Muensterer OJ, Kreutz H, Poplawski A, et al. BMJ Qual Saf. 2021;30(8):622-627.
Preoperative checklists and timeouts are common tools to improve patient safety. Over a 16-month period, this study purposefully and randomly introduced errors during preoperative timeouts for 1,800 procedures but only 54% of these errors were reported by operating team members. The authors suggest that future research should explore ways to improve the quality of surgical timeouts to reduce risks to patient safety.
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.
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.
Certain elements of the ambulatory surgery environment can increase risk of adverse events. Reporting on a series of patient injuries linked to a contracted anesthesiologist at a cataract surgery center, this news article describes how factors such as production pressure and insufficient assessment of contract anesthesiologists' qualifications can contribute to adverse events in outpatient surgery.
This commentary explores insights from the husband of a patient who died due to a medical error and his subsequent commitment to promote application of human factors engineering principles from the aviation industry to improve safety in health care organizations.
Tscholl DW, Weiss M, Kolbe M, et al. Anesth Analg. 2015;121(4):948-956.
This pre-post study demonstrated increases in teamwork after introduction of an anesthesia checklist. Although evidence for checklists in real-world settings is mixed, this work demonstrates their efficacy as part of an intervention study, which is consistent with prior work.
Corbally MT, Tierney E. International journal of pediatrics. 2014;2014:791490.
Many institutions are attempting to increase patient and family engagement in safety efforts. This report on integrating parents of children undergoing surgery into the completion of the WHO surgical safety checklist provides a helpful example of families being successfully incorporated into an existing safety program.
In the preoperative area, a man scheduled for excision of a groin lipoma received regional anesthesia (right iliac block) and was taken to the operating room. There, without alerting anyone, the patient attempted to rise to use the restroom, but—because his leg was numb—fell and hit his head. He reported acute neck pain and was transferred to the local emergency department.
Chow WB, Rosenthal RA, Merkow RP, et al. Journal of the American College of Surgeons. 2012;215:453-66.
This guideline describes recommendations for preoperative assessment of elderly surgical patients, including risk factors for postoperative delirium and pulmonary complications, to enhance safety and reduce readmissions.
Konrad D, Jäderling G, Bell M, et al. Intensive care medicine. 2010;36:100-6.
Rapid response systems function within a variety of structures, but they ultimately remain a mechanism to manage a clinically deteriorating patient. This prospective study demonstrated that implementation of an intensivist physician and nurse–based team led to improvements in cardiac arrest rates and adjusted hospital mortality.
Hove LD, Steinmetz J, Christoffersen JK, et al. Anesthesiology. 2007;106:675-80.
The investigators reviewed claims data to identify cases in which patient mortality was related to anesthesia and found that algorithms, preoperative evaluation, training, education, and use of protocols might prevent such deaths.
Barbara A. Blakeney, MS, RN, is President of the 150,000-member American Nurses Association (ANA). A nurse practitioner and expert in public health practice, policy, and primary care, Ms. Blakeney is on leave from the Boston Public Health Commission, where she has been director of health care services for the homeless. She is the recipient of numerous awards and has been named to Modern Healthcare Magazine's list of the 100 most influential people in health care for the past 3 years.
Despite persuasion from a surgical resident that her mother's life was in danger, a patient's daughter refuses consent for surgery on her mother. This was wise, since the procedure was intended for a different patient with the same unusual surname.
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