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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.

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.
Royal College of Obstetricians and Gynaecologists.
This organization highlights the importance of in-depth reporting and investigation of adverse events in labor and delivery, involving parents in the analysis, engaging external experts to gain broader perspectives about what occurred, and focusing on system factors that contribute to failures. A WebM&M commentary discusses how lapses in fetal monitoring can miss signs of distress that result in harm. The reporting initiative closed in 2021 after presenting its final report. Investigations in this area will now be undertaken by the Healthcare Safety Investigation Branch in England.
Fillo KT. Bureau of Health Care Safety and Quality, Department of Public Health. Boston, MA: Commonwealth of Massachusetts; 2020.
This annual report compiles patient safety data documented by Massachusetts hospitals. The 2019 numbers represent a modest increase in serious reportable events recorded in acute care hospitals, from 1066 the previous year to 1189. This presentation also includes events from ambulatory surgery centers. Previous years reports are also available.

NHS Improvement. Independent Mortality Review of Cardiac Surgery at St George’s University Hospitals NHS Foundation Trust. NHS England. March 2020.

In-depth incident investigations provide details of care process examinations to motivate learning and improvement. This report examines cardiac surgery patient mortality at a National Health Service Trust over a 5-year period. It highlights weakness in professionalism at the individual and organization level as a contributor to the preventable patient deaths catalogued over that time.

Safety in Numbers: Hospital Performance on Leapfrog’s Surgical Volume Standard Based on Results of the 2019 Leapfrog Hospital Survey. Washington DC; 2020.

Surgical volume standards are a metric used to assess the needed experience in performing distinct types of procedures. This report analyzed data from over 2,100 hospitals and found approximately half to be deficient in fully adhering to the standards while implementing mechanisms to minimize unnecessary surgeries
Buissonniere M. Brooklyn NY: Lifebox and Ariadne Labs; 2020.
Checklists are integrated into error reduction strategies and healthcare team communication efforts worldwide but implementation and impact of the tool varies widely. This report examines the use of the WHO Surgical Safety Checklist and barriers to its uptake which include lack of effective staff introduction to the content, misperceptions about the time needed to use the tool and ineffective local contextualization of the content and process.
Farnborough, UK; Healthcare Safety Investigation Branch; December 18, 2019.
Maternal care during and after childbirth is at risk for never events including retained foreign objects. This analysis of a sentinel event involving a retained surgical tampon after childbirth discusses communication, fatigue, and process factors that contributed to the incident. The report suggests improved handoffs as one improvement strategy.
Ruskin KJ; Stiegler MP; Rosenbaum SH; Oxford University Press; OUP.
The perioperative setting is a high-risk environment. This publication discusses the clinical foundations and application of safety concepts in perioperative practice. Chapters cover topics such as human factors, error management, cognitive aids, safety culture, and teamwork.
London, UK: Royal College of Surgeons of England; 2019.
Introducing innovations in practice involves taking calculated risks. To ensure patient safety, new techniques should be accompanied by training, oversight, and heightened awareness of the learning curve. This book provides a framework to guide the design and introduction of new surgical procedures into regular practice. It includes recommendations for auditing, cost assessment, and effectiveness review.
Royal College of Surgeons of England; RCS.
Physical demands and technical complexities can affect surgical safety. This resource is designed to capture frontline perceptions of surgeons in the United Kingdom regarding concerning behaviors exhibited by their peers during practice to facilitate awareness of problems, motivate improvement, and enable learning.
Rockville, MD: Agency for Healthcare Research and Quality. December 2017. AHRQ Publication No. 16(18)-0004-1-EF.
Large-scale collaboratives have achieved success in implementing patient safety improvements. This report describes the work and outcomes of a 3-year surgical safety program funded by AHRQ that involved more than 200 hospitals in the United States. The project employed models and tools to implement surgical site infection prevention strategies. Participants reported substantial reductions of surgical site infections in their facilities.
Agency for Healthcare Research and Quality; AHRQ.
Preventing surgical complications including surgical site infections are a worldwide target for improvement. This toolkit builds on the success of the Comprehensive Unit-based Safety Program to initiate change. The tools represent practical strategies that helped members of a large-scale collaborative to identify areas of weakness, design improvements, and track the impact of the interventions.

Geneva: World Health Organization; 2018. ISBN-13: 978-92-4-155047-5.

Efforts to reduce surgical site infections have achieved some success. The World Health Organization has taken a leading role in eliminating health care–associated harms and has compiled guidelines to address factors that contribute to surgical site infections in preoperative, intraoperative, and postoperative care. The document includes recommendations for improvement informed by the latest evidence. The second edition of the Guidelines was released in 2018.
Stahel PF, ed. New York, NY: McGraw-Hill Education/Medical; 2017. ISBN: 9780071842631.
Surgical residency can be a stressful learning experience. This textbook provides an introduction to nontechnical aspects of safe surgical practice, a collection of case studies that illustrate technical challenges in the operating room, and insights regarding other elements of health care that can affect the safety of surgical care, such as health information technology.
Wiley K, Davies JM. Edmonton, AB: Canadian Patient Safety Institute; 2017.
Proactive analysis can help uncover process weaknesses and ensure improvements are implemented before patients experience harm. This guide provides insights for organizations who seek to implement proactive analysis strategies. Tools and models discussed include Reason's Swiss cheese model and Systems Engineering Initiative for Patient Safety.
Royal College of Surgeons of Edinburgh.
Surgical training is demanding and can result in burnout. This publication explores deficiencies in surgical training that can contribute to a stressful work environment and diminish the safety of care delivery. The report recommends changes to improve work climate and reduce the potential for error, including establishing a strong team culture and promoting human factors training.
Hoyt DB, Ko CY, eds. Chicago, IL: American College of Surgeons; 2017. ISBN: 9780996826242.
Surgery is complex and involves a wide range of possibilities for error that can result in patient harm. This textbook explores both technical and organizational contributors to those factors. The authors provide context for how leaders can address weaknesses across all phases of surgical care to help improve safety. Topics covered include high reliability, teamwork, communication, and patient-centered culture.
Shiralkar U.
Stress, information overload, and high-risk decisions are prevalent in surgery. This book discusses elements of surgical practice that can diminish surgeon performance and contribute to burnout. The author offers recommendations for surgeons to help manage stress levels, including noise reduction, ergonomic considerations, and recognition of fatigue.