… This piece is part of a series on diagnostic excellence. … Berwick DM. Diagnostic excellence through the lens of …

Clinical decision support systems are designed to improve clinical decision-making. The authors of this commentary suggest an alternative, eActions, to reduce clinician burden and increase replicability. Dissemination and use of eActions could contribute to improved clinical care quality and research.

… system to develop resilience . … Staines A, Amalberti R, Berwick DM, et al. COVID-19: patient safety and quality …

Over the last decade, the Lucian Leape Institute has explored five key areas in health care to advance patient safety. These include medical education reform, care integration, patient and family engagement, transparency, and joy and meaning in work and workforce safety for health care professionals. This review highlights progress to date in each area and the challenges that remain to be addressed, including increasing clinician burnout and shortcomings of existing health information technology approaches. The authors also suggest opportunities for further research such as measuring the impact of residency training programs. In a past PSNet interview, Dr. Tejal Gandhi, president of the IHI/NPSF Lucian Leape Institute, discussed improving patient safety at a national level.

Electronic health records have been widely adopted in both inpatient and outpatient settings. This commentary suggests that health information technology provides health care with an opportunity to optimize patient safety measurement in hospitals and that barriers such as data collection burden, mismatched definitions, and ineffective methods of tracking patient harm can be addressed through robust electronic health record design and use.

This commentary discusses findings from the National Patient Safety Foundation report investigating the state of patient safety in the 15 years after To Err Is Human. Focusing on the recommendation that leadership establish and sustain a culture of safety, the authors describe how leaders can engage board members and organizational leadership in this work and highlight the need to provide leaders with education and practical tools.

Silence and poor communication are known threats to patient safety. Despite efforts to promote teamwork and develop shared tools for communication, there are persistent gaps between nurse and physician practices. This study surveyed nurses and physicians working in labor and delivery units and discovered significant differences in their perceptions of patient harm associated with various clinical scenarios. These differences in patient harm ratings were the greatest predictor of speaking up, suggesting that differences in clinical assessment may serve as a useful target for intervention. The authors discuss the negative impact of environments where mental models are not shared, conflict is poorly managed, and disruptive behaviors stifle open communication. A past AHRQ WebM&M commentary discussed a case of "silence" when members of the operating room team were reluctant to speak up to a senior surgeon.

Accompanying a consensus statement, this editorial discusses the challenges of conducting research in complex settings, and notes existing guidelines and resources to help clinicians write and interpret articles about patient safety interventions.

Highlighting goals and strategies of the Partnership for Patients program, this commentary discusses challenges to improving patient safety.

Although significant progress has been made in improving patient safety over the past decade, most health care organizations still experience persistent safety problems. In this commentary, leaders of several leading safety organizations endorse five principles for transforming hospitals and clinics into high reliability organizations. These include transparency in disclosing errors and quality problems, integration of care across teams and disciplines, engaging patients in safety, developing a culture of safety, and reforming medical education to focus on quality and safety. The lead author, Dr. Lucian Leape, was interviewed about his remarkable career in patient safety by AHRQ WebM&M in 2006.