Failure to rescue refers to delayed or missed recognition of clinical deterioration, which can lead to patient complications and death. In this article, the authors used health economics methods to understand the health economic impacts associated with failure to rescue. The authors discuss the economic perspectives of various decision makers and how each group defines value. 

… & safety … BMJ Qual Saf … The use of readmission rates as a metric of care quality remains controversial, as United States–based studies have shown that only a minority of readmissions are preventable. This prospective … literature questioning the utility of readmission rates as a measure of the quality of care. …

… students to learn about patient safety either through a text-based electronic module or a serious game activity with a didactic purpose. Students randomized to the game and the …

This study found that classroom-based crew resource management training for intensive care unit staff was well received and improved self-reported situational awareness tactics, safety culture, and job satisfaction. However, there were no measurable changes in professional communication or patient outcomes compared to control groups.

Many studies have explored how staffing levels influence safe and reliable patient care. Focusing on physician staffing in acute internal medicine, this review describes the way workload, process timing, patient complexity, service set-up, and team skill mix affect staffing needs.

… behavior violates the sterile cockpit concept and may be a source of error during handoffs. …

… study examines the hospital discharge process through a clinical microsystems approach, using detailed interviews … physicians, and primary care physicians to construct a 360-degree view of the factors contributing to effective … ineffective transitions. The major theme that emerged was a lack of consistent information transfer across settings, …

… Ann Intern Med … Care transitions remain a particularly vulnerable time for patient safety, leading to … and intra-hospital handoffs. … Hesselink G, Schoonhoven L, Barach P, et al. Improving patient handovers from hospital to …

Voluntary error reporting systems have traditionally been hampered by low reporting rates among physicians. This Dutch analysis of an initiative to encourage error reporting among resident physicians found that residents who reported errors or near misses scored more highly on objective performance assessments compared with their peers who did not file any reports.

This commentary presents ambiguity, autonomy, complexity, and visibility as challenges to improving safety and makes recommendations to address them.

This study investigates the local implementation and feasibility of an incident reporting system for managing events in primary care practice.

… attending supervision in clinical settings. … Sterkenburg A, Barach P, Kalkman C, Gielen M, ten Cate O. When do supervising …

… commonly used triggers was relatively high, meaning that a significant proportion of acutely unstable patients would … be identified by such criteria. This problem was noted in a prior negative study of rapid response teams. The authors …