Patient falls in the operating room setting: An analysis of reported safety events.

INTRODUCTION: Patient falls are a preventable public health problem, and they are among the most reported safety incidents in the hospital. We used a hospital safety reporting system to examine the nature of reported falls in the perioperative setting at an academic tertiary center. METHODS: In this retrospective study, reports of perioperative safety events listed as "Falls" between 2014 and 2020 were analyzed for severity level and specific event type. RESULTS: Out of 8337 safety reports from 2014 to 2020, 86 were "fall" related (1%). The most common "fall" event type was "ambulating with assistance and the severity level reported was mainly level 1 (no harm, did reach patient, 63%) followed by level 2 (temporary or minor harm, 28%). One of the most frequently reported types of perioperative falls was from a bed or stretcher (15% of falls)". CONCLUSIONS: Our safety data reporting system identified falls as a safety event that causes patient harm in the perioperative setting that could be preventable with a multifaceted interdisciplinary approach. Risk managers can use these data to implement strategies to reduce falls such as creating screening protocols to identify high-risk patients, educating and training healthcare personnel, and optimizing operating room, hospital, and equipment design.

Airway management in the operating room setting: An analysis of reported safety events.

Adverse event reporting systems are important tools for identifying areas of risk and opportunities quality improvement. Perioperative airway management (PAM) carries patient risk. We examine the nature of PAM incident reports at an academic tertiary care center. In this retrospective data review, perioperative safety reports filed under "Airway Management" between 2015 and 2020 were analyzed. Data analyzed included severity level (patient harm) and specific event type. There was a total of 7827 safety reports filed from January 2015 to July 2020, with 67 reports related to "Airway Management" (0.85%). The most common specific event type in this safety reporting database was "Intubation Injury (Mouth, Tooth, Airway)" (35.8%). The most common severity level of all reported events was level 2 (temporary or minor harm, 57%). Our safety reporting data demonstrates that adverse events related to PAM are likely to reach the patient and can cause significant harm. Data from our findings can help providers and risk managers to focus efforts on reducing patient harm. Strategies include continued education in technical skills and crisis management, preparation for the difficult airway, increased availability of video laryngoscopes, ongoing safety reporting and collaborative review of adverse events with implementation of quality improvement measures.

The nature of reported safety events related to care coordination in the operating room setting in a tertiary academic center.

Adverse event reporting systems are important tools for identifying areas of risk and opportunities for education and improvement. Our goal was to examine the nature of perioperative incident reports related to care coordination that were filed by staff at an academic tertiary care center. In this retrospective data review, perioperative safety reports between 2015 and 2020 were analyzed. Information examined included the type of staff who initiated the report, location of the incident, type of incident and the severity level of event, including patient harm. Out of the 7827 reports evaluated, 61.2% of reports were filed by nurses, and 5.6% by physicians. We investigated one particular category called "coordination of care" and found the specific event most commonly reported was insufficient handoff (15.0%-26.9%), with severity level reported primarily being no to minor harm reaching the patient. However, communication failures were judged to be one of leading causes of inadvertent harm. It is imperative for hospital incident reporting systems to collect data on issues related to communication failures and to design interventions with the help of frontline staff to provide high quality, safe care to patients and to remain compliant with regulatory requirements and hospital policies.