“Safety cases” are used in healthcare and other industries to communicate the safety of a product, system, or service. In this study, researchers use the “safety case” approach to evaluate the safety of the Safer Clinical Systems program, which is designed to improve the safety and reliability of clinical pathways.  

Missed recognition of early signs of clinical deterioration can result in transfer to the intensive care unit (ICU) or death. This study investigated whether critical illness events (transfer to ICU or death) impacted another patient's critical illness event in the subsequent six-hour period. Results suggest one or more critical illness events increase the odds of additional patient transfers into the ICU, but not of death. The authors present several explanations for this phenomenon.

The Francis report served as a call to action for improvement, following its recording of elements contributing to systemic failure within the British National Health Service (NHS). This commentary considers the overarching problems that still exist at the NHS and that listening, learning, and leadership involvement are core elements for driving and realizing lasting change throughout the system.

Children with complex medical needs are vulnerable to patient safety threats. This qualitative study explored the perspectives of parents with children living at home with a central venous access device (CVAD). Parents highlight the persistent fear of central line-associated blood stream infections as well as the importance of maintaining a sense of normalcy for their children.

… types of healthcare professionals. … Rotteau L, Goldman J, Shojania KG, et al. Striving for high reliability in …

… whether an incident is considered a voiceable concern. … Dixon-Woods M, Aveling EL, Campbell A, et al. What counts as a …

… in fidelity or did not assess fidelity. … Lo L, Rotteau L, Shojania K. Can SBAR be implemented with high fidelity and …

Incident reporting has long been advocated as a central strategy supporting error reduction, transparency and safety culture, but its implementation and use faces challenges. This commentary challenges the viability of the concept in healthcare, examines barriers to its success, and discusses a technology- based approach to reduce clinician reporting burden.

… nurses, primary care and other essential workers. … Schiff G, Shojania KG. Looking back on the history of patient safety: …

… can lead to organizational failures. … Martin GP, Chew S, Dixon-Woods M. Why do systems for responding to concerns and …

… can motivate and support speaking up behaviors. … Wu F, Dixon-Woods M, Aveling EL, et al. The role of the informal and …

The COVID-19 pandemic has raised concerns about medical product shortages and demand surges, and the resulting effects on patient safety. This viewpoint discusses medical product supply chain vulnerabilities heightened by the COVID-19 pandemic. The authors summarize the evidence on supply chain resilience and medical product shortage, provide examples to illustrate key vulnerabilities, and discuss reactive and proactive solutions for medical product shortage.

Maternal harm is a sentinel event and improving maternal safety is receiving increased attention in both policy and clinical settings. The researchers used qualitative methods to generate a new plain language framework identifying safe behaviors and practices in inpatient maternity units. Several synergistic features were identified including a commitment to safety culture; technical competence; teamwork, cooperation, and positive working relationships.  

This review synthesized research exploring how operational failures (e.g., distractions, situational constraints) in primary care affect the work of primary care physicians. The literature suggests that operational failures are common, and the gap between what physicians perceive that they should be doing and what they were doing (“work-as-imagined” vs, “work-as-done”) is largely attributed to operational failures over which the primary care physicians had limited control. The authors suggest that future research focus on which operational failures have the highest impact in primary care settings in order to prioritize areas for targeted improvement.

This commentary discusses the two ‘gold standard’ research methods used to identify adverse events– retrospective record review and prospective surveillance using triggers. The authors note that these approaches have served to demonstrate the scope of the patient safety problem and to engage clinicians, managers, researchers and policy makers. However, looking forward, they advocate moving away from the imperfect gold standard of adverse event rates and embracing more specific measures of important safety problems.

After findings of gross negligence, the National Health Service (NHS) introduced ‘Freedom to Speak Up Guardians’ to lead safety culture change with the ultimate goal that speaking up about safety issues becomes the norm. The authors used semi-structured interviews with 51 individuals (e.g., Guardians, clinicians, policymakers/regulators, etc.) to describe the rollout of the Guardians. These interviews revealed that the role of the Guardians is rich in potential but that the initial narrow role of addressing only quality and safety concerns was not consistent with the myriad of complex issues brought to them and may indicate the need to expand the role definition.

An international group of educational and health system leaders, educators, front-line clinicians, learners, and patients convened to create a list of actionable strategies that organizations can use to better integrate Quality Improvement Patient Safety (QIPS) education with clinical care. A framework and list of concrete examples describe how groups can get started.

… PSNet interview featured the study's senior author, Mary Dixon-Woods. …

… safer health care systems. … Liu JJ, Rotteau L, Bell CM, Shojania KG. Putting out fires: a qualitative study exploring …

Evidence-based medicine has generated some controversy in quality and safety circles. The commentary highlights weaknesses in the science of evidence-based medicine and suggest that a broader systems-based approach is needed to inform health system redesign and improvement work.