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Atallah F, Hamm RF, Davidson CM, et al. Am J Obstet Gynecol. 2022;227:B2-B10.
The reduction of cognitive bias is generating increased interest as a diagnostic error reduction strategy. This statement introduces the concept of cognitive bias and discusses methods to manage the presence of bias in obstetrics such as debiasing training and teamwork.
Buetti N, Marschall J, Drees M, et al. Infect Control Hosp Epidemiol. 2022;43:553-569.
Central line-associated bloodstream infections (CLABSI) are a target of safety improvement initiatives, as they are common and harmful. This guideline provides an update on recommended steps for organizations to support the implementation of CLASBI reduction efforts.
Combs CA, Goffman D, Pettker CM. Am J Obstet Gynecol. 2022;226:B2-B9.
Readmission reduction as an improvement measure has been found to be problematic as a maternal safety outcome. This statement shares concerns regarding incentivizing hospitalization reductions after birth and explores the potential for patient harm due to pressures to reduce readmissions when needed.
Thibault R, Abbasoglu O, Ioannou E, et al. Clin Nutr. 2021;40:5684-5709.
Mistakes in hospital dietary services can contribute to allergic reactions and patient malnourishment. This guidance shares an improvement approach to care environment food provision that considers clinical concerns and patient limitations as steps toward enhancing patient care.
Combs CA, Einerson BD, Toner LE. Am J Obstet Gynecol. 2021;225:b43-b49.
Maternal and newborn safety is challenged during cesarean delivery due to the complexities of the practice. This guideline recommends specific checklist elements to direct coordination and communication between the two teams engaged in cesarean deliveries. The guideline provides a sample checklist and steps for its implementation.
Kelley-Quon LI, Kirkpatrick MG, Ricca RL, et al. JAMA Surg. 2021;156:76.
Opioid misuse is an urgent patient safety issue, including postsurgical opioid misuse among pediatric patients. Based on the systematic review, a multidisciplinary group of health care and opioid stewardship experts proposes evidence-based opioid prescribing guidelines for children who need surgery. Endorsed guideline statements highlight three primary themes for perioperative pain management in children: (1) health care professionals must recognize the risks of pediatric opioid misuse, (2) use non-opioid pain relief, and (3) pre- and post-operative education for patients and families regarding pain management and safe opioid use.
Bickham P, Golembiewski J, Meyer T, et al. Am J Health Syst Pharm. 2019;76:903-820.
Pharmacists working with surgical teams bring distinct safety context, expertise, and process awareness to perioperative care. These guidelines outline how pharmacists can help reduce medication errors before, during, and after surgery. Perioperative pharmacists can enhance communication, medication histories, and process reliability.

ACR Committee on MR Safety, Greenberg TD, Hoff MN, Gilk TB, et al. J Magn Reson Imaging. 2020;51(2):331-338. 

The reliable adoption of safe practices in clinical and research imaging will reduce risks to diagnostic radiology patients. This guideline builds on existing recommendations as a response to the changing needs of magnetic resonance practitioners and their patients. Strategies to ensure clinical teams stay updated on safety issues in this environment include reviewing and updating guidelines as well as requiring magnetic resonance directors to undergo annual patient safety training.
Rosengart TK, Doherty G, Higgins R, et al. JAMA Surg. 2019;154:647-653.
Potential deterioration of older surgeons' technical performance is a patient safety concern. This guidance developed from a Society of Surgical Chairs panel discussion puts forth several steps to manage the transition of aging surgeons. Recommendations include mandatory cognitive and psychomotor testing for surgeons age 65 and older, respectful consideration of the financial and emotional concerns of aging surgeons, and lifelong mentoring around the transition from clinical to nonclinical roles. The authors anticipate that such initiatives will prompt thoughtful support for aging surgeons that ensures patient safety. In an accompanying editorial, an older physician supports mandatory testing and suggests individual-level steps to address aging as a surgeon, including healthy lifestyle and financial habits.
Radiology ES of, Societies EF of R. Insights Imaging. 2019;10:45.
Numerous factors affect safe imaging practice, including potential harms associated with radiation, staffing demands, and patient physical and psychological well-being. This policy statement provides multidisciplinary insights on safety themes in radiology that go beyond the core concern of inappropriate radiation exposure. The authors recommend tactics to reduce the risks related to data protection, service environment, teamwork, burnout, and training.
Lefebvre G, Calder LA, De Gorter R, et al. J Obstet Gynaecol Can. 2019;41:653-659.
Obstetrics is a high-risk practice that concurrently manages the safety of mothers and newborns. This commentary describes the importance of standardization, checklist use, auditing and feedback, peer coaching, and interdisciplinary communication as strategies to reduce risks. The discussion spotlights the need for national guidelines and definitions to reduce variation in auditing and training activities and calls for heightened engagement of health care professionals to improve the safety and quality of obstetric care in Canada. An Annual Perspective reviewed work on improving maternal safety.
Munoz-Price S, Bowdle A, Johnston L, et al. Infect Control Hosp Epidemiol. 2018:1-17.
This expert guidance provides recommendations to help health care facilities develop policies for preventing health care–associated infections in the operating room. The authors build on existing anesthesia safety practices to outline specific actions for infection prevention and control.
Fox ER, McLaughlin MM. Am J Health Syst Pharm. 2018;75:1742-1750.
Drug shortages are a persistent threat to safe patient care. These guidelines provide a structured approach for care teams to develop an action plan to reduce risks when faced with drug shortages in their work. Recommendations include conducting operational assessments, establishing a drug shortage team, and communicating with patients and providers when a shortage occurs.
Eiland LS, Benner K, Gumpper KF, et al. J Pediatr Pharmacol Ther. 2018;23:177-191.
Pediatric patients are at particularly high risk for medication errors. Challenges pharmacists face when providing care for children include a lack of standard dosage forms and concentrations and patient inability to describe symptoms. These guidelines provide practical recommendations to improve the safety of pediatric pharmacy services.
Guenter P, Worthington P, Ayers P, et al. Nutr Clin Pract. 2018;33:295-304.
Administration of parental nutrition is a specialized process that requires distinct competencies to be safe. This guideline recommends standardized competencies for clinicians to develop and maintain to ensure safe and reliable administration of parenteral nutrition therapy in various care environments and team configurations.
Gelb AW, Morriss WW, Johnson W, et al. Anesth Analg. 2018;126:2047-2055.
Safe anesthesia is a global concern. These standards provide guidance and recommendations for clinicians, administrators, and governments as they review, implement, and manage anesthesia services in a variety of care environments. The standards center on themes related to professional qualification; facilities and equipment; medications and intravenous fluids; monitoring; and anesthesia delivery.
Obstet Gynecol. 2016;128:e54-60.
Incidents involving maternal harm require analysis to provide learning and assist design of prevention strategies. This consensus document outlines an organizational process to determine cases for review and provides a set of diagnostic and complication screening criteria to assess severe maternal morbidity incidents for quality review. The document supersedes the Sentinel Event Alert on maternal harm.