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Arditi L. Peoples Public Radio. December 3, 2019.
Emergency medical services are often provided under chaotic circumstances that may contribute to failure. This story highlights a series of esophageal intubation errors and efforts to minimize this “never event” across the state of Rhode Island. Improvement strategies discussed include practice restrictions for EMT personnel and use of less invasive, less risky processes to provide oxygen as an alternative to intubation, which may reduce esophageal intubation errors
Chang BH, Hsu Y-J, Rosen MA, et al. Am J Med Qual. 2020;35:37-45.
Preventing health care–associated infections remains a patient safety priority. This multisite study compared rates of central line–associated bloodstream infections, surgical site infections, and ventilator-associated pneumonia before and after implementation of a multifaceted intervention. Investigators adopted the comprehensive unit-based safety program, which emphasizes safety culture and includes staff education, identification of safety risks, leadership engagement, and team training. Central line–associated bloodstream infections and surgical site infections initially declined, but rates returned to baseline in the third year. They were unable to measure differences in ventilator-associated pneumonia rates due to a change in the definition. These results demonstrate the challenge of implementing and sustaining evidence-based safety practices in real-world clinical settings. A past PSNet interview discussed infection prevention and patient safety.

Cortegiani A, Gregoretti C, Neto AS, et al; LAS VEGAS Investigators, PROVE Network, Clinical Trial Network of the European Society of Anaesthesiology. Br J Anaesth. 2019;122:361-369.

This study found that patients undergoing surgery at night were more likely to develop intraoperative adverse events, even after adjustment for patient and procedural characteristics. The observed increase in postoperative pulmonary complications was explained by the type of surgery and underlying patient characteristics. This study adds to the body of evidence on risks associated with care outside of usual working hours.
Young S, Shapiro FE, Urman RD. Curr Opin Anaesthesiol. 2018;31:707-712.
Office-based surgery is increasingly common, despite concerns regarding its safety. This review summarizes the literature on ambulatory surgery outcomes and identified risk factors such as case complexity, patient comorbidities, and anesthesia use. Few studies examined anesthesia use in dental care.
Hatch D, Rivard M, Bolton J, et al. Jt Comm J Qual Patient Saf. 2019;45:295-303.
The authors describe how the use of statistical process control charts facilitated rapid identification of a cluster of unplanned extubations in a neonatal intensive care unit. They advocate for the use of continuous monitoring tools to help alert teams to possible safety events and improvement opportunities.
Nguyen MC, Moffatt-Bruce SD, Strosberg DS, et al. Surgery. 2016;160:858-868.
The AHRQ Patient Safety Indicators (PSIs) rely on hospital administrative data to screen for patient safety problems. This study used independent physician chart review to assess the reliability of PSI 11 (postoperative respiratory failure) in identifying clinically significant patient safety events and found a positive predictive value of 38.3%. The authors argue that PSI 11 should not be used as a measure for hospital performance.
Snijders C, van Lingen RA, Klip H, et al. Arch Dis Child Fetal Neonatal Ed. 2009;94:F210-5.
Incident reporting systems are one mechanism for hospitals to both identify and potentially prevent adverse events, although they have frequently failed to meet those expectations. This study describes findings from a voluntary system that produced a significant increase in reported neonatal events, many of which were associated with patient morbidity.
A boy was receiving enteral feedings while recovering from a traumatic brain injury. The nasojejunal tube migrated to the gastric area, and the patient developed pneumonia, likely due to aspiration.
An elderly man with COPD and end-stage congestive heart failure was admitted for increasing shortness of breath, due to a pleural effusion. A resident performed a thoracentesis on the wrong side, and the patient developed a pneumothorax and died. The resident disclosed the error but was devastated.
Zhan C, Smith M, Stryer D. Med Care. 2006;44:182-186.
This Agency for Healthcare Research and Quality (AHRQ)–sponsored study looked at the incidence of accidental iatrogenic pneumothorax (AIP) in patients who underwent certain procedures. They found that AIP occurred most frequently after thoracentesis, but also during other procedures.
Collard HR, Saint S, Matthay MA. Ann Intern Med. 2003;138:494-501.
Health care–associated infections (HAIs) are a common adverse event in hospitalized patients and an increasing source of study for preventive strategies. Ventilator-associated pneumonia (VAP) is one of the four most common HAIs along with catheter-related bloodstream infection, catheter-associated urinary tract infection, and surgical site infection. This systematic review provides a series of recommendations to reduce the incidence of VAP, including use of semi-recumbent positioning, sucralfate rather than H2-antagonists, and aspiration of subglottic secretions in select patient populations. The authors point out that while many studies highlight the success of preventive strategies, no randomized trial has evaluated the effects of combining the preventive practices as an additive bundle or checklist.