Developing surgical and anesthesia resident patient safety competencies through systems-based event analysis. Guide to curricular development and evaluation of longer-term resident perceptions.

Previous studies have demonstrated that residents participating in patient safety event investigations become more engaged in future patient safety activities. Currently, there is a gap in resident participation in patient safety event analyses. The objective was to develop and implement a sustainable, faculty-led curriculum for resident participation in patient safety event investigations and to evaluate resident perceptions of the training at least one year following completion of the training.

The Pursuing Excellence Collaborative: Engaging First-Year Residents and Fellows in Patient Safety Event Investigations.

Objectives: Resident and fellow engagement in patient safety event investigations (PSEIs) can benefit both the clinical learning environment's ability to improve patient care and learners' problem-solving skills. The goals of this collaborative were to increase resident and fellow participation in these investigations and improve PSEI quality.

Methods: This collaborative involved 18 sites-8 sites that had participated in a similar previous collaborative (cohort I) and 10 "new" sites (cohort II).

Implementation outcomes of the Structured and Codified SIG format in electronic prescription directions.

Objective: To determine the extent of implementation, completeness, and accuracy of Structured and Codified SIG (S&C SIG) directions on electronic prescriptions (e-prescriptions).

Materials And Methods: A retrospective analysis of a random sample of 3.8 million e-prescriptions sent from electronic prescribing (e-prescribing) software to outpatient pharmacies in the United States between 2019 and 2021.

COVID-19 aerosol transmission simulation-based risk analysis for in-person learning.

As educational institutions begin a school year following a year and a half of disruption from the COVID-19 pandemic, risk analysis can help to support decision-making for resuming in-person instructional operation by providing estimates of the relative risk reduction due to different interventions. In particular, a simulation-based risk analysis approach enables scenario evaluation and comparison to guide decision making and action prioritization under uncertainty. We develop a simulation model to characterize the risks and uncertainties associated with infections resulting from aerosol exposure in in-person classes.

Comparing the variability of ingredient, strength, and dose form information from electronic prescriptions with RxNorm drug product descriptions.

Objective: To determine the variability of ingredient, strength, and dose form information from drug product descriptions in real-world electronic prescription (e-prescription) data.

Materials And Methods: A sample of 10 399 324 e-prescriptions from 2019 to 2021 were obtained. Drug product descriptions were analyzed with a named entity extraction model and National Drug Codes (NDCs) were used to get RxNorm Concept Unique Identifiers (RxCUI) via RxNorm.

Using Proactive Risk Assessment (HFMEA) to Improve Patient Safety and Quality Associated with Intraocular Lens Selection and Implantation in Cataract Surgery.

Background: A proactive risk assessment using the Healthcare Failure Mode and Effect Analysis (HFMEA) process was completed on the intraocular lens (IOL) selection and implantation process to analyze system vulnerabilities that could cause patient harm. The three largest ophthalmology clinics based on patient surgical volume were studied in the analysis. The analysis included in-clinic eye measurements needed for IOL selection through the actual implantation of the lens in the operating room.

Design of a Novel Multifunction Decision Support Display for Anesthesia Care: AlertWatch® OR.

Background: This paper describes the design of a multifunction alerting display for intraoperative anesthetic care. The design was inspired by the multifunction primary flight display used in modern aviation.

Results: The display retrieves live data from multiple sources; the physiologic monitors, the anesthesia information management system, the laboratory values and comorbidities from patient's problem summary list, medical history or history & physical.

Medical Team Training Improves Team Performance: AOA Critical Issues.

Effective teamwork and communication can decrease medical errors in environments where the culture of safety is enhanced. Health care can benefit from programs that are based on teamwork, as in other high-stress industries (e.g.

Root Cause Analysis and Actions for the Prevention of Medical Errors: Quality Improvement and Resident Education.

The quality of care delivered by orthopedic surgeons continues to grow in importance. Multiple orthopedic programs, organizations, and committees have been created to measure the quality of surgical care and reduce the incidence of medical adverse events. Structured root cause analysis and actions (RCA2) has become an area of interest.

Development, implementation and evaluation of a patient handoff tool to improve safety in orthopaedic surgery.

Objective: To develop, implement and test the effect of a handoff tool for orthopaedic trauma residents that reduces adverse events associated with the omission of critical information and the transfer of erroneous information.

Design: Components of this project included a literature review, resident surveys and observations, checklist development and refinement, implementation and evaluation of impact on adverse events through a chart review of a prospective cohort compared with a historical control group.

Setting: Large teaching hospital.

The Future of Graduate Medical Education: A Systems-Based Approach to Ensure Patient Safety.

In the past 15 years, there has been growing recognition that improving patient safety must be more systems based and sophisticated than the traditional approach of simply telling health care providers to "be more careful." Drawing from his own experience, the author discusses barriers to systems-based patient safety initiatives and emphasizes the importance of overcoming those barriers. Physicians may be slow to adopt standardized patient safety initiatives because of a resistance to standardization, but faculty in training institutions have a responsibility to model safe, effective, systems-based approaches to patient care in order to instill these values in the residents they teach.

Effective followership: A standardized algorithm to resolve clinical conflicts and improve teamwork.

In healthcare, the sustained presence of hierarchy between team members has been cited as a common contributor to communication breakdowns. Hierarchy serves to accentuate either actual or perceived chains of command, which may result in team members failing to challenge decisions made by leaders, despite concerns about adverse patient outcomes. While other tools suggest improved communication, none focus specifically on communication skills for team followers, nor do they provide techniques to immediately challenge authority and escalate assertiveness at a given moment in real time.

The accreditation system after the "next accreditation system".

The Accreditation Council for Graduate Medical Education (ACGME) and the American Board of Medical Specialties and its member boards introduced the six domains of physician competency in 1999. This initiated a national dialogue concerning the elements of competency of the physician, and incorporation of these elements into the framework of evaluation of residents and fellows, as well as the educational programs within which they are trained. The next step in this process will be the ACGME's Next Accreditation System, which the authors describe in this commentary.