To improve patient safety, payers such as the Centers for Medicare & Medicaid have implemented policies that limit reimbursement for certain healthcare-associated harms. This commentary introduces the “Payer Relationships for Improving Diagnoses (PRIDx)” framework describing how payers may implement similar policies to reduce diagnostic errors.

Prescribing antibiotics increases the risk of resistant infections and can lead to patient harm. From December 2019 to November 2020, 389 ambulatory practices participated in a quality improvement project using the Agency for Healthcare Research and Quality Safety Program for Improving Antibiotic Use Program. The goal of the intervention was to support implementation and sustainment of antibiotic stewardship into practice culture, communication, and decision-making. Practices that completed the program and submitted data showed a significant decrease of antibiotic prescribing for acute respiratory infections at program completion in November 2020.

… 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 influenced by four factors: …

… 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 …

… formal organisation in voice about concerns in healthcare: a qualitative interview study. Soc Sci Med. 2021;280:114050. …

… policies regarding antibiotic use. The program led to a significant reduction in antibiotic use over the 1-year period and a 20% reduction in C. difficile  infections. The approach …

… errors to improve patient safety. … Singh H, Bradford A, Goeschel C. Operational measurement of diagnostic safety: …

… and barriers to fulfilling these roles. Role ambiguity was a consistent finding in all three groups highlighting the …

… 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 …

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.