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St Paul, MN: Minnesota Department of Health.
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.
Kepner S, Jones RM. Patient Safety. 2022;4:18-33.
Acute care facilities in Pennsylvania are required to report all Incidents and Serious Events to the state’s Patient Safety Authority. This study updates the 2020 report. Similar to prior reports, Error Related to Procedure/Treatment/Test remained the most commonly reported events, followed by Medication Error, Complication of Procedure/Treatment/Test, and Fall.
Abdelmalak BB, Adhami T, Simmons W, et al. Anesth Analg. 2022;135:198-208.
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.
Douglas RN, Stephens LS, Posner KL, et al. Br J Anaesth. 2021;127:470-478.
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.
Braun BI, Chitavi SO, Perkins KM, et al. Jt Comm J Qual Patient Saf. 2020;46:531-541.
In this retrospective review of ambulatory care infection prevention and control (IPC) breaches reported to state health departments, the authors observed 5% rate of breaches and found that common breaches involved sterilization and disinfection of reusable devices, device reprocessing, and IPC infrastructure. These and other breaches highlight opportunities for additional training, leadership oversight, and resource investment.

MedWatch Safety Alert. Silver Spring, MD: US Food and Drug Administration. June 2, 2020.

Neuromuscular blocking agents are high alert medications that can severely harm patients if used incorrectly. This announcement alerts clinicians to the absence of warning statements on two types of paralyzing agents, as well as to steps to minimize mistaken use.
de Lima A, Osman BM, Shapiro FE. Curr Opin Anaesthesiol. 2019;32.
Office-based anesthesia (OBA) is being performed more commonly internationally. This narrative literature review updates the evidence related to the safety of OBA and makes recommendations for safe practices including; medical directors to be responsible for evidence-based policies, OBA safety and patient checklists emergency procedures, physical setting requirements, pharmacological management, preoperative procedures, airway management and others. The authors identify that lack of consistent regulations and incomplete protocol standardization is problematic.
Washington, DC: Office of the Inspector General; September 2019. Report No. OEI-01-15-00400.
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. 
London, UK: Royal College of Surgeons of England; 2019.
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.
Stanisce L, Ahmad N, Deckard N, et al. Otolaryngol Head Neck Surg. 2019;160:1003-1008.
This pre–post study found that implementation of relative value unit–based payment in a head and neck surgery practice resulted in a higher volume of procedures. The incidence of adverse outcomes, including postoperative hospitalizations, infections, unplanned return surgeries, and emergency department visits, did not change. The authors conclude that the change in payment structure did not impact surgical safety.

Geneva: World Health Organization; 2018. ISBN-13: 978-92-4-155047-5.

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.
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.
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.
Urman RD, Punwani N, Shapiro FE. Curr Opin Anaesthesiol. 2012;25:648-53.
This narrative review explores how the practice of office-based anesthesia has increased and discusses the need for uniform regulations and accreditation to improve patient outcomes.