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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.
Chopra V, O'Malley M, Horowitz J, et al. BMJ Qual Saf. 2022;31:23-30.
Peripherally inserted central catheters (PICC) represent a key source of preventable harm. Using the Michigan Appropriateness Guide for Intravenous Catheters (MAGIC), the authors sought to determine if the appropriateness of PICC use decreased related medical complications including catheter occlusion, venous thromboembolism, and central line-associated bloodstream infections. Use of MAGIC in 52 Michigan hospitals increased appropriate use of PICC lines and decreased medical complications. In a 2019 PSNet Perspective, Dr. Vineet Chopra described the development and implementation of MAGIC in Michigan hospitals.  
Arditi L. Peoples Public Radio. December 3, 2019.
Emergency medical services are often provided under chaotic circumstances that may contribute to failure. This story highlights a series of esophageal intubation errors and efforts to minimize this “never event” across the state of Rhode Island. Improvement strategies discussed include practice restrictions for EMT personnel and use of less invasive, less risky processes to provide oxygen as an alternative to intubation, which may reduce esophageal intubation errors
Chang BH, Hsu Y-J, Rosen MA, et al. Am J Med Qual. 2020;35:37-45.
Preventing health care–associated infections remains a patient safety priority. This multisite study compared rates of central line–associated bloodstream infections, surgical site infections, and ventilator-associated pneumonia before and after implementation of a multifaceted intervention. Investigators adopted the comprehensive unit-based safety program, which emphasizes safety culture and includes staff education, identification of safety risks, leadership engagement, and team training. Central line–associated bloodstream infections and surgical site infections initially declined, but rates returned to baseline in the third year. They were unable to measure differences in ventilator-associated pneumonia rates due to a change in the definition. These results demonstrate the challenge of implementing and sustaining evidence-based safety practices in real-world clinical settings. A past PSNet interview discussed infection prevention and patient safety.
Sangarlangkarn A.
Rigid adherence to protocols may detract from safety when unexpected critical events occur that require deviation from the standard process. This commentary explores insights from a physician, both as a clinician and as a new mother, when health care staff failed to effectively consider patient concerns and knowledge in understanding and treating the cause of postlabor pain. The patient identified the cause and requested appropriate treatment, but nurses consulted protocols for pain after labor and only offered pain medications, which might have exacerbated the problem. The author calls for clinician autonomy to recognize when standardization is not appropriate and how to address individual patient needs.
A woman with multiple myeloma required placement of a central venous catheter for apheresis. The outpatient oncologist intended to order a nontunneled catheter via computerized provider order entry but accidentally ordered a tunneled catheter. The interventional radiologist thought the order was unusual but didn't contact the oncologist. A tunneled catheter was placed without complications. When the patient presented for apheresis, providers recognized the wrong catheter had been placed, and the patient underwent an additional procedure.
Gupta A, Jain S, Croft C. JAMA. 2019;321:504-505.
The authors present a case in which an unnecessary procedure was incorrectly performed on a patient who had opted to pursue hospice care. They highlight factors contributing to the error including those related to use of the electronic health record.
Park CS, Stojiljkovic L, Milicic B, et al. Simul Healthc. 2014;9:85-93.
This educational study found that anesthesiology residents were more likely to initiate an airway technique for which they had received simulation training, even if another technique (for which they received didactic training) would have been more appropriate. This finding demonstrates how training may inadvertently introduce cognitive bias.
While drawing labs on a woman admitted after a lung transplant, a nurse failed to clamp the patient's large-bore central line, allowing air to enter the catheter. The patient suffered a cerebral air embolism and was transferred to the ICU for several days.
A woman found unresponsive at home presented to the ED via ambulance. The cardiology team used the central line placed during resuscitation to deliver medications and fluids during pacemaker insertion. Hours later, a chest radiograph showed whiteout of the right lung, and clinicians realized that the tip of the line was actually within the lung.
While caring for a complex patient in the surgical intensive care unit, a nurse incorrectly set up the continuous renal replacement therapy (CRRT) machine, raising questions about how new nurses should be trained in high-risk procedures.
A man with end-stage renal disease on hemodialysis was dialyzed with equipment that had been inappropriately reused, exposing the patient to another patient's blood numerous times.

Teixeira PGR, Inaba K, Salim A, et al. Arch Surg. 2009;144(6):536-541.

Patient safety in trauma poses unique challenges given the acuity of the patients and the need for rapid assessment in delivering life-saving care. This study analyzed more than 2500 complications discussed at morbidity and mortality (M&M) conferences to characterize their preventability and clinical relevance. Investigators discovered that the complications ripe for quality improvement initiatives included unintended extubations, surgical technical failures, missed injuries, and intravascular catheter-related complications. An invited critique [see link below] reflects on the study's findings and points out the challenges in reporting performance data without needed standardization. A past AHRQ WebM&M commentary discussed the systematic assessment of trauma patients in the context of a missed patient injury.
Snijders C, van Lingen RA, Klip H, et al. Arch Dis Child Fetal Neonatal Ed. 2009;94:F210-5.
Incident reporting systems are one mechanism for hospitals to both identify and potentially prevent adverse events, although they have frequently failed to meet those expectations. This study describes findings from a voluntary system that produced a significant increase in reported neonatal events, many of which were associated with patient morbidity.
Center for Devices and Radiological Health; CDER; Food and Drug Administration; FDA.
This website alerts clinicians and patients to risks for patient harm associated with implanted electronic medical devices, such as insulin infusion pump and pacemakers, when x-rays are used during CT examinations.

Gagnon L. Dermatology Times. June 1, 2005.

This article reports on inappropriate laser use by non-physicians for dermatological procedures. A study presented at the American Society for Laser Medicine and Surgery meeting found prevalent misuse of equipment and improper application.