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

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

High reliability organizations embrace strategies to actively reduce errors and accidents. This commentary outlines a framework that focuses on integrating competencies at all levels of the health care workforce across the organization to support high reliability.

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.

… Jt Comm J Qual Patient Saf … Jt Comm J Qual Patient Saf … This study updates the previously …

… Jt Comm J Qual Patient Saf … Jt Comm J Qual Patient Saf … Forming clinical communities that commit …

Academic medical centers can serve as educational leaders in patient safety improvement. This commentary describes the development of the Armstrong Institute at Johns Hopkins which generated multidisciplinary educational programs and research opportunities that engaged clinicians, administrators, and patients in setting goals to improve safety at their institution. The authors provide insights regarding establishing a safety governance structure, setting a committee agenda, and implementing and evaluating interventions.

… and Quality . The institute is led by safety expert Dr. Peter Pronovost and currently has approximately 70 staff …

… Jt Comm J Qual Patient Saf … Jt Comm J Qual Patient Saf … In 2010, The Joint Commission created … in 2012. A previous AHRQ WebM&M interview with Dr. Peter Pronovost, the lead author of this paper, discussed the …

This review found that little is still understood about the processes, relationships, and organizational factors that influence interprofessional teamwork in intensive care units.

A seminal 2009 report describes the lack of formal curricula in patient safety and quality improvement in medical education as an unmet need, and similar concerns have been raised about nursing and pharmacy education. This study reports on an initiative to develop interprofessional curricula in patient safety, involving both nursing and medical students, at six institutions across the country. Although the institutions encountered many challenges—including a lack of faculty expertise in patient safety—they were able to implement several novel curricula that were well-received by students. However, the authors note that because there are no well-validated means of evaluating students' knowledge and skills in patient safety, their ability to draw conclusions about the effectiveness of interprofessional curricula was limited.

A 3-day course for second year medical students that emphasized teamwork skills and the systems approach resulted in improved patient safety knowledge and teamwork behaviors.

… Commission journal on quality and patient safety … Jt Comm J Qual Patient Saf … This commentary describes how to …

… Journal of cardiothoracic and vascular anesthesia … J Cardiothorac Vasc Anesth … This study implemented a …

This article describes how one hospital used failure mode and effect analysis to identify problems and design Six Sigma interventions to improve the reliability of chemotherapeutic agent preparation.

… Commission journal on quality and patient safety … Jt Comm J Qual Patient Saf … The ability to measure and track … required to accomplish such goals. In this commentary, Dr. Peter Pronovost and colleagues describe the sequential …

… journal of the American College of Medical Quality … Am J Med Qual … Morbidity and mortality ("M&M") conferences are …

This study provides an evaluative framework for addressing whether our health care system is safer compared to years past. The authors discuss a measurement approach that focuses on the following: how often do we harm patients, how often do patients receive the appropriate interventions, how do we know we learned from defects, and how well have we created a culture of safety. Building on a model of structure, process, and outcome measures used to evaluate health care quality, the authors present a detailed discussion of attributes necessary for safety-specific measures. They provide a case-type example of their suggested process to illustrate their framework. Reflecting on the 5 years since release of the IOM report, past commentaries by Leape and Berwick as well as Wachter focused on progress in patient safety and provide further context to the efforts of this study.

… Commission journal on quality and patient safety … Jt Comm J Qual Patient Saf … This medication safety study describes a … strategies. … Kowiatek JG; Weber RJ; Skledar SJ; Frank S; DeVita M. …