… their patient safety culture, but surveys can represent a time burden on staff. An Illinois health system aimed to lessen this burden on staff by creating a shorter, revised survey. The final survey consisted of five … Chung JW, Flaherty V, et al. Development and validation of a brief culture-of-safety survey. Jt Comm J Qual Patient Saf. …

… JAMA … Alarm fatigue is a pervasive contributor to distractions and error. This … progress toward alarm reduction . … Winters BD, Slota JM, Bilimoria KY. Safety culture as a patient safety practice for alarm fatigue. JAMA . …

… to generate sustainable safety progress. … Nasca BJ, Bilimoria KY, Yang AD. Quality and safety in surgery: …

Rapid response teams (RRTs) are intended to quickly identify clinical deterioration and prevent intensive care unit transfer, cardiac arrest, or death. This article summarizes the evidence included in the AHRQ Making Healthcare Safer III report about the use of RRTs to decrease failure to rescue. Although utilization is widespread, the authors conclude that definitive evidence that RRTs are associated with reduced rates of failure to rescue is inconclusive. The authors note that evidence does support that RRTs are associated with reduced secondary outcomes, such as ICU transfer rate and cardiac arrest.

The Hospital Star Rating system was implemented in 2016 to aid patients in identifying safe, high-quality hospitals. The system has evolved over time to address applicability concerns. This commentary highlights changes in the latest reiteration of the program and discusses challenges in its use.

… with the lowest cost per event. … Merkow RP, Shan Y, Gupta AR, et al. A comprehensive estimation of the costs of 30-day …

This study examined variation in operative technical skills among patients undergoing colorectal and non-colorectal procedures and the association with patient outcomes. Higher technical skills were significantly associated with lower rates of complications, unplanned reoperations, and death or serious morbidity. The findings suggest that this skill variation accounts for more than 25% of the variation in patient outcomes.

… Questionnaire to explore whether participation in a comprehensive, multicomponent, statewide surgical quality … comprehensive learning collaborative strategies in a statewide collaborative and changes in hospital safety …

… JAMA Surg … This mixed-methods study analyzed data from a survey of general surgery residents and qualitative … such as infrequent overnight calls or not completing a subinternship. Preparedness was associated with a nearly … lower risk of experiencing burnout . … Engelhardt KE, Bilimoria KY, Johnson JK, et al. A national mixed-methods …

In this survey of 6,264 US general surgery residents, 70% reported experiencing at least one bullying behavior during surgical training and 18% reported frequent bullying. The most common types of bullying behavior were repeated reminders of mistakes, being shouted at, withholding of important information, persistent criticism, and hostility. Women and racial/ethnic minorities reported more frequent bullying. Residents reporting frequent bullying had higher rates of burnout, suicidal thoughts, and thoughts of leaving surgical training.

… (NSQIP) registry data to assess patient outcomes. Over a six-month period, 22.5% of residents self-reported a near-miss medical error and nearly 7% reported an error …

Physician burnout can negatively impact not only physician well-being, but patient safety as well. This national survey of general surgery residents found that about one-third of all respondents reported experiencing discrimination or abuse; 38.5% of residents reported weekly burnout systems and 4.5% reported suicidal thoughts within the past year. Residents reporting burnout or suicidal thoughts were more likely to have experienced discrimination, abuse or sexual harassment. Women reported more exposure to mistreatment, which may account for gender differences in rates of burnout and suicidal thoughts.  

… to which patients received recommended chemotherapy . A significant proportion of breast , lung, and colorectal … conclude that failure to administer chemotherapy is a significant safety gap that should be addressed. …

Establishing a strong culture of safety is an important priority in the health care setting. Prior research examining the association between improved safety culture and patient outcomes has produced mixed results. Using a modified version of the Safety Attitudes Questionnaire (SAQ), researchers surveyed hospital leaders and frontline providers across 49 hospitals in the Illinois Surgical Quality Improvement Collaborative. Consistent with prior research, they found that hospital administrators had more positive perceptions of safety than frontline health care providers. They also found a significant association between improved safety culture as measured by the SAQ and reduced risk of postoperative morbidity and death. A past PSNet perspective discussed the impact of safety culture on safety.

Prior studies have found that patients are often prescribed opioids inappropriately after undergoing surgery. This qualitative study reports on the implementation of a multifaceted effort to reduce opioid prescribing and standardize postoperative pain management at an academic hospital. The investigators identified several barriers to improving prescribing, including time and resource constraints and fear of harming patient satisfaction.

… JAMA surgery … JAMA Surg … This secondary analysis of a prior randomized trial of flexible versus mandated duty … physicians examined reasons for staying past the end of a 24-hour call. Most trainees reported voluntarily staying longer, though a significant proportion reported that program, attending, or …

… to those working within standard duty hours. As in a prior study of surgical training, program directors of … effects of duty hour reform on graduate medical education. A PSNet perspective reviewed changes to the ACGME …

… JAMA … JAMA … This commentary describes a case involving a patient with obstructive sleep apnea who received multiple sedating medications and subsequently had a cardiac arrest while undergoing MRI. The authors explore …

This case report describes an insulin dosing error during hospitalization. The investigation uncovered several root causes, including lack of a standardized medication double-check. The authors note that prompt error disclosure to the patient and family was performed, and the patient required additional monitoring but experienced no further harm.

… JAMA … JAMA … This commentary describes a case of wrong-site surgery , an erroneous breast biopsy, … solutions to prevent errors. … Engelhardt KE, Barnard C, Bilimoria KY. Wrong-Site Surgery.  JAMA . …