The authors describe how the use of statistical process control charts facilitated rapid identification of a cluster of unplanned extubations in a neonatal intensive care unit. They advocate for the use of continuous monitoring tools to help alert teams to possible safety events and improvement opportunities.

Postdischarge medication errors occurred in nearly half of patients hospitalized for acute coronary syndromes or congestive heart failure, with errors more likely to occur in patients with limited health literacy or numeracy.

… Commission journal on quality and patient safety … Jt Comm J Qual Patient Saf … This secret-shopper style observational …

… Surgery … Surgery … A tertiary care hospital successfully improved adherence to a surgical safety checklist by implementing an electronic …

Many adverse event identification methods cannot detect errors until well after the event has occurred, as they rely on screening administrative data or review of the entire chart after discharge. Electronic medical records (EMRs) offer several potential patient safety advantages, such as decision support for averting medication or diagnostic errors. This study, conducted in the Veterans Affairs system, reports on the successful development of algorithms for screening clinicians' notes within EMRs to detect postoperative complications. The algorithms accurately identified a range of postoperative adverse events, with a lower false negative rate than the Patient Safety Indicators. As the accompanying editorial notes, these results extend the patient safety possibilities of EMRs to potentially allow for real time identification of adverse events.

… Chest … Chest … This commentary presents a structured approach to identifying and preventing two …

… positive safety culture in intensive care units, based on a survey of providers at all levels. …

… American journal of surgery … Am J Surg … This follow-up study directly observed surgical teams after they had participated in a crew resource management (CRM) training initiative. The … of CRM programs in health care was strongly recommended in a prior review of the effectiveness of teamwork training. …

A crew resource management teamwork training intervention was implemented at an urban primary care clinic, with the goal of improving care for diabetes patients. The effort resulted in short-term improvements in adherence to evidence-based care processes for diabetes.

This observational study found that several types of patients, including elderly patients and patients transferred from another health care facility, appeared more likely to experience an adverse drug event.

This study evaluated the impact of a newly designed children's hospital on patient safety and job function. The investigators begin with a detailed discussion of the contextual factors involved in their hospital redesign, drawing on human factors approaches in safety interventions. They follow by presenting their hospital design process, sharing both unit and floor layouts aimed to ensure family-centered ideals. Results from the 270 clinical faculty and staff surveys suggested that the majority reported a better overall new facility, more efficient information and patient flow, and high ratings for work environment factors such as lighting and equipment availability. However, providers in intensive care settings expressed concern about the negative impact new designs played in team communications, rates of interruptions, and work processes. As perhaps expected, the findings demonstrated many benefits and some unanticipated consequences of the redesign efforts but ultimately reinforced the need for human factors expertise.

… AORN J … This article provides background on  crew resource … responded to its implementation at one medical center. … France DJ; Stiles R; Gaffney EA; Seddon MR; Grogan EL; Nixon WR Jr; …