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Pérez Zapata AI, Rodríguez Cuéllar E, de la Fuente Bartolomé M, et al. Patient Saf Surg. 2022;16:7.
Trigger tools are one method of retrospectively detecting adverse events. In this study, researchers used data from 31 Spanish hospitals to validate a trigger tool in general and gastrointestinal surgery departments. Of 40 triggers, 12 were identified for optimizing predictive power of the trigger tool, including broad spectrum antibiotherapy, unscheduled postoperative radiology, and reintervention.

Ruskin KJ, ed. Curr Opin Anaesthesiol. 2021;34(6):720-765

Anesthesia services are high risk despite progress made in the specialty to improve its safety. This special section covers issues that affect anesthesia safety such as critical incident debriefing, human factors, and educational strategies.

Farnborough, UK: Healthcare Safety Investigation Branch; June 3, 2021.

Wrong site/wrong patent surgery is a persistent healthcare never event. This report examines National Health Service (NHS) reporting data to identify how ambulatory patient identification errors contribute to wrong patient care. The authors recommend that the NHS use human factors methods to design control processes to target and manage the risks in the outpatient environment such as lack of technology integration, shared waiting area space, and reliance on verbal communication at clinic.
This Primer provides an overview of the history and current status of the patient safety field and key definitions and concepts. It links to other Patient Safety Primers that discuss the concepts in more detail.
Elger BM, Esparaz JR, Nierstedt RT, et al. J Pediatr Surg. 2020;55.
Prior research has shown that engaging parents in promoting the surgical safety of pediatric patients is viewed positively by both parents and staff. In this study, researchers assessed the impact of a digital application, SafeStart, on parental engagement in surgical safety. The application was presented to parents via tablet and required parents to verify safety information for their child throughout the surgical process. They found that use of the application improved parents' knowledge of surgical safety and that parents preferred it to standard surgical consent processes.
Marcus RK, Lillemoe HA, Caudle AS, et al. Ann Surg. 2019;270:937-941.
Although the introduction of new technology in health care is crucial for advancing patient care, unintended consequences are a well-recognized safety challenge. In the field of surgery, innovation ranges from small improvements to drastic change, but there is no clearly established model for evaluating proposed innovations. This study examined the impact of a team of surgical quality officers and perioperative nurses tasked with reviewing proposed surgical innovations, including novel devices and procedures at a single cancer center. Investigators found that compared to the prior processes in place, this team evaluated new products more quickly, decreased the time between product proposal and the intraoperative trial if necessary, and reduced the rate of device-related complications from 10% to 0%. A past PSNet perspective discussed the evolution of patient safety in the field of surgery.

Health Aff (Millwood). 2018;37(11):1723-1908.

The Institute of Medicine report, To Err Is Human, marked the founding of the patient safety field. This special issue of Health Affairs, published 20 years after that report, highlights achievements and progress to date. One implementation study of evidence-based surgical safety checklists demonstrated that leadership involvement, intensive activities, and engagement of frontline staff are all critical to successful adoption of safety practices. Another study demonstrated that communication-and-resolution programs either decreased or did not affect malpractice costs, providing further support for implementing such programs. Experts describe the critical role of human factors engineering in patient safety and outline how to enhance the use of these methods. The concluding editorial by David Bates and Hardeep Singh points to progress in reducing hospital-acquired infections and improving medication safety in acute care settings and highlights remaining gaps in the areas of outpatient care, diagnostic errors, and electronic health record safety. In the related information, the Moore Foundation provides free access to five articles in this special issue.
Meyer TA, McAllister RK. Pharmacy Practice News. March 19, 2018.
Perioperative adverse drug events are common and understudied. Reporting on the complexity of medication administration during surgery, this news article reviews strategies to reduce risks of surgical adverse drug events. Specific tactics discussed include proactive problem identification, medication reconciliation, high-alert medication process vigilance, verbal order reduction, and information technology optimization.
Overdyk FJ, Dowling O, Newman S, et al. BMJ Qual Saf. 2016;25:947-953.
Use of the surgical safety checklist has been linked to improved patient outcomes, but checklist compliance has been variable. In this prospective trial, operating rooms (ORs) were equipped with remote video auditing and then cluster-randomized to either receive, or not receive, real-time feedback. Sign-in, timeout, and signout rates improved dramatically in both groups compared to the low baseline rates. ORs that received real-time feedback had significantly higher compliance scores than those that just had video recordings. Following this study period, all ORs received real-time feedback, resulting in pass rates up to 91% for sign-in, 95% for timeout, and 84% for signout. Mean turnover times for scheduled cases decreased with feedback, indicating enhanced efficiency. An accompanying editorial calls implementing videos with feedback the "next great leap forward" for patient safety. A recent PSNet perspective discussed the benefits of using video in clinical and educational settings.
Dixon JL, Mukhopadhyay D, Hunt J, et al. Am J Surg. 2016;211:1095-8.
In this study, researchers developed a system for surgical time-outs where scanning a patient's wristband launches a presentation on the operating room monitor, which includes a video of the patient stating his or her name, date of birth, surgical procedure, and operative laterality. Although these took longer than standard timeouts (79 seconds versus 49 seconds), 87% of operating room personnel preferred the digital version, and performance of key safety elements significantly improved.
Merry AF, Webster CS, Hannam J, et al. BMJ. 2011;343:d5543.
Drug administration errors are a major safety concern in anesthesiology, as even routine cases can require administration of several high-risk medications. In this randomized controlled trial, a novel system for drug administration was evaluated in comparison with usual anesthesia practice. The new system was designed according to human factors engineering principles and included proven safety measures such as barcode medication administration. Although fewer overall errors occurred with the new system, the reduction in administration errors occurred only when barcoding was performed consistently and safety alerts were heeded. The anesthesia field has long been a leader in patient safety, and in fact, some of the earliest studies in the patient safety field evaluated the role of human factors in anesthesia medication administration errors.
Schmid F, Goepfert MS, Kuhnt D, et al. Anesth Analg. 2011;112:78-83.
Anesthesia equipment alarms went off approximately once per minute during cardiac surgical procedures; however, 80% of these alarms had no clinical consequences. The difficulty of calibrating alarm systems was discussed in an AHRQ WebM&M interview with human factors engineering expert Donald Norman, PhD.

Health Aff (Millwood). 2010;29(9):1564-1619.

Articles in this special issue cover liability costs and defensive medicine, the gap in understanding diagnostic error, and the need for effective patient safety policy.
Nagpal K, Vats A, Lamb B, et al. Ann Surg. 2010;252:225-39.
This systematic review of 38 published studies identified communication failures in all phases of surgical care, including intraoperatively and during postoperative care. Such breakdowns in information transfer, particularly during handoffs, have been linked to adverse events in prior studies. A number of interventions have been proposed to address this issue, including standardized checklists—which were remarkably successful at reducing postoperative complications in a classic study—and incorporation of handoff techniques from other industries. An AHRQ WebM&M commentary discusses the disastrous consequences of an intraoperative communication breakdown.