… support (e.g., help is available when they have a problem) reduces the negative impact of humiliation on their psychological safety. … Appelbaum NP, Santen SA, Perera RA, et al. Influence of psychological …

… primary root causes included communication breakdown and a need for improved suicide interventions . The paper … and completed patient suicides. … Mills PD, Watts BV, Hemphill RR. Suicide and suicide attempts on hospital grounds …

… reactions or complications and communication errors.   … Feeser VR, Jackson AK, Savage NM, et al. When safety event reporting is seen as …

In this retrospective review of root cause analysis (RCA) reports of select gastrointestinal procedures, researchers identified 27 adverse events 30-month period. Nearly half (48%) of events caused major or catastrophic harm. The most frequently reported adverse events were attributable to human factors (22%), medication errors (22%) or retained items; retained items were associated with the most harm.

… clinical situations, and on the front line. Although a variety of methods were identified, the authors highlight … evaluate clinical reasoning assessment tools. … Daniel M, Rencic J, Durning SJ, et al. Acad Med. 2019;94:902-912. …

This analysis of the Veterans Health Administration root cause analysis database identified adverse events that occurred during rehabilitation services, such as physical therapy, occupational therapy, or speech and language therapy. Rehabilitation-related adverse events were extremely rare. The most common incidents were falls and delayed response to clinical deterioration.

Root cause analysis has been widely promoted as a failure analysis tool for use in a variety of settings. This quality improvement project applied the method to patient falls in Veterans Health Administration operating rooms and developed recommendations to guide improvement. Areas of focus included team communication, restraint use, and staff education. An Annual Perspective provides insights regarding how to enhance root cause analysis to help investigate incidents and improve care.

… Patient Saf … This commentary describes the deployment of a interprofessional fellowship program designed to develop …

… report describes how an academic health system utilized a modified Lean framework to uncover weaknesses in reporting …

Communication failures are known to contribute to medical errors. In the field of aviation, crew resource management is used to teach teamwork and effective communication. In this study, researchers evaluated the impact of a team training program developed by the Veterans Health Administration National Center for Patient Safety and modeled after crew resource management training. The Teamwork and Safety Climate Questionnaire was used to evaluate safety climate prior to and after the training. They found that scores on the 27-item survey increased on all questions from baseline to 1 year and conclude that this type of team training improves patient safety by enhancing teamwork and ensuring effective communication among clinicians. A PSNet perspective provides insights on team training.

… Veterans Health Administration intensive care units over a 2-year period. They found that events frequently had … education initiatives. … Corwin GS, Mills PD, Shanawani H, Hemphill RR. Root Cause Analysis of ICU Adverse Events in the …

This study examined root cause analyses performed by the Veterans Health Administration to identify and characterize anesthesia-related safety events. Although a relatively small number of events were found, the authors identified several human factors solutions that, if implemented, could prevent common types of errors.

This review of root cause analysis reports about suicide within 7 days of discharge from inpatient mental health facilities determined that most cases of suicide occurred prior to scheduled outpatient postdischarge follow-up. Many patients who went on to die by suicide left against medical advice but did not meet criteria to be held against their wishes, highlighting the conflict between safety and patient autonomy.

… cognition science, and business, this review outlines a framework for enhancing understanding of multitasking, such …

… concepts into existing curriculum has been advocated as a strategy to prepare resident physicians for safety improvement work. This commentary describes a Veterans Affairs program to incorporate safety leadership …

… , due to errors preceding and following the protocol's use. The authors suggest that additional processes …

… This analysis of 14 cases of wrong-site thoracenteses, a procedure to remove fluid from around the lung, identified … the errors found that clinicians often failed to perform a time out and did not correctly document laterality in … death of a patient is discussed in a previous AHRQ WebM&M commentary . …

This chart review study analyzed information from the Veterans Health Administration national database of root cause analyses to describe adverse events among veterans aged 65 years and older that resulted in sustained injury or death. Frequent incidents were falls, delays in diagnosis or treatment, and medication errors. Inadequate communication was the most common root cause identified in adverse events, and within this category, poor communication among providers (such as handoffs) often resulted in adverse events. Although virtually all root cause analyses led to implementation of action plans, only 40% were deemed effective. Compared to previous research, this study highlights robust use of root cause analysis while emphasizing the need for ongoing monitoring and improvement of corrective actions.

… debriefings recommended by the World Health Organization's Safe Surgery program. Researchers found that practices were …

… Journal of hospital medicine … J Hosp Med … A suicide attempt by a hospitalized patient is considered a never event . The majority of inpatient suicides occur in …