The authors examined contributors to error-associated deaths occurring between 1996-2004 and 2005-2014 and identified a shift from deaths occurring during the early phase of care (e.g., failed resuscitation and hemorrhage) to deaths occurring during the recovery phase (e.g., respiratory failure from aspiration). These findings demonstrate that successful implementation of system improvements can resolve process of care issues, but that ongoing evaluation is critical for continuous process improvement.

An advocate for clinical education (a nurse who rounded with medicine and surgery teams) provided team-specific feedback on patient safety measures to residents and attending physicians based on direct observation of clinical care. The feedback was well received by physicians and was associated with some improvement in hand hygiene practices.

This study describes successful efforts to reduce retained surgical sponges after implementing protocol changes to improve the system.

The researchers audited 9 years of records related to inpatient trauma deaths and found identifiable error patterns that can be used to target error interventions.