The PSNet Collection

Leading causes of anesthesia-related liability claims in ambulatory surgery centers.

Ranum D, Beverly A, Shapiro FE, et al. J Patient Saf. 2021;17(7):513-521.

This analysis of medical malpractice claims identified four leading causes of anesthesia-related claims involving ambulatory surgery centers – dental injuries, pain, nerve damage, and death. The authors discuss the role of preoperative risk assessment, use of routine dental and airway assessment, adequate treatment of perioperative pain, and improving communication between patients and providers.

Dual surgeon operating to improve patient safety.

Ellis R, Hardie JA, Summerton DJ, et al. Surg. 2021;59(7):752-756.

Many non-urgent, non-cancer surgeries were postponed or canceled during COVID-19 surges resulting in a potential loss of surgeons’ “currency”. This commentary discusses the benefits of, and barriers to, dual surgeon operating as a way to increase currency as elective surgeries are resumed.

Simulation-based assessment identifies longitudinal changes in cognitive skills in an anesthesiology residency training program.

Sidi A, Gravenstein N, Vasilopoulos T, et al. J Patient Saf. 2021;17(6):e490-e496.

Nontechnical skills, such as teamwork and communication, can influence performance in technical fields like surgery or emergency medicine. This study found that simulation-based assessments can measure improvements in nontechnical skills and cognitive performance among residents.

Agency information collection activities: Ambulatory Surgery Center Survey on Patient Safety Culture Database; comment request.

Agency for Healthcare Quality and Research. Fed Register. August 31, 2021;86:48703-48705.

This announcement calls for public comment on the intention of the Agency for Healthcare Research and Quality to launch the Ambulatory Surgery Center Survey on Patient Safety Culture Database data collection process. The comment period closes September 30, 2021.

The successful anesthesia patient safety officer.

Cohen JB, Patel SY. Anesth Analg. 2021;133(3):816-820.

Designated safety leadership roles are situated to direct and sustain organizational safety progress. This commentary describes an anesthesiology safety officer function and how it is positioned to motivate staff safety behaviors and support engagement during project challenges.

Quality and safety in surgery: challenges and opportunities.

Nasca BJ, Bilimoria KY, Yang AD. Jt Comm J Qual Patient Saf. 2021;47(9):604-607.

Surgical safety has made advances while new difficulties continuously emerge. This article suggests that the specialties capitalize on artificial intelligence and professional wellness as two avenues to generate sustainable safety progress.

Communication failures contributing to patient injury in anaesthesia malpractice claims.

Douglas RN, Stephens LS, Posner KL, et al. Br J Anaesth. 2021;127(3):470-478.

Effective communication among providers helps ensure patient safety. Through analysis of perioperative malpractice claims using the Anesthesia Closed Claims Project database, researchers found that communication failures contributed to 43% of total claims, with the majority between the anesthesiologist/anesthesia team and the surgeon/surgery team. Methods to improve perioperative communication are discussed.

Prevalence and characteristics of interruptions and distractions during surgical counts.

Bubric KA, Biesbroek SL, Laberge JC, et al. Jt Comm J Qual Patient Saf. 2021;47(9):556-562.

Unintentionally retained foreign objects (RFO) following surgery is a never event. In this study, researchers observed 36 surgical procedures to quantify and describe interruptions and distractions present during surgical counting. Interruptions (e.g., the surgeon or another nurse talking to the scrub nurse) and distractions (e.g., music, background noise) were common. Several suggestions to minimize interruptions and distractions during surgical counts are made.

Local Anesthesia-Induced Coma During Total Knee Arthroplasty.

July 28, 2021

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.

The July Effect in podiatric medicine and surgery residency.

Casciato DJ, Thompson J, Law R, et al. J Foot Ankle Surg. 2021;Epub Jun 4.

The "July Effect" refers to the idea there may be an increase in medical errors in July when newly graduated medical students begin their residencies. In this retrospective chart review of podiatric surgery patients, researchers did not find any statistically significant difference in patient outcomes between surgeries performed during the first quarter of residency (July-September) and the last quarter (April-June). Results suggest robust resident training programs can limit errors that may otherwise occur during this time of transition.

Inadequate Anesthesia Preparation Leading to Difficult Intubation and Severe Hypoxemia

June 30, 2021

A 34-year-old morbidly obese man was placed under general anesthesia to treat a pilonidal abscess. Upon initial evaluation by an anesthesiologist, he was found to have a short thick neck, suggesting that endotracheal intubation might be difficult. A fellow anesthetist suggested use of video-laryngoscopy equipment, but the attending anesthesiologist rejected the suggestion. A first-year resident attempted to intubate the patient but failed.

Safety and Quality in Perioperative Anaesthesia Care.

Preckel B, ed. Best Pract Res Clin Anaesthesiol. 2021;35(1):1-154.

Surgical patients are at high risk for harm, should errors occur. This special issue covers areas of concern in perioperative anesthesia care that include patient allergies, age, sex and gender considerations, and incident reporting system effectiveness.

Wrong Site Surgery - Wrong Patient: Invasive Procedures in Outpatient Settings.

Farnborough, UK: Healthcare Safety Investigation Branch; June 3, 2021.

Wrong site/wrong patent surgery is a persistent healthcare never event. This report examines National Health Service (NHS) reporting data to identify how ambulatory patient identification errors contribute to wrong patient care. The authors recommend that the NHS use human factors methods to design control processes to target and manage the risks in the outpatient environment such as lack of technology integration, shared waiting area space, and reliance on verbal communication at clinic.

ISMP Medication Safety Self Assessment® for Perioperative Settings.

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. The deadline for submitting data is December 10, 2021.

2020 Pennsylvania Patient Safety Reporting: an analysis of serious events and incidents from the nation’s largest event reporting database.

Kepner S, Jones RM. Patient Safety. 2021;3(2):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.

Are operating room distractions, interruptions, and disruptions associated with performance and patient safety? A systematic review and meta-analysis.

Mcmullan RD, Urwin R, Gates PJ, et al. Int J Qual Health Care. 2021;33(2):mzab068.

Distractions in the operating room are common and can lead to errors. This systematic review including 27 studies found that distractions, interruptions, and disruptions in the operating room are associated with a range of negative outcomes. These include longer operative duration, impaired team performance, self-reported errors by colleagues, surgical errors, surgical site infections, and fewer patient safety checks.

Time out! Rethinking surgical safety: more than just a checklist.

Weinger MB. BMJ Qual Saf. 2021;Epub Mar 25.

Checklists are widely used strategies for error reduction and improved communication. This editorial discusses the limitations of checklists for perioperative safety (i.e., when used in isolation or implemented incorrectly) and suggests that safety initiatives taking a systems-oriented approach and organizational buy-in can lead to both perioperative and general safety improvements.

Identification of common themes from never events data published by NHS England.

Omar I, Graham Y, Singhal R, et al. World J Surg. 2021;45(3):697-704.

Never events can result in serious patient harm and indicate serious underlying organizational safety problems. This study analyzed never events occurring between 2012 and 2020 in the National Health Services and categorized 51 common never events into four categories – wrong site surgery (40% of events); retained foreign objects post-procedure (28%); wrong implant/prosthesis (13%); and non-surgical/infrequent never events (19%). Awareness of these themes may support focused efforts to reduce their incidence and development of specific local safety standards.

Common general surgical never events: analysis of NHS England never event data.

Omar I, Singhal R, Wilson M, et al. Int J Qual Health Care. 2021;33(1):mzab045.

Never events, a significant type of adverse event, should never occur in healthcare. This study analyzed 797 surgical never events that occurred from April 2012 to February 2020 in the National Health Service (NHS) England and categorized them into three main categories: wrong-site surgery (53.58%), retained items post-procedure (44.54%), and wrong implant/prosthesis (1.88%). In total 56 common general surgery never events have been found. Being aware of the common themes may help providers to develop more effective strategies to prevent these adverse events.

Sex and gender differences in anesthesia: relevant also for perioperative safety?

Filipescu D, Ştefan M. Best Pract Res Clin Anaesthesiol. 2021;35(1):141-153.

Transgender people are especially vulnerable in healthcare settings. Anesthesiologists are in a critical position to improve transgender patient outcomes by being aware of sex-related differences in physiology, pharmacokinetics, and pharmacodynamics. In addition to research characterizing outcomes of surgery between men and women, future research should address the role of women anesthesiologists in improving patient safety.

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