… 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 influenced by four factors: …

… online open courses (MOOCs) have the ability to reach a broad audience of learners. The Science of Safety in … competence for patient safety among global learners: a prospective cohort study. Nurse Educ …

… formal organisation in voice about concerns in healthcare: a qualitative interview study. Soc Sci Med. 2021;280:114050. …

Preventing health care–associated infections remains a patient safety priority. This multisite study compared rates of central line–associated bloodstream infections, surgical site infections, and ventilator-associated pneumonia before and after implementation of a multifaceted intervention. Investigators adopted the comprehensive unit-based safety program, which emphasizes safety culture and includes staff education, identification of safety risks, leadership engagement, and team training. Central line–associated bloodstream infections and surgical site infections initially declined, but rates returned to baseline in the third year. They were unable to measure differences in ventilator-associated pneumonia rates due to a change in the definition. These results demonstrate the challenge of implementing and sustaining evidence-based safety practices in real-world clinical settings. A past PSNet interview discussed infection prevention and patient 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 …

… Qual Patient Saf … Jt Comm J Qual Patient Saf … Following a sentinel wrong-patient event , a multidisciplinary quality improvement team worked to … via the electronic health record. … Hensley NB, Koch CG, Pronovost PJ, et al. Wrong-Patient Blood Transfusion Error: …

… 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.

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 decisions can have on organizational failure. The authors outline results and lessons learned from implementing the tool.

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 mechanisms exist within health care institutions for raising safety issues, little is known about how such channels promote or discourage employees from speaking up. Researchers conducted interviews with 165 frontline staff and senior leaders working at three academic hospitals in two countries. They found that leaders viewed formal systems for raising concerns favorably, but other respondents felt uneasy reporting concerns through these channels. Such apprehension occurred especially if the concern was based on a general feeling that something might be wrong rather than hard evidence—what the authors refer to as "soft" intelligence. A PSNet perspective discussed how to change safety culture.

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.

Comprehensive unit-based safety programs have been shown to enhance safety in acute care settings. The investigators adapted this program for a primary care setting and report that safety culture improved following implementation of standard work and safety training. The authors did not report on patient outcomes.

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

Overuse of medical care can lead to patient harm. In this survey study, physicians were queried about the overuse of health care as well as contributing factors and solutions. Fear of malpractice was cited as a major reason for overtreatment.

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 …

… 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 …

Utilizing a systems approach to improvement in health care is important to achieve lasting success. This commentary discusses the use of a tool that blends strategy, project monitoring, and process measurement to inform improvements.