A key aspect of patient safety culture is the perception that all team members should speak up about safety concerns. In this study of 165 frontline and senior leader participants, deciding to report a safety event (referred to as a “voiceable concern”) is influenced by four factors: certainty that something is wrong and is an occasion for voice; system versus conduct concerns, forgivability, and normalization. Organizational culture and context effect whether an incident is considered a voiceable concern.

… study. Nurse Educ Today. 2021;104:104984. doi: 10.1016/j.nedt.2021.104984. …

… study. Soc Sci Med. 2021;280:114050. doi: 10.1016/j.socscimed.2021.114050. …

Disruptive and unprofessional behaviors are known threats to safety culture and contribute to burnout among health professionals. In response to an episode of serious misconduct by a clinician, an academic hospital implemented a structured effort to address disruptive behavior by developing mechanisms for frontline staff to voice their concerns. This article reports on the development and implementation of the effort, which focused on addressing longstanding aspects of institutional culture that were perceived as tolerating—and providing tacit endorsement of—prominent leaders who engaged in disruptive behavior.

This study aimed to validate a behavioral marker as a measure of teamwork, specifically in the intensive care unit setting. Researchers found that it was difficult to establish interrater reliability for teamwork when observing behaviors and conclude that assessment of teamwork remains complex in the context of patient safety research.

… Jt Comm J Qual Patient Saf … Jt Comm J Qual Patient Saf … Following a sentinel wrong-patient event … via the electronic health record. … Hensley NB, Koch CG, Pronovost PJ, et al. Wrong-Patient Blood Transfusion Error: …

Teamwork in health care has been embraced as a key element of patient safety. This review summarizes the evidence regarding teamwork, including strategies to measure team performance and the relationship between teamwork and outcomes.

… of the American Society for Healthcare Risk Management … J Healthc Risk Manag … The patient safety community continues …

… of the American Society for Healthcare Risk Management … J Healthc Risk Manag … Health care executives and board …

A work environment in which all team members feel comfortable speaking up about safety concerns is a key aspect of positive safety culture. Although formal mechanisms exist within health care institutions for raising safety issues, little is known about how such channels promote or discourage employees from speaking up. Researchers conducted interviews with 165 frontline staff and senior leaders working at three academic hospitals in two countries. They found that leaders viewed formal systems for raising concerns favorably, but other respondents felt uneasy reporting concerns through these channels. Such apprehension occurred especially if the concern was based on a general feeling that something might be wrong rather than hard evidence—what the authors refer to as "soft" intelligence. A PSNet perspective discussed how to change safety culture.

… journal of the American College of Medical Quality … Am J Med Qual … Organizational infrastructure is important to …

Comprehensive unit-based safety programs have been shown to enhance safety in acute care settings. The investigators adapted this program for a primary care setting and report that safety culture improved following implementation of standard work and safety training. The authors did not report on patient outcomes.

… J Hosp Med … J Hosp Med … The weekend effect refers to worse patient …

The need to improve patient safety is an international concern. This commentary discusses the importance of partnership in reaching the overall goals of global patient safety and highlights experiences in Africa that demonstrate how high-income health care systems can learn from low-income hospitals.

As implementation of comprehensive health information technology (IT) systems becomes more widespread, concern regarding the unintended consequences of such technologies has increased as well. Usability testing is helpful for optimizing implementation of health IT. Researchers analyzed the impact of health IT use on relationships among clinicians over a year-long period across three academic intensive care units. In the two units with higher health IT use, clinicians were more likely to work in an isolated manner, which was associated with an adverse effect on situational awareness, communication, and patient satisfaction. A previous PSNet perspective discussed some of the pitfalls in the development, implementation, and regulation of health IT and what can be learned to improve patient safety going forward.

Transparency in the reporting of quality and safety data demonstrates a commitment to improvement, learning, and patient empowerment regarding provider selection. This commentary suggests potential standards for hospitals to adopt for public reporting of their quality data and advocates for an external entity that reports how hospitals adhere to public reporting of quality measures.

… The Journal of nervous and mental disease … J Nerv Ment Dis … Patients with underlying psychiatric …

… Commission journal on quality and patient safety … Jt Comm J Qual Patient Saf … Utilizing a systems approach to …

Intensive care units (ICUs) are complex environments that carry high risk for medical errors. This review explores the role of safety culture and patient and family engagement in reducing opportunities for error in ICUs. The authors draw from quality improvement processes to provide insights for implementing safety initiatives and involving patients and families in these efforts.

Mental models represent established mindsets that can either hinder or enhance safety. This commentary describes mental models about patient safety that may limit progress, such as acceptance of harm as an expected byproduct of medical care. The authors provide suggested changes to these mindsets, including focusing on developing effective patient safety measures and a systems approach to designing and implementing improvement initiatives.