Gogalniceanu P, Kunduzi B, Ruckley C, et al. Surgery. 2022;172:537-545.
The patient safety field frequently adapts safety methods from aviation, such as checklists and crew resource management. Drawn from fieldwork, interviews with aviation safety experts, and focus groups with patient safety experts, this study adapted interventions from aviation crisis recovery for use in surgical error recovery. Twelve tools were developed based on three broad strategies: situational awareness and workload management; checklists for non-normal situations; decision making and problem solving.
Moody A, Chacin B, Chang C. Curr Opin Anaesthesiol. 2022;35:465-471.
Hospital-acquired pressure injuries are considered a never event. This review presents strategies to prevent pressure injuries in the nonoperating room anesthesia (NORA) population (e.g., patients on ventilators). Proper positioning of the patient, with bolsters and padding, are illustrated.
Marsh KM, Turrentine FE, Knight K, et al. Ann Surg. 2022;275:1067-1073.
Having standardized definitions and classifications of errors allows researchers to better understand potential causes and interventions for improvement. This systematic review identified six broad error categories, 13 definitions of error, and 14 study methods in the surgical error literature. Development and use of a common definition and taxonomy of errors will provide a more accurate indication of the prevalence of surgical error rates.
Parker H, Frost J, Day J, et al. PLoS ONE. 2022;17:e0271454.
Prophylactic antimicrobials are frequently prescribed for surgical patients despite the risks of antimicrobial overuse (e.g., resistance). This review summarizes how and why antimicrobials continue to be prescribed in surgical settings despite evidence of overuse. Eight overarching concepts were identified: hierarchy; fear drives action; deprioritized; convention trumps evidence; complex judgments; discontinuity of care; team dynamics; and practice environment.
Anesthesiologists often must oversee multiple surgeries. This study evaluated adult patients from 23 US academic and private hospitals who underwent major surgery between 2010, and 2017, to examine anesthesiologist staffing ratios against patient morbidity and mortality. The authors categorized the staffing into four groups based on the number of operations the anesthesiologist was covering. The study found that increased anesthesiologist coverage was associated with greater risk-adjusted morbidity and mortality of surgical patients. Hospitals should consider evaluating anesthesiology staffing to determine potential increased risks.
Unintentionally retained foreign objects can be exacerbated by fatigue, distractions, and communication errors. This article highlights the importance of effective teamwork, high reliability orientation, and standardized surgical count methods to minimize the persistent problem of retained surgical items.
Acute care facilities in Pennsylvania are required to report all Incidents and Serious Events to the state’s Patient Safety Authority. This study updates the 2020 report. Similar to prior reports, Error Related to Procedure/Treatment/Test remained the most commonly reported events, followed by Medication Error, Complication of Procedure/Treatment/Test, and Fall.
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.
Perioperative adverse drug events are common and understudied. This review examines factors that contribute to adverse drug events in the surgical setting and discusses prevention strategies that focus on medication reconciliation, technology, standardization, and institutional change.
A 2009 CMS Condition of Participation (CoP) requires that a director of anesthesia services assume overall responsibility for anesthesia administered in the hospital, including procedural sedation provided by nonanesthesiologists. This article reviews the CoP as it relates to procedural sedation, lays out a framework for implementing this role, and describes challenges of implementation in a large health system.
Guzek R, Goodbody CM, Jia L, et al. J Pediatr Orthop. 2022;42:393-399.
Research has demonstrated inequitable treatment of racially minoritized patients resulting in poorer health outcomes. This study aimed to determine if implicit racial bias impacts pediatric orthopedic surgeons’ clinical decision making. While pediatric orthopedic surgeons showed stronger pro-white implicit bias compared to the US general population (29% vs. 19%), the bias did not appear to affect decision making in clinical vignettes.
Krenzischek DA, Card E, Mamaril M, et al. J Perianesth Nurs. 2022;Epub Apr 27.
Patients and caregivers are important partners in promoting safe care. Findings from this cross-sectional study reinforce the importance of patients’ perceived roles in ensuring safe surgery and highlight the importance of patient engagement in mitigating surgical site errors.
Sun EC, Mello MM, Vaughn MT, et al. JAMA Intern Med. 2022;182:720-728.
Physician fatigue can inhibit decision-making and contribute to poor performance. This cross-sectional study examined surgical procedures performed between January 2010 and August 2020 across 20 high-volume hospitals in the United States to determine the association between surgeon fatigue, operating overnight and outcomes for operations performed by the same surgeon the next day. No significant associations were found between overnight surgeries and surgical outcomes for procedures performed the next day.
Operating room fires are never events that, while rare, still harbor great potential for harm. This review discusses settings prone to surgical fire events, prevention strategies, and care management steps should patients be harmed by an operating room fire.
Armstrong BA, Dutescu IA, Nemoy L, et al. BMJ Qual Saf. 2022;31:463-478.
Despite widespread use of surgical safety checklists (SSC), its success in improving patient outcomes remains inconsistent, potentially due to variations in implementation and completion methods. This systematic review sought to identify how many studies describe the ways in which the SSC was implemented and completed, and the impact on provider outcomes, patient outcomes, and moderating factors. A clearer positive relationship was seen for provider outcomes (e.g., communication) than for patient outcomes (e.g., mortality).
A necessary part of successful implementation of new guidelines is ensuring continued adherence. Nine Dutch hospitals implemented a multifaceted program (IMPlementatie Richtlijnen Operatieve VEiligheid [IMPROVE]) to support application of surgical guidelines. Results of guideline use were mixed.
Ryan M, Mekel M, Sinha MS. UptoDate. November 30, 2021
Error disclosure is fundamental to addressing harm and psychological distress after medical error. This review highlights issues associated with surgical error disclosure. It summarizes literature covering legal and ethical issues, honest apology, and skill development to ensure apology communications are effective.
Warner MA, Warner ME. Anesthesiology. 2021;135:963-974.
The legacy of anesthesiology as a leader in patient safety is reviewed as a model for other communities seeking to reduce medical error. The authors highlight the collaboration strategies that the specialty embraced as a key component of its success.
Hammond Mobilio M, Paradis E, Moulton C-A. Am J Surg. 2022;223:1105-1111.
Surgical safety checklists (SSC) have been adopted around the world, but reported compliance rates and use in practice vary widely. This study in one Canadian hospital showed the SSC was used in 82% of Briefings, 76% of Time-Outs, and 22% of Debriefings. Gaps between policy and practice were identified and implications for policy makers, administrators, frontline clinicians, and researchers are discussed.
Malahias M-A, Antoniadou T, Jang SJ, et al. J Am Acad Orthop Surg. 2021;29:e1387-e1395.
Previous research has raised concerns about safety risks associated with overlapping surgery, defined as two procedures performed concurrently, but where critical surgical portions of each procedure occur at different times. Based on a meta-analysis of six articles, the authors of this systematic review found that rates of surgical complications readmissions were similar among overlapping and nonoverlapping surgery in patients undergoing total joint arthroscopy.
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