Teamwork is increasingly seen as an important component of diagnostic excellence. Through a systematic review and observations of team dynamics in a hospital medical ward, researchers identified three areas requiring additional research- (1) team structure, (2) contextual factors, and (3) emergent states (e.g., shared mental models).

… J Health Serv Res Policy … A key aspect of patient safety culture is the perception that … and senior leader participants, deciding to report a safety event (referred to as a “voiceable concern”) is influenced by four factors: …

… online open courses (MOOCs) have the ability to reach a broad audience of learners. The Science of Safety in … competence for patient safety among global learners: a prospective cohort study. Nurse Educ …

… formal organisation in voice about concerns in healthcare: a qualitative interview study. Soc Sci Med. 2021;280:114050. …

… failures contributing to disparities, a commitment from health system leadership to address … among health care workers and leadership.   … Austin JM, Weeks K, Pronovost PJ. Health system leaders' role in addressing …

This review discusses the importance of teamwork in supporting safety, psychological states driving effective safety performance, organizational- and team-level characteristics impacting safety performance, and the role of teams in safety management.

Preventing health care–associated infections remains a patient safety priority. This multisite study compared rates of central line–associated bloodstream infections, surgical site infections, and ventilator-associated pneumonia before and after implementation of a multifaceted intervention. Investigators adopted the comprehensive unit-based safety program, which emphasizes safety culture and includes staff education, identification of safety risks, leadership engagement, and team training. Central line–associated bloodstream infections and surgical site infections initially declined, but rates returned to baseline in the third year. They were unable to measure differences in ventilator-associated pneumonia rates due to a change in the definition. These results demonstrate the challenge of implementing and sustaining evidence-based safety practices in real-world clinical settings. A past PSNet interview discussed infection prevention and patient safety.

… In response to an episode of serious misconduct by a clinician, an academic hospital implemented a structured effort to address disruptive behavior by …

This study aimed to validate a behavioral marker as a measure of teamwork, specifically in the intensive care unit setting. Researchers found that it was difficult to establish interrater reliability for teamwork when observing behaviors and conclude that assessment of teamwork remains complex in the context of patient safety research.

… Qual Patient Saf … Jt Comm J Qual Patient Saf … Following a sentinel wrong-patient event , a multidisciplinary quality improvement team worked to … via the electronic health record. … Hensley NB, Koch CG, Pronovost PJ, et al. Wrong-Patient Blood Transfusion Error: …

Teamwork in health care has been embraced as a key element of patient safety. This review summarizes the evidence regarding teamwork, including strategies to measure team performance and the relationship between teamwork and outcomes.

… cancer surgeries. The program was associated with a significant reduction in surgical site infections and an …

The patient safety community continues to struggle with implementation and sustainability of improvement programs. This commentary describes how one academic medical center used assessment tools to monitor, measure, and improve safety at the patient, provider, unit, and system levels in the organization.

Health care executives and board members have a key role in safety improvement. This article describes the development of a tool and framework to assess the impact leadership decisions can have on organizational failure. The authors outline results and lessons learned from implementing the tool.

A work environment in which all team members feel comfortable speaking up about safety concerns is a key aspect of positive safety culture. Although formal mechanisms exist within health care institutions for raising safety issues, little is known about how such channels promote or discourage employees from speaking up. Researchers conducted interviews with 165 frontline staff and senior leaders working at three academic hospitals in two countries. They found that leaders viewed formal systems for raising concerns favorably, but other respondents felt uneasy reporting concerns through these channels. Such apprehension occurred especially if the concern was based on a general feeling that something might be wrong rather than hard evidence—what the authors refer to as "soft" intelligence. A PSNet perspective discussed how to change safety culture.

Organizational infrastructure is important to ensure sustainability of safety improvements. This commentary describes how one academic medical center integrated structures, processes, and frameworks to build connections within the organization and throughout the community to facilitate success of improvement initiatives.

Comprehensive unit-based safety programs have been shown to enhance safety in acute care settings. The investigators adapted this program for a primary care setting and report that safety culture improved following implementation of standard work and safety training. The authors did not report on patient outcomes.

The weekend effect refers to worse patient outcomes outside of usual business hours. This meta-analysis of 97 studies found that all-cause mortality is higher for patients hospitalized on the weekend compared to the workweek, even after adjustment for staffing, illness severity, and delays in procedures. A recent PSNet interview discussed the weekend effect in health care.

The need to improve patient safety is an international concern. This commentary discusses the importance of partnership in reaching the overall goals of global patient safety and highlights experiences in Africa that demonstrate how high-income health care systems can learn from low-income hospitals.

As implementation of comprehensive health information technology (IT) systems becomes more widespread, concern regarding the unintended consequences of such technologies has increased as well. Usability testing is helpful for optimizing implementation of health IT. Researchers analyzed the impact of health IT use on relationships among clinicians over a year-long period across three academic intensive care units. In the two units with higher health IT use, clinicians were more likely to work in an isolated manner, which was associated with an adverse effect on situational awareness, communication, and patient satisfaction. A previous PSNet perspective discussed some of the pitfalls in the development, implementation, and regulation of health IT and what can be learned to improve patient safety going forward.