Use of health information technology (HIT) can improve care but also lead to unexpected patient harm. In this analysis of incidents and near misses in radiation oncology, a major change in the use of the electronic health record (EHR) led to an increase in reported incidents and near misses. Leaders and HIT professionals should be aware of potential issues and develop a plan to minimize risk prior to major departmental changed including EHR changes.

Using a Safety-II framework, the authors used a mixed-methods approach to retrospectively analyze root cause analysis (RCA) reports of ‘never events’ occurring in the United Kingdom to characterize proposed actions, insights and recommendations to prevent future events. The analysis found that proposed actions were generally of low-to-moderate effectiveness, and that despite identifying systems challenges and weaknesses, many reports did not include proposed actions to mitigate or remove risks. The authors conclude that applying concepts from resilient healthcare can identify vulnerabilities and opportunities for strengthening the RCA system and improving the quality of RCA reports.

Nonclinicians such as hospital administrators or law enforcement officials frequently encounter individuals in the health care context. Researchers developed and tested an instrument to measure nonclinician professionals' interpersonal skills and decision-making in health care environments for use in simulation training. The tool was found to be reliable and valid, and the authors suggest that it could be used to enhance patient safety training for nonclinicians.

This qualitative study employed observation, interviews, and review of documents to examine six health care organizations' efforts to improve their governing processes. Researchers found that the presence of a functioning board and the availability of adequate time and resources to improve were the key factors in enhancing organizational performance. The authors highlight the importance of focusing on these contextual factors when seeking improvement, particularly in public sector health systems.

This study used interviews, direct observation of board meetings, and review of important documents to characterize how the leadership of 15 health care organizations in England approached quality and safety. The investigators identified a subset of organizations that explicitly prioritized quality improvement through use of data, engaging frontline clinicians and patients, and effectively balancing short- and long-term priorities. As board engagement and management practices have been shown to correlate with quality metrics, the best practices identified in this study may be important in the development of more effective organizational leadership around quality and safety.

This study used robust research methods to examine the expected and unanticipated effects of moving to all single-occupancy inpatient rooms. The accompanying editorial points out that on the surface this seems like a common sense intervention likely to improve patient experience and safety. However, this study demonstrates the complex effects even seemingly straightforward interventions can create. Although two-thirds of patients preferred the single rooms, some patients felt more isolated and lonely. Staff expressed concerns about worsened visibility, surveillance, teamwork, and monitoring. In addition, staff workflows had to change significantly and their hourly walking distances increased substantially. There was no evidence that single rooms reduced infections. Although fall rates increased following the move, the researchers felt that based on the patterns and comparison to the control hospital, this may not have been attributable to the single rooms. As the editorial highlights, this study supports the importance of vigorously evaluating a range of impact measures, including quality, safety, costs, and staff and patient experiences.

This observational study of incident report review meetings found that high workload, lack of organizational support, and an autocratic leadership style were barriers to effective analysis of safety events. Safety leadership and participatory interactions facilitated event analysis. This work suggests that analyses of adverse events vary in their effectiveness and should be optimized in order to improve safety.

Patient safety in the homecare setting has begun to garner increasing attention. This systematic review explored patient safety issues related to the emerging use of telecare to provide remote services for patients at home. Many risks were identified, but the authors conclude more study is needed to understand telecare-related patient safety.

This study found that methods of detecting and monitoring safety hazards differed widely across five European countries, making it impractical to attempt international comparisons of patient safety.

Although health care providers felt that incident reporting systems led to positive changes in care processes and staff attitudes regarding patient safety, using such reports to improve care remains challenging.

This study found that morbidity and mortality meetings are underutilized as a tool for continuous learning. Adoption of a standardized process can reduce variation in the way deaths are reviewed and foster a culture of safety.

This commentary explores risk regulation in the English National Health Service and describes its two approaches for patient safety policies.