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.

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.

This commentary reveals how situational awareness and inattentional blindness can affect the reliability of team communications.

This article defines the key components of a "rapid response system" (RRS), which the authors propose as a unifying term for medical emergency teams, rapid response teams, and other similar teams designed to intervene on clinically unstable inpatients. An RRS should consist of an "afferent limb," the mechanism by which team responses are triggered; an "efferent limb," the team of clinicians that responds to an event; an administrative arm responsible for team staffing, education, and implementation; and a quality improvement arm to assess effectiveness of the RRS and identify underlying quality of care issues. RRS effectiveness should be monitored by measuring mortality, cardiac arrests, and unplanned intensive care unit admissions. The authors did not endorse a specific model for the efferent limb, stating that physician-led or nurse-led models may both be appropriate depending on local circumstances. No consensus was reached on whether all hospitals should be mandated to institute an RRS.

… RCA can be in improving quality and safety. … Bagian JP; Gosbee J; Lee CZ; Williams L; McKnight SD; Mannos DM …

Review of activities installed at the U.S. Veterans Health Administration to support the development of a culture of safety through application of systems safety philosophies.