The Accreditation Council for Graduate Medical Education (ACGME) requires post-graduate education to include patient safety curriculum. This article describes the development and evaluation of a curriculum for residents on patient safety investigations using the Root Cause Analysis and Action (RCA2) model. Residents were surveyed at least one year after completion of the training. Sixty-three percent of respondents agreed or strongly agreed residents should be provided with the RCA2 training and nearly half reported having participated on an RCA team since completing the program.

Previous research suggests that residents may underutilize adverse event reporting tools. This article describes an 18-month clinical learning collaborative among 16 sites intended to increase resident and fellow participation in patient safety event investigations. Researchers found the collaborative increased participation in event investigation and improved the quality of the investigation.

Although e-prescribing has improved the safety of medication ordering, preventable errors persist. This study analyzed product descriptions (ingredient, strength, dose form) of more than 10 million e-prescriptions. Results show a wide variety in the way drug product descriptions are entered into e-prescription programs (e.g., 707 variants for “oral tablet” such as tablet, tab, po tab). Poor standardization of terminology in e-prescription programs can lead to incorrect medication order and patient confusion.

Researchers used failure mode and effects analysis to examine intraocular lens implantation. They report uncovering many potential failure modes or safety vulnerabilities and extensive variation in how this procedure is conducted. The authors recommend standardization, changes to equipment and workflows, and quality assurance through direct observation in order to enhance safety.

Team training programs have become a core element of safety improvement strategies worldwide. This commentary describes how one health system implemented a training initiative that focused on communication, use of a preprocedure time-out, and briefings and debriefings to enhance the safety of surgical care. The authors discuss the impact the program had on safety culture and checklist adherence.

This commentary highlights the importance of engaging residents in root cause analysis of errors and near misses. The authors discuss how participation in root cause analysis can educate trainees about process analysis and augment skill development.

Root cause analysis is a widely used strategy for understanding failure in patient care. This review highlights a root cause analysis method and describes tools such as story maps and cause-and-effect diagrams that support the use of this structured approach to examine process weaknesses and implement improvements.

Hierarchy and authority gradients are persistent contributors to poor communication in health care. This commentary describes a way for clinicians to challenge authority and assert themselves to enhance team communication and raise concerns.

Patient safety concepts in medical education are lacking. Discussing the value of teaching medical students to identify and address safety hazards, this commentary calls for faculty to not only provide training for these competencies but personally exhibit safe behaviors and practice.

Wrong-site procedures result in significant patient harm, and prior studies have shown that—contrary to traditional assumptions—many of these errors occur outside the operating room. This analysis of 14 cases of wrong-site thoracenteses, a procedure to remove fluid from around the lung, identified several common themes in these errors. The majority of errors resulted in serious patient injury. Root cause analysis of the errors found that clinicians often failed to perform a time out and did not correctly document laterality in consent forms and clinical records. A case of a wrong-side thoracentesis that resulted in the death of a patient is discussed in a previous AHRQ WebM&M commentary.

This study describes a comprehensive approach to identifying safety hazards in a specific clinical environment, the cardiac surgery operating room, which jointly involved experts in organizational science, human factors, and clinical medicine. The authors detail the numerous methods they applied, including surveys, ethnographic direct observation, and analysis of a large database. Safety culture, teamwork and communication, infection prevention, handoffs, failure to adhere to standard practices, and environmental concerns were identified as six key hazards. This type of in-depth, multidisciplinary approach shows promise for determining and prioritizing safety approaches across various health care settings.

This updated guideline reviews recommendations from an expert panel on safe practices for magnetic resonance use.

Articles in this special issue detail how human factors and ergonomics concepts can contribute to patient safety efforts through improving design, training, and equipment usability.

A seminal study found a strong association between a teamwork training intervention and improved surgical mortality at a large group of Veterans Affairs (VA) hospitals. This analysis of data from the same study also found improvements in surgical morbidity and preventable adverse events after implementation of the VA's Medical Team Training program.

This study demonstrated improved perceptions of teamwork climate among physicians and nurses following a formal teamwork training program. Despite overall improvements, gaps between physician and nurse perceptions persisted.

The Veterans Affairs system improved the timeliness and quality of root cause analysis by implementing a formal recognition program tied to specific quality improvement goals.

This analysis of incorrect surgical procedures in the Veterans Affairs (VA) system found an overall decline in the number of reported wrong-site, wrong-patient, and wrong-procedure errors compared with the authors' prior study. As in the earlier report, half of the incorrect procedures occurred outside of the operating room. Root cause analyses of errors revealed that lack of standardization and human factors issues were major contributing factors. During the time period of this study, the VA implemented a teamwork training program that has been associated with a significant decline in surgical mortality. The authors propose that additional, focused team training may be one solution to this persistent problem.

This study used root cause analysis to identify systematic problems that resulted in incorrect assessment of suicide risk among veterans.

This commentary describes aviation error prevention tactics and suggests that adopting these initiatives in health care can improve patient safety.

The Joint Commission Center for Transforming Healthcare aims to use rigorous quality improvement methodologies to tackle pervasive quality and safety issues. This article details the early progress of the Center's second major initiative, improving handoff communication.