… J Patient Saf … The opioid epidemic has prompted national and … implementing a chronic opioid therapy management system. J Patient Saf. 2022;18(8):e1142-e1149 …

… and building a culture of safety. … Goodwin C, Haas S, Berry W. What I wish I’d known: how experienced physician …

Patient safety learning laboratories (PSLL) encourage a cross-disciplinary, collaborative approach to problem solving. This study reports on how a learning ecosystem supported the success of three distinct PSLLs. Qualitative and quantitative results reveal four types of alignment and supporting practices that contribute to the success of the learning laboratories.

… buy-in on the value of parent engagement. … Khan A, Baird J, Kelly MM, et al. Family safety reporting in medically …

… to lead to improved work satisfaction. … Liu L,  Chien AT, Singer SJ. Exploring system features of primary care …

… effects on patient safety. … Weiseth A, Plough A, Aggarwal R, et al. Improving communication and teamwork during labor: …

… J Patient Saf … Medical errors are a significant cause of … and adverse events in the Emergency Department. … Alsabri M, Boudi Z, Lauque D, et al. Impact of teamwork and … safety in emergency departments: a systematic review. J Patient Saf. 2022;18(1):e351-e361. …

… J Patient Saf … The COVID-19 pandemic has presented numerous … a qualitative study of health system leaders' strategies. J Patient Saf. Epub 2021 Apr 3. …

The World Health Organization (WHO) surgical safety checklist is widely used in surgical settings to prevent errors. This multinational panel representing multiple clinical specialties identified 16 recommendations for checklist content modification and implementation during the COVID-19 pandemic. These recommendations exemplify how the checklist can be adapted to meet urgent and emerging needs of surgical units by targeting important processes and encouraging critical discussions.

… Jt Comm J Qual Patient Saf … As part of a quality improvement …

Ambulatory surgery centers are increasingly utilized to provide surgical care to patients. Quality improvement approaches utilized in the inpatient setting may need to be modified or adapted to be applicable in the ambulatory surgery environment. Researchers describe efforts to implement a surgical safety checklist and infection control techniques across 665 ambulatory surgery centers recruited for the study. They identified several barriers and conclude that the unique aspects of ambulatory surgery centers must be taken into account when implementing quality improvement initiatives.

This study in the Health Affairs patient safety theme issue examines the implementation of surgical safety checklists. Checklists have been shown to improve patient outcomes in randomized control trials, but implementation studies have not consistently demonstrated similar improvements. In this statewide initiative, implementation of the checklist varied significantly among sites. Factors associated with more successful implementation included greater leadership participation, frontline engagement, and more frequent activities for all involved groups, including surgeons, nurses, technicians, and administrators. Sites that invested more funding and time also saw greater checklist implementation. The authors conclude that hospitals that participated more did better. Past PSNet interviews with Lucian Leape and David Urbach discussed their perspectives on surgical safety checklists.

Checklists have been shown to improve surgical outcomes in clinical trials, but their effectiveness in real-world settings is variable. This implementation study examined factors related to checklist use in the operating room for crises rather than routine practice. Investigators surveyed individuals who downloaded a checklist from two websites about whether they used a checklist regularly in specific clinical situations. Thorough checklist implementation, leadership support, and dedicated staff training time led to more regular use of the checklist. Conversely, frontline resistance and lack of clinical champions undermined checklist use. The authors conclude that optimizing organizational conditions should increase the use of checklists during crises in operating rooms. Past PSNet interviews with Lucian Leape and David Urbach discussed their perspectives on surgical safety checklists.

… surgeons could mitigate malpractice risk. A previous WebM&M commentary discussed patient complaints as safety …

High reliability is a goal throughout health care. This commentary describes how lessons from high reliability organizations can be applied to accountable care organizations to enhance quality, reduce costs, and support population health. The authors describe ways to engage organizations in this work through mindfulness, leadership, and research.

Establishing a robust culture of safety, in which all staff feel free to voice concerns without fear of reprisal and leadership explicitly prioritizes safety, is crucial to safety improvement efforts. The most successful safety improvement programs have all explicitly prioritized enhancing safety culture. This study reports on the baseline results of a program that sought to improve surgical safety at hospitals in South Carolina. Safety culture was assessed among operating room personnel in 31 hospitals using a validated instrument. The investigators found a relatively robust association between better perceived safety culture and lower 30-day postoperative mortality. Studies in other clinical settings have found similar results. The hospitals involved in this study subsequently participated in a program to implement the Surgical Safety Checklist, which resulted in a significant improvement in mortality among participating hospitals compared to nonparticipating hospitals. A recent PSNet interview with Dr. Mary Dixon-Woods discussed the evolving concept of safety culture.

A recent AHRQ technical brief on ambulatory safety found that evidence for effective interventions is lacking. This cluster-randomized controlled trial examined whether participation in a multimodal quality improvement intervention enhanced safety processes at primary care clinics compared to usual practice. Using chart review, investigators determined that clinics receiving the intervention—which included a learning network, webinars, in-person meetings, and coaching—improved documentation and patient notification for abnormal test results overall. Also, time between test date and treatment plan was shorter in intervention sites. Through pre–post surveys, they learned that patient perceptions of quality and safety improved modestly for coordination and communication but were otherwise similar between the sites. Staff perceptions of safety and quality were similar pre–post and between intervention and control sites. Barriers to improvement included time and resource constraints, staff turnover, health information technology, and local practice variation. The authors recommend further study to determine the potential for multimodal practice-level interventions to enhance outpatient safety.

… the International Society for Quality in Health Care … Int J Qual Health Care … This qualitative study used data from …

… Commission journal on quality and patient safety … Jt Comm J Qual Patient Saf … Delayed diagnosis of colon cancer due to …

Checklists have been shown to reduce surgical morbidity and mortality in randomized trials, but results of implementation in clinical settings have been mixed. This study reports on a voluntary, statewide collaborative program to implement a surgical safety checklist in South Carolina hospitals. Participating sites undertook a multifaceted process to support checklist implementation and culture change. Cross-institutional educational activities were available to all hospitals in the collaborative. Investigators determined that rates of surgical complications declined significantly in hospitals involved in the collaborative compared with those that did not participate, which had no change in postsurgical mortality over the same time frame. Past PSNet interviews with Lucian Leape and David Urbach discussed their perspectives on surgical safety checklists.