This randomized simulation study examined the use of checklists during simulated pediatric cardiac arrests in the surgical setting. Despite low uptake of the checklists, their availability during the simulations was associated with better performance. The authors recommend use of these checklists to enhance performance in rare critical situations.

Medication errors in anesthesia practice can result in serious patient harm. This commentary examines factors that affect safety of medication delivery in the operating room. The authors provide recommendations to help individuals improve the reliability of their practice and describe human factors to consider to enhance safety.

Overuse of unnecessary tests and procedures contributes to patient harm. In this cohort study, researchers found that patients who developed a hospital-acquired condition after undergoing a procedure that most likely should not have been performed had longer lengths of stay than patients who did not develop a hospital-acquired condition.

Clinical decision-making is a complex process affected by many factors and has important implications for patient outcomes. Using data from the Australian and New Zealand Audit of Surgical Mortality database over a 1-year period, researchers fully audited 3422 deaths and identified 226 cases involving a clinical decision-making incident (CDMI) thought to be concerning by reviewers. The most frequently noted incident was decision to operate, followed by diagnostic error and insufficient postoperative evaluation. The authors suggest that thorough discussion of complex cases in advance of surgery might mitigate CDMIs related to decisions to perform surgery and that retrospectively reviewing deaths for such CDMIs may supplement existing processes for reviewing and learning from surgical mortality. A WebM&M commentary discussed an incident involving a diagnostic error in which a patient was taken to the operating room for an unnecessary surgery.

Checklists like the Universal Protocol are a widely accepted strategy for reducing wrong site, wrong procedure, and wrong patient surgeries. The authors describe a campaign that improved checklist participation and completion in an academic hospital in Australia. A PSNet interview with Lucian Leape explored the challenges of achieving robust and universal use of checklists.

This hospital introduced large print, wall-mounted checklist posters in their operating rooms (ORs) and specifically assigned the leadership of each domain of the checklist to a different OR group (anesthesia, nursing, and surgery). These inexpensive changes led to improvements in team engagement and compliance with the surgical safety checklist process.

This review explores safety in cardiac surgery and suggests that the anesthesiologist in the surgical team is in the optimal position to maintain an overarching view of the care being provided to a patient, able to ensure that evidence-based practices are followed and appropriate care is delivered.

Organizations including The Joint Commission, the World Health Organization, and the Centers for Medicare and Medicaid Services have focused on improving surgical safety. Using Reason's Swiss cheese model, this review analyzes the evidence for surgical checklist implementation to determine its usefulness in preventing wrong-site surgery and recommends tactics to address weaknesses.

This observational study compared the implementation of the WHO Surgical Safety Checklist at a hospital in New Zealand with a neighboring hospital that had served as a pilot site for the study. They found that the pilot hospital adhered to the sign in, time out, and sign out procedures of the checklist more frequently than the hospital that adopted the checklist outside the context of a study. The non-pilot site did have engagement across more disciplines (anesthesia, surgery, nursing), compared with the nurse-only engagement at the pilot hospital. These findings shed light on the difficulty of implementing safety practices widely.

In the context of emergency surgery, this review summarizes error classification, error prevention strategies, and techniques for responding to adverse events.

This qualitative study, based on direct observation of 160 surgical procedures, found that communication breakdowns were significantly correlated with deviations from the expected length of the procedure.

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.

This survey found that anesthesiologists minimized the impact of attitudinal and emotional barriers on reporting unspecified adverse events, except for concerns about being blamed by colleagues. For specified events, the influence of perceived barriers was dependent on whether an error actually occurred.

Discussing the importance of labeling in anesthesia, this commentary makes recommendations to reduce medication errors.

This qualitative study used interviews with operating room personnel to identify aspects of interpersonal relationships and organizational culture that affect teamwork and communication during surgical procedures.

This study used simulation-based training of anesthetists to demonstrate a reduction in error rates in tested scenarios.

This study used a simulated operating theater to evaluate anesthesiologists' error rates when faced with distractions during a clinical emergency. The authors advocate for using this research design to evaluate the effect of safety measures.

This study classifies the types and severity of errors in patients who were treated for trauma and subsequently died.