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Ghaith S, Campbell RL, Pollock JR, et al. Healthcare (Basel). 2022;10:1328.
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.
Bicket MC, Waljee JF, Hilliard P. JAMA Health Forum. 2022;3:e221356.
Concern for improved prescribing of opiates motivated the development of programs and policies that have inadvertently caused new problems. This commentary discusses the impact of nonopioid use during surgery as a patient preference. It discusses the potential for adverse impacts of the strategy while recognizing the unique situation of perioperative use of pain medications.

Farnborough, UK; Healthcare Safety Investigation Branch; May 26, 2022.

Surgical equipment sterilization can be hampered by equipment design, production pressures, process complexity and policy misalignment. This report examines a case of unclean surgical instrument use. It recommends external sterile service assessment and competency review as steps toward improving the reliability of instrument decontamination processes in the National Health Service.
US Food and Drug Administration. October 7, 2021.
Errors of commission during complex procedures can contribute to patient harm. Drawing from an analysis of medical device reports submitted to the Food and Drug Administration, this updated announcement seeks to raise awareness of common adverse events associated with surgical staplers and implantable staples. User-related problems include opening of the staple line, misapplied staples, and staple gun difficulties. Recommendations include ensuring availability of various staple sizes and avoiding use of staples on large blood vessels.
Sidi A, Gravenstein N, Vasilopoulos T, et al. J Patient Saf. 2021;17:e490-e496.
Nontechnical skills, such as teamwork and communication, can influence performance in technical fields like surgery or emergency medicine. This study found that simulation-based assessments can measure improvements in nontechnical skills and cognitive performance among residents.
Speaks L, Helmer SD, Quinn KR, et al. J Surg Educ. 2021;78:e145-e153.
Balancing resident autonomy and supervision is an ongoing challenge in medical training. The authors reviewed patient data to identify adverse outcomes (e.g., complications, readmissions, reoperation, mortality) undergoing common general surgery procedures performed by, or indirectly supervised by, attending surgeons or the chief resident service. Findings suggest that indirect supervision of appendectomies, cholecystectomies, and hernia repairs by the chief resident surgery service is safe and can serve as a model to enhance resident autonomy during training.
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.
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.
Chung EH, Truong T, Jooste KR, et al. J Surg Educ. 2021;78:942-949.
Medical residents are frequently involved in difficult patient conversations, including error disclosure. This paper describes the development and implementation of a novel communications/didactic skills training program for OB/GYN residents. Immediately, and 3-months after training, residents indicated an improvement in their communication skills.

Kuhn CM, Newton RC, Damewood MD, et al, on behalf of the CLER Evaluation Committee, the CLER Operative and Procedural Subprotocol National Advisory Group, and the CLER Program. Chicago, IL: Accreditation Council for Graduate Medical Education; February 2021. ISBN: 9781945365386.

The teaching hospital environment can produce clinician behaviors and mindsets that persist throughout a medical career. This report from a clinical learning environment assessment program shares insights gathered during walking rounds specific to perioperative care and general medicine. The report concluded that residents did not actively report problems and rarely participated in event investigations.
Koike D, Nomura Y, Nagai M, et al. Int J Qual Health Care. 2020;32:522-530.
Nontechnical skills are gaining interest as one way to enhance surgical team performance and patient safety. In this single-center study, the authors found that a perioperative bundle that introduced nontechnical skills to the surgical team was effective in reducing operative time.   
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.  
Gabrysz-Forget F, Young M, Zahabi S, et al. J Surg Educ. 2020;77:1552-1561.
This survey of surgical residents explored their experiences and perceptions of error recovery training (i.e., how to recognize and manage a technical error in order to ensure patient safety). Nearly all respondents thought error recovery was a key competency, yet only one-third felt they were adequately trained to recover from major events. Error recovery should be incorporated into formal surgical curriculum to support trainees and increase surgical safety.
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.
Pugh CM, Law KE, Cohen ER, et al. Am J Surg. 2020;219:214-220.
Using a human factors engineering framework, this study reviewed video of residents performing a simulated hernia repair to identify and characterize errors, error detection and error recovery. The twenty participating residents made 314 errors; the majority were technical errors (63%) and commission errors (69%; defined as failure to perform a surgical step correctly). Nearly half of all errors went undetected by the residents during the procedure, but when errors were detected, the majority were able to be resolved.
Mackenzie CF, Shackelford SA, Tisherman SA, et al. Surgery. 2019;166:835-843.
This study evaluated trauma readiness among surgical residents following trauma surgery training and its impact on critical errors. Resident trauma readiness index increased significantly following the training, and training resulted in fewer critical errors committed by residents when compared with practicing surgeons. The trauma readiness index may help identify surgeons who would benefit from additional follow up training.
Shapiro FE, ed. Int Anesthesiol Clin. 2019;57:1-162.
This publication presents patient safety concepts for anesthesia practice, including decision aids to educate and empower patients about anesthesia choice, environmental hazards, interpersonal communication, team training, and use of technology and simulation as educational tools.