The PSNet Collection

The Hidden Danger of Unseen Intravenous Catheters

October 27, 2021

A 6-week-old infant underwent a craniotomy and excision of abnormal brain tissue for treatment of hemimegalencephaly and epilepsy.

Awareness of human factors in the operating theatres during the COVID-19 pandemic

October 27, 2021

Understanding the ways in which human factors, such as non-technical skills, influence individual and team performance can ultimately improve patient safety, particularly in high-intensity settings such as operating rooms. The Observation of Non-technical Skills and Teamwork (ONSet) program, created by the Cambridge University Hospitals, uses observation and feedback from Human Factors Champions to evaluate the impact of human factors education in operating rooms.

Letter to Health Care Providers: Safe Use of Surgical Staplers and Staples.

US Food and Drug Administration. October 7, 2021.

Errors of commission during complex procedures can contribute to patient harm. Drawing from an analysis of medical device reports submitted to the Food and Drug Administration, this updated announcement seeks to raise awareness of common adverse events associated with surgical staplers and implantable staples. User-related problems include opening of the staple line, misapplied staples, and staple gun difficulties. Recommendations include ensuring availability of various staple sizes and avoiding use of staples on large blood vessels.

A systematic review of interventions used to enhance implementation of and compliance with the World Health Organization surgical safety checklist in adult surgery.

Liu LQ, Mehigan S. AORN J. 2021;114(2):159-170.

Surgical safety checklists (SSC) have been shown to improve outcomes, but effective implementation remains a challenge. This systematic review evaluated the effectiveness of interventions to increase compliance with the World Health Organization’s SSC for adult surgery. Interventions generally fell into one of four categories: modifying the method of SSC delivery, integrating or tailoring the tool for local context, promoting awareness and engagement, and managing organizational policy. Study findings suggest that all approaches resulted in some improvement in compliance.

Health Equity and Maternal Health

October 6, 2021

This piece discusses an expanded view of maternal and infant safety that includes the concept of whole-person care, which addresses the structural and social determinants of maternal health.

In conversation with….Alison Stuebe, MD, MSc and Kristin Tully, PhD

October 6, 2021

Alison Stuebe, MD, MSc, is a professor and Division Director for Maternal-Fetal Medicine in the Department of Obstetrics and Gynecology at the University of North Carolina (UNC) at Chapel Hill and the co-director of the Collaborative for Maternal and Infant Health. Kristin Tully, PhD, is a research assistant professor in the Department of Obstetrics and Gynecology at UNC Chapel Hill and a member of the Collaborative for Maternal and Infant Health.

Evolving factors in hospital safety: a systematic review and meta-analysis of hospital adverse events.

Sauro KM, Machan M, Whalen-Browne L, et al. J Patient Saf. 2021;Epub Sep 2.

Hospital adverse events are common and can contribute to serious patient harm. This systematic review included 94 studies (representing 590 million admissions from 25 countries) examining trends in hospital adverse events from 1961 to 2014. Findings indicate that hospital adverse events have increased over time and that over half are considered preventable.

There is an app for that: mobile technology improves complication reporting and resident perception of their role in patient safety

September 29, 2021

Morbidity and mortality (M&M) conferences are standard components of medical training programs yet medical residents underutilize incident reporting systems that feed into M&M conferences. To encourage incident reporting among residents, the Department of Orthopedic Surgery at Cedars Sinai Medical Center launched a web-based, real-time complication reporting platform to capture complications.

Dual surgeon operating to improve patient safety.

Ellis R, Hardie JA, Summerton DJ, et al. Surg. 2021;59(7):752-756.

Many non-urgent, non-cancer surgeries were postponed or canceled during COVID-19 surges resulting in a potential loss of surgeons’ “currency”. This commentary discusses the benefits of, and barriers to, dual surgeon operating as a way to increase currency as elective surgeries are resumed.

Simulation-based assessment identifies longitudinal changes in cognitive skills in an anesthesiology residency training program.

Sidi A, Gravenstein N, Vasilopoulos T, et al. J Patient Saf. 2021;17(6):e490-e496.

Nontechnical skills, such as teamwork and communication, can influence performance in technical fields like surgery or emergency medicine. This study found that simulation-based assessments can measure improvements in nontechnical skills and cognitive performance among residents.

Society for Maternal-Fetal Medicine Special Statement: Surgical safety checklists for cesarean delivery.

Combs CA, Einerson BD, Toner LE. Am J Obstet Gynecol. 2021;Epub Jul 30.

Maternal and newborn safety is challenged during cesarean delivery due to the complexities of the practice. This guideline recommends specific checklist elements to direct coordination and communication between the two teams engaged in cesarean deliveries. The guideline provides a sample checklist and steps for its implementation.

Coping with errors in the operating room: intraoperative strategies, postoperative strategies, and sex differences.

D'Angelo JD, Lund S, Busch RA, et al. Surgery. 2021;170(2):440-445.

This study evaluated the type and effectiveness of resident and faculty coping strategies following an intraoperative error and the interaction with physician gender. Results show that while men and women surgeons experience adverse events at approximately the same rate, the coping methods utilized and effectiveness of the methods varied.

Maternal Safety

Ensuring maternal safety is a patient safety priority. This library reflects a curated selection of PSNet content focused on improving maternal safety. Included resources explore strategies with the potential to improve maternal care delivery and outcomes, such as high reliability, care standardization, teamwork, unit-based safety initiatives, and trigger tools.

Quality and safety in surgery: challenges and opportunities.

Nasca BJ, Bilimoria KY, Yang AD. Jt Comm J Qual Patient Saf. 2021;47(9):604-607.

Surgical safety has made advances while new difficulties continuously emerge. This article suggests that the specialties capitalize on artificial intelligence and professional wellness as two avenues to generate sustainable safety progress.

Communication failures contributing to patient injury in anaesthesia malpractice claims.

Douglas RN, Stephens LS, Posner KL, et al. Br J Anaesth. 2021;127(3):470-478.

Effective communication among providers helps ensure patient safety. Through analysis of perioperative malpractice claims using the Anesthesia Closed Claims Project database, researchers found that communication failures contributed to 43% of total claims, with the majority between the anesthesiologist/anesthesia team and the surgeon/surgery team. Methods to improve perioperative communication are discussed.

Chief resident indirect supervision in training safety study: is a chief resident general surgery service safe for patients?

Speaks L, Helmer SD, Quinn KR, et al. J Surg Educ. 2021;Epub Aug 4.

Balancing resident autonomy and supervision is an ongoing challenge in medical training. The authors reviewed patient data to identify adverse outcomes (e.g., complications, readmissions, reoperation, mortality) undergoing common general surgery procedures performed by, or indirectly supervised by, attending surgeons or the chief resident service. Findings suggest that indirect supervision of appendectomies, cholecystectomies, and hernia repairs by the chief resident surgery service is safe and can serve as a model to enhance resident autonomy during training.

FDA Safety Communication: update--robotically-assisted surgical devices in mastectomy.

MedWatch Safety Alert. Silver Spring, MD: US Food and Drug Administration; August 20, 2021.

This announcement seeks to raise awareness of the potential risks associated with the use of robotic-assisted surgical devices in mastectomies or cancer-related care. Recommendations for patients who may seek to have robotically assisted surgery include asking about their surgeon's experience with these procedures and discussing benefits, risks, and alternatives regarding available treatment options with their health care provider. Suggestions for health care providers include completing specialized training on procedures they perform. A WebM&M commentary described the challenges and benefits associated with robotic surgery.

Do black and white patients experience similar rates of adverse safety events at the same hospital?

Gangopadhyaya A. Washington DC; Urban Institute: July 2021.

Racial inequities have been revealed by the COVID pandemic as a distinct patient safety concern. This report examined racial differences using patient safety indicators to measure hospital-acquired conditions, insurance coverage, and hospital patient population. The results indicate Black patients have reduced safety, that insurance coverage had little influence on safety and hospitals with a higher Black patient population experienced more adverse events that those serving a white patient population.

Effects of a brief team training program on surgical teams' nontechnical skills: an interrupted time-series study.

Gillespie BM, Harbeck EL, Kang E, et al. J Patient Saf. 2021;17(5):e448-e454.

Nontechnical skills such as teamwork and communication can influence surgical performance. This Australian hospital implemented a team training program for surgical teams focused on improving individual and shared situational awareness which led to improvements in nontechnical skills.

Using performance improvement to enhance time-out compliance and prevent wrong-site surgery.

Vance ME, Proctor T, Schmidt KA. AORN J. 2021;113(6):635-642.

The perioperative setting is a high-risk environment. This continuing education model discusses safety threats and evidence-based best practices to deliver nursing care in perioperative settings and promote a culture of safety.

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