This mixed-methods study sought to identify factors contributing to the early readmission of critical care patients. Through interviews with 58 intensive care unit survivors and caregivers, researchers found that complex health needs and inadequate psychological support contributed to early, unplanned readmission to the hospital. The authors suggest that further work should be done to develop care pathways that anticipate these needs.

Health care leaders increasingly recognize the importance of engaging patients in quality and safety initiatives. Researchers examined how boards of directors at two National Health System hospitals in England gathered and operationalized patient feedback. Patient input informed strategic priorities and inspired initiatives but was underutilized to ensure improvement.

A post-surgical complication experienced by one of the authors—himself a patient safety researcher—is examined in detail using root cause analysis.

This study describes a survey tool for measuring organizational learning and provides a framework for how to assess and learn from incidents.