A missed or delayed diagnosis of stroke places patients at risk of permanent disability or death. This article describes how interdisciplinary teams used a failure modes, effects, and criticality analysis (FMECA) to create an acute stroke diagnostic process map, identify failures, and highlight existing safeguards. The FMECA process identified several steps in the diagnostic process as the most critical failures to address, including failure to screen patients for stroke soon after presentation to the Emergency Department (ED), failure to obtain an accurate history, and failure to consider a stroke diagnosis during triage.

… in patient outcomes. … Stulberg JJ, Huang R, Kreutzer L, et al. Association between surgeon technical skills and …

Establishing a strong culture of safety is an important priority in the health care setting. Prior research examining the association between improved safety culture and patient outcomes has produced mixed results. Using a modified version of the Safety Attitudes Questionnaire (SAQ), researchers surveyed hospital leaders and frontline providers across 49 hospitals in the Illinois Surgical Quality Improvement Collaborative. Consistent with prior research, they found that hospital administrators had more positive perceptions of safety than frontline health care providers. They also found a significant association between improved safety culture as measured by the SAQ and reduced risk of postoperative morbidity and death. A past PSNet perspective discussed the impact of safety culture on safety.

Prior studies have found that patients are often prescribed opioids inappropriately after undergoing surgery. This qualitative study reports on the implementation of a multifaceted effort to reduce opioid prescribing and standardize postoperative pain management at an academic hospital. The investigators identified several barriers to improving prescribing, including time and resource constraints and fear of harming patient satisfaction.

Measuring safety culture is a core patient safety activity, but the relationship between safety culture and adverse events remains unclear. This prospective cohort study measured nursing home safety culture using the AHRQ Nursing Home Survey on Patient Safety Culture and also measured rates of catheter-associated urinary tract infections (CAUTIs) as part of a quality improvement collaborative. Although safety culture survey results improved and CAUTIs declined over time, after accounting for other factors such as nursing home size and nonprofit versus for-profit status, there was no association between safety culture score and CAUTI rates. The authors recommend focusing on technical aspects of infection control such as standard protocols for catheter insertion rather than safety culture in order to improve patient safety outcomes. Correspondence published in the same issue points out limitations of a related study on the AHRQ Hospital Survey on Patient Safety Culture.

Prior studies have demonstrated that managers have more positive perceptions of safety culture than frontline staff across multiple health care settings. This study demonstrated that staff responses to AHRQ's Nursing Home Survey on Safety Culture were higher for administrators than for clinical staff. The authors call for reporting safety culture results by role rather than by facility.

Medical malpractice law is intended to foster high quality care and discourage negligence among health care providers. This observational study took advantage of differing malpractice laws by state and examined the extent to which the malpractice environment is associated with hospital quality. Investigators assessed quality using several measures: validated processes-of-care measures, such as whether evidence-based actions were appropriately taken for common conditions like myocardial infarction, pneumonia, heart failure, and surgical care; patient experience as measured by the Hospital Consumer Assessment of Healthcare Providers and Systems; imaging efficiency as reported by Medicare's Hospital Compare website; AHRQ Patient Safety Indicators; and 30-day readmission and hospital mortality rates. There were no associations between any of these quality outcomes and the rate of paid claims per 100 physicians. Areas with a higher malpractice geographic cost index had lower 30-day mortality but higher readmission rates, and higher malpractice costs were correlated with more inefficiency in some types of imaging. The authors conclude that malpractice environment does not appear to be associated with quality, but higher malpractice costs may lead to overtreatment.

The Centers for Medicare and Medicaid Services no longer reimburses hospitals for catheter-associated urinary tract infections (CAUTIs), considered a form of preventable harm to patients. Although research in the hospital setting has shown that preventing CAUTIs is possible, little is known about how health care system integration affects the success of infection prevention initiatives. Researchers queried US Department of Veterans Affairs (VA) nursing homes and non-VA nursing homes participating in the AHRQ Safety Program for Long-Term Care collaborative, hypothesizing that those within the integrated VA system would have a more developed infection prevention infrastructure. Out of 494 nursing homes surveyed, 353 responded. A greater proportion of VA nursing homes reported tracking and sharing of CAUTI data, but more non-VA nursing homes had developed policies around catheter use and insertion. The authors conclude that VA and non-VA nursing homes can share best practices so that they can be broadly applied. A past PSNet interview discussed CAUTI prevention.

Failure mode and effect analysis (FMEA) is a human factors engineering method used to examine a process in health care to identify potential safety risks. Comparing a traditional resource-intensive FMEA with a simplified version, this analysis found that the simplified method identified risks accurately. These results should encourage more widespread use of this more feasible version of FMEA.

Observation has been used as a way to study opportunities for improvement in teamwork, practice, and guideline compliance. According to this review, observation was utilized most often in high-risk environments—like the emergency department—and helped to identify weaknesses in care processes. The authors also describe drawbacks to this method, such as the Hawthorne effect and the substantial resources required to train observers and data analyzers.

This research group performed a failure mode and effect analysis to study handoffs between the operating room and the intensive care unit for liver transplant patients at a large academic medical center. The authors identified 81 process failures and outlined recommendations to mitigate many of these risks.

This systematic review investigated root causes of wrong-site surgery and identified three vulnerabilities: transcription errors prior to surgery, intraoperative verification failures, and omitting steps in the verification process. The Universal Protocol does not mitigate these vulnerabilities, suggesting that further interventions are required to prevent wrong-site surgeries. A recent AHRQ WebM&M commentary provides an overview of wrong-site surgery and best practices to prevent it.

Pagers have been a mainstay for urgent clinician–clinician communication for many decades. Increasingly physicians are using a variety of electronic devices, including smartphones and Web-based technologies. This systematic review identified 16 articles that studied different technologies for urgent clinician communication. Each strategy had potential advantages and pitfalls. For example, smartphones are associated with decreased transmission time compared to pagers, but they also result in more clinician interruptions. There is very little evidence linking any specific communication method with benefits for patient care. Future study could more robustly explore which forms of communication are best for clinicians and patients. A prior AHRQ WebM&M commentary describes a case of serious patient harm related to a smartphone interruption.

This commentary discusses electronic communication in hospitals, including unintended consequences and how variability in information quality and accuracy may affect patient outcomes.

Medication errors are likely the most common patient safety threat in ambulatory care, and this survey of primary care patients revealed many issues that are putting patients at risk for adverse drug events. Patients assumed that their primary care doctor was aware of all their medications, including those prescribed by other physicians, despite evidence documenting poor information sharing between community physicians. Although prior studies show that pharmacist counseling may reduce medication error rates in outpatients, only a minority of patients receiving new prescriptions reported receiving counseling (from a physician or pharmacist) regarding potential adverse effects. The discordance between patient assumptions and physician knowledge about medication regimens points to a need for greater patient engagement in medication reconciliation efforts.

This study uses qualitative methods—and biting humor—to vividly illustrate how building a culture of safety often requires identifying and dealing with individuals who are resistant to change.

This study highlights the importance of leadership and outlines the specific behaviors that may foster success in infection prevention activities.

Direct observation of signouts revealed that residents giving and receiving signout generally agreed on a patient's overall severity of illness, but did not agree on prioritization of specific acute problems.

Clinician surveys were used to develop a list of high-alert medications (drugs associated with adverse events) for pediatric intensive care unit patients. The surveys identified several medications not included on the Institute for Safe Medication Practices high-alert list.

This study used focus groups to explore problems in clinician-to-clinician communication among pediatricians. Participants noted significant organizational and system barriers to effective communication, resulting in impaired patient safety.