Maternal morbidity and mortality remain a significant problem in U.S. health care. This article describes Texas and Oklahoma’s adoption of a perinatal quality improvement initiative, including the implementation of the Alliance for Innovation of Maternal Health (AIM) patient safety bundles and use of teamwork and communication tools in obstetric units. Findings suggest that adoption of initiative components varies across obstetric units; the majority of units had standardized processes for serious events (obstetric hemorrhage, massive transfusion, severe hypertension) but fewer units offered regular training on effective teamwork and communication for their staff.

Burnout, characterized by emotional exhaustion that results in depersonalization and decreased accomplishment at work, is correlated with poor patient safety culture. Multiple initiatives to measure and reduce healthcare worker burnout have emerged recently. This Department of Defense study used the AHRQ Hospital Survey on Patient Safety Culture to determine the scope of burnout in military hospitals, explore the relationship between burnout and teamwork, and explore effects of teamwork on burnout.

The quality and culture of the health care work environment is known to affect care delivery. This commentary discusses human-centered and participatory design approaches as avenues for developing improvements in clinician well-being that will enhance safety for staff, providers, and patients.

… talk, but also walk the walk. … Lazzara EH, Salisbury M, Hughes AM, et al. The morbidity and mortality conference: …

… practicing primary care physicians is needed. … Burke HB, King HB. Responses of physicians to an objective safety and …

High reliability remains an elusive goal for health care organizations. The authors of this study posit that medical teams’ ABCs – attitudes, behaviors, and cognitions – are critical for high-reliability, enhancing team adaptation and increasing patient safety. The article outlines practical tools and educational strategies that can be leveraged by a variety of healthcare organizations to improve team-based care.

A culture of safety is a key component to successful, sustainable patient safety programs. The authors review existing models of safety culture and propose a framework which synthesizes information across fragmented concepts – including organizational culture, social identity, and social learning – to illustrate the dynamic nature and drivers of safety culture.

This article summarizes evidence-based recommendations for team-based patient care during the COVID-19 pandemic. These recommendations focus on team functioning, safety culture, and resilience. The authors discuss how individual-, team-, and organizational-level stressors, as well as work-life stressors, can affect team performance. 

This review discusses the importance of teamwork in supporting safety, psychological states driving effective safety performance, organizational- and team-level characteristics impacting safety performance, and the role of teams in safety management.

Human factors are frequently an important contributing factor to patient safety events. This review describes the role of human factors in patient safety and presents three case studies of human factors affecting care in the NICU. A PSNet Human Factors Primer on human factors expands on these concepts.

Team development is an important focus of safety improvement. This article provides an overview of team training science and highlights aviation, military, and health care failures that motivated research to understand the psychology of teams. The authors emphasize the importance of multidisciplinary collaboration and the contributions of psychologists as research partners in this work.

This study aimed to validate a behavioral marker as a measure of teamwork, specifically in the intensive care unit setting. Researchers found that it was difficult to establish interrater reliability for teamwork when observing behaviors and conclude that assessment of teamwork remains complex in the context of patient safety research.

Patients are at risk for adverse events after they transition from hospital to home. This direct observation and interview study identified significant concerns related to care transitions from hospital to home health care among patients discharged from the hospital. The study team found instances of missing and erroneous information. Information also had to be gleaned from multiple sources, and too much information could cause confusion and interfere with home health care. The authors recommend redesigning the care transition process from hospital to home health care providers in order to promote safety.

Teamwork in health care has been embraced as a key element of patient safety. This review summarizes the evidence regarding teamwork, including strategies to measure team performance and the relationship between teamwork and outcomes.

Emergency department crowding is linked to medication errors and other preventable harm. Crowding requires providers to evaluate patients quickly under suboptimal conditions, such as in hallways or waiting rooms with inadequate nursing support, which may lead to diagnostic errors. This cross-sectional survey of emergency medicine physicians assessed how evaluating patients in the hallway or with a companion present changed their usual diagnostic practices. Researchers found that 90% of physicians altered their history-taking or physical examination, and 40% reported a diagnostic error or delay as a result. The most common missed diagnoses were suicidal ideation, abuse or neglect, and genitourinary system disease. A PSNet Perspective and a WebM&M commentary discussed strategies to reduce diagnostic errors in emergency departments.

Electronic health record (EHR) alerts are a major source of alert fatigue among providers. This study suggests that EHR alerts and workload may contribute to primary care provider burnout. The authors conclude that both individual and organizational level interventions are necessary to address workload related to EHR alerts.

Research on teamwork as a key component of safe care delivery has primarily focused on the hospital setting. This commentary highlights six elements that enable development, functionality, and assessment of teamwork in the ambulatory setting.

The Partnership for Patients is a government initiative to reduce health care–acquired conditions. This commentary describes a large-scale implementation of the Partnership for Patient methods across the Military Health System. The authors report the results of the program and recommend continuous leadership engagement to achieve success.

This systematic review found that team training programs primarily focus on improving communication among providers, generally involve simulation, and usually assess efficacy with self-report. The authors conclude that team training is improving but remains suboptimal.