Root cause analysis (RCA) is a process frequently employed by health care institutions to understand the sequence of events leading to an adverse event or near miss. Experts have previously highlighted flaws with the RCA process and suggested ways to improve it. In this study, researchers reviewed 302 RCAs and concluded that many of the proposed solutions were weak, consisting largely of educational interventions, changes to processes, and enforcing policy. A recent Annual Perspective explores ongoing problems with the RCA process and sheds light on opportunities to improve its application in health care.

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

A multidisciplinary simulation training program that emphasized crew resource management resulted in enhanced knowledge, improved perception of safety culture, and a reduction in the incidence of patient safety events in a pediatric emergency department.

This commentary highlights elements of human factors that can be applied to improve efficiency and safety in health care.

This commentary describes a conceptual model to address risks associated with procedures commonly performed in emergency departments.

This commentary discusses reliability theory in patient safety and describes an assessment framework to help measure the reliability of processes and practices in hospitals.

This commentary explores how health information technology can affect care delivery in the emergency department.

This study highlights contributing factors that lead to physician overrides of drug safety alerts, including incorrect rules and reasoning applied to justify such actions.

Resident work-hour restrictions and The Joint Commission have provided two drivers in recent years for improving patient handoffs. Despite efforts to develop standardized approaches, providers remain concerned about the impact of inadequate handoffs. This study reviewed nearly 400 articles to outline the seven primary functions of handoffs with each tied to a set of different interventions for improvement. The functions included information processing, narratives, accountability, social interaction, and cultural norms. The authors suggest that the diversity in handoff measurement reflects the lack of consensus about the primary purpose of a handoff, and that the definition should avoid an overly narrow construct. An accompanying editorial [see link below] highlights the challenges in developing handoff improvement strategies. A past AHRQ WebM&M commentary discussed a case of a handoff error that led to an adverse event.

Alerts within a computerized provider order entry system were not able to prevent medication errors resulting from drug–drug interactions. The authors hypothesize that the inadequacy of the alerts themselves was responsible for this failure, with problems including an excessive number of false-positive alerts and unclear instructions for preventing drug interactions.

Reviewing the conceptual framework for handoffs in emergency departments, this article analyzes obstacles and potential errors, discusses models for effective patient transitions, and provides strategies for enhancing handoffs and measuring outcomes.

This review highlights the mixed impact of CPOE systems on clinical workflow, including the noted impact on efficiency and limitations caused by poor user–system interactions.

Use of color-coded medications resulted in a reduction in medication errors in simulated pediatric emergency department scenarios.  

This policy statement describes ten principles developed to address quality gaps in transitions of care between inpatient and outpatient settings. Recommendations include coordinating clinicians, having a transition record, standardizing communication formats, and using evidence-based metrics to monitor outcomes.

This study found that implementation of a computerized physician order entry system appeared to impair some aspects of nurse–physician communication.

This study examined nearly 2000 drug–drug interaction (DDI) alerts that were overridden by providers and noted differential triggers based on clinician knowledge or specialty. The authors conclude that simply turning off DDI alerts is limited by these differential triggers and inconsistent drug monitoring, which may raise safety concerns that are prevented by the alerts themselves.

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.