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The National Quality Forum has defined 29 never events—patient safety problems that should never occur, such as wrong-site surgery and patient falls. Since 2003, Minnesota hospitals have been required to report such incidents. The 2021 report summarizes information about 508 adverse events that were reported, representing a significant increase in the year covered. Earlier reports document a fairly consistent count of adverse events. The rise reflected here is likely due to demands on staffing and care processes associated with COVID-19. Pressure ulcers and fall-related injuries were the most common incidents documented. Reports from previous years are available.

Surgical equipment sterilization can be hampered by equipment design, production pressures, process complexity and policy misalignment. This report examines a case of unclean surgical instrument use. It recommends external sterile service assessment and competency review as steps toward improving the reliability of instrument decontamination processes in the National Health Service.

This report summarizes patient safety improvement work in the state of Pennsylvania and reviews the 2021 activities of the Patient Safety Authority, including the Agency's response to the COVID-19 pandemic, video programs, liaison efforts, publication programs, and the launch of a new learning management system.

Ambulatory surgery centers harbor unique characteristics that affect safety culture. This analysis from the Agency for Healthcare Research and Quality (AHRQ) shares results of 235 ambulatory surgery centers (ASCs) participating in the Surveys on Patient Safety Culture (SOPS) Ambulatory Surgery Center Survey. Most respondents (92%) rated their organization as committed to learning and continuous improvement.

Wrong site/wrong patent surgery is a persistent healthcare never event. This report examines National Health Service (NHS) reporting data to identify how ambulatory patient identification errors contribute to wrong patient care. The authors recommend that the NHS use human factors methods to design control processes to target and manage the risks in the outpatient environment such as lack of technology integration, shared waiting area space, and reliance on verbal communication at clinic.

The latest publication from the Agency for Healthcare Research and Quality (AHRQ) reports results of 282 ambulatory surgery centers (ASC) participating in the Surveys on Patient Safety Culture (SOPS) Ambulatory Surgery Center Survey. The majority of respondents (86%) rated their organization’s overall safety rating as excellent or very good.

Checklists are integrated into error reduction strategies and healthcare team communication efforts worldwide but implementation and impact of the tool varies widely. This report examines the use of the WHO Surgical Safety Checklist and barriers to its uptake which include lack of effective staff introduction to the content, misperceptions about the time needed to use the tool and ineffective local contextualization of the content and process.

Ambulatory surgery centers (ASC) are established venues for surgical care despite lack of engagement in assessment to ensure their safety. This report analyzed a variety of components related to high quality ASC services and found them lacking in appropriately skilled clinical staffs, patient communication processes and safety practice implementation.

Ambulatory surgery centers (ASC) play an increasing role in complex surgical care, but methods to assure patients are safe in these environments are unreliable. This report found that Medicare surveys to assess ASC quality and safety concerns were not done or the results identifying problems were often unheeded. The lack of review and follow-up exposed patients to health-care associated infections, lack of medication oversight and poor pre-operative assessment. 

Introducing innovations in practice involves taking calculated risks. To ensure patient safety, new techniques should be accompanied by training, oversight, and heightened awareness of the learning curve. This book provides a framework to guide the design and introduction of new surgical procedures into regular practice. It includes recommendations for auditing, cost assessment, and effectiveness review.

Pain management has emerged as a complex safety concern. This report discusses four organizational prerequisites to improve pain management: prioritization, education, patient- and family-centeredness, and effective systems of care. Recommended steps for leadership to successfully implement safe pain management include obtaining commitment, convening a multidisciplinary working group, developing a plan, and executing the plan.

Efforts to reduce surgical site infections have achieved some success. The World Health Organization has taken a leading role in eliminating health care–associated harms and has compiled guidelines to address factors that contribute to surgical site infections in preoperative, intraoperative, and postoperative care. The document includes recommendations for improvement informed by the latest evidence. The second edition of the Guidelines was released in 2018.

This report provides information about a national program focused on improving safety in ambulatory surgery. The initiative included surgical safety checklists, webinars, and other tools, with the goal of enhancing safety culture and reducing surgical site infections.

This report provides background on the Minnesota Never Events reporting initiative, tips for patients on how to receive the safest care possible, and a table of events reported by all hospitals in the state.

To help prevent tubing misconnections, this toolkit offers frequently asked questions and corresponding answers about small-bore connectors.

This report analyzes sentinel events reported in Utah from 2001 to 2011 and includes best practices, current efforts to address safety concerns, and plans for future improvement initiatives.

This report makes recommendations and provides strategies to ensure safe practice in surgical care.

This guide offers tools and strategies to ensure that care in the ambulatory setting is safely provided, evidence-based, and aligned with Joint Commission requirements.

Through a qualitative evaluation of the Minnesota statewide reporting initiative, this report suggests ways to improve the reporting system to facilitate continued learning and transparency.