High reliability principles from other high-risk industries are frequently adapted to health care to improve safety. In this qualitative study, researchers found that those working on hospital units with better safety performance tended to use language describing responses to safety issues and errors more consistent with high reliability principles than units with lower safety performance.

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.

… of the American Society for Healthcare Risk Management … J Healthc Risk Manag … 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 …

High reliability organizations embrace strategies to actively reduce errors and accidents. This commentary outlines a framework that focuses on integrating competencies at all levels of the health care workforce across the organization to support high reliability.

Patient safety approaches often draw from high reliability industries outside of health care. This implementation study described a peer-to-peer assessment program adapted from the nuclear power industry. Two academic medical centers assessed each other's patient safety performance. Each center examined its peer's prevention of central line–associated bloodstream infections (CLABSI), hand hygiene compliance, and overall safety culture as an organization. Peer-to-peer assessments were conducted via site visits, which involved interviews and direct observation. They resulted in rapid practice changes such as dissemination of unit-specific CLABSI rates and central line procedure audits. The process was widely accepted by leaders and frontline staff at both sites. The authors contend that peer-to-peer assessment is feasible and has potential to improve patient safety.

Timely and accurate handoff communication is a critical aspect of patient safety. This survey of hospital staff found that positive perceptions of handoff practices were associated with safety culture, as measured by the AHRQ Hospital Survey on Patient Safety Culture. The authors suggest focusing on improving handoffs as a strategy to enhance safety culture.

… widely diverging participant responses. There was a lack of leadership engagement with frontline staff around … in their safety strategies. Simulation appears to be a promising leadership education strategy that may uncover gaps in current leadership practices. A PSNet perspective explored how leaders can promote cultural …

… engagement. Higher levels of engagement (defined as a positive work-related mindset including dedication and …

… Jt Comm J Qual Patient Saf … Jt Comm J Qual Patient Saf … The … settings. This commentary describes the development of a quality improvement collaborative designed to facilitate the implementation of CUSP in a group of academic and community hospitals. In addition to … science of improving patient safety in a past AHRQ WebM&M interview . …

… American journal of infection control … Am J Infect Control … This study determined that results from … each separate aspect of safety climate is linked to a particular safety problem. …

This narrative review found substantial evidence that team training can enhance care coordination and patient outcomes, including morbidity and mortality. Bundled interventions had the greatest impact. The authors suggest widespread implementation of team training across health care settings to enhance safety.

… Journal of patient safety … J Patient Saf … This literature review identifies ethical, …

… AJR. American journal of roentgenology … AJR Am J Roentgenol … This review examines diagnostic errors and …

Rapid response systems (RRSs) are somewhat effective at preventing cardiorespiratory arrest outside the intensive care unit, according to this AHRQ-funded systematic review published as part of a patient safety supplement in the Annals of Internal Medicine. The review also identifies barriers and facilitators to effective implementation of RRSs in different contexts.

This systematic review—part of the AHRQ Making Health Care Safer II report—found some evidence that interventions, such as teamwork training, executive walk rounds, and structured communications approaches, can improve safety culture, especially when bundled together as a multicomponent intervention.

… Commission journal on quality and patient safety … Jt Comm J Qual Patient Saf … This commentary discusses the importance …

… that have been identified in prior research , including a lack of detailed evaluation of the programs’ effect on …

… not admissions of fault) from being used as evidence in a lawsuit, and others have enacted mandatory error reporting … laws, error reporting laws, and malpractice rates on a state-by-state basis. Although significant variation exists …

Teamwork training programs continue to emerge despite past reviews suggesting their mixed effectiveness in changing behavior. This study conducted a multilevel evaluation of the TeamSTEPPS training program within an operating room service line and used a comparison unit at a separate facility. Following a 4-hour didactic program, the trained group demonstrated increases in the quantity and quality of presurgical procedure briefings and the use of teamwork behaviors observed during cases. Similar to past efforts, increases were also noted in perceptions of safety culture and teamwork attitudes. This study adds to the literature by employing a multilevel evaluation strategy, using a comparison unit, and observing actual behavior change that was attributed to the training. Patient outcomes were not part of the measurement strategy.

… Journal of nursing care quality … J Nurs Care Qual … This study used focus groups to develop a framework for understanding how nurses work in teams with a view toward developing teamwork training strategies for …