Tiered huddle systems (THS) include staff at all levels of the organization- frontline healthcare workers, managers, directors, and executives- and have been shown to increase adverse event reporting and improve safety culture. This US health system implemented a three-level THS in hospital and ambulatory settings to increase event reporting. Based on an interrupted time series analysis, reporting increased for total safety events, including near misses.

… order to evaluate its impact on patient safety outcomes. … Shea T, De Cieri H, Vu T, et al. How is safety climate …

The COVID-19 pandemic has disrupted many aspects of health care delivery, including how hospitals prevent common hospital-acquired conditions such as pressure injuries. Based on retrospective data, the authors of this study did not identify a longitudinal increase in hospital-acquired pressure injuries between March and July 2020. The authors discuss how prior organizational efforts to reduce hospital-acquired pressure injuries allowed their hospital to quickly adapt existing workflows and processes to respond to the COVID-19 pandemic.

The increased use of telehealth during the COVID-19 pandemic has not been without challenges. This article uses the Systems Engineering Initiative for Patient Safety (SEIPS) model to assess barriers related to telehealth implementation during the pandemic and the impact on patients, providers, technology, care processes, organizations, and the environment.

This qualitative study examined incident reports about surgical patients, comparing trainee reports to those submitted by attending surgeons and nurses. Trainees were more likely to enter reports anonymously and completed more elements for each report, but they also used more blame language and submitted fewer reports overall. The results suggest that encouraging trainee reporting may shed light on surgical safety.

… to establish a culture that contributed to the program's sustained improvements. …

Change initiatives require broad-based collective design strategies to ensure the range of needs are addressed. This commentary explains how one hospital group used codesign methods to engage leadership in a teamwork and culture improvement project. The authors describe specific tools and tactics used to implement the work and summarize the value of the approach for other health care organizations.

… & safety … BMJ Qual Saf … Over the last decade, the Lucian Leape Institute has explored five key areas in health care to … , Dr. Tejal Gandhi, president of the IHI/NPSF Lucian Leape Institute, discussed improving patient safety at a …

This pre–post analysis found a significant drop in medication error rates after implementation of an antibiotic stewardship program. The authors attribute this improvement to pharmacist medication review, which has been shown to enhance medication safety across multiple settings.

Duty hour reform for trainees was undertaken to improve patient safety. However, experts have raised concerns that duty hour limits have reduced educational opportunities for trainees. This study randomized internal medicine residency programs to either standard duty hour rules from the Accreditation Council on Graduate Medical Education (ACGME) or less stringent policies that did not mandate the maximum shift length or time off between shifts. Investigators found that trainees in both groups spent similar amounts of time in direct patient care and educational activities, and scores on examinations did not differ. Interns in flexible duty hour programs reported worse well-being and educational satisfaction compared to those working within standard duty hours. As in a prior study of surgical training, program directors of flexible duty hour programs reported higher satisfaction with trainee education. These results may help allay concerns about detrimental effects of duty hour reform on graduate medical education. A PSNet perspective reviewed changes to the ACGME requirements to create flexibility for work hours within the maximum 80-hour workweek.

Analyzing data from a prior trial of flexible versus traditional duty hours, this study found that female residents perceived patient safety as worse than male residents. Changes in duty hours had mixed effects on these self-reported outcomes and seemed to exacerbate gender differences. The authors recommend further study to determine how to improve learning for trainees regardless of gender.