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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.
Abdelmalak BB, Adhami T, Simmons W, et al. Anesth Analg. 2022;135:198-208.
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.
Zheng MY, Lui H, Patino G, et al. J Patient Saf. 2022;18:e401-e406.
California law requires adverse events that led to serious injury or death because of hospital noncompliance to be reported to the state licensing agency. These events are referred to as “immediate jeopardy.” Using publicly available data, this study analyzed all immediate jeopardy cases between 2007 and 2017. Of the 385 immediate jeopardy cases, 36.6% led to patient death, and the most common category was surgical.
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.

Institute for Safe Medication Practices

The perioperative setting is a high-risk area for medication errors, should they occur. This assessment provides hospitals and outpatient surgical providers a tool to examine their medication use processes and share data nationwide for comparison. Organizational participation can identify strengths and gaps in their systems to design opportunities that prevent patient harm. 
De Cassai A, Negro S, Geraldini F, et al. PLoS One. 2021;16:e0257508.
Inattentional blindness occurs when individuals miss an unexpected event due to competing attentional tasks.  This study asked anesthesiologists to review the anesthetic management of five simulated cases, one of which included the image of a gorilla in the radiograph, to evaluate inattentional blindness. Only 4.9% of social media respondents reported an abnormality, suggesting that inattentional blindness may be common; the authors suggest several strategies to reduce this error.

Bekes JL, Sackash CR, Voss AL, et al. AANA J. 2021;89(4):319-324.

Pediatric medication errors during anesthesia can lead to significant harm and are largely preventable. This review identifies several themes around medication errors including dosing and incorrect medication. Successful error reduction strategies, such as standardized labeling and pre-filled syringes, are also described.
Leeftink AG, Visser J, de Laat JM, et al. Ergonomics. 2021:1-11.
Failure mode and effect analysis (FMEA) is widely used to identify latent safety hazards. The authors of this study proposed combining healthcare failure mode and effect analysis (HFMEA) with computer simulation (HFMEA-CS) for prospective risk analysis of complex and potentially harmful processes. Use of HFMEA-CS to analyze medication processes during admission and discharge for patients with a rare adrenal tumor led to a reduction in drug delivery and system errors, as well as increased drug adherence.
Urman RD, Seger DL, Fiskio JM, et al. J Patient Saf. 2021;17:e76-e83.
Harm from opioids is a widely recognized patient safety issue, and potential harm associated with short-term use is a growing area of concern. This analysis of a previously opioid-free surgical population identified a high rate of potential opioid-related adverse drug events (ORADEs); risk was strongly associated with route and duration of post-operative opioid administration. The presence of an ORADE was associated with longer postoperative length of stay, higher hospitalization costs, lower odds of discharge home, and higher odds of death.
Haché M, Sun LS, Gadi G, et al. Paediatr Anaesth. 2020;30:1348-1354.
The Wake Up Safe initiative includes a registry of serious adverse events occurring in pediatric anesthesia. This study analyzed events reported between 2010 and 2015. The most common anesthesia-related events were medication events, respiratory complications, and cardiac events. Approximately 85% of these events were considered to be preventable.  

Ruskin KJ, ed. Curr Opin Anaesthesiol.  2020;33(6):774-822.

The complexity of care delivery requires complementary approaches to prevent mistakes. This special section shares clinical and organizational tactics to address anesthesiology safety issues. They include automation failures, the role of the obstetric anesthesiologist in maternal safety, and monitoring effectiveness. 
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.
Duffy CC, Bass GA, Duncan JR, et al. J Patient Saf. 2022;18:16-25.
Incident reporting systems are central to most patient safety programs, but studies have identified barriers to effective use. This study used clinical vignettes describing a medication error or near miss to explore error awareness and attitudes towards reporting and disclosure among anesthesiologists. Approximately one-third of anesthesiologists recalled having had medication safety training. Perioperative medication error awareness and assessment of potential harm were variable, and the likelihood of patient disclosure and incident reporting was low. Education programs utilizing vignettes should be utilized to raise awareness about error reporting and disclosure behaviors.  

Halamek LP, ed. Semin Perinatol. 2019;43(8):151172-151182.
 

The neonatal intensive care unit (NICU) is a complex environment that serves a vulnerable population at increased risk for harm should errors occur. This special issue draws from a multidisciplinary set of authors to explore patient safety issues arising in the NICU. Included in the issue are articles examining topic such as video assessment, diagnostic error, and human factors engineering in the NICU.
Litman RS. J Patient Saf Risk Manag. 2019;24:158-165.
This commentary explores how gaps in legal and regulatory structure affect anesthesia medication safety. The author advocates for use of a public health law framework to prevent certain types of perioperative medication errors made by anesthesiologists. Policy approaches that require organizations to provide prefilled syringes and barcoding scanners are suggested to avoid vial- and syringe-related mistakes.
Williams GD, Muffly MK, Mendoza JM, et al. Anesth Analg. 2017;125:1515-1523.
Underreporting of adverse events is a known shortcoming of incident reporting systems. This pre–post study demonstrated an increase in reporting of perioperative adverse events through a multifaceted intervention that included interviewing clinicians about barriers to reporting and creating a local requirement to complete adverse event reports using an electronic incident reporting system. The study team concluded that mandated reporting addresses underuse of incident reporting systems.
Group S and P in LS. Br J Surg. 2015;102:1204-12.
This controlled study evaluated the effect of a protocolled pharmacist intervention—which included medication reconciliation and regular medication review—on medication errors in elective surgery patients. There was no difference in the incidence of adverse drug events compared to patients receiving usual care.
Vadera S, Griffith SD, Rosenbaum BP, et al. J Surg Educ. 2015;72:1209-16.
This pre-post study examines the effects of the 2003 ACGME duty hours reform on medication errors among hospitalized surgical patients. The authors hypothesized that the increase in handoffs and a changing attitude toward work—also referred to as a shift-work mentality—might lead to an increase in medication errors. Using the Nationwide Inpatient Sample, a representative sample of hospitalizations maintained by AHRQ's Healthcare Cost and Utilization Project, investigators compared medication error rates for surgical patients between 2000–2003 versus 2003–2011, accounting for trends over time and patient and hospital level covariates. Error rates for teaching hospitals were higher than expected based on patient and hospital characteristics, leading the researchers to conclude that duty hour reform increased medication errors. The magnitude of the effect was modest, and only reached statistical significance for 2 of the 8 years they examined. The effects of duty hours on safety remain controversial, without a clear consensus.
Tscholl DW, Weiss M, Kolbe M, et al. Anesth Analg. 2015;121:948-956.
This pre-post study demonstrated increases in teamwork after introduction of an anesthesia checklist. Although evidence for checklists in real-world settings is mixed, this work demonstrates their efficacy as part of an intervention study, which is consistent with prior work.