… about safety threats. Based on direct observations and a survey of teamwork and safety climate, researchers …

Organizations are encouraged to learn from failure. The authors surveyed hospital pharmacists to explore how organizational learnings relates to safety culture and found that the strongest contributors to safety culture were organizations prioritizing and supporting training and education.

… … Health Expect … The Patient Reporting and Action for a Safe Environment (PRASE) study was a large patient engagement intervention that proactively … safety hazards that patients and volunteers identified. A recent PSNet interview with Rebecca Lawton, lead …

… … Health Expect … This qualitative evaluation found that a volunteer-administered patient engagement intervention was … staff. The authors suggest that this intervention is a promising approach to enhance patient engagement . …

… to requiring more aggressive interventions and transfer to a higher level of care. Rapid response teams have been widely … utilized an electronic physiological surveillance system—a real-time decision support system based on patients' vital … physiological surveillance system was associated with a statistically significant reduction in mortality for a …

Clinicians must routinely triage and manage clinical issues over the telephone, but prior research has shown that this process is often error-prone. This simulation study of telephone triage in hospitalized patients found bidirectional problems with communication, as nurses frequently failed to provide crucial information and physicians did not take appropriate action even when properly informed.

The SBAR (situation, background, assessment, recommendation) communication tool has been implemented in an effort to improve nurse–physician communication, particularly by telephone. For this simulation study, 20 nurse–physician pairs were enrolled and the nurse in each pair was randomized to receive six written clinical scenarios to convey to the physician (three using the SBAR format, three in the usual format). Investigators found that relevant information was often not communicated by the nurse nor elicited by physicians, and use of SBAR did not improve communication.

The investigators shadowed emergency department nurses and physicians and identified the types of interruptions that occurred and what factors contributed to them.