The Measurement and Monitoring of Safety Framework (MMSF) draws on principles of high-reliability to increase patient safety at the organizational level. This commentary describes the Canadian Learning Collaborative’s experience implementing MMSF and highlights several key elements for successful implementation.

… BMJ … Primary care often initiates a diagnostic process that is vulnerable to miscommunication, … delay in primary care occurs. The authors suggest a systems approach targeting interconnected process elements … and sustain improvement. … Black GB, Lyratzopoulos G, Vincent CA, et al. Early diagnosis of cancer: systems …

… such as delays in access or diagnosis. … Averill P, Vincent C, Reen G, et al. Conceptual and practical challenges …

The role of healthcare disparities in patient safety is an emerging priority. This article summarizes disparities in preventable harm and outlines solutions to reducing inequalities in patient safety at the individual-, leadership-, and system-levels, such as identifying clear chains of accountability for adverse events and improving incident measurement and analysis specific to marginalized patient groups.

… for practical action are described. … Amalberti R, Staines A, Vincent C. Embracing multiple aims in healthcare improvement …

… J Patient Saf Risk Manag … The July effect is a phenomenon that presumably results in poor care due to the … active, independent practice . The authors discuss how a systemic approach is required to situate these … to provide the safest care possible. … Wu AW, Vincent C, Shapiro DW, et al. Mitigating the July effect. J …

… effect. The authors propose viewing the weekend effect as a proxy for staffing levels and the influence of other … or other ancillary services. … Marang-van de Mheen PJ, Vincent C. Moving beyond the weekend effect: how can we best …

… Arch Dis Child … In the second of a two-part series , using examples from newborn units, the authors present a framework for supporting practitioners in low-resource … and (4) enhancing responses to hazardous situations. … Vincent CA, Mboga M, Gathara D, et al. Arch Dis Child.  Epub …

Health systems are encouraged to proactively identify patient safety risks. In the first of a two-part series, the authors draw on the  Systems Engineering Initiative for Patient Safety (SEIPS) framework  to discuss the strengths and challenge of a low-resource newborn unit from a systems perspective and SEIPS’ implications for patient safety.

… for transforming health systems across the world – a country-specific blueprint for change, tangible steps to … to improve safe care delivery.   … Braithwaite J, Vincent C, Garcia-Elorrio E, et al. Transformational …

In this editorial, patient safety experts discuss threats to healthcare safety and quality due to the COVID-19 pandemic (e.g., failures in infection prevention and control, diagnostic errors, issues with laboratory testing) and highlight positive changes and opportunities, such as improved care coordination, supply chain innovations, accelerated learning, expansion of telemedicine, and prioritizing the safety and well-being of health care workers.

This editorial discusses priority areas for maintaining and promoting the well-being of the healthcare workforce during the COVID-19 pandemic. The authors discuss the importance of providing adequate personal protective equipment (PPE), supporting basic daily needs (e.g., provision of in-hospital food stores), ensuring frequent and visible communication, supporting mental and emotional well-being, addressing ethical concerns, promoting wellness, and showing gratitude for staff.

… J Qual Health Care … The authors of this editorial propose a five-step strategy for patient safety and quality … the learning system to develop resilience . … Staines A, Amalberti R, Berwick DM, et al. COVID-19: patient safety …

This analysis of 220 national incident data from England and Wales’ National Reporting and Learning System  sought to identify safety concerns experienced by children on long-term ventilation at home. The most common problems were with the equipment and devices (e.g., faulty or damaged equipment) or procedures and treatment (e.g. tracheostomy tube becomes dislodged). The reports clearly stated harm to the child in 41% of incidents, such as emergency tracheostomy change or hospital admission. Identified contributory factors involved the patients, staff performance, family caregivers, equipment, organizational, and environmental features.

… did not align in their perception of the seriousness of a given symptom. The authors theorized that misalignment … testing and deterioration in patient–physician trust. A WebM&M commentary described how the cost of a diagnostic test led to a late diagnosis of colon cancer. …

… BMJ Qual Saf … BMJ Qual Saf … Health care is considered a high-risk industry due to clinical, administrative, … economic, and regulatory stressors. This review explores a range of approaches to managing the safety of patients in …

Nontechnical skills, such as teamwork and communication, are critical to safe care delivery, but can be difficult to measure. This systematic review examined validated approaches for assessing nontechnical skills using direct observation. Researchers analyzed 118 articles that discussed 76 unique tools for measuring nontechnical skills. This wide range of instruments assessed individuals or teams in various health care settings, either in simulation or actual clinical practice. They identified substantial variability in how these approaches were validated and whether individual studies reported the usability of each tool. The authors spotlight the need for standardization in how to develop, test, and implement assessments of nontechnical skills. A related editorial discusses the findings of this systematic review in the context of previous research and advocates for future work to standardize assessment of nontechnical skills in health care.

… as measuring the impact of residency training programs. In a past PSNet interview , Dr. Tejal Gandhi, president of the … Leape Institute, discussed improving patient safety at a national level. …

… by the Imperial College Mortality Surveillance System (a national hospital mortality surveillance system that … trusts. On average, mortality risk decreased after a trust received a mortality alert. However, the authors conclude that random …

… safety … BMJ Qual Saf … This study examined the impact of a safety assessment intervention across nine public health …