth Nurs. 2019;34:978-998.
This integrative review examined the factors contributing to perioperative adverse events resulting from anesthesia. Researchers found that both active errors, such as medication errors or inattention, and latent errors, such as communication failures, contributed to adverse events.