Shared mental models contribute to effective team collaboration and communication. Based on interviews and thematic analysis, the authors explored mental models between the emergency department (ED) and skilled nursing facility (SNF). The authors found that these healthcare professionals had misaligned mental models regarding communication during care transitions and healthcare setting capability, and that these misalignments led to consequences for patients, professionals, and the organization.

In this simulation study, emergency department physicians completed standardized tasks using actual electronic health records (EHRs) at four sites. Even though two sites used Epic and two used Cerner EHRs, the number of clicks per task, time to task completion, and error rates varied widely. The authors highlight the importance of local implementation decisions as well as design and development in supporting usability and safety of electronic health records.

… of the American Medical Informatics Association : JAMIA … J Am Med Inform Assoc … Poor usability of electronic health records is a patient safety concern. This qualitative study found that …

… BMJ Qual Saf … BMJ Qual Saf … Root cause analysis (RCA) is a process frequently employed by health care institutions to … interventions, changes to processes, and enforcing policy. A recent Annual Perspective explores ongoing problems with …

… Jt Comm J Qual Patient Saf … Jt Comm J Qual Patient Saf … Resilience is a characteristic that enables individuals to adapt to …

… of the American Society for Healthcare Risk Management … J Healthc Risk Manag … The authors reviewed 334 root cause … analyses (RCA) using systems science principles to create a toolkit for applying RCA results to make practice changes. …

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

This survey of emergency medical services (EMS) personnel found that lower perceived safety culture was associated with an increased risk of adverse events in patients and an increased risk of injury in EMS providers.

This survey found that the perception of safety culture varied widely among prehospital emergency medical service agencies, with air medical emergency services tending to report slightly more positive views on safety.

This qualitative study found that while safety issues in pediatric prehospital care are not uncommon, most go unreported.

… journal of the American College of Medical Quality … Am J Med Qual … This article reports on the development and validation of a version of the Safety Attitudes Questionnaire specifically …

This article describes how applying a just culture and systems approach to adverse events may help change the "blame-and-shame" mentality in emergency medical service provision.

This study used focus groups, in-depth interviews, and event reporting methods to conclude that Emergency Medical Services (EMS) providers are concerned about existing system issues that require improvement strategies, and about the safety culture in which they work.

This study of closed malpractice claims against prehospital emergency medical services found that clinical management was an infrequent source of malpractice allegations, trailing emergency vehicle accidents and patient handling mishaps.

… to be the center of communication while interruptions were a common event for both physicians and nurses. …

Adoption of smart infusion pump technology was intended to improve medication safety, but past reports describe the ability of nurses to create work-arounds. This study examined preventable intravenous adverse drug events (IV-ADEs) and discovered that only 4% could be intercepted by a smart pump. Investigators reviewed medical records, both before and after adoption of smart pumps, to draw these conclusions. They also provide a qualitative analysis of errors causing preventable IV-ADEs and propose solutions that would improve smart pump technology.

… events were associated with more than $6600 in costs and a 4.8 day longer length of stay. The most notable finding was …

… of uniting patient safety principles and usability. … Fairbanks RJ, Caplan SH, Bishop PA, Marks AM, Shah MN. Usability study of … hazards. Ann Emerg Med. 2007;50(4):424-432. doi:10.1016/j.annemergmed.2007.03.029 …