Root cause analysis (RCA) is a common method to investigate adverse events and identify contributing factors. To expand resident understanding of and participation in RCA, the authors developed simulated RCAs that were applicable to a broad set of specialties and included other healthcare professionals whose disciplines were involved in the event (e.g., nurses, pharmacists). After participating in the simulated RCAs, there was an increase in trainees understanding of RCA and intent to report adverse events.

… BMJ Qual Saf … BMJ Qual Saf … This study used a mixed-methods approach to characterize the impact of two … institutions. Students in these programs reported a positive impact of the fellowship on their careers, with …

This qualitative study examined incident reports about surgical patients, comparing trainee reports to those submitted by attending surgeons and nurses. Trainees were more likely to enter reports anonymously and completed more elements for each report, but they also used more blame language and submitted fewer reports overall. The results suggest that encouraging trainee reporting may shed light on surgical safety.

… patient safety competency development is increasingly a goal of graduate medical education, skills to teach them … describes the development, implementation, and outcomes of a curriculum developed to meet quality improvement and …

Engaging trainees in quality improvement efforts has been an important area of focus within graduate medical education, but less is known about how health system resources are aligned with these activities. Researchers used survey data to better understand the perceptions of internal medicine residency program directors regarding health system support for and alignment with graduate medical education quality improvement efforts.

This analysis of specialty-specific milestones for graduate medical education found that about 40% mentioned patient safety or quality improvement. Emphasis on patient safety and quality improvement skills varied by specialty. The authors conclude that patient safety concepts are addressed in graduate medical education competencies.

… study, researchers described lessons learned from creating a leadership role that bridges quality and safety activities …

… Comm J Qual Patient Saf … This pre-post study found that a standardized pharmacist review of patient medications prior …

… residents and fellows in quality and safety programs is a recognized strategy to address a gap in medical education. This commentary describes a six-factor framework to integrate safety concepts into …

The Clinical Learning Environment Review (CLER) program was developed to evaluate the performance of teaching institutions in six key areas that affect patient outcomes. This commentary describes how poor safety culture in clinical practice can counteract the effect of educating medical students about quality and safety principles. The authors note unintended consequences of the CLER program and strategies to avoid them.

… how two medical centers utilized the fishbone diagram as a tool to analyze diagnostic errors . A health care facility in Maine developed a root cause analysis model to determine common factors, and …

Although diagnostic errors cause considerable morbidity and mortality, thus far organizations have focused on preventing errors that are more easily measured. This commentary provides two examples of organizational approaches to minimizing diagnostic error. In one, Maine Medical Center established a voluntary reporting system for diagnostic error coupled with a revised root cause analysis process to determine both cognitive and systems causes of these errors. In the other example, the Kaiser Permanente system leveraged their electronic medical record to establish electronic "safety nets" to identify patients at risk of diagnostic error. These mainly focused on ensuring appropriate follow-up of abnormal lab tests (particularly cancer screening tests) and sufficient monitoring of high-risk medications. As failure to appropriately follow-up on lab abnormalities is a common source of patient harm in ambulatory care, this system—which identified thousands of patients requiring urgent follow-up—likely averted many cases of preventable harm. An accompanying editorial by Dr. Hardeep Singh encourages health care organizations to develop processes for examining missed opportunities for making timely diagnoses.

A longitudinal curriculum for internal medicine residents, using simulated patient scenarios, resulted in improved ability to recognize the cognitive biases that can contribute to diagnostic errors.

… the development, implementation, and evaluation of a curriculum to enhance medical educators' quality …

… anchoring and availability. Most residents also described a strategy to prevent similar errors in the future. A near miss stemming from an initial diagnostic error is …

Computerized provider order entry (CPOE) systems prevent prescribing errors by warning clinicians about medication interactions or contraindications. However, extensive research has shown that clinicians ignore many warnings, especially those perceived as clinically inconsequential. In this randomized trial, investigators created a "hard stop" warning that essentially prevented co-prescribing of warfarin and trimethoprim-sulfamethoxazole (a combination that exposes patients to severe bleeding risks). Although the hard stop was much more successful than a less stringent warning at preventing co-prescribing, the trial was stopped and the warning abandoned because several patients experienced delays in needed treatment with one of the drugs. The accompanying editorial by Dr. David Bates points out that this study vividly illustrates the unintended consequences of CPOE, a persistent issue that has slowed the pace of CPOE implementation.

Rapid response systems serve an important patient safety function in hospitals by helping detect systematic problems in care, and emerging evidence indicates that such teams may improve some clinical outcomes. This study evaluated the views of frontline providers—bedside nurses and resident physicians—toward a rapid response team (RRT). Both groups agreed that the presence of the RRT improved patient safety, and both also felt that the RRT did not adversely affect their educational experience or patient care skills. These findings have been previously demonstrated for nurses. Interestingly, both nurses and residents who had more experience with the RRT felt more positively about its effects. The RRT in this study consisted of a critical care nurse, a respiratory therapist, and a pharmacist with physician backup.

Patients who received specific instructions (from physicians, nurses, or pharmacists) when prescribed the anticoagulant warfarin experienced fewer hospitalizations due to bleeding complications. The Agency for Healthcare Research and Quality (AHRQ) has published a patient information guide for warfarin therapy.

… analyzed orders entered and discontinued within 2 hours as a trigger for inexpensive and rapid real-time …