Error management training (EMT) encourages learners to make errors during training, and then engage in positive discussions about recognition of those errors. This commentary calls for increased use of EMT for surgical students and residents to promote error recovery.

Closed-loop communication prevents confusion and ensures the healthcare team is operating under a shared mental model. In order to investigate closed-loop communication in real-life care (as opposed to simulations), researchers observed 60 interprofessional teams, including 120 anesthesia personnel. The number of callouts, check-backs, and confirmations were analyzed, revealing only 45% of callouts resulted in closed-loop communication.

Operating room (OR) “black boxes”;– which combine continuous monitoring of intraoperative data with video and audio recording of operative procedures – are increasingly used to improve clinical and team performance. This study surveyed OR professionals in Denmark and Canada about safety attitudes and privacy concerns regarding OR black box use. Participants were primarily concerned with safety climate and teamwork in the OR and use of OR black boxes can support learning and improvements in these areas. The North American cohort expressed more concerns about data safety.

Efforts to embed patient safety content into defined post-graduate medical curriculum face challenges due to time, culture, and program resource demands. This statement provides detailed safety and quality content recommendations for maternal-fetal medicine fellows that focus on topics such as safety culture, event reporting, and disparities.

Healthcare professionals who are involved in patient safety incidents can experience psychological distress. Using three case examples from surgery, urology, and maternity care, this study explored the emotional experience of healthcare professionals involved in patient safety incidents. The authors discuss the importance of providing support for recovery after involvement in a patient safety incident and protecting professionals from workplace pressures.

A 2012 review estimated that diagnostic errors in the intensive care unit (ICU) may contribute to up to 8% of patient deaths. This narrative review identifies common causes of diagnostic error (e.g., cognitive bias) and suggests a diagnostic framework. Cognitive de-biasing strategies and increasing time spent with the patient are recommended as strategies for reducing diagnostic errors in this vulnerable patient population.

Real-time use of artificial intelligence in the operating room allows surgeons to avoid or immediately address intraoperative adverse events. This review summarizes 13 articles published since 2010 that report on the use of artificial intelligence to predict intraoperative adverse events. Most studies used video and more than half were intended to detect bleeding.

Near-miss incidents present useful learning opportunities but frequently go unreported. This study used a computerized trigger tool to identify near-miss incidents in the emergency department (ED). Results show approximately 23% of ED visits during the 13-month study period included a near-miss incident. This analysis suggests computerized trigger tools can be useful to identify near misses that otherwise go unreported.

Effective nurse managers support a culture of safety and improved patient outcomes. This study explores strategies implemented by meso-level nurse leaders - nurse managers between executive leadership and direct care nurses – to enable a culture of safety in perioperative settings. Four strategies were identified: (a) recognizing the unique perioperative management environment, (b) learning not to take interactions personally, (c) developing "super meso-level nurse leader" skills, and (d) appealing to policies and patient safety.

Patient engagement is cornerstone to safe care initiatives. This qualitative study including 28 acute care patients explored how patients contribute to safety and highlight the importance of reassurance and vigilance.

The COVID-19 pandemic dramatically changed healthcare delivery and impacted the ways healthcare teams function. Using interprofessional focus groups, this study explored the perspectives of medical intensive care unit (MICU) team members on the role of TeamSTEPPS® during the first year of the COVID-19 pandemic. Participants discussed how TeamSTEPPS® impacted teamwork and communication through shared mental models, trust, role definition, and effective briefing/debriefing and transitions of care strategies. Participants also identified several challenges to TeamSTEPPS® implementation related to the MICU environment, the ongoing pandemic, power dynamics, and patient acuity.

Emergency room crowding is a persistent factor that degrades safety for patients of all ages. This collection provides background, best practices, and recommendations to reduce emergency department crowding and its negative impact on pediatric care. The publications examine factors that influence crowding and improvement at the input, departmental, and hospital/outpatient stages of emergency care.

Surgical fires, while rare, can result in the injury, permanent disability, or death of patients or healthcare workers. Between 2000 and 2020, 565 surgical fires resulting in injury were reported to the FDA’s Manufacturer and User Facility Device Experience (MAUDE) database. Fires were most likely to occur during upper aerodigestive tract and head and neck surgeries; these were also most likely to result in life-threatening injury.

Trust between patients and providers is essential to safe, effective healthcare. This survey of German patients undergoing implant surgeries (e.g., hip and knee replacements, dental implants, cochlear implants) found that adverse events negatively impact patient trust in their physicians, but effective patient-provider communication can mitigate the impacts.

High-risk opioid prescribing can increase the risk of abuse and overdose. This study evaluated the impact of four opioid prescribing policies for opioid-naïve patients – nonopioid medications during surgery, decreased opioid doses in operating rooms, standardized electronic health record alerts, and limits on postoperative opioid supply – implemented by one opioid stewardship program in a large US healthcare system between 2016 and 2018. Post-implementation, researchers observed decreases in postoperative opioid prescription doses, fewer opioid prescription refills, and less patient-reported discharge pain.

Research has identified variations in treatment that are unlikely to be related to patient characteristics, such as region. In this study, surgeons describe their preferences for and experiences with a device which caused widespread harm to women and was ultimately recalled by several patient safety agencies: transvaginal mesh for the treatment of pelvic floor devices in women. Even when surgeons arrived at the same decision (to perform surgery or not), wide variations were observed during the decision-making process.

Pharmacists are increasingly involved in the emergency department (ED) medication process. This review summarizes the characteristics and impacts of interventions. The most common type of intervention is medication review/reconciliation and/or identification and resolution of medication errors. Interventions including pharmacist co-prescribing or co-charting in the ED resulted in the largest reduction in medication errors.

The World Health Organization’s Surgical Safety Checklist has been used in populations around the globe to reduce surgical complications and improve operating room teamwork. This mixed methods study involved nearly 150 surgical nurses in Turkey. Nurses reported inconsistent use of the checklist, described barriers to its use, and offered suggestions to increase compliance with completion.