Handoffs from one care team to another present significant risks to the patient if essential patient information is not shared or understood by all team members. Stakeholders at this children’s hospital developed a structured tool for handoff between surgery and pediatric or neonatal intensive care units. Transfer of information and select patient outcomes improved, handoff time was unchanged, and attendance by all team members increased.

Effective communication between patients and providers – including after an adverse event – is essential for patient safety. This qualitative study identified unique challenges experienced by parents and providers when communicating about adverse birth outcomes – high expectations, powerful emotions, rapid change and progression, family involvement, multiple patients and providers involved, and litigious environment. The authors outline strategies recommended by parents and providers to address these challenges.

A culture of safety is a key component to successful, sustainable patient safety programs. The authors review existing models of safety culture and propose a framework which synthesizes information across fragmented concepts – including organizational culture, social identity, and social learning – to illustrate the dynamic nature and drivers of safety culture.

Clinicians who are involved in an adverse even often experience emotional and psychological distress afterwards. A survey found that 80% of responding pediatric surgeons had personally experienced a medical error resulting in significant patient harm or death. Only one-quarter of those respondents were satisfied with the institutional support they received afterwards. Respondents cited numerous barriers (lack of trust, blame, shame) to receiving support.    

Engaging patients and families is an important strategy in ensuring safe health care delivery. In this prospective, observational study, use of a parent-centered script did not improve parent engagement during the preinduction checklist and resulted in an expected decline in checklist adherence.  

Morbidity and mortality (M&M) conferences are designed to review adverse events. They are one method by which physicians undergo peer review to evaluate their performance and can allow health systems to identify potential avenues for improving patient safety. A survey of pediatric surgeons found that while the M&M participation was high, few believed the process results in practice changes or preventing future events. M&Ms considered most effective had a structured approach, were data driven with loop closure, emphasized multidisciplinary participation, and served as an educational forum.

Research has shown that the effectiveness of surgical safety checklists in improving patient outcomes is mixed and may depend in part on implementation as well as providers' attitudes toward the importance of such checklists. In this survey study involving pediatric surgeons, 94% reported using surgical safety checklists but just 55% reported that they perceived such checklists to improve safety.

Preventable harm can inflict lasting emotional damage on patients and families. Although many safety experts have examined how adverse events affect health care workers (second victims), patients' emotional experience of these events has garnered less scientific attention. The Agency for Healthcare Research and Quality convened diverse stakeholders, including patients, to identify research priorities to better elucidate how adverse events emotionally impact patients and families. They identified 4 priorities and delineated 20 steps organizations can take immediately to support those who experience adverse events, such as involving patients and families in developing solutions, incorporating emotional harm in organizational approaches to safety, and engaging patient advocates and leaders in improvement work. An Annual Perspective examined the shift toward a just culture in patient safety, which requires reckoning with the impact of errors on patients and families.

Clinical skill development in surgery is evolving beyond technical expertise as focus has shifted to how teamwork and human factors affect safety. This commentary describes three key activities associated with surgical safety efforts, including monitoring surgical quality through national data analysis, bundling field-tested processes to prevent surgical site infections, and utilizing surgical checklists.

This study compared direct observation to voluntary reporting for identification of errors and near misses in pediatric surgery. As with prior studies, the team observed underreporting of adverse events and near misses. The authors advocate for systems approaches to enhance reporting.

Communication-and-resolution programs emphasize early disclosure of adverse events to patients and families, but implementing this patient-centered approach can be challenging. Researchers found that simulation was useful in helping stakeholders understand what patients and families experience after an adverse event and suggest that such understanding might lead to improved response.

Adverse event investigation has not traditionally included patient perspectives. In this study, investigators interviewed patients and family members following an adverse event to determine whether they could identify any underlying causes of the incident. Each patient and family member was able to identify at least one contributing factor and make recommendations to address these underlying causes. The most frequent contributing cause reported was inadequate staff knowledge or qualification. However, the majority of participants were not involved in root cause analysis or other formal event investigation. This study is consistent with prior work that demonstrated the value of involving patients in error investigation. The authors conclude that patient perspectives should be included in event analysis.

Implementation of surgical checklists remains incomplete, despite evidence supporting their use. This survey study revealed that clinicians had positive perceptions of checklists 1 year after implementation, suggesting that resistance to checklist use is not a major barrier in this setting.

Checklists have improved surgical outcomes in clinical trials and are widely recommended, but a recent observational study showed no change in surgical outcomes following checklist adoption. This study sought to improve adherence to surgical checklists at a single institution. Trained observers assessed checklist performance over three 1-year periods during which various interventions were implemented. The authors report only 30% adherence to the WHO surgical checklist 1 year after adoption. Developing clinician leadership, teamwork training, and stakeholder engagement led to a significant increase in checklist adherence 2 years following implementation. This work underscores the resources and effort needed for successfully implementing safety checklists. In a past AHRQ WebM&M interview, Peter Pronovost discussed utilizing checklists as a tool to improve patient safety.

Patient engagement is increasingly recognized as a key element for patient safety. Although patients and family members may provide unique insights into adverse events, they are rarely asked to participate in medical error investigations, such as root cause analyses. Using detailed interviews, this study revealed that clinicians and hospital administrators generally support including patients and family members in these types of activities, but they are not sure how best to do so. A group of patients and health care experts at a national conference explored these findings and felt that patient involvement was desirable, but they identified many concerns and limitations with this approach. A recent AHRQ WebM&M perspective by Dr. Saul Weingart discussed the opportunities for patient engagement in patient safety.

Poor adherence to individual elements of a surgical safety checklist was noted in this study conducted at a tertiary care children's hospital. The authors attributed this finding to poor implementation and dissemination of the checklist.