In this retrospective study, researchers used electronic health record and quality assurance issue (QAI) data to analyze risk factors associated with patient safety events in the emergency department (ED). Multivariable analyses showed several potential risk factors for safety events – including length of time in the ED, which increased the odds of a safety event by 4.5% for each hour spent in the ED.

An essential part of patient safety in surgery, operating room briefings or "time-outs" are mandated by the Joint Commission as a strategy to prevent wrong-site surgery. Although briefings (and postoperative debriefings) have largely been implemented as an error prevention strategy, this study demonstrates that these structured multidisciplinary meetings can also be used to prospectively identify safety hazards. The investigators included formal documentation of any defects (concerns or problems arising at any point during the procedure) into the briefing and debriefing process, and identified equipment hazards and communication failures as among the most common sources of latent error. As organizations continue to search for methods of obtaining comprehensive safety information, data gathered in this fashion can provide an important window into patient safety hazards.

… Hosp Epidemiol … The landmark Keystone ICU project, a statewide quality improvement initiative that used … has been widely publicized, and this study reports a similar success in reducing rates of ventilator-associated …

… strong evidence for the impact and sustainability of a multifaceted quality improvement (QI) initiative that … over the relationship between QI and research, and led to a 2009 Eisenberg award for the Keystone Center . Dr. …

… Commission journal on quality and patient safety … Jt Comm J Qual Patient Saf … Improving teamwork and communication  is a key strategy to prevent errors in the operative setting . … This prospective cohort study describes the development of a standardized briefing and debriefing tool. Investigators …

… outcome occurs. This study analyzed case review data from a single emergency department over a 7-year period. Investigators found that physicians …

… J Crit Care … J Crit Care … The Keystone ICU project is a … patient safety. This project, funded by AHRQ, represented a collaboration between patient safety experts at Johns …

… N. Engl. J. Med. … N Engl J Med … Catheter-related bloodstream infections (CRBSI) remain a common and deadly patient safety issue in intensive care … to adopt similar programs. … Pronovost P, Needham D, Berenholtz S, et al. An intervention to decrease …