Supporting and improving clinician well-being has long been a safety focus and received renewed focus during the COVID-19 pandemic. This study sought to understand efforts undertaken to support clinicians’ well-being in Joint Commission-accredited hospitals and Federally Qualified Health Centers (FQHC). Only half of responding hospitals and FQHCs reported implementing at least one action towards improving clinician well-being (e.g., establishing a wellness committee) and few had implemented a comprehensive approach.

Testing process improvements prior to implementation can help identify and address potential unintended consequences on practice. This commentary explores how a quality improvement initiative seeking to reduce the opportunity for mistakes may have resulted in treatment delays.

… Saf … The Joint Commission identifies inpatient suicide as a sentinel event . Little is known about the epidemiology of … suicide immediately after psychiatric hospital discharge. A prior WebM&M commentary highlighted additional strategies …

Professionalism in medicine is considered an essential component of safety culture, but efforts to monitor and address disruptive behaviors among physicians have not produced the desired outcomes. This commentary discusses the need for more explicit emphasis on building physician skills and attitudes to support zero harm, process improvement, high reliability, and commitment to excellence in all areas of medical care.

Limited health literacy has been linked to poor comprehension of written instructions. This study found that spoken instructions were also frequently misunderstood by patients with poor health literacy.

… of the TeamSTEPPS Teamwork Attitudes Questionnaire, a survey instrument designed to measure attitudes toward … The TeamSTEPPS teamwork training program was developed as a collaboration between the Agency for Healthcare Research …

This AHRQ-funded study found that physicians usually chose appropriate reasons for excluding patients from inclusion in quality measurement programs.

Discrepancies in patients' medications at the time of hospital admission are common. Performed at an academic medical center, this cohort study used a pharmacist-led medication reconciliation process to determine a "gold standard" medication list for newly admitted patients, identify discrepancies between patients' medication lists and the medications ordered by admitting physicians, and investigate risk factors for preventable medication errors. More than one-third of patients had at least one discrepancy, with elderly patients and patients with more complex medication regimens being at higher risk—factors also documented in prior research. Patients who presented their own medication list or pill bottles were at reduced risk. The medication reconciliation process used in this study is available as an online toolkit.

Failure to adequately follow up on test results is a known problem after hospital discharge, in primary care settings, and within computerized systems. This study reviewed more than 5400 patient medical records from 19 community-based and 4 academic primary care practices and discovered a 7.1% rate of failure to inform (or document informing). Interestingly, investigators found that partial electronic health records (EHRs), with a mix of paper and electronic systems, were associated with higher failure rates than those practices without an EHR or with a complete EHR. Variations in failure rates among practices, ranging from 0% to 26%, suggest that best practices can make a significant difference. A past AHRQ WebM&M commentary discussed the impact of delayed notification for a test result following hospital discharge.

Introduction of an electronic discharge summary was associated with more timely communication with outpatient physicians and improved communication of potential patient safety problems, such as test results that were pending at the time of discharge.

This prospective cohort study found increased mortality among elderly persons with poor health literacy, even after adjusting for confounding factors. Poor health literacy has previously been linked to inability to understand prescription drug labels.

Patients discharged from the hospital experience an unacceptably high rate of medical errors. Prior research suggests that suboptimal communication between hospital physicians and outpatient physicians could contribute to these problems. This study systematically reviewed the literature to determine the frequency of communication problems between physicians at hospital discharge and to identify interventions that ameliorated this problem. The investigators found that direct communication occurred rarely, and the primary means of communication (the dictated discharge summary) generally was not available in a timely fashion and often contained inadequate information for proper follow-up care. Based on this review, the authors provide suggestions for standardizing information transfer at discharge and improving the timeliness of communication.

Poor health literacy has been identified as an important threat to patient safety, particularly through potentially contributing to adverse drug events. In this study, researchers surveyed patients in three urban primary care clinics serving predominantly indigent populations, and found that low health literacy was independently associated with misunderstanding of prescription drug label instructions. Although the study did not directly evaluate if misunderstanding led to medication errors, the study adds to a growing body of research documenting that patients with low and marginal health literacy have difficulty comprehending prescribing information. In the accompanying editorial, Dr. Dean Schillinger calls for development of standardized systems for transmitting medication instructions to patients in a clear and understandable fashion.

This article describes the development of the US Department of Defense's team training program for military health facilities, entitled TeamSTEPPS (Team Strategies and Tools to Enhance Performance and Patient Safety). The program was based on two prior military crew resource management (CRM) programs and prior evidence in the field and was adapted to address issues encountered in military facilities, including the rapid turnover of personnel and the need to adapt to the cultures of specific military services. The program consists of teaching core skills in leadership, situation monitoring, team support, and communication through an interactive curriculum stressing application to everyday scenarios. The article extensively reviews the challenges of implementing the program and future plans for disseminating and evaluating the training.

This study addresses the relationship between low health literacy and comprehension of common prescription drug warning labels. Patients at an urban primary care clinic underwent structured interviews to address their understanding of specific one-step warnings (ie, take with food) and multi-step warnings (ie, avoid prolonged exposure to sunlight while taking this medication). The majority of the study population had low or marginal health literacy, defined as reading at an 8th grade level or lower. Patients with low literacy were significantly less likely to correctly interpret warning labels, and multi-step instructions were misinterpreted by the majority of respondents across all literacy levels. Misinterpretation of these common warnings could conceivably lead to misuse of medications or adverse drug events.

… is safer compared to years past. The authors discuss a measurement approach that focuses on the following: how … know we learned from defects, and how well have we created a culture of safety. Building on a model of structure, process, and outcome measures used to …

The investigators analyzed electronic records and found that dosing errors were common in ambulatory care settings for patients with renal insufficiency. They conclude that computerized decision support systems should be implemented in ambulatory care.

… to assess physician competence in these areas. … Baker DP; Salas E; King H; Battles J; Barach P. …

… engagement of their leadership, and this article provides a thoughtful model for other academic medical centers to …