… J Health Serv Res Policy … A key aspect of patient safety culture is the perception that … and senior leader participants, deciding to report a safety event (referred to as a “voiceable concern”) is … incident is considered a voiceable concern. … Dixon-Woods M, Aveling EL, Campbell A, et al. What counts as a voiceable …

… online open courses (MOOCs) have the ability to reach a broad audience of learners. The Science of Safety in … competence for patient safety among global learners: a prospective cohort study. Nurse Educ …

… and support speaking up behaviors. … Wu F, Dixon-Woods M, Aveling EL, et al. The role of the informal and formal organisation in voice about concerns in healthcare: a qualitative interview study. Soc Sci Med. 2021;280:114050. …

… BMJ Qual Saf … This article describes results of a cross-sectional recontact survey of Massachusetts residents … stated at least one emotional impact, avoiding the doctor(s) or facility(s) involved in the error, and two-thirds of respondents …

… In response to an episode of serious misconduct by a clinician, an academic hospital implemented a structured effort to address disruptive behavior by …

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.

… Qual Patient Saf … Jt Comm J Qual Patient Saf … Following a sentinel wrong-patient event , a multidisciplinary quality improvement team worked to … via the electronic health record. … Hensley NB, Koch CG, Pronovost PJ, et al. Wrong-Patient Blood Transfusion Error: …

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.

The patient safety community continues to struggle with implementation and sustainability of improvement programs. This commentary describes how one academic medical center used assessment tools to monitor, measure, and improve safety at the patient, provider, unit, and system levels in the organization.

Health care executives and board members have a key role in safety improvement. This article describes the development of a tool and framework to assess the impact leadership decisions can have on organizational failure. The authors outline results and lessons learned from implementing the tool.

A work environment in which all team members feel comfortable speaking up about safety concerns is a key aspect of positive safety culture. Although formal mechanisms exist within health care institutions for raising safety issues, little is known about how such channels promote or discourage employees from speaking up. Researchers conducted interviews with 165 frontline staff and senior leaders working at three academic hospitals in two countries. They found that leaders viewed formal systems for raising concerns favorably, but other respondents felt uneasy reporting concerns through these channels. Such apprehension occurred especially if the concern was based on a general feeling that something might be wrong rather than hard evidence—what the authors refer to as "soft" intelligence. A PSNet perspective discussed how to change safety culture.

Organizational infrastructure is important to ensure sustainability of safety improvements. This commentary describes how one academic medical center integrated structures, processes, and frameworks to build connections within the organization and throughout the community to facilitate success of improvement initiatives.

Comprehensive unit-based safety programs have been shown to enhance safety in acute care settings. The investigators adapted this program for a primary care setting and report that safety culture improved following implementation of standard work and safety training. The authors did not report on patient outcomes.

… for staffing , illness severity, and delays in procedures. A recent PSNet interview discussed the weekend effect in …

… factors and solutions. Fear of malpractice was cited as a major reason for overtreatment. …

The need to improve patient safety is an international concern. This commentary discusses the importance of partnership in reaching the overall goals of global patient safety and highlights experiences in Africa that demonstrate how high-income health care systems can learn from low-income hospitals.

As implementation of comprehensive health information technology (IT) systems becomes more widespread, concern regarding the unintended consequences of such technologies has increased as well. Usability testing is helpful for optimizing implementation of health IT. Researchers analyzed the impact of health IT use on relationships among clinicians over a year-long period across three academic intensive care units. In the two units with higher health IT use, clinicians were more likely to work in an isolated manner, which was associated with an adverse effect on situational awareness, communication, and patient satisfaction. A previous PSNet perspective discussed some of the pitfalls in the development, implementation, and regulation of health IT and what can be learned to improve patient safety going forward.

Transparency in the reporting of quality and safety data demonstrates a commitment to improvement, learning, and patient empowerment regarding provider selection. This commentary suggests potential standards for hospitals to adopt for public reporting of their quality data and advocates for an external entity that reports how hospitals adhere to public reporting of quality measures.

Patients with underlying psychiatric conditions may be particularly vulnerable to adverse events. This retrospective study analyzed 790 medical or surgical hospitalizations among adults with serious mental illness in Maryland hospitals over a 10-year period. Numerous patient, provider, and systems factors were correlated with adverse events. The authors suggest that improving safety in patients with mental illness will require multifaceted interventions.

… patient safety … Jt Comm J Qual Patient Saf … Utilizing a systems approach to improvement in health care is important … lasting success. This commentary discusses the use of a tool that blends strategy, project monitoring, and process …