Teamwork is an essential component of ensuring high quality, safe healthcare. This article describes findings from the Redesigning SystEms to Improve Teamwork and Quality for Hospitalized Patients (RESET) study, which evaluated the impact of complementary interventions to redesign unit-based care (unit-based physician teams, nurse-physician co-leadership, interprofessional rounds, performance reports, patient engagement) on interprofessional teamwork and patient outcomes. Findings demonstrate improved teamwork climate scores among nurses (but not physicians), but researchers did not identify a significant impact on patient outcomes.

Quality improvement and patient safety initiatives are difficult to implement and sustain. This commentary describes factors that contributed to successful implementation of the REdesigning SystEms to Improve Teamwork and Quality for Hospitalized Patients (RESET) study. Consistent with other research, important factors included leadership involvement, goal alignment, site leader commitment, and nurse/physician agreement that improvement was needed. The authors suggest hospital leaders consider these contextual factors prior to implementing similar improvement projects.

The COVID-19 pandemic challenged infection prevention and control practices. Findings from this survey of infection prevention professionals from acute care hospitals in the United States found that while CLABSI and VAE preventive practices either increased or remained consistent, use of CAUTI preventive practices decreased during the pandemic.

Use of one-way communication technologies, such as pagers, in hospitals have led to workarounds to improve communication. Through observation, shadowing, interviews, and focus groups with nurses and physicians, this study describes antecedents, types, and effects of workarounds and their potential impact on patient safety.

Communication failures can lead to patient harm. Based on observations, interviews, and focus groups with nurses and physicians, the authors found that physician responsiveness to communications from bedside nurses depends on a combination of factors including the clarity of the message, physician preference for one communication via text, page, phone call, and other factors, such as trust, interpersonal relationships, and different clinical perspectives.

In 2013, the UK National Health Service (NHS) implemented 7-day services to ensure that patients admitted on weekends receive quality care. To examine the impact of the policy, this analysis compared error rates among patients admitted to the hospital as emergencies on weekends versus weekdays before and after policy implementation. Error rates were not significantly different on weekends compared to weekdays, but errors rates overall improved significantly after implementation of 7-day services.

Teamwork is essential to providing high quality, safe healthcare. This survey of general medicine nurses, nurse assistants, and physicians at four hospitals identified significant differences in perceptions of teamwork climate and collaboration across professional categories. While a majority of physicians reported the quality of collaboration with nurses as high, less than half of nurses gave high ratings to the quality of collaboration with physicians. Future teamwork training efforts should target the discrepancy in perceived teamwork across professional categories.

This article describes the evolution of the “zero harm” campaign, challenges in measuring preventable harm, and potential harms of zero-harm initiatives (e.g., misclassifying preventable events, failing to consider opportunity costs).  

Prior research has found that diagnostic errors comprise approximately one-fifth of preventable errors among hospitalized patients. Academic clinical care poses unique risks for diagnostic error because the frontline providers are residents and medical students. Thus, accurate diagnosis relies on robust communication between learners and their supervisors. A team of social scientists and clinicians conducted an ethnographic study of physicians on academic inpatient rounds to identify barriers to timely and correct diagnoses. They found that reliance on one-way communication methods and insufficient face-to-face interactions with patients and consultants hindered effective diagnostic decision-making. Additionally, the electronic health record led to data overload and data fragmentation. The authors offer concrete suggestions for more clinician- and patient-centered technical tools. A WebM&M commentary discussed a diagnostic error involving learners in psychiatry.

Although electronic health records have addressed some patient safety concerns, they have also introduced new risks. In this survey study in oncology, nearly 300 individuals, including physicians, nurse practitioners, and nurses, completed a survey ranking their practice's reliance on the electronic health record (from 1= "all paper" to 5= "all electronic") and measuring safety culture and quality of clinician–clinician communication. Investigators found that individuals describing a greater degree of electronic health record use reported lower safety culture scores, and individuals who rated communication higher also perceived safety culture as more optimal. The authors suggest that challenges to electronic health record use may affect oncology practitioners' perceptions of safety. A previous PSNet interview discussed the role of health information technology in patient safety.

This study focused on three types of device-associated infections: catheter-associated urinary tract infection (CAUTI), central line–associated bloodstream infection (CLABSI), and ventilator-associated pneumonia (VAP). Investigators surveyed hospital infection control leaders at 528 hospitals about prevention practices for each of these infections. More than 90% of respondents had established surveillance for CAUTI rates throughout their facilities, nearly 100% used two key CLABSI prevention techniques as part of their insertion protocol, and 98% used semirecumbent positioning to prevent VAP. Gaps remain in use of antimicrobial devices across all three of these infection types. The authors conclude that, although implementation of evidence-based infection practices are improving over time, some gaps in device-associated infection prevention persist. A past PSNet perspective discussed the history around efforts to address preventable hospital-acquired infections.

Communication failures are a common underlying factor in adverse events. Although the relationship between communication failures and safety has been best studied in the operating room, this issue likely contributes to safety problems in all settings of care. Investigators examined incident reports at an academic medical center to characterize how communication problems contribute to adverse events. Errors of purpose—a type of error in which the goals of the communication event remain unresolved, implying that situational awareness was not achieved—were among the most common types of communication problems identified. The authors point out that while structured communication tools (such as the I-PASS handoff tool) can improve the accuracy and completeness of information transfer, they are not well suited to improving communication in clinically ambiguous situations. Communication problems most often led to delays in care without physical harm, highlighting the difficulty of measuring communication issues compared to other types of safety events. A WebM&M commentary discussed a series of communication errors that led to a child's death.

Measuring patient safety remains an ongoing challenge. This systematic review examined whether preventable death rates could be used as a measure of hospital quality. Researchers reviewed 23 studies and found that estimates of preventable in-hospital death are consistently low. Ascertainment of preventability was not consistent across multiple clinician-reviewers, and the authors estimate that cases would need review by eight or more clinicians to achieve the precision required. The authors conclude that preventable death rates would not be a valid or reliable measure of patient safety. A past PSNet interview discussed the development of hospital standardized mortality ratios and their role in monitoring performance.

Researchers describe the use of video reflexive ethnography to improve communication between physicians and nurses during rounds at a single academic medical center. They conclude that video reflexive ethnography is feasible and may have the potential to improve communication between physicians and nurses.

Communication problems persistently contribute to medical error. This review focuses on the exchange of information between care team members. The authors describe an eight-element framework that targets trust, hierarchy, and technology as an approach to communication improvement that embraces the interpersonal nature of safe health care delivery.

When a patient experiences a major surgical complication, a health care team's inability to prevent subsequent postoperative death is known as failure to rescue. Stakeholders at five Michigan hospitals identified two changeable causes of failure to rescue: delayed recognition of evolving complications and communication deficiencies. A WebM&M commentary discussed a failure to rescue and system-level means to address the adverse outcome.

This direct observation study of hospitalist teams on rounds and conducting follow-up work examined the interaction between systems problems and cognitive errors in diagnosis. Researchers found that information gaps related to electronic health records, challenges with handoffs, and time constraints all contributed to difficulties in diagnostic cognition. The authors suggest considering both systems and cognitive challenges to diagnosis in order to promote safety.

The literature on effective approaches to improving quality and safety generally focuses on high reliability organizations and positive deviants—organizations or units that have achieved notable successes. This systematic review sought to characterize organizations that struggle to improve quality. The authors identified five domains that exemplify struggling organizations, including lack of a clear mission and organizational structure for improving quality and inadequate infrastructure.

Infection control precautions including use of personal protective equipment (PPE) are critical for preventing transmission of infections within health care settings. This direct observation study observed frequent failures in use of PPE, including entering rooms without using PPE at all, PPE process mistakes, and slips in properly executing PPE use. The authors suggest that given the wide range of failures, a variety of strategies are needed to improve use of PPE.

This ethnographic study examined the process of making a diagnosis among academic inpatient medical teams. Investigators observed that diagnosis requires dialogue within team, needed data is often not available, and distractions and time pressure are frequent. These observations may inform future interventions to improve timeliness and accuracy of diagnosis.