Many interventions targeting healthcare-acquired condition reduction and prevention target a single condition, rather than the risks of multiple conditions. This proof-of-concept study discusses clinician feedback on a proposed dashboard to enhance clinicians’ management combining the risks of multiple conditions (catheter-associated urinary tract infections, pressure injuries, and falls).

… J Health Serv Res Policy … A key aspect of patient safety … about speaking out in hospitals: A qualitative study. J Health Serv Res Policy. Epub 2022 Jan 3. …

… study. Nurse Educ Today. 2021;104:104984. doi: 10.1016/j.nedt.2021.104984. …

… can motivate and support speaking up behaviors. … Wu F, Dixon-Woods M, Aveling EL, et al. The role of the informal … study. Soc Sci Med. 2021;280:114050. doi: 10.1016/j.socscimed.2021.114050. …

Disruptive and unprofessional behaviors are known threats to safety culture and contribute to burnout among health professionals. In response to an episode of serious misconduct by a clinician, an academic hospital implemented a structured effort to address disruptive behavior by developing mechanisms for frontline staff to voice their concerns. This article reports on the development and implementation of the effort, which focused on addressing longstanding aspects of institutional culture that were perceived as tolerating—and providing tacit endorsement of—prominent leaders who engaged in disruptive behavior.

This study aimed to validate a behavioral marker as a measure of teamwork, specifically in the intensive care unit setting. Researchers found that it was difficult to establish interrater reliability for teamwork when observing behaviors and conclude that assessment of teamwork remains complex in the context of patient safety research.

… Jt Comm J Qual Patient Saf … Jt Comm J Qual Patient Saf … Following a sentinel wrong-patient event … via the electronic health record. … Hensley NB, Koch CG, Pronovost PJ, et al. Wrong-Patient Blood Transfusion Error: …

Teamwork in health care has been embraced as a key element of patient safety. This review summarizes the evidence regarding teamwork, including strategies to measure team performance and the relationship between teamwork and outcomes.

The patient safety community continues to struggle with implementation and sustainability of improvement programs. This commentary describes how one academic medical center used assessment tools to monitor, measure, and improve safety at the patient, provider, unit, and system levels in the organization.

… of the American Society for Healthcare Risk Management … J Healthc Risk Manag … Health care executives and board …

Disruptive behavior in health care can diminish patient safety. This commentary reviews individual and organizational tactics to address incivility in nursing. The author discusses TeamSTEPPS and other communication interventions as strategies for improvement.

A work environment in which all team members feel comfortable speaking up about safety concerns is a key aspect of positive safety culture. Although formal mechanisms exist within health care institutions for raising safety issues, little is known about how such channels promote or discourage employees from speaking up. Researchers conducted interviews with 165 frontline staff and senior leaders working at three academic hospitals in two countries. They found that leaders viewed formal systems for raising concerns favorably, but other respondents felt uneasy reporting concerns through these channels. Such apprehension occurred especially if the concern was based on a general feeling that something might be wrong rather than hard evidence—what the authors refer to as "soft" intelligence. A PSNet perspective discussed how to change safety culture.

This survey study examined remote electronic health record use by attending physicians for resident supervision. Nearly all respondents reported accessing the electronic health record remotely. Of these, 92% reported discovering clinically relevant information that the residents had not conveyed to them. The authors conclude that this "backstage" supervision requires further study to identify best practices for safety and education.

Organizational infrastructure is important to ensure sustainability of safety improvements. This commentary describes how one academic medical center integrated structures, processes, and frameworks to build connections within the organization and throughout the community to facilitate success of improvement initiatives.

… Jt Comm J Qual Patient Saf … Jt Comm J Qual Saf … Comprehensive unit-based safety programs have …

… J Hosp Med … J Hosp Med … The weekend effect refers to worse patient …

The need to improve patient safety is an international concern. This commentary discusses the importance of partnership in reaching the overall goals of global patient safety and highlights experiences in Africa that demonstrate how high-income health care systems can learn from low-income hospitals.

As implementation of comprehensive health information technology (IT) systems becomes more widespread, concern regarding the unintended consequences of such technologies has increased as well. Usability testing is helpful for optimizing implementation of health IT. Researchers analyzed the impact of health IT use on relationships among clinicians over a year-long period across three academic intensive care units. In the two units with higher health IT use, clinicians were more likely to work in an isolated manner, which was associated with an adverse effect on situational awareness, communication, and patient satisfaction. A previous PSNet perspective discussed some of the pitfalls in the development, implementation, and regulation of health IT and what can be learned to improve patient safety going forward.

Transparency in the reporting of quality and safety data demonstrates a commitment to improvement, learning, and patient empowerment regarding provider selection. This commentary suggests potential standards for hospitals to adopt for public reporting of their quality data and advocates for an external entity that reports how hospitals adhere to public reporting of quality measures.

… The Journal of nervous and mental disease … J Nerv Ment Dis … Patients with underlying psychiatric …