Optimizing communication during handoffs in the operating room and many other contexts within health care is key to maintaining patient safety. Although prior research has shown that communication breakdowns frequently contribute to adverse events, the degree to which medical errors can be attributed to communication failures as the primary cause remains unknown. In this systematic review, researchers found three dominant categories of medical error: errors of commission, errors of omission, and errors resulting from communication deficiencies. Of the 42 articles that met inclusion criteria, errors of communication were common in 3 studies. They conclude that medical errors more often result from errors of commission or omission rather than miscommunication. A past WebM&M commentary described an incident involving miscommunication in the operating room that led to an error in patient care.

This commentary explores barriers to implementing TeamSTEPPS, such as limited resources, inadequate training, and poor understanding of the effect of hierarchy on safety, and recommends tactics to address them.

Detailing principles of crew resource management and human factors in TeamSTEPPS, this commentary recommends including these concepts in simulation training.

… J Pediatr Nurs … J Pediatr Nurs … Evaluating the evidence on a tool that … its strengths and weaknesses. … Meguerdichian MJ, Clapper TC. The Broselow tape as an effective medication dosing instrument: a review of the literature.  J Pediatr Nurs . 2012;27(4):416-420. …

The authors describe the systemwide initiative to support a culture of safety at Sentara Healthcare, a 2005 Eisenberg award winner.

This hospital received national recognition for their incentive programs and leadership engagement, and for successfully balancing a culture that supports a "just" approach to error without avoiding accountability. The application of Red Rules, a stop-the-line philosophy, and simplification of administrative barriers helped them achieve an environment that supports safety and learning.