This article describes the use of a new accident analysis technique (CAST, or Causal Analysis based on Systems Theory), an alternative approach to root cause analysis. The CAST approach is based on the principle that accidents are not only the result of individual system component failures or errors but more generally result due to inadequate enforcement of constraints on the behavior of the system components (i.e., safety constraints enforced by controls, such as checklists).  Many adverse events (AEs) appear to be related to the design of the system involved and not attributable to unsafe individual behavior. This technique can be useful in identifying causal factors to help health care systems learn from mistakes and design systems-level changes to prevent future AEs.

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 Medicare Patient Safety Monitoring System was developed to track adverse events nationally to support robust safety improvement. This review summarizes the history of the Medicare Patient Safety Monitoring System and its evolution into a new system that seeks to enhance the standardization and utilization of the collected data.

The landmark Keystone ICU study, which achieved remarkable sustained reductions in central line–associated bloodstream infections in intensive care unit (ICU) patients, stands as one of the most prominent successes of the patient safety field. Although the use of a checklist gathered the most publicity, the study's key insight was that preventing health care–associated infections (HAIs) required extensive attention to improving safety culture by addressing the socioadaptive factors within hospitals that contributed to HAIs. In this new AHRQ funded national study, the Comprehensive Unit-based Safety Program was implemented at 603 hospitals in 32 states, with the goal of preventing catheter-associated urinary tract infections in ICU and ward patients. The effort involved socioadaptive interventions (various approaches shown to improve safety culture) and technical interventions (targeted training to reduce usage of indwelling urinary catheters and providing regular data feedback to participating units). Catheter usage and infection rates significantly decreased in ward patients, although no change was found in ICU patients. This study thus represents one of the few safety interventions that has achieved a sustainable improvement in a clinical outcome. An earlier article described the implementation of the program, which involved collaboration between state and national agencies and academic centers. In a 2008 PSNet interview, the study's lead author discussed his work on preventing HAIs.

Resilience is a characteristic that enables individuals to adapt to uncertain conditions in their work environment to prevent failure. Summarizing a workshop on how resilience can enhance patient safety, this commentary defines key elements of resilient organizations and provides examples of resilience engineering techniques applied in health care.

The effects of more than a decade of national efforts dedicated to improve patient safety remain largely unclear. This study used the Medicare Patient Safety Monitoring System (MPSMS) database to assess national trends in adverse event rates between 2005 through 2011 for patients hospitalized with acute myocardial infarction, congestive heart failure, pneumonia, or conditions requiring surgery. The analysis included a large study sample with more than 60,000 patients across 4372 hospitals. The results show a significant decline in adverse event rates for acute myocardial infarction and congestive heart failure, translating to an estimated 81,000 in-hospital adverse events averted in 2010–2011. However, there were no measurable overall improvements for patients admitted with pneumonia or surgical conditions. Some events, such as pressure ulcers in surgical patients, actually increased despite considerable national attention to these problems. This study suggests that national patient safety initiatives have led to real progress in some areas but have not created across-the-board improvements.

The continued progress in eliminating central line–associated bloodstream infections (CLABSIs) in intensive care units (ICUs) stands as one of the patient safety movement's major successes. The initial efforts to prevent CLABSI in the ICU at Johns Hopkins Hospital, championed by Dr. Peter Pronovost, were subsequently replicated in the landmark Keystone ICU project in Michigan. This study describes the results of an AHRQ-funded effort to extend the Keystone ICU approach nationwide, attempting to prevent infections in more than 1000 ICUs in 44 states. The initiative, which combined the well-publicized infection control checklist with interventions to enhance safety culture (such as the comprehensive unit-based safety program) and continuous data measurement and feedback, achieved a reduction in CLABSI rates of more than 40%. This remarkable series of interventions exemplifies the value of using a sociotechnical approach to improving safety and has likely saved thousands of lives.

The authors reviewed 334 root cause analyses (RCA) using systems science principles to create a toolkit for applying RCA results to make practice changes.

Voluntary error reporting systems are perhaps the most controversial of the available tools for detecting patient safety incidents. A sizable body of research has characterized the limitations of such systems, but they remain a cornerstone of safety efforts at many institutions. This consensus conference, sponsored by the World Alliance for Patient Safety, drew together an international group of error reporting experts in order to develop a learning community for incident reporting. The ultimate goal was to develop guidelines for effective use of reporting systems to improve safety. Discussing the advantages and challenges of current reporting systems, this article proposes guidelines for maximizing incident reporting utility (based on a previously published framework). A previous article discussed the use of different types of reporting systems to obtain a comprehensive view of patient safety within an institution.

… of organizational and social discussion of accidents. … Cook RI, Nemeth CP. “Those found responsible have been …

This study describes a scientific analysis for assessing medical devices by combining a hospital staff assisted by human factors with medical professionals versed in equipment assessment.

… a widely publicized heart-lung transplant error in 2003. … Cook RI, Wreathall J, Smith A, et al. Probabilistic risk assessment of accidental …

The authors introduce a set of articles that explore how clinicians plan and manage their work in the emergency department through the spectrum of clinical workload, learning techniques, equipment use, and communication.

This study examined sensemaking within the context of the intensive care unit (ICU). The investigators used direct observation of ICU teams on rounds, in order to analyze how clinicians responded to the inherent complexity of ICU care, and to determine how clinicians attempted to avoid error and adverse outcomes. Clinicians used a variety of mechanisms to establish "cooperative conditioning," a shared understanding of the patient's acute needs and risks, which maximizes patient safety by establishing a common group culture and approach to decision making. The authors' approach is derived from the seminal study of sensemaking in organizations, an account of the Mann Gulch disaster.

The authors studied the use of cognitive artifacts (eg, schedules) in the operating room in order to understand the cognitive work of providers in coping with complex clinical interactions.

This commentary discusses the concept of "sensemaking" as a mechanism to better understand and mitigate the factors that contribute to medical errors. The authors begin by presenting a conceptual framework of sensemaking before discussing both retrospective (eg, root cause analysis) and prospective (eg, failure mode and effect analysis) tools that can be employed within organizations. After discussing probabilistic risk assessment, a case example is provided to illustrate the use of these tools and what is learned from their collective findings. The authors conclude that identifying risks to patient safety represents a critical step in prevention through the design of targeted interventions.

The authors report on the results of a consensus conference that focused on safety for patients with diabetes and other endocrine diseases. They list the recommendations from the multidisciplinary expert panel convened for the conference.

This cross-sectional observational study discovered a number of unintended consequences of bar code medication administration (BCMA) technology implementation and the potential for new paths to adverse drug events. Using ethnographic observation techniques on nearly 70 nurse-BCMA interactions, investigators identified and discuss five negative side effects of the new medication process. Both conceptual and operational frameworks are presented, but the authors point out that their findings do not call for abandoning the technology. They argue that, with implementation of any new technology, redesign and anticipation of unintended effects must be considered. The technique of observation described in this study may serve as a very useful tool for similar technology advances and implementation.

… is used to improve patient safety. … Perry SJ, Wears RL, Cook RI. J Patient Saf. 2005;1(1)56-61. …