Organizational pressures sometimes lead to redeployment or task reallocation such as shifting infusion tasks from specialty nurse teams to generalist nurses. This survey of nurses in the United States found that infusion task reallocation led to increased job demands and reduced resources, thereby contributing to lower perceived organizational safety.

Retained surgical items (RSI) are a never event, a serious and preventable event. After experiencing a high rate of RSIs, this United States health system implemented a bundle to reduce RSI, improve near-miss reporting, and increase process reliability in operating rooms. The bundle consisted of five elements: surgical stop, surgical debrief, visual counters, imaging, and reporting.

Achieving high reliability is a goal for every healthcare organization. Based on interviews with hospital leadership, clinicians, and staff, this study explored how healthcare professionals understand and perceive high-reliability principles. Findings indicate that some principles are more supported than others and identified inconsistent understanding of principles across different types of healthcare professionals.

Achieving high-reliability remains a goal for hospitals and care teams. The authors of this commentary discuss how the COVID-19 pandemic impacted high-reliability practices and suggest a more inclusive approach to creating and sustaining high reliability by involving patients, families, and other types of care professionals (such as chaplains, social workers).

Achieving high reliability is an ongoing goal for health care. This survey of 25 pediatric organizations participating in a patient safety collaborative identified an inverse association between safety culture and patient harm, but found that elements of high-reliability, leadership, and process improvement were not associated with reduced patient harm.

Implementing effective interventions supporting medication reconciliation is an ongoing challenge. Using qualitative data, the authors explored how different hospitals implemented one evidence-based medication reconciliation toolkit. Thematic analyses suggest that the most commonly used implementation strategies included restructuring (e.g., altered staffing, equipment, data systems); quality management tools (e.g., audit and feedback, advisory boards); thorough planning and preparing for implementation; and education and training with stakeholders.

… was weakened with higher safety climate perceptions . … Vogus TJ, Ramanujam R, Novikov Z, et al. Adverse events and …

Prior research has found that perceptions about safety climate varies across neonatal intensive care units (NICUs). This large cross-sectional study examining the impact of caregiver perceptions of safety climate on clinical outcomes found that stronger safety climates were associated with lower risk of healthcare-associated infections, but climate did not affect mortality rates.

High reliability industries such as aviation ensure safety amidst high-risk work environments and rapidly changing conditions. Achieving high reliability in health care remains an ongoing challenge. Researchers surveyed hospitals in the Children's Hospitals' Solutions for Patient Safety (CHSPS) network to understand the extent of adoption of high reliability practices. Of the 46 hospitals that responded to the survey, about 80% were determined to be approaching high reliability using the High Reliability Health Care Maturity model described in the study. The authors conclude that the majority of hospitals in the CHSPS network demonstrate opportunity to improve across all three high reliability domains in the model including leadership, safety culture, and robust process improvement. A past PSNet interview discussed high reliability as it relates to health care.

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.

… J Patient Saf … J Patient Saf … Health care–associated … development of the Hospital Safety Score. … Pakyz AL, Wang H, Ozcan YA, Edmond MB, Vogus TJ. Leapfrog Hospital Safety Score, Magnet Designation, …

High reliability organizations are those within high-risk industries that have adopted processes to detect and address failures before harm occurs. This survey study of nurses and nurse managers found that use of reliability-enhancing work practices, such as giving frontline employees mechanisms to recommend organizational change, is associated with fewer medication errors and falls. These results suggest that high reliability strategies can support patient safety.

High reliability has been an elusive goal for hospitals and care teams. This commentary examines habit as a mechanism to ensure that high performance practices are applied routinely during care delivery to enhance reliability.

This ethnographic study explored the underlying reasons for safety and communication problems at the transition of care between the emergency department and hospital wards. Through observation and interviews with physicians and hospital leadership, the study identifies structural and cultural barriers to effective communication and reveals time-consuming workarounds that physicians utilized to ensure patient safety.

One strategy to improve patient safety is public reporting of performance data, and hospital quality ratings have proliferated. In this study, researchers examined the extent of agreement among hospital ratings issued by U.S. News & World Report, HealthGrades, The Leapfrog Group, and Consumer Reports. Each rating system has a different emphasis, varying inclusion and exclusion criteria, and focuses on different measures of quality. There is very little agreement among the ratings for either high or low performance—not one hospital was rated as a top performer across all four ratings—which makes these ratings challenging for consumers to interpret or use in decision making. These findings are consistent with prior work demonstrating variability in surgical quality rankings. The authors call for transparency in how ratings are constructed and clear communication with consumers to facilitate informed decisions regarding their care. A recent AHRQ WebM&M interview with Leah Binder, President and CEO of The Leapfrog Group, explored the development of the Hospital Safety Score and Leapfrog Hospital Survey.

This cross-sectional study found that reports of nurses' safety organizing, behaviors meant to identify and address errors, were associated with decreased turnover and less emotional exhaustion, adding to the evidence for fostering a positive safety culture.

Discontinuity between providers is a well-known source of errors, with problems arising from handoffs and signouts both in hospital and at hospital discharge. This quality improvement initiative aimed to enhance handoffs in 23 children's hospitals over a 12-month period. Following introduction of a structured handoff tool, handoff-related care failures declined and provider satisfaction with handoffs increased. Handoff-related care failures were defined as insufficient information transfer that affected the patient, such as reporting inaccurate test results or miscommunication that led to duplicated medications. This study is the largest to date of a standardized handoff approach, and these results are consistent with prior smaller studies. A past AHRQ WebM&M commentary describes pitfalls of handoffs.

… Journal of patient safety … J Patient Saf … Despite availability of multiple publicly …

This review details a framework to help health care organizations develop, implement, and enhance safety culture.

… the concept of situational awareness in bedside nursing. … Sitterding MC, Broome ME, Everett LQ, Ebright P. …