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Prevention of perioperative medication errors.

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Nanji K. UpToDate. June 23, 2022.

Perioperative adverse drug events are common and understudied. This review examines factors that contribute to adverse drug events in the surgical setting and discusses prevention strategies that focus on medication reconciliation, technology, standardization, and institutional change.

A blueprint for success: implementation of the Center for Medicare and Medicaid Services mandated anesthesiology oversight for procedural sedation in a large health system.

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Abdelmalak BB, Adhami T, Simmons W, et al. Anesth Analg. 2022;Epub May 12.

A 2009 CMS Condition of Participation (CoP) requires that a director of anesthesia services assume overall responsibility for anesthesia administered in the hospital, including procedural sedation provided by nonanesthesiologists. This article reviews the CoP as it relates to procedural sedation, lays out a framework for implementing this role, and describes challenges of implementation in a large health system.

Implicit racial bias in pediatric orthopaedic surgery.

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Guzek R, Goodbody CM, Jia L, et al. J Pediatr Orthop. 2022;Epub May 9.

Research has demonstrated inequitable treatment of racially minoritized patients resulting in poorer health outcomes. This study aimed to determine if implicit racial bias impacts pediatric orthopedic surgeons’ clinical decision making. While pediatric orthopedic surgeons showed stronger pro-white implicit bias compared to the US general population (29% vs. 19%), the bias did not appear to affect decision making in clinical vignettes.

Patients' perceptions of importance for self-administered correct site surgery checklist: a multisite study.

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Krenzischek DA, Card E, Mamaril M, et al. J Perianesth Nurs. 2022;Epub Apr 27.

Patients and caregivers are important partners in promoting safe care. Findings from this cross-sectional study reinforce the importance of patients’ perceived roles in ensuring safe surgery and highlight the importance of patient engagement in mitigating surgical site errors.

Decontamination of Surgical Instruments.

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Farnborough, UK; Healthcare Safety Investigation Branch; May 26, 2022.

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.

Antifatness in the surgical setting.

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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.

Assessment of perioperative outcomes among surgeons who operated the night before.

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Sun EC, Mello MM, Vaughn MT, et al. JAMA Intern Med. 2022;Epub May 23.

Physician fatigue can inhibit decision-making and contribute to poor performance. This cross-sectional study examined surgical procedures performed between January 2010 and August 2020 across 20 high-volume hospitals in the United States to determine the association between surgeon fatigue, operating overnight and outcomes for operations performed by the same surgeon the next day. No significant associations were found between overnight surgeries and surgical outcomes for procedures performed the next day.

Fire safety in the operating room.

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Ehrenwerth J. UptoDate. May 25, 2022.

Operating room fires are never events that, while rare, still harbor great potential for harm. This review discusses settings prone to surgical fire events, prevention strategies, and care management steps should patients be harmed by an operating room fire.

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.

Patient Safety Authority Annual Reports.

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Pennsylvania Patient Safety Authority. Harrisburg, PA: Patient Safety Authority; April 2022.

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.

Saline Flush Leads to Acute Paralysis of an Awake Patient: Risks of Improper Medication Labeling in an Operating Room

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April 27, 2022

This WebM&M describes an adverse event due to mislabeling or “syringe swap” in a preoperative patient. The commentary outlines several recommendations and safeguards to ensure that medications administration is safe.

Effect of the surgical safety checklist on provider and patient outcomes: a systematic review.

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Armstrong BA, Dutescu IA, Nemoy L, et al. BMJ Qual Saf. 2022;31:463-478.

Despite widespread use of surgical safety checklists (SSC), its success in improving patient outcomes remains inconsistent, potentially due to variations in implementation and completion methods. This systematic review sought to identify how many studies describe the ways in which the SSC was implemented and completed, and the impact on provider outcomes, patient outcomes, and moderating factors. A clearer positive relationship was seen for provider outcomes (e.g., communication) than for patient outcomes (e.g., mortality).

Annual Perspective: Psychological Safety of Healthcare Staff

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March 31, 2022

A psychologically safe environment for healthcare teams is desirable for optimal team performance, team member well-being, and favorable patient safety outcomes. This piece explores facilitators of and barriers to psychological safety across healthcare settings. Future research directions examining psychological safety in healthcare are discussed.

Increased adherence to perioperative safety guidelines associated with improved patient safety outcomes: a stepped-wedge, cluster-randomised multicentre trial.

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Emond YEJJM, Calsbeek H, Peters YAS, et al. Br J Anaesth. 2022;128:562-573.

A necessary part of successful implementation of new guidelines is ensuring continued adherence. Nine Dutch hospitals implemented a multifaceted program (IMPlementatie Richtlijnen Operatieve VEiligheid [IMPROVE]) to support application of surgical guidelines. Results of guideline use were mixed.

Disclosure of errors in surgical procedures.

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Ryan M, Mekel M, Sinha MS. UptoDate. November 30, 2021

Error disclosure is fundamental to addressing harm and psychological distress after medical error. This review highlights issues associated with surgical error disclosure. It summarizes literature covering legal and ethical issues, honest apology, and skill development to ensure apology communications are effective.

Delayed Diagnosis and Treatment of an Occult Hemothorax Following Complicated Central Line Insertion Leads to Cardiac Arrest

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January 26, 2022

This case involves a 2-year-old girl with acute myelogenous leukemia and thrombocytopenia (platelet count 26,000 per microliter) who underwent implantation of a central venous catheter with a subcutaneous port. The anesthetist asked the surgeon to order a platelet transfusion to increase the child’s platelet count to above 50,000 per microliter. In the post-anesthesia care unit, the patient’s arterial blood pressure started fluctuating and she developed cardiac arrest.

The evolution of the Anesthesia Patient Safety Movement in America: lessons learned and considerations to promote further improvement in patient safety.

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Warner MA, Warner ME. Anesthesiology. 2021;135:963-974.

The legacy of anesthesiology as a leader in patient safety is reviewed as a model for other communities seeking to reduce medical error. The authors highlight the collaboration strategies that the specialty embraced as a key component of its success.

ISMP Medication Safety Self Assessment® for Perioperative Settings.

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Institute for Safe Medication Practices

The perioperative setting is a high-risk area for medication errors, should they occur. This assessment provides hospitals and outpatient surgical providers a tool to examine their medication use processes and share data nationwide for comparison. Organizational participation can identify strengths and gaps in their systems to design opportunities that prevent patient harm. The deadline for submitting data is February 11, 2022.

"Some version, most of the time": the surgical safety checklist, patient safety, and the everyday experience of practice variation.

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Hammond Mobilio M, Paradis E, Moulton C-A. Am J Surg. 2021;Epub Nov 24.

Surgical safety checklists (SSC) have been adopted around the world, but reported compliance rates and use in practice vary widely. This study in one Canadian hospital showed the SSC was used in 82% of Briefings, 76% of Time-Outs, and 22% of Debriefings. Gaps between policy and practice were identified and implications for policy makers, administrators, frontline clinicians, and researchers are discussed.

Outcomes and patient safety in overlapping vs. nonoverlapping total joint arthroplasty: a systematic review and meta-analysis.

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Malahias M-A, Antoniadou T, Jang SJ, et al. J Am Acad Orthop Surg. 2021;29:e1387-e1395.

Previous research has raised concerns about safety risks associated with overlapping surgery, defined as two procedures performed concurrently, but where critical surgical portions of each procedure occur at different times. Based on a meta-analysis of six articles, the authors of this systematic review found that rates of surgical complications readmissions were similar among overlapping and nonoverlapping surgery in patients undergoing total joint arthroscopy.

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