Collaborating to implement rapid-cycle learning is a strategy to design and sustain patient safety innovations. This commentary describes an AHRQ-funded learning laboratory, the Institute for the Design of Environments Aligned for Patient Safety. The authors outline the infrastructure of the initiative and highlight how its research integrates the results of their activities into system-level improvement.

The Comprehensive Unit-based Safety Program (CUSP) reduced central line–associated bloodstream infections (CLABSI) in intensive care units nationwide, but its effectiveness varies among settings. This analysis found that units with a strong safety culture had greater success in lowering CLABSI with CUSP implementation than units with a worse safety culture. The authors suggest addressing a unit's safety culture prior to implementing CUSP to augment its impact.

The AHRQ Patient Safety Indicators (PSIs) represent quality measures derived from administrative data. However, concerns about validity have led to increased scrutiny. This retrospective study analyzed all PSIs identified by standard algorithms over a 1-year period at a single academic medical center. A review team reversed 185 of the 657 PSIs initially identified, citing the two main reasons for reversal to be algorithm limitations and coding misinterpretations. The authors concluded that if PSIs continue to be publicly reported and carry financial implications for hospitals, the quality of administrative data and accuracy of PSI algorithms must be improved.

Conducted at hospitals participating in the On the CUSP: Stop BSI initiative, this qualitative study analyzed how hospitals engaged frontline staff in efforts to prevent health care–associated infections. Investigators found that broader organizational efforts to improve safety culture facilitated an atmosphere where staff felt comfortable speaking up about potentially unsafe situations.

Health systems have widely employed teamwork training as a strategy for improving patient safety. With increasingly constrained hospital budgets, there has been a new focus on showing the business case for patient safety programs. This study calculated the return on investment of a system-wide crew resource management training program at a large academic medical center. Over 3 years, the program trained approximately 3000 health system employees, costing an estimated $3.6 million, due to programmatic costs, time away from work, and leadership time. However, there was a 25% reduction in observed to expected adverse events across the same time period, which, if attributed to this training program, would result in an estimated $12–$28 million in savings, yielding at least a $9 million return on investment. A prior AHRQ WebM&M perspective discussed strengthening the business case for patient safety.

Incomplete handoffs and insufficient communication regarding key clinical information may lead to adverse events or missed or delayed diagnoses. This analysis of data from the AHRQ Hospital Survey of Patient Safety Culture sought to determine how perceptions of organizational factors that affect safety can contribute to optimal handoffs. Perceived teamwork across units was a significant predictor for successful handoffs. Perceptions of staffing adequacy and management support for patient safety efforts were also related to good handoffs. Among frontline staff, open communication was associated with optimal handoffs, while among management safe handoffs were linked to a continuous learning culture. These findings add to existing studies which underscore the need for high-reliability organizations to promote safety efforts. The authors advocate for hospital leadership to promote teamwork and open communication to augment handoffs in their facilities. Dr. Vineet Arora discussed the challenges of handoffs in a prior AHRQ WebM&M interview.

Voluntary error reporting is a critical mechanism for identifying patient safety issues in an organization. However, the process is dependent on a culture of safety that enables providers to report mistakes and near misses. This study used the AHRQ Hospital Survey on Patient Safety Culture comparative database to test organizational factors that may predict more robust error reporting. Error feedback and organizational learning were most associated with perceptions of frequent error reporting, supporting the importance of hospitals demonstrating that reports are seriously considered and acted upon. Some manager respondents did not seem to recognize the significance of perceived management support in enabling error reporting. A prior AHRQ WebM&M perspective discussed the establishment of a safety culture in health care organizations.

Efforts to promote patient safety include initiatives to implement computerized provider order entry (CPOE) systems. This secondary data analysis estimated that the likely penetration of CPOE in hospitals across the country will approach only 80% by 2029. The authors discuss these estimates and also advocate for a new generation of CPOE systems to foster the growing demands for rapid adoption of this technology.

This survey of physicians involved in implementing information technology found concerns about the effects of IT on physician efficiency and patient safety.

The authors conducted focus groups to assess nurses' experiences with using smart pumps and the ways in which they overcame challenges associated with this technology.

The authors used a component of Rogers' diffusion of innovations model to explore pharmacy directors' perceptions of the adoption and implementation of medication safety technologies.