This article describes one academic medical center’s use of the Donabedian framework to rapidly identify and mitigate COVID-19 related safety concerns.  This data-driven approach to systems learning is generalizable beyond the current pandemic and can be applied to other organizational changes.

In this editorial, patient safety experts discuss threats to healthcare safety and quality due to the COVID-19 pandemic (e.g., failures in infection prevention and control, diagnostic errors, issues with laboratory testing) and highlight positive changes and opportunities, such as improved care coordination, supply chain innovations, accelerated learning, expansion of telemedicine, and prioritizing the safety and well-being of health care workers.

… or issues impeding job performance. … Bae SH, Dang D, Karlowicz KA, et al. Triggers contributing to health …

… RJ; Pronovost PJ; Sutcliffe KM; Kasda EM; Maragakis LL; Paine L; Sawyer MD; Winner L. …

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.

… Risk Manag … 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 …

In light of recent expert analysis and improvement work, the concept of treating diagnosis as team activity is gaining acceptance. This review describes a framework for engaging nurses in the diagnostic process to enhance multidisciplinary teamwork and patient involvement. The authors suggest improvements in health care culture is required to implement the recommended changes, which include a focus on creating opportunities for shifting the process to be more patient centered.

… important limitations . This study used data gathered from a university hospital's incident reporting system to develop a hospital-specific high-risk medication list. …

… of health care. This implementation study described a peer-to-peer assessment program adapted from the nuclear …

… victims . This study described the implementation of a peer support program for second victims. The program …

Program infrastructure that incorporates the knowledge of staff at executive and unit levels can enable system improvements to be sustained over time. This commentary describes how an academic medical center integrated departmental needs with overarching organizational concerns to inform safety and quality improvement work. The authors highlight the need for flexibility and structure to ensure success.

Patients are at risk for adverse events after they transition from hospital to home. This study used review of malpractice claims and stakeholder focus groups to inform planning tools for postdischarge care transitions. Pilot testing of the tools demonstrated acceptability and feasibility for patients and providers. These results suggest that malpractice data can inform safety improvement approaches.

… Saf … Health care has recently adopted high reliability as a goal, but progress to reaching that standard has been … achieving high reliability must establish and sustain a culture of safety throughout the health care system. …

… they had witnessed an episode of disruptive behavior by a clinician that directly resulted in harm to a patient. …

… engagement. Higher levels of engagement (defined as a positive work-related mindset including dedication and …

… The authors provide insights regarding establishing a safety governance structure, setting a committee agenda, and implementing and evaluating …

… Am J Med Qual … Health care has a history of tolerating intimidating and disruptive behavior … high reliability in measuring disruptive behavior. A past AHRQ WebM&M perspective discusses how to identify and manage …

This commentary advocates for adopting a broad definition of close calls and reveals one hospital's application of this strategy to identify areas requiring improvement.

… Nursing Care Quality … J Nurs Care Qual … Health care has a history of tolerating intimidating and disruptive behavior … engage in demeaning or threatening behaviors. Conducted at a large academic medical center, this study used a newly developed survey to determine the incidence of …

… Journal of hospital medicine … J Hosp Med … A medication reconciliation process conducted by bedside …