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Farnborough, UK; Healthcare Safety Investigation Branch; May 26, 2022.

Surgical equipment sterilization can be hampered by equipment design, production pressures, process complexity and policy misalignment. This report examines a case of unclean surgical instrument use. It recommends external sterile service assessment and competency review as steps toward improving the reliability of instrument decontamination processes in the National Health Service.
Pennsylvania Patient Safety Authority. Harrisburg, PA: Patient Safety Authority; April 2022.
This report summarizes patient safety improvement work in the state of Pennsylvania and reviews the 2021 activities of the Patient Safety Authority, including the Agency's response to the COVID-19 pandemic, video programs, liaison efforts, publication programs, and the launch of a new learning management system.
Gillespie BM, Harbeck EL, Rattray M, et al. Int J Surg. 2021;95:106136.
Surgical site infections (SSI) are a common, yet largely preventable, complication of surgery which can result in increased length of stay and hospital readmission. In this review of 57 studies, the cumulative incidence of SSI was 11% in adult general surgical patients and was associated with increased length of stay (with variation by types of surgery).

A 61-year-old male was admitted for a right total knee replacement under regional anesthesia. The surgeon – unaware that the anesthesiologist had already performed a right femoral nerve block with 20 ml (100mg) of 0.5% racemic bupivacaine for postoperative analgesia – also infiltrated the arthroplasty wound with 200 mg of ropivacaine. The patient was sedated with an infusion of propofol throughout the procedure.

Kepner S, Jones RM. Patient Safety. 2021;3:6-21.
Acute healthcare facilities in Pennsylvania are required to report all events of harm or potential harm to the Pennsylvania Patient Safety Reporting System (PA-PSRS). Of all submitted events in 2020, 97% were from hospitals, and 97% were incidents; 3 percent were serious events. The most common event was Error Related to Procedure/Treatment/Test (32%). There was a 5.3% decrease from the prior year in the number of reported events, indicating the COVID-19 pandemic had an impact on reporting activity.
Roberts SCM, Beam N, Liu G, et al. J Patient Saf. 2020;16:e317-e323.
The increase in maternal morbidity and mortality is a priority patient safety issue. This study compared miscarriage treatment-related morbidity and adverse events among hospitals, ambulatory surgery centers (ASCs), and office-based settings. Although there were slightly more events in hospitals than ASCs or office-based settings, study findings do not support limiting miscarriage treatment to a particular setting.
Braun BI, Chitavi SO, Perkins KM, et al. Jt Comm J Qual Patient Saf. 2020;46:531-541.
In this retrospective review of ambulatory care infection prevention and control (IPC) breaches reported to state health departments, the authors observed 5% rate of breaches and found that common breaches involved sterilization and disinfection of reusable devices, device reprocessing, and IPC infrastructure. These and other breaches highlight opportunities for additional training, leadership oversight, and resource investment.
Sweet W, Snyder D, Raymond M. J Healthc Risk Manage. 2020.
This article describes one health system’s experience implementing an infection prevention program into risk management in an outpatient setting. Over a two-year period post-implementation, the system identified and corrected high-risk practices, increased compliance to device guidance, increased efficiency with the use of central sterile processing departments, and developed a staff competency training structure.
Young S, Shapiro FE, Urman RD. Curr Opin Anaesthesiol. 2018;31:707-712.
Office-based surgery is increasingly common, despite concerns regarding its safety. This review summarizes the literature on ambulatory surgery outcomes and identified risk factors such as case complexity, patient comorbidities, and anesthesia use. Few studies examined anesthesia use in dental care.
Schaefer MK, Jhung M, Dahl M, et al. JAMA. 2010;303:2273-9.
This study discovered that nearly 70% of ambulatory surgical centers had at least one lapse in infection control. The most common lapses involved using a single-dose medication vial for more than one patient and failure to adhere to recommended practices for equipment handling.
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 2020 report summarizes information about 366 adverse events that were reported, representing a slight increase each year since the reports were first published. Pressure ulcers and fall-related injuries were the most common incidents documented. Reports from previous years are available.