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Hofer IS, Cheng D, Grogan T. Anesth Analg. 2021;133(3):698-706.
Anesthesia-related adverse events have been associated with increased length of stay, morbidity and mortality. This study investigated the effect of missed documentation of select comorbidities on postoperative length of stay and mortality. Results indicate that missed documentation of one of the comorbid conditions increased risk of length of stay, and mortality was increased with missed atrial fibrillation.
Abraham J, Meng A, Sona C, et al. Int J Med Inform. 2021;151:104458.
Standardized handoff protocols from the operating room to the intensive care unit have improved patient safety, but clinician compliance and long-term sustainability remain poor. This study identified four phases of post-operative handoff associated with risk factors: pre-transfer preparation, transfer and set up, report preparation and delivery, and post-transfer care. The authors recommend “flexibly standardized” handoff intervention tools for safe transfer from operating room to intensive care.
Centers for Medicare & Medicaid Services.
The Centers for Medicare and Medicaid Services (CMS) provides consumers with publicly available information on the quality of Medicare-certified hospital care through this Web site. The site includes specific information for both patients and hospitals on how to use the data to guide decision-making and improvement initiatives. Most recently, listings from the Hospital-Acquired Condition Reduction Program (HACRP) and data on Department of Veterans Affairs hospitals were added to the reports available.
Urman RD, Seger DL, Fiskio JM, et al. J Patient Saf. 2021;17(2):e76-e83.
Harm from opioids is a widely recognized patient safety issue, and potential harm associated with short-term use is a growing area of concern. This analysis of a previously opioid-free surgical population identified a high rate of potential opioid-related adverse drug events (ORADEs); risk was strongly associated with route and duration of post-operative opioid administration. The presence of an ORADE was associated with longer postoperative length of stay, higher hospitalization costs, lower odds of discharge home, and higher odds of death.

Odor PM, Bampoe S, Lucas DN, et al the Pan-London Peri-operative Audit and Research Network (PLAN), for the DREAMY Investigators Group. Anaesthesia. Epub 2021 Jan 12.

Accidental patient awareness during anesthesia can result in significant patient distress and harm. This prospective cohort study, including 3,115 patients, identified high rates of accidental awareness during general anesthesia for obstetric surgery. In some patients, accidental awareness resulted in distressing experiences, paralysis, or a provisional diagnosis of post-traumatic stress disorder.
Chaudhry H, Nadeem S, Mundi R. Clin Orthop Relat Res. 2021;479(1):47-56.
The COVID-19 pandemic has dramatically increased the use of telehealth across various medical specialties.This systematic review did not identify any differences in patient or surgeon satisfaction or patient-reported outcomes with telehealth for orthopedic care delivery as compared to in-person visits.However, the authors note that the included studies did not adequately capture or report safety endpoints, such as complications or missed diagnoses.
Kannampallil T, Lew D, Pfeifer EE, et al. BMJ Qual Saf. 2021;30(9):755-763.
Prior research has found that intraoperative anesthesia handovers can increase patient morbidity and mortality. However, this retrospective cohort study, focused on pediatric surgical patients treated, found that intraoperative anesthesia handovers were not associated with adverse postoperative outcomes.  
Purnell S, Zheng F. Surg Clin North Am. 2020;101(1):109-119.
COVID-19 restrictions and patient concerns have expanded access to telemedicine worldwide. This review examines the use of telemedicine in surgical services. The authors found it to be a safe care modality for low-risk patients receiving low-risk procedures. They found that telemedicine in surgical services evidence base is expanding and its value is built on local, real-time approaches that involve services designed to consider patient needs and comfort. 
Antonacci AC, Dechario SP, Antonacci C, et al. J Surg Res. 2021;258:47-53.
Cognitive bias is an important source of medical error. In this analysis of over 700 general surgical cases with complications, the authors attributed cognitive bias in one-third of all cases. These cases were also associated with an increase in management errors (e.g., diagnostic, communication, or therapeutic errors) and a lower standard of care.  
Merkow RP, Shan Y, Gupta AR, et al. Jt Comm J Qual Patient Saf. 2020;46(10):558-564.
Postoperative complications can increase costs due to additional healthcare utilization such as further testing, reoperation, or additional clinical services. This study used data from the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) to estimate 30-day costs resulting from postoperative complications. Prolonged ventilation, unplanned intubation, and renal failure were associated with the highest cost per event, whereas urinary tract infection, superficial surgical site infection, and venous thromboembolism were associated with the lowest cost per event.
Nafiu OO, Mpody C, Kim SS, et al. Pediatrics. 2020;146(2):e20194113.
The authors analyzed National Surgical Quality Improvement Program (NSQIP) Pediatric data from 2012 through 2017 to explore racial differences in postsurgical complications among healthy children. Compared to white children, African American children were three times as likely to die within 30 days after surgery and were more likely to develop postoperative complications and serious adverse events. These results can help guide future research exploring the mechanisms underlying racial differences in postsurgical outcomes in children.
Barth RJ, Waljee JF. JAMA Surg. 2020;155(7):543-544.
This commentary discusses the harms of opioid overprescribing, particularly among opioid-naïve patients. The authors suggest that opioid dependence, abuse, or overdose in an opioid-naïve patient undergoing surgery should be considered a “never event” and discuss strategies for appropriate prescribing by surgeons.
Storesund A, Haugen AS, Flaatten H, et al. JAMA Surg. 2020;155(7):562-570.
This study assessed the impact of combined use of two surgical safety checklists on morbidity, mortality, and length of stay – the Surgical Patient Safety System (SURPASS) is used to address preoperative and postoperative care, and the World Health Organization surgical safety checklist (WHO SSC) is used for perioperative care.  In addition to existing use of the WHO SSC, the SURPASS checklist was implemented in three surgical departments in one tertiary hospital in Norway. Results demonstrated that combined use of these checklists was associated with reduced complications reoperations, and readmissions, but combined use did not impact mortality or length of stay.
Russ S, Latif Z, Hazell AL, et al. JMIR mHealth and uHealth. 2019;8.
Using a participatory action research approach, this study evaluated a smartphone app intended to empower surgical patients and caregivers to help optimize their care. Forty-two patients were enrolled in the study and they underwent a variety of different surgical procedures. Most patients felt that app was useful and informative (79%), was easy to use (74%) and helped participants to ask better questions (76%) and feel more involved in conversations about their care. However, almost half of participants (48%) were unsure about how the app could affect safety, citing that safety was the responsibility of the clinical staff alone rather than patients.
Koers L, van Haperen M, Meijer CGF, et al. JAMA Surg. 2019;155(1):e194704.
Failure to rescue is a significant cause of morbidity and mortality and is often associated with human error. In this innovative study, the authors posit that the use of cognitive aids, which are prompts that can help practitioners’ complete evidence-based tasks (e.g. symptom-specific checklists, flowcharts, and clinical guidelines), could improve timely recognition and effective management of complications in a surgical population. The study randomized surgeons and nurses to manage deteriorating patients in simulated scenarios with or without the use of cognitive aids. Use of cognitive aids significantly reduced omitted critical management steps and failure to adhere to best practices.  
Three patients were at the same hospital over the course of a few months for vascular access device (VAD) placement and experienced adverse outcomes. The adverse outcomes of two of them were secondary to drugs given for sedation, while the third patient’s situation was somewhat different. Vascular access procedures are extremely common and are relatively short but may require the use of procedural sedation, which is usually very well tolerated but can involve significant risk, as these cases illustrate.
Hall AJ, Toner NS, Bhatt PM. British journal of neurosurgery. 2019;33:495-499.
Research has found that checklists can improve patient safety in various surgical specialties but their use in neurosurgery is limited. This single center study implemented a neurosurgical postoperative checklist, which resulted in more patients undergoing a postoperative review and increases in appropriate medication prescribing. 
Berman L, Ottosen M, Renaud E, et al. Journal of pediatric surgery. 2019;54:1872-1877.
Morbidity and mortality (M&M) conferences are designed to review adverse events. They are one method by which physicians undergo peer review to evaluate their performance and can allow health systems to identify potential avenues for improving patient safety. A survey of pediatric surgeons found that while the M&M participation was high, few believed the process results in practice changes or preventing future events. M&Ms considered most effective had a structured approach, were data driven with loop closure, emphasized multidisciplinary participation, and served as an educational forum.
McIsaac DI, Hamilton GM, Abdulla K, et al. BMJ Qual Saf. 2020;29(3):209-216.
The AHRQ Patient Safety Indicators (PSIs), which are used to screen administrative data for patient safety events, have been revised in response to the new ICD-10 coding system. This study sought to validate the accuracy of ICD-10-based PSIs for detecting postoperative adverse events, compared to the National Surgical Quality Improvement Program reference standard. Although the PSIs had relatively high negative predictive value (meaning that the absence of a PSI meant that the patient likely had not experienced an adverse event), the overall accuracy was not sufficient to warrant using PSIs as the sole strategy to detect adverse events.
Cooper WO, Spain DA, Guillamondegui O, et al. JAMA Surgery. 2019;154.
Physicians who behave unprofessionally toward other health care workers compromise both safety culture and patient health. Hostile behavior among surgeons is particularly harmful because surgical care is both teamwork-dependent and has high stakes. Although many have reported anecdotally that disrespectful surgeon behavior has led to patient harm, it is challenging to study systematically. Investigators sought to determine whether patients whose surgeons had coworker reports of unprofessional behavior experienced more harm. Surgeons at two academic medical centers who had coworker reports of unprofessional behavior in the 3 years before a surgery were more likely to have patients experience both medical and surgical complications after the surgery. These findings highlight the importance of empowering team members to report unprofessional behavior so that it can be remediated. Two WebM&M commentaries describe different approaches to addressing unprofessional physician behavior.