Maternal morbidity and mortality remain a significant problem in U.S. health care. This article describes Texas and Oklahoma’s adoption of a perinatal quality improvement initiative, including the implementation of the Alliance for Innovation of Maternal Health (AIM) patient safety bundles and use of teamwork and communication tools in obstetric units. Findings suggest that adoption of initiative components varies across obstetric units; the majority of units had standardized processes for serious events (obstetric hemorrhage, massive transfusion, severe hypertension) but fewer units offered regular training on effective teamwork and communication for their staff.

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

Massive online open courses (MOOCs) have the ability to reach a broad audience of learners. The Science of Safety in Healthcare MOOC was delivered in 2013 and 2014. At completion of the course, participants reported increased confidence on all six measured domains (teamwork, communication, managing risk, human environment, recognizing and responding, and culture). At 6 months post-completion, the majority agreed the content was useful and positively influenced their clinical practice, demonstrating that MOOCs are an effective interprofessional learning format.

… and support speaking up behaviors. … Wu F, Dixon-Woods M, Aveling EL, et al. The role of the informal and formal organisation in voice about concerns in healthcare: a qualitative interview study. Soc Sci Med. 2021;280:114050. …

… errors to improve patient safety. … Singh H, Bradford A, Goeschel C. Operational measurement of diagnostic safety: …

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

… medicine … Crit Care Med … This study aimed to validate a behavioral marker as a measure of teamwork , specifically in the intensive care …

Following a sentinel wrong-patient event, a multidisciplinary quality improvement team worked to enhance the safety of blood transfusion. The authors report significant improvement in protocol adherence following institution of barcoding and auditing via the electronic health record.

… Am Psychol … Teamwork in health care has been embraced as a key element of patient safety. This review summarizes the …

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.

… Risk Manag … 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 …

… BMJ Qual Saf … BMJ Qual Saf … 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 … occurred especially if the concern was based on a general feeling that something might be wrong rather than …

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.

… care settings. The investigators adapted this program for a primary care setting and report that safety culture …

… for staffing , illness severity, and delays in procedures. A recent PSNet interview discussed the weekend effect in …

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.

… of health IT use on relationships among clinicians over a year-long period across three academic intensive care … awareness, communication, and patient satisfaction. A previous PSNet perspective discussed some of the pitfalls …

… decrease medication errors, adverse drug events remain a significant source of harm. Patients in the intensive care … detection of medication errors and adverse drug events. A previous WebM&M commentary discussed a case involving a serious medication …

… in the reporting of quality and safety data demonstrates a commitment to improvement, learning, and patient …

… with serious mental illness in Maryland hospitals over a 10-year period. Numerous patient, provider, and systems …