… 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 Today. 2021;104:104984. doi: 10.1016/j.nedt.2021.104984. …

… the term "disruptive behavior" to illustrate the lack of a consistent definition of such behavior. The authors submit that a single definition is needed to develop effective policy and …

… Commission journal on quality and patient safety … Jt Comm J Qual Patient Saf … Standardizing handoffs is a recommended strategy to reduce error . This commentary describes a tool developed to support handoffs from the operating room …

… reduce errors and accidents. This commentary outlines a framework that focuses on integrating competencies at all …

Patients are at risk for adverse events after they transition from hospital to home. This study used review of malpractice claims and stakeholder focus groups to inform planning tools for postdischarge care transitions. Pilot testing of the tools demonstrated acceptability and feasibility for patients and providers. These results suggest that malpractice data can inform safety improvement approaches.

This study found that cardiac surgical teams had a more positive safety culture (as measured by the AHRQ Hospital Survey on Patient Safety Culture) than other surgical teams. Similar to prior studies in which managers reported a more positive safety culture than frontline staff, in this study surgeons reported more optimal safety culture compared to nurses and perfusionists. This gap in perceived safety culture requires further study.

… Jt Comm J Qual Patient Saf … Jt Comm J Qual Patient Saf … Forming … describes the development of 14 clinical communities as a way to support institutional quality improvement goals in a large health care system. The authors report the benefits …

Academic medical centers can serve as educational leaders in patient safety improvement. This commentary describes the development of the Armstrong Institute at Johns Hopkins which generated multidisciplinary educational programs and research opportunities that engaged clinicians, administrators, and patients in setting goals to improve safety at their institution. The authors provide insights regarding establishing a safety governance structure, setting a committee agenda, and implementing and evaluating interventions.

This study describes a comprehensive approach to identifying safety hazards in a specific clinical environment, the cardiac surgery operating room, which jointly involved experts in organizational science, human factors, and clinical medicine. The authors detail the numerous methods they applied, including surveys, ethnographic direct observation, and analysis of a large database. Safety culture, teamwork and communication, infection prevention, handoffs, failure to adhere to standard practices, and environmental concerns were identified as six key hazards. This type of in-depth, multidisciplinary approach shows promise for determining and prioritizing safety approaches across various health care settings.

… Journal of critical care … J Crit Care … This review found that little is still …

This scientific statement from the American Heart Association (AHA) reviews the current state of knowledge on safety issues in the operating room (OR) and provides detailed recommendations for hospitals to implement to improve safety and patient outcomes. These recommendations include using checklists and formal handoff protocols for every procedure, teamwork training and other approaches to enhance safety culture, applying human factors engineering principles to optimize OR design and minimize fatigue, and taking steps to discourage disruptive behavior by clinicians. AHA scientific statements, which are considered the standard of care for cardiac patients, have traditionally focused on clinical issues, but this article (and an earlier statement on medication error prevention) illustrates the critical importance of ensuring safety in this complex group of patients.

This review discusses the importance of improving health care quality and safety and details several efforts to augment safety in cardiac surgery.

… Health Aff (Millwood) … Health Aff (Millwood) … A seminal 2009 report describes the lack of formal curricula … the institutions encountered many challenges—including a lack of faculty expertise in patient safety—they were able …

… detailed observation of cardiac surgical procedures by a multidisciplinary team, including clinicians and human …

… BMJ quality & safety … BMJ Qual Saf … A 3-day course for second year medical students that …

… Commission journal on quality and patient safety … Jt Comm J Qual Patient Saf … This commentary describes how to implement a perioperative handoff tool to improve interdisciplinary …

… Journal of cardiothoracic and vascular anesthesia … J Cardiothorac Vasc Anesth … This study implemented a standardized handoff protocol, which improved information …

… journal of the American College of Medical Quality … Am J Med Qual … To detect and analyze errors, health care has … reporting and root cause analysis . This commentary draws a contrast between this approach and that used in the nuclear … focuses on prospective error detection through the use of a robust peer-to-peer assessment process. Nuclear power …

… the International Society for Quality in Health Care … Int J Qual Health Care … This study found that reducing errors … medical devices/equipment in the operating room (OR) was a key opportunity for error prevention , whereas medication safety was a focus for prevention outside the OR. …

This article describes how one hospital used failure mode and effect analysis to identify problems and design Six Sigma interventions to improve the reliability of chemotherapeutic agent preparation.