… improve safety culture. This US health system implemented a three-level THS in hospital and ambulatory settings to … events, including near misses . … Adapa K,  Ivester T, Shea C, et al. The effect of a system-level tiered huddle system on reporting patient …

Patients' perceptions of care may provide valuable insights for improving safety. Researchers surveyed patients seen in an academic emergency department over a one-year period. They found that patients were able to accurately identify adverse events and near misses, only a small fraction of which were also submitted to an existing incident reporting system.

This analysis of medication shortages in the emergency department revealed that there have been shortages of high-acuity medications for which no substitute is available. This suggests further investigation into patient safety implications of drug shortages is needed.

… risk transparency from vendors and clients, and a call for legal responsibility from vendors. An AHRQ WebM&M commentary discusses a patient who received an extra dose of vancomycin due to …

… … Jt Comm J Qual Patient Saf … This commentary describes a conceptual model to address risks associated with …

Teamwork training programs have resulted in some notable successes, but many other attempts have failed to yield improved patient outcomes, in part because of a lack of evidence showing that teamwork training results in durable provider behavior change. In this AHRQ-funded study, the TeamSTEPPS training program was introduced in two intensive care units (one pediatric and one adult surgical), after meticulous preparatory planning that emphasized the utility of the training for frontline care providers, engaged higher-level support for the effort, and established clear metrics for effectiveness. The program resulted in improvement in directly observed team behaviors and measures of safety culture, and also improved 2 of 3 targeted patient-level outcomes. A related editorial discusses the role of targeted teamwork training interventions in the context of efforts to develop high reliability organizations.

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

… were unaware that the Universal Protocol , which requires a time-out before any invasive procedure, also applies to …

Adverse events after discharge were common in this study of patients who were discharged within 24 hours after hospital admission.

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.

The author comments on the conditions that allow for confirmation bias in emergency medicine decision making and suggests automation, cognitive forcing strategies, and metacognition as strategies to minimize its occurrence.

Gender, racial, and ethnic disparities in healthcare can affect patient safety and lead to poor outcomes. This study used actors portraying patients to explore the impact of race and sex on physicians’ decision-making about use of cardiac catheterization for chest pain. Analyses indicate that women and Black patients with chest pain were less likely to be referred for cardiac catheterization compared to white men.