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Adverse Health Events in Minnesota: Annual Reports.

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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.

High-reliability organisation principles implemented in dentistry.

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Minyé HM, Benjamin EM. Br Dent J. 2022;232:879-885.

High reliability organization (HRO) principles used in other high-risk industries (such as aviation) can be applied patient safety. This article provides an overview of how HRO principles (preoccupation with failure, situational awareness, reluctance to simplify, deference to expertise, and commitment to resilience) can be successfully applied in dentistry.

Does root cause analysis improve patient safety? A systematic review at the Department of Veterans Affairs.

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Shah F, Falconer EA, Cimiotti JP. Qual Manag Health Care. 2022;Epub Feb 15.

Root cause analysis (RCA) is a tool commonly used by organizations to analyze safety errors. This systematic review explored whether interventions implemented based on RCA recommendations were effective at preventing similar adverse events in Veterans Health Affairs (VA) settings. Of the ten retrospective studies included in the review, all reported improvements following RCA-recommended interventions implementation, but the studies used different methodologies to assess effectiveness. The authors suggest that future research emphasize quantitative patient-related outcome measures to demonstrate the impact and value of RCAs.

Curated Libraries

COVID-19 Pandemic Impact on Healthcare Associated Conditions

National Healthcare Quality and Disparities Reports.

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Rockville, MD: Agency for Healthcare Research and Quality.

In this annual publication, AHRQ reviews the results of the National Healthcare Quality Report and National Healthcare Disparities Report. The 2021 report highlights that a wide range of quality measures have shown improvement in quality, access, and cost.

The July Effect in podiatric medicine and surgery residency.

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Casciato DJ, Thompson J, Law R, et al. J Foot Ankle Surg. 2021;60:1152-1157.

The "July Effect" refers to the idea there may be an increase in medical errors in July when newly graduated medical students begin their residencies. In this retrospective chart review of podiatric surgery patients, researchers did not find any statistically significant difference in patient outcomes between surgeries performed during the first quarter of residency (July-September) and the last quarter (April-June). Results suggest robust resident training programs can limit errors that may otherwise occur during this time of transition.

Wrong Site Surgery–Wrong Tooth Extraction.

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Farnborough, UK: Healthcare Safety Investigation Branch; April 22, 2021.

Wrong-site surgery in dentistry is a frequent and persistent never event. This report examines a case of pediatric wrong tooth extraction to reveal how the application of safety standards is influenced by the work environment and discusses the use of forcing functions to create barriers to error in practice.

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.

How satisfied are patients and surgeons with telemedicine in orthopaedic care during the COVID-19 pandemic? A systematic review and meta-analysis.

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Chaudhry H, Nadeem S, Mundi R. Clin Orthop Relat Res. 2021;479:47-56.

The COVID-19 pandemic has dramatically increased the use of telehealth across various medical specialties.This systematic review did not identify any differences in patient or surgeon satisfaction or patient-reported outcomes with telehealth for orthopedic care delivery as compared to in-person visits.However, the authors note that the included studies did not adequately capture or report safety endpoints, such as complications or missed diagnoses.

Safety of surgical telehealth in the outpatient and inpatient setting.

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Purnell S, Zheng F. Surg Clin North Am. 2020;101:109-119.

COVID-19 restrictions and patient concerns have expanded access to telemedicine worldwide. This review examines the use of telemedicine in surgical services. The authors found it to be a safe care modality for low-risk patients receiving low-risk procedures. They found that telemedicine in surgical services evidence base is expanding and its value is built on local, real-time approaches that involve services designed to consider patient needs and comfort.

Patient Safety.

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Levett-Jones T, ed. Clin Sim Nurs. 2020;44(1):1-78; 2020;45(1):1-60.

Simulation is a recognized technique to educate and plan to improve care processes and safety. This pair of special issues highlights the use of simulation in nursing and its value in work such as communication enhancement, minority population care, and patient deterioration.

Nonoperating room anaesthesia: safety, monitoring, cognitive aids and severe acute respiratory syndrome coronavirus 2.

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Borshoff DC, Sadleir P. Curr Opin Anaesthesiol. 2020;33:554-560.

The COVID-19 pandemic has resulted in the delivery of anesthesia outside of operating rooms, such as in emergency departments, intensive care units, and makeshift field hospitals. This review examines challenges in maintaining patient safety while providing anesthesia services in nontraditional operating room environments.

Design and implementation of the infection prevention program into risk management: managing high level disinfection and sterilization in the outpatient setting.

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Sweet W, Snyder D, Raymond M. J Healthc Risk Manage. 2020.

This article describes one health system’s experience implementing an infection prevention program into risk management in an outpatient setting. Over a two-year period post-implementation, the system identified and corrected high-risk practices, increased compliance to device guidance, increased efficiency with the use of central sterile processing departments, and developed a staff competency training structure.

Health care provider factors associated with patient-reported adverse events and harm.

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Giardina TD, Royse KE, Khanna A, et al. Jt Comm J Qual Patient Saf. 2020;46:282-290.

This study analyzed self-reported adverse events captured on a national online questionnaire to determine the association between patient-reported contributory factors and patient-reported physical, emotional or financial harm. Contributory factors identified in the analysis focused on issues with health care personnel communication, fatigue, or response (e.g., doctor was slow to arrive, nurse was slow to respond to call button). These patient-reported contributory factors increased the likelihood of reporting any type of harm.

Eleven basic procedures/practices for dental patient safety.

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Perea-Pérez B, Labajo-González E, Acosta-Gío AE, et al. J Patient Saf. 2020;16.

Based on malpractice claims data in Spain, the authors propose eleven recommendations to mitigate preventable adverse events in dentistry. These recommendations include developing a culture of safety, improving the quality of clinical records, safe prescribing practices, using checklists in oral surgical procedures, and having an action plan for life-threatening emergencies in the dental clinic.

Finding dental harm to patients through electronic health record-based triggers.

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Walji MF, Yansane A, Hebballi NB, et al. JDR Clin Trans Res. 2020;5:271-277.

Building upon prior research developing trigger tools for identifying preventable errors in dentistry, this study reviewed 1,885 electronic health records (EHR) across four dental practices and found that 16% contained an adverse event. The most common events were pain (27.5%), hard tissue (14.8%) or soft tissue injuries (14.8%) and nerve injuries (13.3%). An EHR-based trigger tool can be an effective approach to identifying safety incidents and measuring the quality of care.

Preventable closed claims in the AANA Foundation closed malpractice claims database.

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Kremer MJ, Hirsch M, Geisz-Everson M, et al. AANA J. 2019;87.

This thematic analysis identified 123 events comprising malpractice claims in the closed claims database of the American Association of Nurse Anesthetists (AANA) Foundation that the investigators determined could have been prevented by the Certified Registered Nurse Anesthetist involved. Among the factors identified as being associated with preventable events were communication failures, violations of the AANA Standards for Nurse Anesthesia Practice, and errors in judgment.

The evolution of patient safety procedures in an oral surgery department

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Graham C, Reid S, Lord TC, et al. Br Dent J. 2019;226:32-38.

Reporting and avoidance of “never events,” such as a wrong tooth extraction, is important for providing consistently safe dental care. This article describes changes made in safety procedures, including introducing surgical safety briefings or huddles in an outpatient oral surgery unit of the United Kingdom’s National Health Service, that eliminated never events for more than two years.

Safety in office-based anesthesia: an updated review of the literature from 2016 to 2019

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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.

Organisation for Economic Co-operation and Development: Health at a Glance 2019.

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Safe primary care – prescribing; Safe acute care – surgical complications and health care-associated infections, Safe acute care – obstetric trauma. Chapters In: Organisation for Economic Co-operation and Development. Health at a Glance 2019: OECD Indicators, OECD Publishing, Paris: 2019.

This report documents the overall state of health care, based on an international analysis of population health and health system performance data, with specific chapters on patient safety in surgery, obstetrics and prescribing in primary care. The results identify areas for improvement while outlining areas of concern.

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