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Otolaryngol Head Neck Surg. 2018-2022.

Otolaryngology-head and neck surgery is vulnerable to wrong site errors and other challenges present in surgical care. This series of articles highlights key areas of importance for the specialty as they work to enhance patient safety. The latest 2022 installment covers psychological safety.
Wylie JA, Kong L, Barth RJ. Ann Surg. 2022;276:e192-e198.
“Opioid never event” (ONE) is a proposed classification to describe dependence or overdose among opioid-naïve patients prescribed opioids at hospital discharge. Based on a retrospective review of medical records of patients at one academic medical center, researchers estimated that the ONE affected approximately 2 per 1,000 opioid-naïve surgical patients and persistent opioid use 90 to 360 days after surgery was present in 45% of patients with ONEs.
Stenquist DS, Yeung CM, Szapary HJ, et al. J Am Acad Orthop Surg Glob Res Rev. 2022;6:e22.00079.
The I-PASS structured handoff tool has been widely implemented to improve communication during handoffs and patient transfers. In this study, researchers modified the I-PASS tool for use in orthopedic surgery and assessed the impact on adverse clinical outcomes. After 18 months, there was sustained adherence to the tool and the quality of handoffs improved, but no notable changes in clinical outcomes were identified.

Farnborough, UK: Healthcare Safety Investigation Branch; 2022. HSIB Report no. NI-005831

This report summarizes the work of an independent office that examines maternity care safety lapses in the United Kingdom. It discusses the number of investigations done, criteria for investigation selection and primary improvement themes drawn from the review of 706 investigations in the period covered which include clinical assessment and oversight, care escalation, and fetal monitoring. The report outlines the goal to establish a maternity review effort as an independent entity in 2023.
Ghaith S, Campbell RL, Pollock JR, et al. Healthcare (Basel). 2022;10:1328.
Obstetric and gynecologic (OB/GYN) physicians are frequently involved in malpractice lawsuits, some of which result in catastrophic payouts. This study categorized malpractice claims involving OB/GYN trainees (students, residents, and fellows) between 1986 and 2020. Cases are categorized by type of injury, patient outcome, category of error, outcome of lawsuit, and amount of settlement.
Burfeind KG, Zarnegarnia Y, Tekkali P, et al. Anesth Analg. 2022;Epub Aug 19.
The American Geriatrics Society (AGS) Beers Criteria serves as a guideline for prescribers to avoid potentially inappropriate medications (PIM) in geriatric patients (age 65 years and older). In this retrospective cohort study, nearly 70% of geriatric patients undergoing elective surgery received at least one PIM identified by the Beers Criteria. Patients, including cognitively impaired and frail patients, who received at least one PIM, had longer length of hospital stay after surgery.
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.
Baimas-George M, Ross SW, Hetherington T, et al. J Trauma Acute Care Surg. 2022;93:409-417.
Emergency surgery carries an increased risk of death compared to elective surgery. This study used a regional electronic health record (EHR) to examine clinical risk factors associated with mortality in emergency general surgery. Risk factors for both inpatient and 1-year mortality included older age, underweight, neutropenia, and elevated lactate.
van Dalen ASHM, Jung JJ, Nieveen van Dijkum EJM, et al. J Patient Saf. 2022;18:617-623.
Leveraging lessons learned in aviation, patient safety researchers have begun exploring the use of medical data recorders (i.e., “black boxes”) to identify errors and threats to patient safety. This cross-sectional study found that a medical data recorder identified an average of 53 safety threats or resilience support events among 35 standard laparoscopic procedures. These events primarily involved communication failures, poor teamwork, and situational awareness failures.
Prieto JM, Falcone B, Greenberg P, et al. J Surg Res. 2022;279:84-88.
Hospitalized children are vulnerable to patient safety risks. Using a large malpractice claims database, researchers found that a wide range of pediatric surgical specialties – including orthopedics, general surgery, and otolaryngology – are most frequently associated with malpractice lawsuits. The study identified several potentially modifiable factors (i.e., patient evaluations, technical performance, and communication) that can lead to improvements in pediatric surgical safety.

Plymouth Meeting, PA: Institute for Safe Medication Practices; 2022.

Medication errors associated with surgery and other invasive procedures can result in patient harm. This 10-element guidance suggests effective practices to address identified weaknesses in perioperative and procedural medication processes. Recommendations provided cover topics such as drug labeling, communication, and risk management.
Keil O, Brunsmann K, Boethig D, et al. Paediatr Anaesth. 2022;32:1144-1150.
Harm from pediatric anesthesia-related errors is infrequent, but largely preventable. This pediatric hospital developed and implemented an anesthesia-specific checklist to be used before anesthesia induction. This study presents the types of errors identified by the checklist over the course of one year.
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.

US Senate Finance Committee. 117th Cong (2021-2022). August 3, 2022.

Organ transplantation processes require reliable communication and technical expertise to ensure safety for organ delivery and patient care. This hearing discussed the findings of a United States Senate investigation into waste and harm in the US organ transplant system. Blood-type mistakes, transport failures, and process challenges were amongst the problems discussed.
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.
Uffman JC, Kim SS, Quan LN, et al. Pediatr Qual Saf. 2022;7:e574.
Pediatric patients are highly vulnerable to patient safety events in the hospital. This retrospective study of infants less than 6 months of age admitted for ambulatory surgery found that the recommended 2-hour postoperative monitoring did not affect patient safety.   
St Paul, MN: Minnesota Department of Health.
The National Quality Forum has defined 29 never events—patient safety problems that should never occur, such as wrong-site surgery and patient falls. Since 2003, Minnesota hospitals have been required to report such incidents. The 2021 report summarizes information about 508 adverse events that were reported, representing a significant increase in the year covered. Earlier reports document a fairly consistent count of adverse events. The rise reflected here is likely due to demands on staffing and care processes associated with COVID-19. Pressure ulcers and fall-related injuries were the most common incidents documented. Reports from previous years are available.
Burns ML, Saager L, Cassidy RB, et al. JAMA Surg. 2022;157:807-815.
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.
Weston M, Chiodo C. AORN J. 2022;115:569-575.
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.