The World Health Organization's (WHO) Surgical Safety Checklist (SSC) has resulted in improved surgical outcomes; however, use of the checklist varies. In this study, surgical personnel (surgeons, anesthesiologists, nurse anesthetists, surgical nurses, and assistant nurses) were surveyed about use of the SCC in their hospital, including who was responsible for ensuring its use. Although most groups reported it was not clear who was responsible for implementing the SSC prior to surgery, they believed it was the assistant nurse.

Sentinel events are adverse events that result in death or severe patient harm and require a full organizational investigation to identify root causes and make recommendations to prevent recurrence. This study pooled sentinel event reports from 28 Dutch hospitals to identify common system-level contributing factors. Aggregation of system-level factors may provide more urgency in implementing recommendations than a single case at one organization.

Interruptions during diagnostic decision-making and clinical tasks can adversely impact patient care. This article reviews empirically-tested strategies from healthcare and cognitive psychology that can inform future research on mitigating the effects of interruptions during diagnostic decision-making. The authors highlight strategies to minimize the negative impacts of interruptions and strategies to prevent distractions altogether; in addition, they propose research priorities within the field of diagnostic safety.

Failure Mode, Effect and Criticality Analysis (FMECA) is a prospective method for identifying and preventing potential error risks. Using FMECA, public health medical residents calculated a Risk Priority Number (RPN), or criticality, for each possible failure mode in cancer treatment prescription and administration. Each phase of the cancer treatment process had at least one critical step identified, and actions were developed to reduce the likelihood of the error occurring and/or to increase the likelihood of the error being detected.

Human factors engineering has the potential to mitigate failures by designing workspaces and processes to prevent errors from occurring. This guidance uses the hierarchy of controls framework to organize human-factors recommendations focusing on the design of anesthesia environments and equipment to infuse protections into care service.

Human factors science focuses on designing systems that make it easy for workers to do the right thing and difficult to do the wrong thing. This narrative review focuses on human factors science in anesthesia. Research is described as it relates to the hierarchy of controls model: design, barriers, mitigations, education, and training.

Interhospital transfers pose a serious risk to patients. In this study, nurse anesthetists and intensive care nurses described strategies to ensure safe transport for patients who are intubated or who may require intubation. Strategies include clear and adequate communication between providers prior to transport, stabilizing and optimizing the patient’s condition, and ensuring that appropriate drugs and equipment are prepared and available.

Safety strategies from high-reliability industries such as aviation and nuclear power are frequently adapted for healthcare. In this study, pilots described crisis preparedness strategies, which surgical safety experts then developed into a framework consisting of six behavioral interventions: anticipate threats, briefing, checklists, drill rehearsal, individual and team empowerment, and debriefing. An earlier study by the authors describes the second phase in managing crisis: crisis recovery.

Intravenous (IV) medication smart pumps can improve medication administration, but usability issues can compromise safety. This article outlines strategic recommendations regarding the implementation of smart pump technology to improve patient safety. Recommendations include standardization of infusion concentrations, improving drug libraries using a human-centered approach, and increasing stakeholder engagement.

Leveraging lessons learned in aviation, patient safety researchers have begun exploring the use of medical data recorders (i.e., “black boxes”) to identify errors and threats to patient safety. This cross-sectional study found that a medical data recorder identified an average of 53 safety threats or resilience support events among 35 standard laparoscopic procedures. These events primarily involved communication failures, poor teamwork, and situational awareness failures.

Harm from pediatric anesthesia-related errors is infrequent, but largely preventable. This pediatric hospital developed and implemented an anesthesia-specific checklist to be used before anesthesia induction. This study presents the types of errors identified by the checklist over the course of one year.

Interruptions and distractions in healthcare settings can inhibit safe care. This simulation study found that medical staff reaction time to changes in vital signs during stressful situations (telephone ringing, ambulance signal) was significantly slower than during non-stressful situations, which may increase the likelihood of medical errors.

The COVID-19 pandemic led to a significant increase in the use of telehealth. This article summarizes several challenges that need to be addressed (e.g., human factors, provider-patient relationships, structural, and technological factors) in order to support continuous improvement in the safety of health care delivered via telemedicine.