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.

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.

The complexities of the care environment are known contributors to harm and initiative failure. The authors suggest that systemic versus siloed approaches to patient harm reduction will reduce difficulty in accomplishing improvement.

… culture inhibits their work in this area. … Monsees E, Goldman J, Vogelsmeier A, Popejoy L. Nurses as antimicrobial …

… Alert on maternal harm . … J. … K. … S. … R. … I. … S. … Goldman … Macmillan … Kitto … Wu … Silver … Reeves … M. … J. Goldman … K. M. Macmillan … S. Kitto … R. Wu … I. Silver … S. …

Burnout, stress, and personal challenges can affect clinicians' ability to provide safe care. This article explores factors that prevent clinicians from seeking support and provides suggestions for organizations to encourage health care providers to solicit help, such as establishing a culture of wellness, second victim initiatives, substance abuse assistance, and domestic violence programs.

Poor test result management can lead to missed or delayed diagnosis. This qualitative study of clinicians involved in test result management found that lack of clear responsibility for test results, inability to track result follow-up via technology, and absence of standardized workflow and expectations impede timely test result notification and follow-up. The authors recommend employing both workflow and technology solutions to address this safety gap.

Medical imaging overuse is associated with increased rates of cancer related to radiation exposure. Researchers found that displaying radiation exposure and cost information to clinicians ordering radiologic studies may affect their decision to request diagnostic imaging and raise clinician awareness around radiation risks and study costs.

Misuse of prescription opioids represents a serious patient safety issue. In this study, investigators examined opioid prescribing to Medicare beneficiaries upon hospital discharge. They found that new opioid use was common after discharge and that prescribing rates varied widely across hospitals.

Patients' experiences with safety issues influence their perceptions of hospital quality. This study examined online reviews of hospitals and found concerns discussed in narratives that would not have surfaced using the Hospital Consumer Assessment of Healthcare Providers and Services patient satisfaction instrument. A significant proportion of narrative reviews raised concern about safety and trust.

This commentary discusses how clinical scenarios can reveal potential barriers to interoperability between health information systems and medical devices to ensure they are effectively integrated to support safe clinical workflow, process documentation, and data sharing. The authors describe a patient-controlled analgesia failure to illustrate the scenario method. A previous WebM&M commentary discussed risks inherent in lack of system interoperability.

Leaders of quality improvement/patient safety and continuing education in Canada felt that efforts in these two domains were separated and that there were many opportunities to collaborate. However, they had differing views on how to best integrate programs.

This retrospective single center study found that more than 40% of pediatric patients with malaria were initially misdiagnosed, compared to only 13% of adult patients with malaria. One potential reason for these diagnostic errors was that children were much more likely to present with prominent abdominal symptoms.

Readmissions and adverse events after discharge are a continued patient safety problem, as evidenced by the fact that more than 2500 hospitals have been penalized by the Centers for Medicare and Medicaid Services due to excessive readmission rates. Comprehensive programs such as Project RED and the Care Transitions Intervention have successfully prevented readmissions by using a dedicated transition provider (usually a nurse) who contacts the patient before and after discharge and helps coordinate care. This randomized controlled trial, conducted in an urban safety net hospital, found that such an approach did not reduce 30-day readmission rates—and may have increased postdischarge emergency department visits—compared with usual discharge care for a group of elderly, ethnically, and linguistically diverse patients with low health literacy. The study findings reinforce the importance of customized, patient-centered discharge approaches and highlight barriers to generalizing interventions to improve safety across sites of care and patient populations. These challenges are explored further in an AHRQ WebM&M interview with Dr. Eric Coleman, a pioneer in the field of care transitions and a recipient of a MacArthur Award.

This study describes the development of improved alerts and alternate treatment algorithms to reduce the number of adverse drug events associated with potentially inappropriate medication use in the elderly.