… Health Care … Maternal morbidity and mortality remain a significant problem in U.S. health care. This article describes Texas and Oklahoma’s adoption of a perinatal quality improvement initiative, including the …

This article describes one academic health center’s protocol to initiate universal preoperative screening and testing for COVID-19 as they began to restore nonurgent, essential surgical care.

This systematic review of opioid stewardship practices following surgery identified eight intervention studies intended to reduce postsurgical opioid use. Organizational-level interventions such as changing orders in the electronic health record, demonstrated clear reductions in opioid prescribing. Clinician-facing interventions such as development and dissemination of local guidelines also led to reduced opioid prescribing. The authors emphasize the need for more high-quality evidence on opioid stewardship interventions.

… cancer surgeries. The program was associated with a significant reduction in surgical site infections and an …

Standardization of care protocols has been shown to improve perioperative outcomes. This article presents the results of an evidence review to develop best practices for perioperative care around colorectal surgery. The authors acknowledge the need for local tailoring in implementing these recommendations.

… factors and solutions. Fear of malpractice was cited as a major reason for overtreatment. …

… decrease medication errors, adverse drug events remain a significant source of harm. Patients in the intensive care … detection of medication errors and adverse drug events. A previous WebM&M commentary discussed a case involving a serious medication …

Patients requiring intensive care are particularly vulnerable to preventable adverse events, including health care–associated infections. This AHRQ-funded study examined the effect of a collaborative to prevent adverse events in patients requiring mechanical ventilation in 56 intensive care units (ICUs) in 2 states over a 3-year period. The participating ICUs introduced a multifaceted intervention structured around the Comprehensive Unit-based Safety Program, focusing on implementing evidence-based safety processes by explicitly addressing barriers to improvement and engaging in regular data audit and feedback. Participating hospitals were able to significantly reduce the rate of ventilator-associated adverse events (including ventilator-associated pneumonia) over the study period. Although the study is limited by lack of a concurrent control group, the results indicate the power of collaborative efforts to drive large-scale improvement.

Program infrastructure that incorporates the knowledge of staff at executive and unit levels can enable system improvements to be sustained over time. This commentary describes how an academic medical center integrated departmental needs with overarching organizational concerns to inform safety and quality improvement work. The authors highlight the need for flexibility and structure to ensure success.

… Am J Med Qual … Am J Med Qual … A major challenge in improving patient safety is sustaining … over time. The landmark Michigan Keystone ICU project was a large-scale quality improvement effort that led to near … the 10 years following that study. Investigators found a continued decline in CLABSIs from 2005 through 2013, with …

… yearly. More recent studies have challenged that estimate. A recent British study found that only 3.6% of inpatient … too many patients die needlessly due to unsafe care. … Makary MA, Daniel M. Medical error-the third leading cause of death in the US.  …

… on accountability measures . The program included creating a robust quality management infrastructure through the … communities, and transparently reporting monthly data with a detailed step-based accountability plan for underachieving … an enduring quality management infrastructure, a project management office, and a formal accountability …

… to fewer infections. Although this work does not establish a clear cause-and-effect relationship between safety culture …

This commentary explores elements of the hospital environment that can contribute to sleep deprivation and malnutrition in patients, including care complexity, hospital census, poor communication, and noise. The authors advocate for designing more patient-centered hospital systems to prevent this type of harm.

… describes the development of 14 clinical communities as a way to support institutional quality improvement goals in a large health care system. The authors report the benefits … collective knowledge. The article highlights the use of a unit-level engagement model and physician champions as key …

… The authors provide insights regarding establishing a safety governance structure, setting a committee agenda, and implementing and evaluating …

… … Acad Med … This study describes the early experience of a new infrastructure for quality and safety at Johns Hopkins Medicine. A major component of this effort was the 2011 creation of the … The new governance structure includes oversight from a patient safety and quality board committee. The overall …

… of patient safety … J Patient Saf … Patient stories are a growing component of understanding the impact of medical … related to medical care. Almost half of respondents filed a complaint with an oversight agency, a much higher … echo prior literature on patient reports. A past AHRQ WebM&M perspective explores best practices for error disclosure. …

… Catastrophic payments most frequently arose as a result of a diagnostic error and were more likely to occur for … was discussed by Dr. Troyen Brennan in a past AHRQ WebM&M interview . …