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Zhang D, Gu D, Rao C, et al. BMJ Qual Saf. 2022;Epub Jun 1.
Clinician workload has been linked with poor patient outcomes. This retrospective cohort study assessed the outcomes for patients undergoing coronary artery bypass graft (CABG) performed as a surgeons’ first versus non-first procedure of the day. Findings suggest that prior workload adversely affected outcomes for patients undergoing CABG surgery, with increases in adverse events, myocardial infarction, and stroke compared to first procedures.
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.
Nanji K. UpToDate. June 23, 2022.
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.
Devarajan V, Nadeau NL, Creedon JK, et al. Pediatrics. 2022;149:e2020014696.
Several factors contribute to the increased risk of prescribing errors for children, including weight-based dosing and drug formulation. This quality improvement project in one pediatric emergency department identified four key drivers and implemented four interventions to reduce errors. Prescribing errors were reduced across three plan-do-study-act cycles, and improvements were maintained six months after the final cycle.
Powell ES, Bond WF, Barker LT, et al. J Patient Saf. 2022;18:302-309.
Telehealth is increasingly used to connect rural hospitals with specialists in other areas and can improve patient outcomes. This study found that in situ simulation training in rural emergency departments resulted in small increases in the use of telemedicine for patients presenting with sepsis and led to improvements in sepsis process care outcomes.
Wooldridge AR, Carayon P, Hoonakker PLT, et al. Hum Factors. 2022;Epub Jun 5.
Handoffs between inpatient care settings represent a vulnerable time for patients. This qualitative study explores how team cognition occurs during care transitions and interprofessional handoffs between inpatient settings and the influence of sociotechnical systems, such as communication workflows or electronic heath record-based interfaces) influence team cognition. Participants highlighted how interprofessional handoffs can both enhance (e.g., information exchange) and hinder (e.g., logistic challenges and imprecise communication) team cognition.
Abdelmalak BB, Adhami T, Simmons W, et al. Anesth Analg. 2022;Epub May 12.
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;Epub May 9.
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.
Serou N, Slight RD, Husband AK, et al. J Patient Saf. 2022;18:358-364.
Operating rooms are high-risk healthcare settings. This study reviewed serious surgical incidents occurring at large teaching hospitals in one National Health Service (NHS) trust. The authors outline several possible contributing factors (i.e., equipment and resource factors, team factors, work environment factors, and organizational and management factors) discuss recommendations for safer care.
Bentley SK, Meshel A, Boehm L, et al. Adv Simul (Lond). 2022;7:15.
In situ simulations are an effective method to identify latent safety threats (LST). Seventy-four in situ cardiac arrest simulations were conducted in one hospital, identifying 106 unique LSTs. Four LSTs were deemed imminent safety threats and were immediately resolved following debrief; another 15 were prioritized as high-risk.
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;Epub May 23.
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.
Ramani S, Halpern TA, Akerman M, et al. Am J Obstet Gynecol. 2022;226:556.e1-556.e9.
Cesarean delivery can lead to adverse outcomes and is commonly used as a measure of obstetrical quality; however, these measures do not account for preexisting maternal and neonatal morbidities, which may increase risk for cesarean delivery. This article describes the development and testing of a new obstetrical quality measure that integrates cesarean delivery rates adjusted for preexisting high-risk maternal factors as well as maternal and neonatal morbidities. Among obstetricians in one large hospital, researchers found that this metric led to significantly different clinician rankings in terms of obstetrical quality (compared to rankings based on crude or adjusted cesarean delivery rates alone.) The authors suggest that this new metric can help identify opportunities for practice improvement among individual clinicians and institutions.
Aranaz-Ostáriz V, Gea-Velázquez De Castro MT, López-Rodríguez-Arias F, et al. Int J Environ Res Public Health. 2022;19:4761.
Preventable adverse events (AE) can occur across medical settings. This study of patients admitted to a surgical ward in Spain compared rates of AE in operated and non-operated patients. Operated patients were more than twice as likely to experience an AE compared with non-operated patients. The most common AE was infection following surgery, affecting 24% of operated and 9% of non-operated patients.
Estiri H, Strasser ZH, Rashidian S, et al. J Am Med Inform Assoc. 2022;Epub May 2.
While artificial intelligence (AI) in healthcare may potentially improve some areas of patient care, its overall safety depends, in part, on the algorithms used to train it. One hospital developed four AI models at the start of the COVID-19 pandemic to predict risks such as hospitalization or ICU admission. Researchers found inconsistent instances of model-level bias and recommend a holistic approach to search for unrecognized bias in health AI.
Lazzara EH, Simonson RJ, Gisick LM, et al. Ergonomics. 2022;Epub Apr 19.
Structured handoffs support appropriate communication between teams or departments when transferring responsibility for care. This meta-analysis aimed to determine if structured, standardized post-operative anesthesia handoffs improved provider, patient, organizational and handoff outcomes. Postoperative outcomes moved in a generally positive direction when compared with non-standardized handoffs. The authors suggest additional research into pre- and intra-operative handoffs is needed.
Massart N, Mansour A, Ross JT, et al. J Thorac Cardiovasc Surg. 2022;163:2131-2140.e3.
Surgical site infections and other postoperative healthcare-acquired infections (HAIs) can lead to significant patient morbidity and mortality. This retrospective study examined the relationship between HAIs after cardiac surgery and postoperative inpatient mortality. Among 8,853 patients undergoing cardiac surgery in one academic hospital in France, 4.2% developed an HAI after surgery. When patients developing an HAI were matched with patients who did not, the inpatient mortality rate was significantly greater among patients with HAIs (15.4% vs. 5.7%).

Ehrenwerth J. UptoDate. May 25, 2022.

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.
Paterson EP, Manning KB, Schmidt MD, et al. J Emerg Nurs. 2022;48:319-327.
Automated dispensing cabinets (ADCs) can reduce medication dispensing errors by requiring pharmacist verification. This study found that medication overrides (i.e., bypassing pharmacist review before administration) in one pediatric emergency department were frequently not due to an emergent situation requiring immediate medication administration and could have been avoided.
Baartmans MC, Hooftman J, Zwaan L, et al. J Patient Saf. 2022;Epub Apr 21.
Understanding human causes of diagnostic errors can lead to more specific targeted, specific recommendations and interventions. Using three classification instruments, researchers examined a series of serious adverse events related to diagnostic errors in the emergency department. Most of the human errors were based on intended actions and could be classified as mistakes or violations. Errors were more frequently made during the assessment and testing phases of the diagnostic process.