The PSNet Collection

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Andreou A. Scientific American. May 26, 2022.

Negative comments and attitudes indicate a lack of professionalism that can affect patient care. This article shares concerns about surgeon biases toward patients who are overweight and calls for clinicians to recognize the problem and address it.

APSF endorsed statement on revising recommendations for patient monitoring during anesthesia.

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The APSF Committee on Technology. APSF Newsletter. 2022;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.

Curated Libraries

Medication/Drug Errors

Do you know what doses are being programmed in the OR? Make it an expectation to use smart infusion pumps with DERS.

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ISMP Medication Safety Alert! Acute Care Edition. 2020;25.

Dose error-reduction systems (DERS) are standard functions in smart pumps. While they are designed to recognize dosing and programming errors, it has been observed that DERS are not fully utilized in operating rooms (OR). This article shares recommendations for addressing this medication safety gap including working with anesthesia providers and OR team members to establish use of DERS as an expected practice.

5 cataract surgeries, 5 people blinded: what went wrong?

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Kowalczyk L.

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.

Awareness of patient safety grows with increased outpatient surgeries.

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Aston G. Hosp Health Netw. September 9, 2014.

As outpatient surgery becomes more prevalent, attention around related safety concerns grows. This news article highlights federally supported initiatives that utilized reporting incentives and surgical safety checklists to improve safety in ambulatory surgery centers.

At surgery clinic, rush to save Joan Rivers's life.

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Hartocollis A; Goodman JD.

Office-based anesthesia is becoming more common despite concerns regarding its safety. This newspaper article reports on factors to enhance safety of surgical care in ambulatory settings, such as adequate screening of patient risks, availability of staff trained to perform intubations when needed, and ensuring access to lifesaving equipment as strategies.

Drawn curtains, muted alarms, and diverted attention lead to tragedy in the postanesthesia care unit.

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ISMP Medication Safety Alert! Acute Care Edition. March 21, 2013;18:1-3.

This newsletter article discusses factors that contributed to the death of a patient in an ambulatory surgery center and recommends improved monitoring practices and alarm management in post-anesthesia care units.

Medical malpractice: why is it so hard for doctors to apologize?

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Sanghavi D.

Discussing barriers to physician error disclosure, this article details how an apology-and-offer approach and analyzing claims data can improve transparency and health care safety.

Wife 'heartbroken' at death blamed on meningitis.

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Cohen E.

This news piece reports on a patient who may have been misdiagnosed with a stroke after receiving a contaminated steroid injection.

Scant oversight of drug maker in fatal meningitis outbreak.

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Grady D, Pollack A, Tavernise S. New York Times. October 6, 2012.

This newspaper article discusses how the drug shortage and use of compounded drugs contributed to an outbreak of fungal meningitis in the United States. The outbreak has already led to more than a dozen deaths.

Noah's story: please listen.

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Lord T. Patient Saf Qual Healthc. March/April 2012;9:38-41,44.

This article details how miscommunication and lack of patient-centered care contributed to errors that led to the death of a child.

Ambulatory surgery facilities: a comprehensive review of medication error reports in Pennsylvania.

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Grissinger M, Dabliz R. Pa Patient Saf Advis 2011 Sep;8(3):85-93.

Analyzing reports of medication errors in ambulatory surgery centers, this article discusses common error types and provides suggestions to prevent such events and prioritize improvement efforts.

Improving patient safety in the office: The Institute for Safety in Office-Based Surgery.

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Urman RD, Shapiro FE. APSF Newsletter. 2011;3-4,9.

This piece discusses an ambulatory surgery safety improvement program and describes its background, goals, and checklist initiative.

A pinpoint beam strays invisibly, harming instead of healing.

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Bogdanich W; Rebelo K.

This article explores inaccuracy of dosage, lack of protocol adherence, and absence of transparency as trends that hinder learning from radiological adverse events.

Seeking a safer surgery: some states crack down on doctors who perform unregulated outpatient procedures.

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Landro L.

This article discusses growing legal oversight on outpatient surgery performed in physicians' offices and identifies ways in which patients can assess a facility before deciding to have a procedure there.

In just a flash, simple surgery can turn deadly.

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Landro L.

This newspaper article discusses increasing concerns over potential burn injuries in the hospital setting and reports on efforts to raise awareness of the dangers and promote preventative measures.

How hepatitis probe led to clinic: old-fashioned legwork yielded clues that came together.

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Allen M. Las Vegas Sun. March 2, 2008.

This article describes how investigators determined the root causes and source of a hepatitis outbreak in Nevada—one clinic's unsafe injection practices.

Final five: ASCs told to target patient safety.

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Rollins G. Hospitals & health networks. 2007;81:53-4, 56, 1.

This article discusses a National Quality Forum initiative endorsing quality measures that can be publicly reported to elucidate the safety of ambulatory surgical care.

Walk inside, have surgery. But is it safe?

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Brooks A.

This article provides a brief review of safety concerns associated with free-standing surgical centers.

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