Weaving a healthcare tapestry of safety and communication.

James Hay; Susan Collin; Suzy Koruth

Commentary

Weaving a healthcare tapestry of safety and communication.

July 16, 2014

Hay J, Collin S, Koruth S. Nurs Manage. 2014;45(7):40-6.

View more articles from the same authors.

This commentary describes how a medical-surgical unit developed an initiative that combined nursing theory, compassion, clinical nurse leadership, and crew resource management to bolster implementation of a morning briefing to improve safety culture and staff communication.

PubMed citation

Available at

Related Resources From the Same Author(s)

Effect of behavioral interventions on inappropriate antibiotic prescribing among primary care practices: a randomized clinical trial.

February 24, 2016

Patient safety: disclosure of medical errors and risk mitigation.

August 3, 2016

System issues leading to "found-on-floor" incidents: a multi-incident analysis.

January 27, 2021

Leadership oversight for patient safety programs: an essential element.

January 17, 2018

Reduction in warfarin adverse events requiring patient hospitalization after implementation of a pharmacist-managed anticoagulation service.

June 1, 2005

Clinical reasoning in the wild: premature closure during the COVID-19 pandemic.

August 19, 2020

Investigating the causes of adverse events.

June 7, 2017

Racial disparities in diagnostic delay among women with breast cancer.

August 18, 2021

Medication administration variances before and after implementation of computerized physician order entry in a neonatal intensive care unit.

January 16, 2008

The effects of the second victim phenomenon on work-related outcomes: connecting self-reported caregiver distress to turnover intentions and absenteeism.

December 21, 2016

Patient safety culture and the second victim phenomenon: connecting culture to staff distress in nurses.

August 10, 2016

The Second Victim Experience and Support Tool: validation of an organizational resource for assessing second victim effects and the quality of support resources.

October 22, 2014

The response of the APPD, CoPS and AAP to the Institute of Medicine report on resident duty hours.

April 7, 2010

Discharge rounds in the 80-hour workweek: importance of the trauma nurse practitioner.

September 26, 2007

Using a bar-coded medication administration system to prevent medication errors in a community hospital network.

December 21, 2005

The incidence and nature of adverse events during pediatric sedation/anesthesia with propofol for procedures outside the operating room: a report from the Pediatric Sedation Research Consortium.

March 18, 2009

Interactive questioning in critical care during handovers: a transcript analysis of communication behaviours by physicians, nurses and nurse practitioners.

May 28, 2014

No excuses: the reality that demands action.

September 1, 2005

Incidence and nature of adverse events during pediatric sedation/anesthesia for procedures outside the operating room: report from the Pediatric Sedation Research Consortium.

October 18, 2006

ASHP guidelines on preventing medication errors with chemotherapy and biotherapy.

April 22, 2015

Missed and delayed diagnoses of non-COVID conditions--collateral harm from a pandemic.

August 5, 2020

A serious threat to patient safety: the unintended misuse of FentaNYL patches.

May 1, 2013

Sounding the alarm. Nurses, organizations work to address alarm fatigue.

November 20, 2013

The role of nursing surveillance in keeping patients safe.

August 15, 2012

Accelerating the adoption of a safety culture.

April 1, 2015

What's in your kit? A safety checkup may be in order.

November 25, 2015

Do not put medication safety "on hold" with boarded patients.

July 28, 2010

Social risk, health inequity, and patient safety.

October 5, 2022

High-alert medications: shared accountability for risk identification and error prevention.

September 29, 2010

Identified safety risks with splitting and crushing oral medications.

April 7, 2010

Weighing in on medication safety.

December 2, 2009

Choosing the right strategy for medication error reduction—part I and part II.

July 2, 2008

Failure mode and effects analysis: a useful tool for risk identification and injury prevention.

August 8, 2007

Standardizing safety.

August 9, 2006

Is patient safety synonymous with quality nursing care? Should it be? A brief discourse.

November 2, 2005

An elusive balance — residents' work hours and the continuity of care.

July 4, 2007

A safe haven for nurses to report medication errors? Clarian and Spectrum Health Systems prove it is possible!

September 14, 2005

Supporting involved health care professionals (second victims) following an adverse health event: a literature review.

August 15, 2012

Leadership behaviors, attitudes and characteristics to support a culture of safety.

September 28, 2022

Health care professionals as second victims after adverse events: a systematic review.

October 24, 2012

Assessing and monitoring override medications in automated dispensing devices.

May 31, 2006

High-risk, high-alert medication management practices in a regional state psychiatric facility.

May 9, 2007

The role of education in developing a culture of safety through the perceptions of undergraduate nursing students: an integrative literature review.

January 9, 2019

The complexity, diversity, and science of primary care teams.

June 20, 2018

When clinicians drop out and start over after adverse events.

March 14, 2018

Measuring nursing error: psychometrics of MISSCARE and practice and professional issues items.

June 3, 2015

Implementation of a rapid response team: a success story.

June 17, 2009

The COVID trap: pediatric diagnostic errors in a pandemic world.

August 25, 2021

Rapid response systems: from implementation to evidence base.

November 3, 2010

Implementation and outcomes of a rapid response team.

October 3, 2007

Theoretical approaches for investigating patient safety.

June 1, 2005

Frequency and nature of potentially harmful preventable problems in primary care from the patient's perspective with clinician review: a population-level survey in Great Britain.

September 26, 2018

Care at the point of impact: insights into the second-victim experience.

May 18, 2016

Interruptions during nurses' work: a state-of-the-science review.

April 17, 2013

Situation, background, assessment, and recommendation–guided huddles improve communication and teamwork in the emergency department.

December 16, 2015

The limits of checklists: handoff and narrative thinking.

June 25, 2014

Medication safety in acute care in Australia: where are we now? Part 2: a review of strategies and activities for improving medication safety 2002-2008.

October 14, 2009

Medication safety in acute care in Australia: where are we now? Part 1: a review of the extent and causes of medication problems 2002-2008.

September 16, 2009

The development of the National Reporting and Learning System in England and Wales, 2001-2005.

June 7, 2006

The role of information technology in healthcare communications, efficiency, and patient safety: application and results.

April 25, 2007

Frequency and severity of parenteral nutrition medication errors at a large children's hospital after implementation of electronic ordering and compounding.

August 19, 2015

Safe injection, infusion, and medication vial practices in health care (2016).

April 6, 2016

Barriers to emergency departments' adherence to four medication safety–related Joint Commission National Patient Safety Goals.

January 21, 2009

Alarm system management: evidence-based guidance encouraging direct measurement of informativeness to improve alarm response.

April 1, 2015

Patient safety culture transformation in a children's hospital: an interprofessional approach.

April 30, 2014

The morbidity and mortality meeting: time for a different approach?

December 2, 2015

A piece of my mind. Despite my best intentions.

November 22, 2017

Patient Safety.

February 8, 2012

A piece of my mind. I'm sorry.

July 1, 2015

The future of graduate medical education: a systems-based approach to ensure patient safety.

July 22, 2015

Using information to optimize medical outcomes.

June 17, 2009

Could it happen here? Learning from other organizations' safety errors.

November 12, 2008

Getting boards on board: engaging governing boards in quality and safety.

April 2, 2008

Patient safety: lessons learned.

March 1, 2006

The evolution of the apology.

February 7, 2007

When incidents happen.

August 2, 2006

How I minimize mistransfusion risk in my hospital.

July 26, 2006

Patient safety: what is really at issue?

October 26, 2005

The enabling, enacting, and elaborating factors of safety culture associated with patient safety: a multilevel analysis.

September 9, 2020

The effect of nursing care delivery models on quality and safety outcomes of care: A cross‐sectional survey study of medical‐surgical nurses.

November 6, 2019

Improving medication management through the redesign of the hospital code cart medication drawer.

January 18, 2012

Clinical decision support and malpractice risk.

July 13, 2011

"Teach-back" from a patient's perspective.

March 2, 2016

Frontline nurses' clinical judgment in recognizing, understanding, and responding to patient deterioration: a qualitative study.

April 5, 2023

Improving communication from hospital to skilled nursing facility through standardized hand-off: a quality improvement project.

January 25, 2023

Patient safety: numerical skills and drug calculation abilities of nursing students and Registered Nurses.

March 31, 2010

Copying and pasting of examinations within the electronic medical record.

August 30, 2006

Improving medication reconciliation in the outpatient setting.

May 2, 2007

Medical team training improves team performance: AOA critical issues.

October 18, 2017

COVID-19 has united patients and providers against institutional betrayal in health care: a battle to be heard, believed, and protected.

August 19, 2020

Safety measurement and monitoring in healthcare: a framework to guide clinical teams and healthcare organisations in maintaining safety.

May 21, 2014

What I wish I’d known: how experienced physician managers diagnose, treat and prevent disruptive behaviour.

September 21, 2022

Diagnostic time-outs to improve diagnosis.

April 20, 2022

Perianesthesia nursing advocacy: an influential voice for patient safety.

June 11, 2008

An intervention to enhance nursing staff teamwork and engagement.

February 21, 2007

Identifying hospitalized patients at risk for harm: a comparison of nurse perceptions vs. electronic risk assessment tool scores.

July 19, 2017

Second victims and mindfulness: a systematic review.

August 21, 2019

The risks to patient safety from health system expansions.

April 18, 2018

Applied use of safety event occurrence control charts of harm and non-harm events: a case study.

July 20, 2016

Resident to resident handoffs in the emergency department: an observational study.

October 22, 2014

Related Resources

Annual Perspective

Improving Diagnostic Safety and Quality

April 26, 2023

Rooting an error review process in just culture: lessons learned.

October 5, 2022

Annual Perspective

Annual Perspective: Psychological Safety of Healthcare Staff

March 31, 2022

Understanding the peer, manager, and system influence on patient safety.

February 10, 2021

Nurse burnout predicts self-reported medication administration errors in acute care hospitals.

January 20, 2021

Detecting medication administration errors.

September 18, 2019

When safety climate is not enough: examining the moderating effects of psychosocial hazards on nurse safety performance.

August 28, 2019

Nurses' safety motivation: examining predictors of nurses' willingness to report medication errors.

August 7, 2019

Organisational learning in hospitals: a concept analysis.

June 19, 2019

Targeting the fear of safety reporting on a unit level.

March 20, 2019

Decreasing surgical site infections by developing a high reliability culture.

February 6, 2019

The role of education in developing a culture of safety through the perceptions of undergraduate nursing students: an integrative literature review.

January 9, 2019

Are clinical instructors preventing or provoking adverse events involving students: a contemporary issue.

October 10, 2018

Impact of nurse peer review on a culture of safety.

October 3, 2018

Preventing medication errors in the information age.

September 5, 2018

A national study links nurses' physical and mental health to medical errors and perceived worksite wellness.

March 21, 2018

Practical application of high-reliability principles in healthcare to optimize quality and safety outcomes.

February 7, 2018

Incorporating quality and safety values into a CLABSI simulation experience.

September 28, 2016

Using Kotter's change model for implementing bedside handoff: a quality improvement project.

August 24, 2016

Nurses' role in medical error recovery: an integrative review.

April 20, 2016

Nurses' perspectives regarding the disclosure of errors to patients: a qualitative study.

December 17, 2014

Accountability in nursing practice: why it is important for patient safety.

December 10, 2014

Work-arounds observed by fourth-year nursing students.

November 19, 2014

Should I report? A qualitative study of barriers to incident reporting among nurses working in nursing homes.

October 29, 2014

Relationship of adverse events and support to RN burnout.

October 8, 2014

Speaking up: factors and issues in nurses advocating for patients when patients are in jeopardy.

August 27, 2014

Some IV medications are diluted unnecessarily in patient care areas, creating undue risk.

July 2, 2014

Nursing student medication errors: a snapshot view from a school of nursing's quality and safety officer.

February 26, 2014

Feeling safe during an inpatient hospitalization: a concept analysis.

February 5, 2014

'You talking to me?' Docs and feedback.

September 18, 2013

See More About The Topic

Hospitals

Nurses

Nurse Managers

Quality and Safety Professionals

Organizational Behaviorists

Weaving a healthcare tapestry of safety and communication.

Connect With Us

Sign up for Email Updates

Agency for Healthcare Research and Quality

Weaving a healthcare tapestry of safety and communication.

Connect With Us

Sign up for Email Updates

Agency for Healthcare Research and Quality

PSNet Log in

Submit Your Case

Continue as a Guest

Continue Logged In

Submit Your Case

Continue as a Guest

Already have a PSNet

Account?

New Users

Submit Your Innovations

Continue as a Guest

Continue Logged In

Submit Your Innovations

Continue as a Guest

Continue logged in

New Users to the PSNet site