Racial and ethnic minoritized patients frequently have poorer postoperative outcomes. The hospital in this study found the opposite and sought the perspectives of minority and non-minority patients to explore potential contributing factors. Both groups of patients described positive communication with nurses and physicians, trust in the team, and family support. Only one unique factor came up for the ethnic minority patients: having someone, an interpreter, accompany them to the operating room made them feel safe.

A necessary part of successful implementation of new guidelines is ensuring continued adherence. Nine Dutch hospitals implemented a multifaceted program (IMPlementatie Richtlijnen Operatieve VEiligheid [IMPROVE]) to support application of surgical guidelines. Results of guideline use were mixed.

… and collaborative networks may reduce variations. … Atsma F,   Elwyn G, Westert G. Understanding unwarranted variation in clinical …

Auditing for compliance with safety practices is performed frequently in the health care setting, both for learning and feedback as well as for regulatory purposes. In this survey study involving boards of directors and hospital leaders from 89 acute care hospitals in the Netherlands, researchers sought to identify factors for effective auditing and provide suggestions for how hospital boards can use such auditing practices to inform governance.

In health care, executive walk rounds are used to help senior leadership engage in discussions about safety issues with frontline staff. Although prior research has demonstrated a positive impact of walk rounds on safety culture in the hospital setting, less is known about their value in other types of care settings. In this mixed methods analysis, executive walk rounds were implemented across six long-term care institutions. Leaders reported that participating in walk rounds increased their awareness around safety issues and enhanced their engagement with frontline staff. An accompanying editorial discusses the utility of walk rounds in improving the safety culture in nursing homes.

This systematic review revealed that limited evidence exists exploring handoffs from intensive care units to general wards, and most of the studies identified were of low quality. Two promising interventions include employing liaison nurses working across multiple settings and structured communication, which has been shown to improve handoffs. The authors advocate for these interventions to be tested widely in rigorous studies to determine their effectiveness.

In this survey study, one-third of respondents reported an experience with an impaired or incompetent colleague within the last year. One limitation to the survey findings was the low 28% response rate, but the authors note that even if all non-respondents had no such encounters, the results suggest at least 9% of health care professionals have dealt with impaired or incompetent colleagues.

Currently, no reliable method exists for comparing patient safety between hospitals. The hospital standardized mortality ratio, which compares observed with expected mortality for specific diagnoses, is widely used but has been decried as inaccurate and subject to gaming. Similarly, deaths in patients with low-mortality diagnoses are also used to identify safety problems, but these events are rare and unpredictable in many cases. Adverse events are known to result in longer hospitalizations. This Dutch study used a national database to examine whether unexpectedly long length of stay could be used as an indicator of the safety and quality of care. This preliminary study found that rates of unexpectedly long hospital stays varied widely between hospitals and were correlated with other quality measures. Although much more work is required to validate this measure, it may fill a need as a measure of patient safety that allows comparisons between hospitals.

This commentary describes how misidentifying patients' preferences affects their care and recommends tactics to prevent it.

This study used focus groups to analyze how health care professionals may minimize the risk of patient error—errors committed by patients themselves.

Preliminary research has found that patient factors may contribute to errors—for example, when the patient fails to take medications as prescribed. In this study, focus groups of patients and health care professionals were used to identify and characterize the types of errors that can be committed by patients. The authors identified two main groups of errors: action errors, errors of patient behavior such as failing to attend an appointment, and mental errors, which are errors of patients' thought processes. Included among mental errors are factors that have been linked to errors, such as low health literacy. The authors suggest that further research should investigate how interactions among patients, clinicians, and systems lead to harmful adverse events.

The authors discuss the role patients play in contributing to medical error.

The authors provide a brief history of the patient safety movement and insights into why the time is right to implement change in worldwide health care safety.