Peer review can provide clinicians an opportunity to learn from failure, but the process has yet to be standardized.  This article describes the development and implementation of an evidence-based, structured, reproducible care review system at one emergency department affiliated with an academic hospital. The authors outline the care review process, which includes direct care staff feedback; single provider and peer review; structured case rating; systems analysis; loop closure; practice and education output; and consideration of psychological safety.

Workplace violence in the health care setting is common and poses an ongoing risk for providers and staff. The Joint Commission issued a sentinel event alert to raise awareness about the risks associated with physical and verbal violence against health care workers and suggests numerous strategies organizations can use to address the problem, including establishing reporting systems and developing quality improvement interventions. The authors describe a quality improvement initiative involving the development and iterative testing of a huddle handoff tool to optimize communication between the emergency department (ED) and an admitting unit regarding patients with the potential for violent behavior. The huddle tool led to improved perceptions of safety during the patient transfer process by both the ED nurses and the admitting medical units. An accompanying editorial highlights the importance of taking a systems approach to address workplace safety. A PSNet perspective explored how a medical center developed a process to identify, prioritize, and mitigate hazards in health care settings.