Hospital-acquired pressure ulcers, categorized as a never event, are underreported, particularly when related to medical devices. Interviews with experts in hospital-acquired pressure ulcers revealed four domains related to reporting: 1) individual health professional factors, 2) professional interactions, 3) incentives and resources, and 4) capacity for organizational change. Teamwork, openness, and feedback were seen as the main facilitators to reporting, and financial consequences was a contributing barrier.

In health care, executive walk rounds are used to help senior leadership engage in discussions about safety issues with frontline staff. Although prior research has demonstrated a positive impact of walk rounds on safety culture in the hospital setting, less is known about their value in other types of care settings. In this mixed methods analysis, executive walk rounds were implemented across six long-term care institutions. Leaders reported that participating in walk rounds increased their awareness around safety issues and enhanced their engagement with frontline staff. An accompanying editorial discusses the utility of walk rounds in improving the safety culture in nursing homes.

The growing focus on enhancing health care safety has placed new demands on hospital leadership to implement improvement initiatives. Examining governance of patient safety in the emergency department, this systematic review found that robust tools for monitoring patient safety and reporting errors are lacking.

This qualitative study explored the means by which intensive care unit nurses enhance their patients' perception of safety. Nurses emphasized the importance of communicating with patients and families, ensuring patients' physical safety, and building trust with families so that patients feel safe.

In this survey study, one-third of respondents reported an experience with an impaired or incompetent colleague within the last year. One limitation to the survey findings was the low 28% response rate, but the authors note that even if all non-respondents had no such encounters, the results suggest at least 9% of health care professionals have dealt with impaired or incompetent colleagues.

Although 12-hour nursing shifts are common in the United States, this study found that only 15% of European nurses worked 12 hours or more. Similar to prior research, longer nursing shifts were associated with lower quality of care and compromised patient safety. This study also found that nurses working extended shifts reported more care left undone. Nurses who worked overtime, even if shift length was less than 10 hours, described similar concerns. The authors warn that policies to adopt standard 12-hour nursing shifts as a cost-effective way of maintaining nurse–patient ratios may contribute to burnout. A past AHRQ WebM&M interview with Barbara Blakeney discussed the importance of proper nursing staffing for patient safety, and a prior AHRQ WebM&M commentary examines the complexities around balancing nurse staffing and workload.

In this cluster randomized trial, a strategy that sought to improve nurses' hand hygiene by emphasizing team commitment and leadership engagement did achieve higher hand hygiene rates compared with a standard quality improvement approach. However, the overall rate of hand hygiene adherence remained poor in both groups.

Focus groups of patients, hospital physicians, outpatient physicians, and nurses revealed many aspects of organizational culture that impede progress in enhancing care transitions. A recent systematic review identified promising strategies for improving continuity of care at discharge.

Care transitions remain a particularly vulnerable time for patient safety, leading to an increasing emphasis on effective handoff communication. Adverse events following hospital discharge are common, affecting nearly 20% of patients. This review summarizes interventions aimed at improving patient discharge from hospital to primary care; a number of effective strategies and measured outcomes are compiled. The efforts described are primarily focused on smoothing the coordination of care and communication between hospital and primary care providers and pharmacists. An AHRQ WebM&M conversation with Dr. Vineet Arora explores extra-hospital and intra-hospital handoffs.

Improving patient safety requires development of a culture of safety and transformation into a learning organization—one that has the capacity to rapidly address problems through information sharing and learning from past experience. In this systematic review, the authors characterize the published literature on organizational safety programs, and summarize published data on error detection methods (such as incident reporting systems), error analysis, and systems to mitigate and reduce specific errors (such as diagnostic errors and medication errors). The review is limited by publication bias (the preferential publication of studies with positive results) and the descriptive nature of most studies, reducing the generalizability of these studies for other organizations. An AHRQ WebM&M perspective discusses organizational approaches to safety improvement in academic and community settings.

This study describes the implementation of a patient safety program focused on evidence-based guidelines to reduce the incidence of pressure ulcers, falls, and urinary tract infections. The authors discuss the challenges of their program development and implementation, including the need for reliable feedback systems on performance.