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Tewfik G, Naftalovich R, Kaushal N, et al. Br J Anaesth. 2022;128:e28-e32.
Adverse event reporting and tracking are essential components to safety improvement. This letter to the editor summarizes the barriers to accurate adverse event tracking in anesthesiology, including fear of blame or lack of education regarding the importance of identifying reportable events, and the role of Anesthesia Information Management Systems for improving incident reporting and tracking.
Pérez Zapata AI, Rodríguez Cuéllar E, de la Fuente Bartolomé M, et al. Patient Saf Surg. 2022;16:7.
Trigger tools are one method of retrospectively detecting adverse events. In this study, researchers used data from 31 Spanish hospitals to validate a trigger tool in general and gastrointestinal surgery departments. Of 40 triggers, 12 were identified for optimizing predictive power of the trigger tool, including broad spectrum antibiotherapy, unscheduled postoperative radiology, and reintervention.

Ruskin KJ, ed. Curr Opin Anaesthesiol. 2021;34(6):720-765

Anesthesia services are high risk despite progress made in the specialty to improve its safety. This special section covers issues that affect anesthesia safety such as critical incident debriefing, human factors, and educational strategies.

A 78-year-old woman with macular degeneration presented for a pars plana vitrectomy (PPV) under monitored anesthesia care (MAC) with an eye block. At this particular hospital, eye cases under MAC are typically performed with an eye block by the surgeon after the anesthesiologist has administered some short-acting sedation, commonly with remifentanil. On this day, there was a shortage of premixed remifentanil and the resident – who was unfamiliar with the process of drug dilution – incorrectly diluted the remifentanil solution.

Hofer IS, Cheng D, Grogan T. Anesth Analg. 2021;133:698-706.
Anesthesia-related adverse events have been associated with increased length of stay, morbidity and mortality. This study investigated the effect of missed documentation of select comorbidities on postoperative length of stay and mortality. Results indicate that missed documentation of one of the comorbid conditions increased risk of length of stay, and mortality was increased with missed atrial fibrillation.
Nasca BJ, Bilimoria KY, Yang AD. Jt Comm J Qual Patient Saf. 2021;47:604-607.
Surgical safety has made advances while new difficulties continuously emerge. This article suggests that the specialties capitalize on artificial intelligence and professional wellness as two avenues to generate sustainable safety progress.
MedWatch Safety Alert. Silver Spring, MD: US Food and Drug Administration; August 20, 2021.
This announcement seeks to raise awareness of the potential risks associated with the use of robotic-assisted surgical devices in mastectomies or cancer-related care. Recommendations for patients who may seek to have robotically assisted surgery include asking about their surgeon's experience with these procedures and discussing benefits, risks, and alternatives regarding available treatment options with their health care provider. Suggestions for health care providers include completing specialized training on procedures they perform. A WebM&M commentary described the challenges and benefits associated with robotic surgery.
Schnock KO, Biggs B, Fladger A, et al. J Patient Saf. 2021;17:e462-e468.
Hospitals have implemented radiofrequency identification (RFID) technology to improve patient safety. This systematic review of 5 studies suggests that use of RFID can lead to rapid, accurate detection of retained surgical instruments (RSIs) and reduced risk of counting errors.
Abraham J, Pfeifer E, Doering M, et al. Anesth Analg. 2021;132:1563-1575.
Intraoperative handoffs between anesthesiologists are frequently necessary but are not without risk. This systematic review of 14 studies of intraoperative handoffs and handoff tools found that use of handoff tools has a positive impact on patient safety. Additional research is needed around design and implementation of tools, particularly the use of electronic health records to record handoffs.  

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

Surgical patients are at high risk for harm, should errors occur. This special issue covers areas of concern in perioperative anesthesia care that include patient allergies, age, sex and gender considerations, and incident reporting system effectiveness.

Two separate patients undergoing urogynecologic procedures were discharged from the hospital with vaginal packing unintentionally left in the vagina. Both cases are representative of the challenges of identifying and preventing retained orifice packing, the critical role of clear handoff communication, and the need for organizational cultures which encourage health care providers to communicate and collaborate with each other to optimize patient safety.

Ruskin KJ, ed. Curr Opin Anaesthesiol.  2020;33(6):774-822.

The complexity of care delivery requires complementary approaches to prevent mistakes. This special section shares clinical and organizational tactics to address anesthesiology safety issues. They include automation failures, the role of the obstetric anesthesiologist in maternal safety, and monitoring effectiveness. 
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.
Kandagatla P, Su W-TK, Adrianto I, et al. J Healthc Qual. 2021;43:101-109.
This study examined the association of inpatient harms (e.g., infections, medication-related harms) and 30-day readmissions through a retrospective analysis of adult surgical patients in a single heath system over a two year period. The authors found that the harms with the highest 30-day readmission rates were pressure ulcers (45%), central line-associated bloodstream infections (40%), Clostridium difficile infections (29%), international normalized ratio >5 for patients taking Warfarin (26%), and catheter-associated urinary tract infections. The authors also described the accuracy of a risk prediction model to identify high-risk patients for 30-day admissions.  
Russ S, Latif Z, Hazell AL, et al. JMIR Mhealth Uhealth. 2019;8.
Using a participatory action research approach, this study evaluated a smartphone app intended to empower surgical patients and caregivers to help optimize their care. Forty-two patients were enrolled in the study and they underwent a variety of different surgical procedures. Most patients felt that app was useful and informative (79%), was easy to use (74%) and helped participants to ask better questions (76%) and feel more involved in conversations about their care. However, almost half of participants (48%) were unsure about how the app could affect safety, citing that safety was the responsibility of the clinical staff alone rather than patients.
Loftus TJ, Tighe PJ, Filiberto AC, et al. JAMA Surg. 2019;155:148-158.
Artificial intelligence (AI) can inform decision making and reduce diagnostic uncertainty. These authors discuss challenges in surgical decision-making– such as complexity, time constraints and uncertainty – and how AI can be leveraged using the EHR and mobile devices to overcome these challenges and augment surgical decision-making.
Etherington N, Usama A, Patey AM, et al. BMJ Open Qual. 2019;8:e000686.
This qualitative study sought to identify barriers and enablers influencing stakeholder support of the Operating Room (OR) Black Box, an audio-video recording device similar to that used on airplanes. Stakeholders were mostly supportive of the OR Black Box, but several potential barriers were identified, such as time pressures in the OR and perceptions that the Black Box may negatively impact clinical performance. Authors concluded that the OR Black Box must be positioned as a patient safety initiative to improve practice.