Computerized provider order entry (CPOE), clinical decision support (CDS), and other technologies can reduce prescribing errors, but their initial implementation may present new errors. This study reports prescribing errors before and after transition to digital hospital records. Results show significant decreases in prescribing errors after transition, but also identified new problems, such as alert fatigue, that needed additional attention to remediate.

High-reliability organizations frequently assess the strength of their safety culture. In this article, researchers compare the results of a safety culture assessment (SCA) of a helicopter squadron and investigation of an accident that occurred shortly after survey administration. Results of the SCA showed the safety culture was mature, but the investigation revealed otherwise, indicating the SCA had little predictive value.

Proficient safety professionals are the cornerstone of effective patient safety programs. In this study, safety professionals provided insights about theoretical factors influencing the role of safety professionals in healthcare (e.g., legal regulation, organizational context, safety culture).

… lessons learned from CRM trainings. … Buljac-Samardžić M, Dekker-van Doorn CM, Maynard MT. What do we really know about …

… and may contribute to less burnout. … Buljac-Samardžić M, Dekker-van Doorn C, Van Wijngaarden J. Detach yourself: the …

This study explored whether combining participatory design and experiential learning supports the adaptation and adoption of TOPplus, which is a communication tool to support and improve communication and teamwork among the operating room team. Adaptation varied amongst the ten participating Dutch hospitals, but all implemented the intervention with all surgical disciplines, and this approach gave teams the opportunity to adapt the intervention to fit their needs and local context. 

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.

This interview study examined the self-perceptions of safety professionals at an energy company, a high reliability industry often used as a model for patient safety. The results reveal that safety professionals often have contradictory roles within an organization, including relational influence versus formal authority and interpersonal skill versus technical knowledge. The findings highlight the challenge of integrating safety professionals into the larger health care enterprise.

Teamwork is a core element of care coordination and safety. Articles in this special issue explore current research and activity on teamwork and teamwork training. Topics include organizational support for a team environment, teamwork as a fall-reduction strategy, interdisciplinary team development, and research design.

Interruptions can contribute to medication errors, but efforts to reduce interruptions may result in unintended consequences. The authors suggest that designing interventions around high reliability and resilience principles can address risks and increase the likelihood of lasting improvements.

A just culture balances organizational context with appropriate accountability after an error. This commentary outlines moral and safety issues that just culture approaches should address to build trust for blame-free response to error and enable learning from failure.

Interruptions are a common occurrence in health care. This commentary suggests that research about interruptions clearly determine definitions, data collection methods, and processes that are affected to enhance understanding regarding the impact of disruptions on patient safety.

Safety problems are common in nursing homes and other long-term care facilities, and prior work has shown that safety culture in these settings is generally poor. This validation study found that the Safety Attitudes Questionnaire was a reliable tool for measuring safety culture in nursing homes in the Netherlands. This is a necessary step for much needed research on nursing home safety.

Highlighting how the systems approach is often misunderstood to ascribe responsibility for failure to the system when things go wrong, this commentary explains that the approach is instead meant to reduce variation and enhance individual responsibility and competence with standard procedures.

In the context of public reactions to the Francis report, this commentary discusses why the poor conditions were missed and how to prevent failures from recurring once they are identified. The authors advocate for a just culture that balances blame and accountability to address complexities in the health care setting.