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1 - 20 of 192

The APSF Committee on Technology. APSF Newsletter2022;37(1):7–8.

Variation across standards and processes can result in misunderstandings that disrupt care safety. This guidance applied expert consensus to examine existing anesthesia monitoring standards worldwide. Recommendations are provided for organizations and providers to guide anesthesia practice in a variety of environments to address patient safety issues including accidental patient awareness during surgery.
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.
Armstrong BA, Dutescu IA, Nemoy L, et al. BMJ Qual Saf. 2022;Epub Apr 7.
Despite widespread use of surgical safety checklists (SSC), its success in improving patient outcomes remains inconsistent, potentially due to variations in implementation and completion methods. This systematic review sought to identify how many studies describe the ways in which the SSC was implemented and completed, and the impact on provider outcomes, patient outcomes, and moderating factors. A clearer positive relationship was seen for provider outcomes (e.g., communication) than for patient outcomes (e.g., mortality).

A psychologically safe environment for healthcare teams is desirable for optimal team performance, team member well-being, and favorable patient safety outcomes. This piece explores facilitators of and barriers to psychological safety across healthcare settings. Future research directions examining psychological safety in healthcare are discussed.

Emond YEJJM, Calsbeek H, Peters YAS, et al. Br J Anaesth. 2022;128:562-573.
A necessary part of successful implementation of new guidelines is ensuring continued adherence. Nine Dutch hospitals implemented a multifaceted program (IMPlementatie Richtlijnen Operatieve VEiligheid [IMPROVE]) to support application of surgical guidelines. Results of guideline use were mixed.

Ryan M, Mekel M, Sinha MS. UptoDate. November 30, 2021

Error disclosure is fundamental to addressing harm and psychological distress after medical error. This review highlights issues associated with surgical error disclosure. It summarizes literature covering legal and ethical issues, honest apology, and skill development to ensure apology communications are effective.

This case involves a 2-year-old girl with acute myelogenous leukemia and thrombocytopenia (platelet count 26,000 per microliter) who underwent implantation of a central venous catheter with a subcutaneous port. The anesthetist asked the surgeon to order a platelet transfusion to increase the child’s platelet count to above 50,000 per microliter. In the post-anesthesia care unit, the patient’s arterial blood pressure started fluctuating and she developed cardiac arrest.

Ehrenwerth J. UptoDate. November 5, 2021.

Operating room fires are never events that, while rare, still harbor great potential for harm. This review discusses settings prone to surgical fire events, prevention strategies, and care management steps should patients be harmed by an operating room fire.
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. The deadline for submitting data is February 11, 2022.
Hammond Mobilio M, Paradis E, Moulton C-A. Am J Surg. 2021;Epub Nov 24.
Surgical safety checklists (SSC) have been adopted around the world, but reported compliance rates and use in practice vary widely. This study in one Canadian hospital showed the SSC was used in 82% of Briefings, 76% of Time-Outs, and 22% of Debriefings. Gaps between policy and practice were identified and implications for policy makers, administrators, frontline clinicians, and researchers are discussed.
Malahias M-A, Antoniadou T, Jang SJ, et al. J Am Acad Orthop Surg. 2021;29:e1387-e1395.
Previous research has raised concerns about safety risks associated with overlapping surgery, defined as two procedures performed concurrently, but where critical surgical portions of each procedure occur at different times. Based on a meta-analysis of six articles, the authors of this systematic review found that rates of surgical complications readmissions were similar among overlapping and nonoverlapping surgery in patients undergoing total joint arthroscopy.

Croke L. Guideline for prevention of unintentionally retained surgical items. AORN J. 2021;114(6):4-6. doi: 

Retained surgical items (RSI) are a never event, yet they continue to happen. This commentary summarizes recent changes to an existing guidance that defines a range of retained devices or products to coalesce with industry terminology. The author shares steps to reduce the potential for RSI retention. A related webinar will be held February 2, 2022.

Famolaro T, Hare R, Tapia A, Yount et al. Rockville, MD: Agency for Healthcare Research and Quality; December 2021. AHRQ Publication No. 22-0004.

Ambulatory surgery centers harbor unique characteristics that affect safety culture. This analysis from the Agency for Healthcare Research and Quality (AHRQ) shares results of 235 ambulatory surgery centers (ASCs) participating in the Surveys on Patient Safety Culture (SOPS) Ambulatory Surgery Center Survey. Most respondents (92%) rated their organization as committed to learning and continuous improvement.

A 52-year-old woman presented for a lumpectomy with lymphoscintigraphy and sentinel lymph node biopsy (SLNB) after being diagnosed with ductal carcinoma in situ (DICS). On the day of surgery, the patient was met in the pre-operative unit by several different providers (pre-operative nurse, resident physician, attending physician, and anethesiology team) to help prepare her for the procedure. In the OR, the surgical team performed two separate time-outs while the patient was being prepped, placed under general anesthesia, and draped.

Wallis CJD, Jerath A, Coburn N, et al. JAMA Surg. 2022;157:146-156.
Gender, racial, and ethnic disparities in healthcare can adversely impact patient safety and lead to poor outcomes. This retrospective study examined surgeon-patient sex discordance and perioperative outcomes among adult patients in Ontario, Canada, undergoing common elective or emergent surgical procedures from 2007 to 2019. Among 1.3 million patients, sex discordance between surgeon and patient was associated with a significant increased likelihood of adverse perioperative outcomes, including death. Subgroup analyses indicate that this relationship is driven by worse outcomes among female patients treated by male surgeons.
Brown B, Bermingham S, Vermeulen M, et al. BMJ Open Qual. 2021;10:e001593.
Despite evidence of the benefits of the World Health Organization’s surgical safety checklist, implementation and sustainability are inconsistent in many hospitals. Using five cycles of Plan-Do-Study-Act, a hospital in Adelaide, South Australia, was able to increase use of the checklist from 3.5% to 63%. Staff reported that they felt the new checklist process improved patient safety and was easily incorporated into their workflow.
Liu C, McKenzie A, Sutkin G. J Surg Edu. 2021;78:1938-1947.
Communication failures are a common cause of patient harm. This qualitative study found that potentially ambiguous language is common in surgical training settings. In addition to creating challenges for trainee comprehension of surgical instruction, ambiguous language can lead to miscommunications and near misses.