Implementation challenges can hinder the effectiveness of the WHO Surgical Safety Checklist (SSC). This study describes the validation of the Checklist Performance Observation for Improvement (CheckPOINT) tool to assess SSC implementation fidelity. Based on testing in simulated and real-life clinical practice, researchers found that that the tool can reliably assess implementation fidelity and identify opportunities for improvement.

Patient falls are associated with poorer clinical outcomes, and increased costs to the health system. This study describes the economic costs of implementing the Fall Tailoring Interventions for Patient Safety (Fall TIPS) Program in eight American hospitals. Results show the Fall TIPS program reduced falls by 19%, avoiding over $14,000 of costs per 1,000 patient days.

An accurate understanding of the frequency, severity, and preventability of adverse events is required to effectively improve patient safety. This study included review of more than 2,800 inpatient records from 11 American hospitals with nearly one quarter having at least one preventable or not preventable adverse event. Overall, approximately 7% of all admissions included at least one preventable event and 1% had a severity level of serious or higher. An accompanying editorial by Dr. Donald Berwick sees the results of this study as a needed stimulus for leadership to prioritize patient safety anew.

Structured tools are increasingly used to identify diagnostic errors and related harms using electronic health record data. In this study, researchers compared the performance of two validated tools (Safer Dx and the DEER taxonomy) to identify diagnostic errors among patients with preventable or non-preventable deaths. Findings indicate that diagnostic errors and diagnostic process failures contributing to death were higher in preventable deaths (56%) but were also present in non-preventable deaths (17%).

Disruptive behavior includes behaviors that show disrespect for others and impede safe delivery of patient care. This commentary presents a framework for new physician managers to address disruptive behavior modeled after clinical medicine: diagnose, treat, prevent. The authors stress maintaining curiosity during the “diagnostic” phase, careful consideration of “treatment” and follow-up, and “prevention” of future disruption though intentional training and building a culture of safety.

Adverse events can be identified through multiple methods, including trigger tools and voluntary reporting systems. In this comparison study, the Global Trigger Tool identified 79 AE in 88 oncology patients, compared to 21 in the voluntary reporting system; only two AE were identified by both. Results indicate multiple sources should be used to detect AE.

Patient safety dashboards are used to communicate real-time patient data to appropriately augment care. This study found that higher usage of an electronic patient safety dashboard resulted in lower 30-day readmission rates among patients discharged from adult medicine units compared to lower usage groups.

Labor and delivery is a high-risk care environment. This study evaluated a quality improvement initiative (TeamBirth) designed to promote shared decision-making and safety culture in labor and delivery. This mixed-methods study included both clinicians and patients at four hospitals and found that the program was feasible, increased the use of huddles, and had no negative effects on patient safety.

Checklists and other cognitive aids are used in a variety of clinical settings to improve patient safety. Building on an example from emergency medicine, the authors highlight the importance of implementation science methods to ensure the most effective use of these cognitive aids.

Debriefing is an established strategy teams use to learn from critical events, reduce event occurrence, and improve failure response. This review examines how debriefing principles can be embedded for use of the practice in real time, rather than developed in simulated circumstances, to improve anesthesia safety.

This study examined variation in operative technical skills among patients undergoing colorectal and non-colorectal procedures and the association with patient outcomes. Higher technical skills were significantly associated with lower rates of complications, unplanned reoperations, and death or serious morbidity. The findings suggest that this skill variation accounts for more than 25% of the variation in patient outcomes.

As part of a quality improvement initiative to enhance surgical onboarding, the authors used semi-structured interviews with 20 physicians to understand potential areas of risk when a physician begins working in an unfamiliar setting. Qualitative analysis found that three key findings: (1) physicians often receive little to no onboarding when starting to practice in a new setting, which can limit their ability to provide safe care; (2) physicians felt onboarding inadequately fostered strong interpersonal relationships among health care teams, which impedes psychological safety and team cohesion, and; (3) physicians noted an increased risk of patient harm during emergency situations in new settings due to lack of understanding of culture, workflow, roles/responsibilities and available equipment.

… Jt Comm J Qual Patient Saf … The Fall TIPS (Tailoring Interventions …

… Am J Surg … Using a human factors engineering framework, this study reviewed video of residents performing a simulated hernia repair to identify and characterize errors … and commission errors (69%; defined as failure to perform a surgical step correctly). Nearly half of all errors went …

Checklists are a popular yet controversial strategy for improving the safety of frontline care. The authors in this commentary debate the weaknesses and strengths of checklists through a discussion of the evidence.

… Journal of clinical medicine research … J Clin Med Res … Ambulatory surgery centers are increasingly … environment. Researchers describe efforts to implement a surgical safety checklist and infection control techniques …

Debriefing after a critical event is a strategy drawn from high reliability industries to learn from failures and improve performance. This retrospective study of critical events in inpatient anesthesiology practice found that debriefing occurred in 49% of the incidents. Debriefs were less likely to occur when critical communication breakdowns were involved, and more than half of crisis events included at least one such breakdown. Interviews with care teams revealed that communication breakdowns present in some incidents impeded the subsequent debriefing process. The authors call for more consistent implementation of debriefing as a recommended patient safety process. A previous WebM&M commentary discussed an incident involving miscommunication between a surgeon and an anesthesiologist.

This study in the Health Affairs patient safety theme issue examines the implementation of surgical safety checklists. Checklists have been shown to improve patient outcomes in randomized control trials, but implementation studies have not consistently demonstrated similar improvements. In this statewide initiative, implementation of the checklist varied significantly among sites. Factors associated with more successful implementation included greater leadership participation, frontline engagement, and more frequent activities for all involved groups, including surgeons, nurses, technicians, and administrators. Sites that invested more funding and time also saw greater checklist implementation. The authors conclude that hospitals that participated more did better. Past PSNet interviews with Lucian Leape and David Urbach discussed their perspectives on surgical safety checklists.

… without substantially lengthening rounding time. A past PSNet interview discussed the safety benefits of …

… Researchers describe the development and implementation of a multicomponent safety intervention bundle developed to … decreased, the intervention did not lead to a reduction in the rate of potentially harmful errors. A past PSNet perspective discussed the use of smart pumps to …