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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.

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.

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.

Guideline for prevention of unintentionally retained surgical items.

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Croke L. Guideline for prevention of unintentionally retained surgical items. AORN J. 2021;114(6):4-6. doi:

Retained surgical items (RSI) are a never event, yet they continue to happen. This commentary summarizes recent changes to an existing guidance that defines a range of retained devices or products to coalesce with industry terminology. The author shares steps to reduce the potential for RSI retention. A related webinar will be held February 2, 2022.

Curated Libraries

Medication/Drug Errors

The nature of reported safety events related to care coordination in the operating room setting in a tertiary academic center.

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Krishnan S, Wheeler KK, Pimentel MP, et al. J Healthc Risk Manag. 2022;41:25-29.

Incident reporting systems are used to detect patient safety concerns and determine potential causes and opportunities for improvements. In the perioperative setting of one hospital, insufficient handoffs were the most common event type in the “coordination of care” category. Use of structured handoffs is recommended to improve communication and patient safety.

To Dilute or Not Dilute: Drug Errors and Consequences in the Operating Room

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October 27, 2021

A 78-year-old woman with macular degeneration presented for a pars plana vitrectomy (PPV) under monitored anesthesia care (MAC) with an eye block. At this particular hospital, eye cases under MAC are typically performed with an eye block by the surgeon after the anesthesiologist has administered some short-acting sedation, commonly with remifentanil. On this day, there was a shortage of premixed remifentanil and the resident – who was unfamiliar with the process of drug dilution – incorrectly diluted the remifentanil solution.

Quality and safety in surgery: challenges and opportunities.

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

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.

2020 Pennsylvania Patient Safety Reporting: an analysis of serious events and incidents from the nation’s largest event reporting database.

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Kepner S, Jones RM. Patient Safety. 2021;3:6-21.

Acute healthcare facilities in Pennsylvania are required to report all events of harm or potential harm to the Pennsylvania Patient Safety Reporting System (PA-PSRS). Of all submitted events in 2020, 97% were from hospitals, and 97% were incidents; 3 percent were serious events. The most common event was Error Related to Procedure/Treatment/Test (32%). There was a 5.3% decrease from the prior year in the number of reported events, indicating the COVID-19 pandemic had an impact on reporting activity.

Identification of common themes from never events data published by NHS England.

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Omar I, Graham Y, Singhal R, et al. World J Surg. 2021;45:697-704.

Never events can result in serious patient harm and indicate serious underlying organizational safety problems. This study analyzed never events occurring between 2012 and 2020 in the National Health Services and categorized 51 common never events into four categories – wrong site surgery (40% of events); retained foreign objects post-procedure (28%); wrong implant/prosthesis (13%); and non-surgical/infrequent never events (19%). Awareness of these themes may support focused efforts to reduce their incidence and development of specific local safety standards.

Common general surgical never events: analysis of NHS England never event data.

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Omar I, Singhal R, Wilson M, et al. Int J Qual Health Care. 2021;33:mzab045.

Never events, a significant type of adverse event, should never occur in healthcare. This study analyzed 797 surgical never events that occurred from April 2012 to February 2020 in the National Health Service (NHS) England and categorized them into three main categories: wrong-site surgery (53.58%), retained items post-procedure (44.54%), and wrong implant/prosthesis (1.88%). In total 56 common general surgery never events have been found. Being aware of the common themes may help providers to develop more effective strategies to prevent these adverse events.

Cutaneous Procedures Adverse Events Reporting (CAPER).

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The American Society for Dermatologic Surgery Association and the Northwestern University Department of Dermatology.

Voluntary reporting systems collect adverse event data to inform improvement and education efforts. This site provides a platform for physicians and their staff to submit adverse experiences associated with dermatologic surgery equipment, medications or biologics.

Outcomes from Wake Up Safe, the pediatric anesthesia quality improvement initiative.

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Haché M, Sun LS, Gadi G, et al. Paediatr Anaesth. 2020;30:1348-1354.

The Wake Up Safe initiative includes a registry of serious adverse events occurring in pediatric anesthesia. This study analyzed events reported between 2010 and 2015. The most common anesthesia-related events were medication events, respiratory complications, and cardiac events. Approximately 85% of these events were considered to be preventable.

Wrong-site surgery in Pennsylvania during 2015–2019: a study of variables associated with 368 events from 178 facilities.

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Yonash RA, Taylor M. Patient Safety. 2020;2:24-39.

Wrong-site surgeries can lead to serious patient harm and are considered never events by the National Quality Forum. Based on events reported to the Pennsylvania Patient Safety Reporting System between 2015 and 2019, the authors identified an average of 1.42 wrong-site surgery events per week and found that three-quarters of events resulted in temporary or permanent patient harm. The authors present several evidence-based strategies to reduce the likelihood of wrong-site surgery, including preoperative and intraoperative verification, site marking, and timeouts.

A qualitative content analysis of retained surgical items: learning from root cause analysis investigations.

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Hibbert PD, Thomas MJW, Deakin A, et al. Int J Qual Health Care. 2020;32:184-189.

Based on 31 root cause analysis reports of surgical incidents in Australia, this study found that the most commonly retained surgical items were surgical packs (n=9) and drain tubes (n=8). While most retained items were detected on the day of the procedure (n=7), about 16% of items were detected 6-months or later post-procedure. The study found that complex or lengthy procedures were more likely to lead to a retained item, and many retained items, such as drains or catheters, occur in postoperative settings where surgical counts are not applicable.

What constitutes effective team communication after an error?

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Hart WM, Doerr P, Qian Y, et al. AMA J Ethics. 2020;22:E298-E304.

Communication has become a foci of improvement efforts across the spectrum of patient safety. This article discusses a surgical complication incident that illustrates the importance of transparency, disclosure and collaboration as elements of a successful approach to communication that can successfully manage the impact of an adverse incident.

“This is the wrong patient's blood!”: Evaluating a Near-Miss Wrong Transfusion Event

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January 29, 2020

A 74-year-old male with a history of hypertension, hyperlipidemia, paroxysmal atrial fibrillation, coronary artery disease, congestive heart failure with an EF of 45%, stage I chronic kidney disease and gout presented for a total hip replacement.

Design and impact of a novel surgery-specific second victim peer support program.

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El Hechi MW, Bohnen JD, Westfal M, et al. J Am Coll Surg. 2019;230:926-933.

This paper describes the implementation of a "second victim" peer-support program in the surgery department at a tertiary care center. The program trained surgical attendings and trainees to provide peer-support for other surgeons involved in major adverse events. After one-year follow-up, 81% of affected surgeons elected to receive peer support. The majority (81%) felt the program had a positive impact on safety culture by providing a confidential, safe, and timely intervention for so-called "second victims". A 2011 Perspective on Safety with Dr. Albert Wu discussed ways that organizations can support "second victims."

Office-based surgery and patient outcomes.

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Young S, Shapiro FE, Urman RD. Curr Opin Anaesthesiol. 2018;31:707-712.

Office-based surgery is increasingly common, despite concerns regarding its safety. This review summarizes the literature on ambulatory surgery outcomes and identified risk factors such as case complexity, patient comorbidities, and anesthesia use. Few studies examined anesthesia use in dental care.

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