Hospital-acquired pressure ulcers, categorized as a never event, are underreported, particularly when related to medical devices. Interviews with experts in hospital-acquired pressure ulcers revealed four domains related to reporting: 1) individual health professional factors, 2) professional interactions, 3) incentives and resources, and 4) capacity for organizational change. Teamwork, openness, and feedback were seen as the main facilitators to reporting, and financial consequences was a contributing barrier.

In health care, executive walk rounds are used to help senior leadership engage in discussions about safety issues with frontline staff. Although prior research has demonstrated a positive impact of walk rounds on safety culture in the hospital setting, less is known about their value in other types of care settings. In this mixed methods analysis, executive walk rounds were implemented across six long-term care institutions. Leaders reported that participating in walk rounds increased their awareness around safety issues and enhanced their engagement with frontline staff. An accompanying editorial discusses the utility of walk rounds in improving the safety culture in nursing homes.

The growing focus on enhancing health care safety has placed new demands on hospital leadership to implement improvement initiatives. Examining governance of patient safety in the emergency department, this systematic review found that robust tools for monitoring patient safety and reporting errors are lacking.

This qualitative study explored the means by which intensive care unit nurses enhance their patients' perception of safety. Nurses emphasized the importance of communicating with patients and families, ensuring patients' physical safety, and building trust with families so that patients feel safe.

In this survey study, one-third of respondents reported an experience with an impaired or incompetent colleague within the last year. One limitation to the survey findings was the low 28% response rate, but the authors note that even if all non-respondents had no such encounters, the results suggest at least 9% of health care professionals have dealt with impaired or incompetent colleagues.

Although 12-hour nursing shifts are common in the United States, this study found that only 15% of European nurses worked 12 hours or more. Similar to prior research, longer nursing shifts were associated with lower quality of care and compromised patient safety. This study also found that nurses working extended shifts reported more care left undone. Nurses who worked overtime, even if shift length was less than 10 hours, described similar concerns. The authors warn that policies to adopt standard 12-hour nursing shifts as a cost-effective way of maintaining nurse–patient ratios may contribute to burnout. A past AHRQ WebM&M interview with Barbara Blakeney discussed the importance of proper nursing staffing for patient safety, and a prior AHRQ WebM&M commentary examines the complexities around balancing nurse staffing and workload.

Numerous studies have identified unintended consequences associated with health information technology (IT) and computerized provider order entry, but most of these focused exclusively on the hospital setting. This study, which analyzed data from a national database of medication errors in the Netherlands, extends prior studies by examining medication errors related to IT in community pharmacies as well as hospitals. Overall, nearly one in six medication errors was attributable to problems with IT. Human factors engineering issues, such as poorly designed screens and displays, were at the root of a large proportion of these errors. Dr. Donald Norman, a founder of the human factors engineering field, was interviewed by AHRQ WebM&M in 2009.

In this cluster randomized trial, a strategy that sought to improve nurses' hand hygiene by emphasizing team commitment and leadership engagement did achieve higher hand hygiene rates compared with a standard quality improvement approach. However, the overall rate of hand hygiene adherence remained poor in both groups.

Focus groups of patients, hospital physicians, outpatient physicians, and nurses revealed many aspects of organizational culture that impede progress in enhancing care transitions. A recent systematic review identified promising strategies for improving continuity of care at discharge.

… extra-hospital and intra-hospital handoffs. … Hesselink G, Schoonhoven L, Barach P, et al. Improving patient handovers …

Conducted in 70 primary care clinics in the Netherlands, this study found that clinicians' perceptions of safety culture bore little relationship to the actual incidence of patient safety events in their clinics.

Multicenter collaboratives have been used to successfully address a variety of patient safety problems. However, this study found that despite the growing use of collaboratives, the essential factors for ensuring success of these efforts remain unclear.

Many organizations issue alerts to warn clinicians and safety professionals about emerging safety issues. The Joint Commission's Sentinel Event Alerts and the Institute for Safe Medication Practices' Medication Safety Alerts are two prominent examples. The effectiveness of these alerts was examined in this Dutch study, which evaluated the degree to which hospital pharmacies implemented three specific medication safety recommendations made by the national Central Medication Incidents Registration (CMR) system. Many pharmacies had yet to implement any of the recommendations 2 years after they were issued, and only one of those recommendations had been implemented by a majority of pharmacies. The authors conclude that passive dissemination of medication safety information is likely an insufficient method.

This study sought to quantify adverse events associated with physical therapy and occupational therapy in the outpatient setting but was limited by incomplete record keeping.

This study found a low rate of patient safety incidents involving telephone care interactions. Most incidents were related to failures in clinical reasoning. A past AHRQ WebM&M commentary discussed potential pitfalls in providing medical advice by telephone.

Structured interviews revealed that primary care physicians and nurses had a broad view of patient safety in ambulatory care, encompassing organizational, cultural, and professional factors.

Improving patient safety requires development of a culture of safety and transformation into a learning organization—one that has the capacity to rapidly address problems through information sharing and learning from past experience. In this systematic review, the authors characterize the published literature on organizational safety programs, and summarize published data on error detection methods (such as incident reporting systems), error analysis, and systems to mitigate and reduce specific errors (such as diagnostic errors and medication errors). The review is limited by publication bias (the preferential publication of studies with positive results) and the descriptive nature of most studies, reducing the generalizability of these studies for other organizations. An AHRQ WebM&M perspective discusses organizational approaches to safety improvement in academic and community settings.

This systematic review of studies of teamwork in health care found that adding personnel with specific clinical expertise to teams appeared to improve performance, but did not necessarily improve patient outcomes.

This study describes the implementation of a patient safety program focused on evidence-based guidelines to reduce the incidence of pressure ulcers, falls, and urinary tract infections. The authors discuss the challenges of their program development and implementation, including the need for reliable feedback systems on performance.

This study analyzed adverse events in two primary care practices and found that half had health consequences and a third led to worsening of symptoms or an unplanned hospital admission.