… go right will increase debriefings overall. … Bentley SK, McNamara S, Meguerdichian M, et al. Debrief it all: a tool …

This feasibility study surveyed 1,750 patients using the primary care patient measure of safety (PC PMOS) tool to obtain patient feedback about the safety of their care in primary care settings. Findings indicate that this approach complements existing safety improvement activities, can be integrated into existing feedback service requirements, and should be explored further by larger effectiveness trials.

Early warning systems and trigger tools are frequently used in inpatient settings to identify clinical deterioration and prevent adverse events in pediatric populations, but their use in community settings to improve illness detection and time to treatment is less common. The article discusses a consensus workshop, the goal of which was to develop the “severe illness getting noticed sooner” (SIGNS-for-kids) tool to empower parents and caregivers by identifying specific cues of severe illness in infants and children. The panel, comprised of parents and healthcare experts, identified five cues: (1) behavior, such as reduced interaction or lack of movement, (2) breathing, including noticeable breathing or long pauses between breaths, (3) skin, such as jaundice or blueish skin/tongue, (4) fluids, such as persistent vomiting or lack of urine, and (5) response to rescue treatments, or deterioration despite use of usually effective treatment.

Medication reconciliation is an important component of strategies for preventing adverse events after hospital discharge. Studies show that comprehensive medication interventions (including medication reconciliation) by hospital-based pharmacists can reduce adverse events and readmissions in older patients. This Canadian study sought to evaluate whether medication reconciliation and education by community pharmacists could also achieve the same aims for recently discharged patients. This nonrandomized study used propensity score analysis to evaluate outcomes of patients who received medication reconciliation and review of medication adherence performed by community pharmacists during a dedicated visit. Researchers found that patients receiving the service had a reduction in readmissions and death. The magnitude of benefit was small overall, but it was larger in patients who were filling a new prescription for a high-risk medication. Although the nonrandomized design precluded firmer conclusions, this study indicates that community-based medication reconciliation and review may be a promising strategy for reducing adverse events after discharge.

In this qualitative study, researchers analyzed narratives from a national sample of 348 patients. They conclude that patient narratives complement patient experience survey data and provide actionable information for quality improvement.

This study used survey data collected in 2010, 2014, and 2015 to examine public perceptions of health care quality information over time. Investigators found that the public was more likely to be aware of quality information in 2014 and 2015 compared to 2010. Patients with higher educational attainment and patients from racial and ethnic minority populations were more likely to report awareness of health care quality. They conclude that this growing awareness provides an opportunity to enhance patient engagement.

Learning collaboratives are multimodal interventions that are often used to implement evidence-based practices. This perspective from AHRQ scientists proposes a taxonomy to describe collaboratives' distinct elements: innovation, or the type of positive change; communication among members; duration and sustainability; and social systems, or the organization and culture of the collaborative. The authors suggest that efforts to evaluate learning collaboratives or quality improvement interventions employ this taxonomy.

Prior studies have demonstrated that managers have more positive perceptions of safety culture than frontline staff across multiple health care settings. This study demonstrated that staff responses to AHRQ's Nursing Home Survey on Safety Culture were higher for administrators than for clinical staff. The authors call for reporting safety culture results by role rather than by facility.

Catheter-associated urinary tract infections are considered preventable never events. This pre–post implementation project conducted in long-term care facilities employed a multimodal intervention, similar to the Keystone ICU project. This sociotechnical approach included checklists, care team education, leadership engagement, communication interventions, and patient and family engagement. The project was conducted over a 2-year period across 48 states. In adjusted analyses, this effort led to a significant decrease in catheter-associated urinary tract infections, despite no change in catheter utilization, suggesting that needed use of catheters became safer. A related editorial declares this project "a triumph" for AHRQ's Safety Program for Long-term Care.

The Centers for Medicare and Medicaid Services no longer reimburses hospitals for catheter-associated urinary tract infections (CAUTIs), considered a form of preventable harm to patients. Although research in the hospital setting has shown that preventing CAUTIs is possible, little is known about how health care system integration affects the success of infection prevention initiatives. Researchers queried US Department of Veterans Affairs (VA) nursing homes and non-VA nursing homes participating in the AHRQ Safety Program for Long-Term Care collaborative, hypothesizing that those within the integrated VA system would have a more developed infection prevention infrastructure. Out of 494 nursing homes surveyed, 353 responded. A greater proportion of VA nursing homes reported tracking and sharing of CAUTI data, but more non-VA nursing homes had developed policies around catheter use and insertion. The authors conclude that VA and non-VA nursing homes can share best practices so that they can be broadly applied. A past PSNet interview discussed CAUTI prevention.

… N. Engl. J. Med. … New Engl J Med … Patient stories have the …

Multi-institution quality improvement collaboratives have been used to successfully address a variety of patient safety problems, including medication errors and health care–associated infections. This controlled study, conducted in primary care clinics, examined the effect of a quality improvement collaborative designed to promote patient-centered care and enhance service quality. Clinics that participated in the collaborative did not achieve greater improvements in the targeted measures compared with control clinics, although all clinics (both intervention and control) showed improvement over the study period. The authors speculate that the collaborative approach may be useful for more specific, targeted safety problems.

The World Health Organization's surgical safety checklist requires preoperative estimation of blood loss, with the goal of having adequate transfusion capacity available if necessary. This prospective study found that surgeons and anesthesiologists were generally accurate in their assessment of transfusion needs, but 1 in 14 patients still had an unexpected blood loss requiring transfusion.

… and suggests that open communication can prevent it. … McNamara SA. AORN J. 2011;93:796-801.   …

This commentary reviews steps to identify, sterilize, and prepare instruments before surgery that, if not conducted in a multidisciplinary and respectful way, can cause stress and increase potential for error.

This commentary discusses disruptive behavior in health care settings and describes interventions and tactics to raise awareness of the problem.

Through space and process design improvements, a medication safety project increased use of double-check procedures and reduced interruptions and distractions.

Root cause analysis of errors in interpreting radiographic studies in oncology patients revealed several areas for improvement, ranging from technical factors to active errors and human factors.