Learning collaboratives within the Canadian Patient Safety Institute are working to implement the Measurement and Monitoring of Safety Framework (MMSF). This paper describes the collaboratives’ experiences with integrating MMSF into their organizations. Hospitals reported small scale success and described challenges with implementation when the Framework was not aligned with existing quality and safety processes.

Implementation science is the practice of applying research to healthcare policies and practices. This study explores the role of implementation science in the success of quality improvement projects. Inclusion of expert implementation specialists and coaches were identified as best practices for successful quality improvement and patient safety projects. COVID-19 presented challenges for some facilities, however, including halting previously successful projects.

Achieving high reliability is a goal for every healthcare organization. Based on interviews with hospital leadership, clinicians, and staff, this study explored how healthcare professionals understand and perceive high-reliability principles. Findings indicate that some principles are more supported than others and identified inconsistent understanding of principles across different types of healthcare professionals.

This article describes learning collaboratives conducted by the Canadian Patient Safety Institute and Canadian Home Care Association aimed at increasing capacity and capability to improve healthcare quality and mitigate and prevent harm from homecare safety incidents such as falls.

Engaging patients and their families in quality and safety is considered central to providing truly patient-centered care. This systematic review included 48 studies involving the input of patients, family members, or caregivers on health care quality improvement initiatives to identify factors that facilitate successful engagement, patients' perceptions regarding their involvement, and patient engagement outcomes.

Adverse events occur frequently in the home care setting. A previous study estimated that about 10% of patients receiving home care experienced an adverse event, and research suggests that a significant proportion of these may be preventable. Early identification of patients at increased risk for harm in the home care setting may help inform hospital discharge planning and improve patient safety. Analyzing data from two prior Canadian home care patient safety studies, researchers found that both increased dependency for instrumental activities of daily living and a higher number of comorbid medical conditions placed patients at greater risk for adverse events. A past PSNet perspective discussed safety issues associated with care transitions after hospital discharge.

Research has established that disclosure of medical errors to patients and families is essential for maintaining a therapeutic alliance. However, less is known about what patients and families may expect regarding the disclosure of near misses. In this interview study, parents of hospitalized children expressed varying preferences surrounding disclosure of errors, near misses, and the degree to which they desired their children participate in the disclosure process.

Detecting and measuring patient safety hazards remains challenging, but assessing the potential for a given safety problem to cause harm is even more difficult. Experts therefore sought to achieve consensus around an all-cause pediatric harm measurement tool using a modified Delphi process. They vetted 108 possible trigger tools that can indicate an incipient safety risk, including use of reversal agents for high-risk medications and diagnosis of health care–associated infections. After multiple rounds of discussion and evidence review, investigators produced a list of 51 triggers, which they plan to pilot test. The authors assert that this work is the first step toward identifying harm to pediatric patients in real-time.

The SQUIRE guidelines were developed to improve reporting on research and initiatives targeted toward improving quality and safety of health care. This commentary provides examples for authors who seek to apply the revised guidelines in safety improvement work and write about their experiences.

This prospective error investigation study combined a trigger approach to identify possible adverse events with medical record review and structured interviews to determine underlying causes for adverse events. Investigators found that a myriad of factors contribute to adverse events, and multiple distinct interventions would be needed to prevent the detected events. The authors advocate for a framework to classify underlying causes together when they can be addressed by the same intervention.

This randomized controlled trial of different resident shift lengths (12, 16, and 24 hours) sought to examine how duty hours affect patient safety, housestaff well-being, and handoffs. The authors found no effects on patient safety outcomes, including adverse events and mortality. This study adds to literature suggesting that decreasing duty hours does not improve safety for hospitalized patients.

… may be greatly inflated and unreliable. A prior WebM&M perspective reviewed recent strategies for promoting and …

Home care is one of the fastest growing sectors of the health care field, but recent research has raised safety concerns among patients receiving home services. A prospective cohort study revealed that 10% of home care patients experienced an adverse event, an incidence comparable to that found in hospitalized patients. This study used a Delphi approach to determine the types of adverse events in home care that should be considered serious (in terms of the level of patient harm) and preventable. Four types of serious preventable events were identified: inappropriate client service plans, medication errors requiring emergency treatment, catheter-associated infections, and incidents related to care that did not fall within practice standards. The authors advocate for using this classification scheme as the basis for a home care adverse event reporting system, analogous to state reporting systems for serious errors occurring in hospitalized patients.

This study estimated a cost of approximately CAD $260,000 over 4 years to develop and run a safety learning system for family physician clinics in Calgary, Alberta. Policy makers and payers may need to determine whether there is an adequate return on investment for the sustainability of these types of programs.

Adverse events are thought to be common in patients receiving home health care, but few high-quality studies address this issue. This prospective cohort study found that 1 in 10 home care patients experienced an adverse event each year, and more than half of these events were considered preventable.

The hospital discharge process is often disorganized and lacks standardization. As a result, adverse events after hospital discharge are disturbingly common. This study reports on a multidisciplinary, collaborative effort—involving hospitalists, primary care physicians, home care and bedside nurses, and pharmacists—to develop a standardized hospital discharge checklist. The resulting tool is designed to be used daily during hospitalization as part of interprofessional discharge planning rounds and consists of seven domains that address key aspects of the hospital-to-home transition, including medication reconciliation and communication between physicians. Further validation will be required to demonstrate that this checklist can prevent adverse events in broad hospitalized patient populations.

In this study, 13.2% of home care patients experienced an adverse event, and approximately one-third of these were considered preventable.

This systematic review attempted to quantify the excess attributable cost of patient safety events in hospital care but found considerable methodologic weaknesses in the available literature addressing this question.

Hospitalized children are particularly vulnerable to specific types of errors, such as medication errors. This Canadian study used a trigger tool approach to estimate the frequency of all types of adverse events in hospitalized children, and found that nearly 1 in 10 pediatric patients suffers an adverse event while hospitalized. This prevalence is similar to classic studies performed in adult populations. Preventable adverse events, which accounted for approximately half of all events, were particularly common in children undergoing surgery or requiring intensive care. Diagnostic errors also accounted for a significant proportion of preventable adverse events. A preventable error in a critically ill 8-month-old child is discussed in an AHRQ WebM&M commentary.

Progress has been achieved in several areas of patient safety, but the cost-effectiveness of successful interventions remains an important question for policymakers and organizational leadership. This systematic review evaluated the cost-effectiveness of interventions to address 15 key safety targets (including health care–associated infections, adverse drug events, retained foreign bodies after surgery, and wrong-site surgery), but identified only 7 methodologically adequate economic analyses. Based on this limited dataset, the authors identified 4 cost-effective safety interventions, including checklists to prevent catheter-related bloodstream infections and medication reconciliation conducted by pharmacists. More robust economic analyses will be required in order to help prioritize safety interventions in the future.