… J Health Serv Res Policy … A key aspect of patient safety … about speaking out in hospitals: A qualitative study. J Health Serv Res Policy. Epub 2022 Jan 3. …

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

… study. Soc Sci Med. 2021;280:114050. doi: 10.1016/j.socscimed.2021.114050. …

Disruptive and unprofessional behaviors are known threats to safety culture and contribute to burnout among health professionals. In response to an episode of serious misconduct by a clinician, an academic hospital implemented a structured effort to address disruptive behavior by developing mechanisms for frontline staff to voice their concerns. This article reports on the development and implementation of the effort, which focused on addressing longstanding aspects of institutional culture that were perceived as tolerating—and providing tacit endorsement of—prominent leaders who engaged in disruptive behavior.

This study aimed to validate a behavioral marker as a measure of teamwork, specifically in the intensive care unit setting. Researchers found that it was difficult to establish interrater reliability for teamwork when observing behaviors and conclude that assessment of teamwork remains complex in the context of patient safety research.

… Jt Comm J Qual Patient Saf … Jt Comm J Qual Patient Saf … Following a sentinel wrong-patient event … via the electronic health record. … Hensley NB, Koch CG, Pronovost PJ, et al. Wrong-Patient Blood Transfusion Error: …

Teamwork in health care has been embraced as a key element of patient safety. This review summarizes the evidence regarding teamwork, including strategies to measure team performance and the relationship between teamwork and outcomes.

The patient safety community continues to struggle with implementation and sustainability of improvement programs. This commentary describes how one academic medical center used assessment tools to monitor, measure, and improve safety at the patient, provider, unit, and system levels in the organization.

Health care executives and board members have a key role in safety improvement. This article describes the development of a tool and framework to assess the impact leadership decisions can have on organizational failure. The authors outline results and lessons learned from implementing the tool.

A work environment in which all team members feel comfortable speaking up about safety concerns is a key aspect of positive safety culture. Although formal mechanisms exist within health care institutions for raising safety issues, little is known about how such channels promote or discourage employees from speaking up. Researchers conducted interviews with 165 frontline staff and senior leaders working at three academic hospitals in two countries. They found that leaders viewed formal systems for raising concerns favorably, but other respondents felt uneasy reporting concerns through these channels. Such apprehension occurred especially if the concern was based on a general feeling that something might be wrong rather than hard evidence—what the authors refer to as "soft" intelligence. A PSNet perspective discussed how to change safety culture.

… journal of the American College of Medical Quality … Am J Med Qual … Organizational infrastructure is important to …

Comprehensive unit-based safety programs have been shown to enhance safety in acute care settings. The investigators adapted this program for a primary care setting and report that safety culture improved following implementation of standard work and safety training. The authors did not report on patient outcomes.

The weekend effect refers to worse patient outcomes outside of usual business hours. This meta-analysis of 97 studies found that all-cause mortality is higher for patients hospitalized on the weekend compared to the workweek, even after adjustment for staffing, illness severity, and delays in procedures. A recent PSNet interview discussed the weekend effect in health care.

Overuse of medical care can lead to patient harm. In this survey study, physicians were queried about the overuse of health care as well as contributing factors and solutions. Fear of malpractice was cited as a major reason for overtreatment.

The need to improve patient safety is an international concern. This commentary discusses the importance of partnership in reaching the overall goals of global patient safety and highlights experiences in Africa that demonstrate how high-income health care systems can learn from low-income hospitals.

As implementation of comprehensive health information technology (IT) systems becomes more widespread, concern regarding the unintended consequences of such technologies has increased as well. Usability testing is helpful for optimizing implementation of health IT. Researchers analyzed the impact of health IT use on relationships among clinicians over a year-long period across three academic intensive care units. In the two units with higher health IT use, clinicians were more likely to work in an isolated manner, which was associated with an adverse effect on situational awareness, communication, and patient satisfaction. A previous PSNet perspective discussed some of the pitfalls in the development, implementation, and regulation of health IT and what can be learned to improve patient safety going forward.

Transparency in the reporting of quality and safety data demonstrates a commitment to improvement, learning, and patient empowerment regarding provider selection. This commentary suggests potential standards for hospitals to adopt for public reporting of their quality data and advocates for an external entity that reports how hospitals adhere to public reporting of quality measures.

Patients with underlying psychiatric conditions may be particularly vulnerable to adverse events. This retrospective study analyzed 790 medical or surgical hospitalizations among adults with serious mental illness in Maryland hospitals over a 10-year period. Numerous patient, provider, and systems factors were correlated with adverse events. The authors suggest that improving safety in patients with mental illness will require multifaceted interventions.

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

Intensive care units (ICUs) are complex environments that carry high risk for medical errors. This review explores the role of safety culture and patient and family engagement in reducing opportunities for error in ICUs. The authors draw from quality improvement processes to provide insights for implementing safety initiatives and involving patients and families in these efforts.