Promoting resilience across and within healthcare organizations is a key component of Safety-II. This qualitative study involving six teams across three hospitals in the Netherlands found that healthcare professionals, managers, and quality advisors hold differing perspectives regarding the right approach to clinical practices and the importance of certain clinical actions. The authors underscore the importance of team reflections to foster resilience and accountability across all levels within healthcare organizations.

Barcode medication administration (BCMA) technology is a useful tool to reduce medication administration errors (MAE) in the operating room. This study used a pre-post design to estimate the rate of MAE before and after BCMA implementation on infusion pumps. MAE were significantly reduced and up to 90% of errors were considered preventable, if the staff had utilized BCMA. Reasons for not using BCMA included unreadable barcodes, lack of time, and resistance to new processes.

A just culture in healthcare balances organizational and individual responsibility and accountability when medical errors occur. This qualitative study including five healthcare organizations in the Netherlands concluded that open communication and emotional responses are important components of just culture. Researchers also identified several challenges in fostering a just culture, including how individual accountability is addressed and how to combine transparency with patient and clinician privacy.

There is a long-standing tension between health care regulation and just culture principles. This qualitative study explored the experiences of mental health professionals, managers and other healthcare organization staff, as well as inspectors, regarding the role of healthcare inspectors in enabling a just culture. Three themes emerged – (1) the role of the inspector as both a catalyst for learning and a potential barrier, (2) just culture involves relationships between different layers within and outside the organization, and (3) to enable just culture in which inspectors would strike a balance between organizational responsibility and timely regulatory intervention.

Measuring errors and adverse events in health care remains challenging, but is essential to achieving safe care. Using qualitative research and informal data, the authors discuss the importance of “soft signals” in patient safety risk assessment, which are warning signs that are not typically formally measured but that indicate problems with safe care, such as patient complaints about poor hygiene, observed disruptive staff behavior, and whistleblower complaints.

… … de Kam D, Kok J, Grit K, Leistikow I, Vlemminx M, Bal R. How incident reporting systems can stimulate social …

A part of the SAFE-LEAD program to promote safety culture in Norwegian nursing homes and home care services, this paper describes perceived challenges by managers and employees in nursing home and home care services prior to intervention implementation. Focus groups with managers and employees reported several challenges, including: lack of care continuity; difficulties balancing budgetary and care needs; lack of communication between care systems and tools (such as different EHR systems that do not communicate), and; inadequate time leading to different error reporting cultures.

Patients in long-term care are at risk for many types of adverse events. This article describes a leadership development intervention to promote safety culture in Norwegian nursing homes and home care services. A WebM&M commentary reviewed quality and safety issues in nursing homes.

Patient and family engagement enriches both incident reporting and adverse event investigations. These qualitative interviews with Dutch hospital managers highlight two assets patients and families offer during incident investigations: they provide details hospital staff cannot otherwise capture and the opportunity to regain trust. An Annual Perspective discussed novel approaches to engaging patients in their safety.

This commentary discusses reliability theory in patient safety and describes an assessment framework to help measure the reliability of processes and practices in hospitals.

This study highlights contributing factors that lead to physician overrides of drug safety alerts, including incorrect rules and reasoning applied to justify such actions.

Alerts within a computerized provider order entry system were not able to prevent medication errors resulting from drug–drug interactions. The authors hypothesize that the inadequacy of the alerts themselves was responsible for this failure, with problems including an excessive number of false-positive alerts and unclear instructions for preventing drug interactions.

This review highlights the mixed impact of CPOE systems on clinical workflow, including the noted impact on efficiency and limitations caused by poor user–system interactions.

This study found that implementation of a computerized physician order entry system appeared to impair some aspects of nurse–physician communication.

This study examined nearly 2000 drug–drug interaction (DDI) alerts that were overridden by providers and noted differential triggers based on clinician knowledge or specialty. The authors conclude that simply turning off DDI alerts is limited by these differential triggers and inconsistent drug monitoring, which may raise safety concerns that are prevented by the alerts themselves.

The authors analyze the success of the Open Care Information System, a communication protocol for exchanging medication data, within the context of the stakeholders involved.

The authors review the literature on physician response to electronic medication safety alerts and interpret the results through Reason's model of accident causation. They also suggest potential improvements to the alerting process.

The authors report on the development of a set of performance indicators for all hospitals in the Netherlands.

The authors draw from their aggregated experience in qualitative assessment of clinical information systems in the United States, Europe, and Australia to propose a framework for understanding unexpected adverse consequences of patient care information systems (PCIS) on clinical work. The adverse effects are broadly divided into errors in the process of entering and retrieving information in or from the system and errors in the communication and coordination processes that the PCIS is intended to support. The authors highlight the mismatch between the linear, rigid design of software and the cognitive, social, and organizational realities of health care delivery. The article was among the first and most influential in a wave of papers highlighting potential drawbacks in clinical information technology, and tempering the impression of computerized provider order entry systems as a universal good.