Healthcare has borrowed many safety practices from aviation such as checklists, crew resource management, and safety culture. In this study, interviews with aviation experts identify non-technical skills that leaders require in a safety culture environment which the authors adapt for surgical leaders. The core attribute was "humble confidence," with three additional domains: management of risk, management of opportunity, and management of people. The authors developed the Safety Leadership Assessment Matrix (SLAM) to assess these non-technical skills in surgeon leaders.

Organizational incident reporting allows for investigation of contributing factors and formation of improvement recommendations, but some recommendations are weak (e.g., staff training) and do not result in system change. This review found 4,579 recommendations from 11 studies, with less than 7% classified as "strong". There was little explanation for how the recommendations were generated or if they resulted in improvements in safety or quality of care. The authors contend additional research into how recommendations are generated and if they result in sustained improvement is needed.

Primary care often initiates a diagnostic process that is vulnerable to miscommunication, uncertainty, and delay. This commentary examines how cancer diagnosis delay in primary care occurs. The authors suggest a systems approach targeting interconnected process elements including enhanced use of information technology to help with monitoring and care coordination to realize and sustain improvement.

… such as delays in access or diagnosis. … Averill P, Vincent C, Reen G, et al. Conceptual and practical challenges …

Safety strategies from high-reliability industries such as aviation and nuclear power are frequently adapted for healthcare. In this study, pilots described crisis preparedness strategies, which surgical safety experts then developed into a framework consisting of six behavioral interventions: anticipate threats, briefing, checklists, drill rehearsal, individual and team empowerment, and debriefing. An earlier study by the authors describes the second phase in managing crisis: crisis recovery.

The role of healthcare disparities in patient safety is an emerging priority. This article summarizes disparities in preventable harm and outlines solutions to reducing inequalities in patient safety at the individual-, leadership-, and system-levels, such as identifying clear chains of accountability for adverse events and improving incident measurement and analysis specific to marginalized patient groups.

… for practical action are described. … Amalberti R, Staines A, Vincent C. Embracing multiple aims in healthcare improvement …

… J Patient Saf Risk Manag … The July effect is a phenomenon that presumably results in poor care due to the … active, independent practice . The authors discuss how a systemic approach is required to situate these … to provide the safest care possible. … Wu AW, Vincent C, Shapiro DW, et al. Mitigating the July effect. J …

… effect. The authors propose viewing the weekend effect as a proxy for staffing levels and the influence of other … or other ancillary services. … Marang-van de Mheen PJ, Vincent C. Moving beyond the weekend effect: how can we best …

… Arch Dis Child … In the second of a two-part series , using examples from newborn units, the authors present a framework for supporting practitioners in low-resource … and (4) enhancing responses to hazardous situations. … Vincent CA, Mboga M, Gathara D, et al. Arch Dis Child.  Epub …

Health systems are encouraged to proactively identify patient safety risks. In the first of a two-part series, the authors draw on the  Systems Engineering Initiative for Patient Safety (SEIPS) framework  to discuss the strengths and challenge of a low-resource newborn unit from a systems perspective and SEIPS’ implications for patient safety.

Delivering high-quality, safe healthcare requires coordination and integration of complex systems and activities. The authors propose three initiatives to further practical opportunities for transforming health systems across the world – a country-specific blueprint for change, tangible steps to reduce inequities within and across health systems, and learning from both errors and successes to improve safe care delivery.  

In this editorial, patient safety experts discuss threats to healthcare safety and quality due to the COVID-19 pandemic (e.g., failures in infection prevention and control, diagnostic errors, issues with laboratory testing) and highlight positive changes and opportunities, such as improved care coordination, supply chain innovations, accelerated learning, expansion of telemedicine, and prioritizing the safety and well-being of health care workers.

This editorial discusses priority areas for maintaining and promoting the well-being of the healthcare workforce during the COVID-19 pandemic. The authors discuss the importance of providing adequate personal protective equipment (PPE), supporting basic daily needs (e.g., provision of in-hospital food stores), ensuring frequent and visible communication, supporting mental and emotional well-being, addressing ethical concerns, promoting wellness, and showing gratitude for staff.

The authors of this editorial propose a five-step strategy for patient safety and quality improvement staff to leverage their skills to support patients, staff, and organizations during the COVID-19 pandemic. It includes (1) strengthening the system and environment, (2) supporting patient, family and community engagement and empowerment, (3) improving clinical care through separation of workflows and development of clinical decision support, (4) reducing harm by proactively managing risk for patients with and without COVID-19, and (5) enhancing and expanding the learning system to develop resilience.

This study assessed the impact of combined use of two surgical safety checklists on morbidity, mortality, and length of stay – the Surgical Patient Safety System (SURPASS) is used to address preoperative and postoperative care, and the World Health Organization surgical safety checklist (WHO SSC) is used for perioperative care.  In addition to existing use of the WHO SSC, the SURPASS checklist was implemented in three surgical departments in one tertiary hospital in Norway. Results demonstrated that combined use of these checklists was associated with reduced complications reoperations, and readmissions, but combined use did not impact mortality or length of stay.

This qualitative study examined how perioperative teams integrate surgical safety checklists into daily surgical practice and existing risk management strategies.  Perceived usefulness was the primary factor associated with use (69%); nurse anesthetists and anesthesiologists were more likely than other provider types to express that their existing safety protocols were sufficient and that elements of the checklist are redundant. The perception of usefulness was found to have considerable impact on checklist execution and communication, and the tool is most effective when it is an integrated part of the multidisciplinary risk management strategy.

Using a participatory action research approach, this study evaluated a smartphone app intended to empower surgical patients and caregivers to help optimize their care. Forty-two patients were enrolled in the study and they underwent a variety of different surgical procedures. Most patients felt that app was useful and informative (79%), was easy to use (74%) and helped participants to ask better questions (76%) and feel more involved in conversations about their care. However, almost half of participants (48%) were unsure about how the app could affect safety, citing that safety was the responsibility of the clinical staff alone rather than patients.

This analysis of 220 national incident data from England and Wales’ National Reporting and Learning System  sought to identify safety concerns experienced by children on long-term ventilation at home. The most common problems were with the equipment and devices (e.g., faulty or damaged equipment) or procedures and treatment (e.g. tracheostomy tube becomes dislodged). The reports clearly stated harm to the child in 41% of incidents, such as emergency tracheostomy change or hospital admission. Identified contributory factors involved the patients, staff performance, family caregivers, equipment, organizational, and environmental features.

… did not align in their perception of the seriousness of a given symptom. The authors theorized that misalignment … testing and deterioration in patient–physician trust. A WebM&M commentary described how the cost of a diagnostic test led to a late diagnosis of colon cancer. …