Skip to main content

All Content

Search Tips
Published Date
Original Publication Date
Original Publication Date
PSNet Publication Date
1 - 20 of 29

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.

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.

Berman L, Rialon KL, Mueller CM, et al. J Pediatr Surg. 2021;56:833-838.
Clinicians who are involved in an adverse even often experience emotional and psychological distress afterwards. A survey found that 80% of responding pediatric surgeons had personally experienced a medical error resulting in significant patient harm or death. Only one-quarter of those respondents were satisfied with the institutional support they received afterwards. Respondents cited numerous barriers (lack of trust, blame, shame) to receiving support.    
Buhlmann M, Ewens B, Rashidi A. J Clin Nurs. 2020;30:1195-1205.
Adverse events can have significant impacts on the providers involved. This systematic review explored the experiences of critical incidents on nurses and midwives and their perceived support from the healthcare system. The article discusses the emotional, physical, and professional impacts; perceptions of personal, peer and workplace support; and how nurses and midwives move forward and cope with the impact of critical incidents.  
Britton CR, Hayman G, Stroud N. J Perioper Pract. 2021;31:44-50.
The COVID-19 pandemic has highlighted the crucial role that team and human factors play in healthcare delivery. This article describes the impact of a human factors education and training program focused on non-technical skills and teamwork (the ONSeT project) – on operating room teams during the pandemic. Results indicate that the project improved team functioning and team leader responsiveness.
During surgery for a forearm fracture, a woman experienced a drop in heart rate to below 50 beats per minute. As the consultant anesthesiologist had stepped out to care for another patient, the resident asked the technician to draw up atropine for the patient. When the technician returned with an unlabeled syringe without the medication vial, the resident was reluctant to administer the medication, but did so without a double check after the technician insisted it was atropine. Over the next few minutes, the patient's blood pressure spiked to 250/135 mm Hg.
Royal College of Surgeons of England; RCS.
Physical demands and technical complexities can affect surgical safety. This resource is designed to capture frontline perceptions of surgeons in the United Kingdom regarding concerning behaviors exhibited by their peers during practice to facilitate awareness of problems, motivate improvement, and enable learning.
Arriaga AF, Sweeney RE, Clapp JT, et al. Anesthesiology. 2019;130:1039-1048.
Debriefing after a critical event is a strategy drawn from high reliability industries to learn from failures and improve performance. This retrospective study of critical events in inpatient anesthesiology practice found that debriefing occurred in 49% of the incidents. Debriefs were less likely to occur when critical communication breakdowns were involved, and more than half of crisis events included at least one such breakdown. Interviews with care teams revealed that communication breakdowns present in some incidents impeded the subsequent debriefing process. The authors call for more consistent implementation of debriefing as a recommended patient safety process. A previous WebM&M commentary discussed an incident involving miscommunication between a surgeon and an anesthesiologist.
BMJ. 2018;363:k3033.
Patients who experience care complications are vulnerable to psychological consequences that can affect their relationship with their clinical teams. This commentary relates insights from a patient who experienced complications resulting from care, the negative impact on her relationship with her surgeon, and how she felt when her surgeon expressed empathy. The author offers recommendations for clinicians to demonstrate their concern and improve practice when problems occur.
Lee S-H, Khanuja HS, Blanding RJ, et al. J Patient Saf. 2021;17:e582-e586.
Poor teamwork in operating rooms is associated with higher postoperative complication and mortality rates. The TeamSTEPPS program has successfully enhanced operating room teamwork, but behavioral changes are difficult to sustain. This pre–post cohort study showed that a TeamSTEPPS reinforcement program improved surgical staff leadership and communication.
Cohen E. CNN. March 24, 2016.
Poor communication regarding medical errors can contribute to patient and family frustration and fear. Reporting on a case involving disclosure of a wrong-site surgery, this news article describes a resolution program to help patients cope after a preventable error. The program includes apology, disclosure, and explanation of what occurred as well as financial compensation.
Sanfey H, Fromson J, Mellinger J, et al. J Am Coll Surg. 2015;221:621-7.
Physician burnout has been linked to medical errors among surgeons. This national survey study of 212 surgeons identified differences in how male and female surgeons deal with seeking assistance when under stress. Men and women worked similar hours, but female surgeons were less satisfied with work–life balance and personal fulfillment. Male surgeons were more likely to seek support from colleagues or friends, whereas women tended to go to professional counselors.
Ford DA. AORN J. 2015;102:85-9.
Noise in health care settings can hinder communication and contribute to distractions. This commentary discusses noise in the operating room and reviews strategies for nurses to reduce its presence, including raising awareness of the problem, enhancing team communication, and designing alarm management initiatives.
Balogun JA, Bramall AN, Bernstein M. J Surg Educ. 2015;72:1179-84.
According to this qualitative study, surgery resident physicians perceive that catastrophic errors result from system problems and provide lessons for future practice. Participants did not feel comfortable discussing errors with staff and reported work culture as a barrier to asking for support, demonstrating the need to teach trainees about error disclosure.
Abd Elwahab S, Doherty E. The Surgeon. 2014;12.
Medical errors affect not only the patients and families involved, but the clinicians and organization as well. This commentary focuses on physicians as second victims and how mistakes influence their emotional health, stress levels, and work performance.
Weaver SJ, Rosen MA, DiazGranados D, et al. Jt Comm J Qual Patient Saf. 2010;36:133-42.
Teamwork training programs continue to emerge despite past reviews suggesting their mixed effectiveness in changing behavior. This study conducted a multilevel evaluation of the TeamSTEPPS training program within an operating room service line and used a comparison unit at a separate facility. Following a 4-hour didactic program, the trained group demonstrated increases in the quantity and quality of presurgical procedure briefings and the use of teamwork behaviors observed during cases. Similar to past efforts, increases were also noted in perceptions of safety culture and teamwork attitudes. This study adds to the literature by employing a multilevel evaluation strategy, using a comparison unit, and observing actual behavior change that was attributed to the training. Patient outcomes were not part of the measurement strategy.