Failure to rescue refers to delayed or missed recognition of clinical deterioration, which can lead to patient complications and death. In this article, the authors used health economics methods to understand the health economic impacts associated with failure to rescue. The authors discuss the economic perspectives of various decision makers and how each group defines value. 

This education study randomized medical students to learn about patient safety either through a text-based electronic module or a serious game activity with a didactic purpose. Students randomized to the game and the electronic module performed equally well on a patient safety knowledge assessment, and both groups performed better than students who did not have any patient safety education. Although students found the game more engaging, it also lasted about 3 hours compared to 1 hour for the text-based module.

This analysis of videotaped postoperative patient handoffs revealed that the majority of clinicians engaged in multitasking—handover of both equipment and clinical information—while transferring care. Such behavior violates the sterile cockpit concept and may be a source of error during handoffs.

Although seminal studies have documented persistent problems in care transitions, including readmissions and adverse events after discharge, understanding of the basic mechanisms of these problems remains incomplete. This Dutch study examines the hospital discharge process through a clinical microsystems approach, using detailed interviews with patients, nurses, hospital physicians, and primary care physicians to construct a 360-degree view of the factors contributing to effective and ineffective transitions. The major theme that emerged was a lack of consistent information transfer across settings, implying the need for both technological solutions and increased personal contact between hospital-based and outpatient clinicians. This study is part of a special theme issue of BMJ Quality and Safety dedicated to the issue of care transitions.

… and intra-hospital handoffs. … Hesselink G, Schoonhoven L, Barach P, et al. Improving patient handovers from hospital …

Voluntary error reporting systems have traditionally been hampered by low reporting rates among physicians. This Dutch analysis of an initiative to encourage error reporting among resident physicians found that residents who reported errors or near misses scored more highly on objective performance assessments compared with their peers who did not file any reports.

This commentary presents ambiguity, autonomy, complexity, and visibility as challenges to improving safety and makes recommendations to address them.

This study investigates the local implementation and feasibility of an incident reporting system for managing events in primary care practice.

… tasks, and describes the differences between each group’s expectations around this entrustment process. An … in clinical settings. … Sterkenburg A, Barach P, Kalkman C, Gielen M, ten Cate O. When do supervising …