Implementation challenges can hinder the effectiveness of the WHO Surgical Safety Checklist (SSC). This study describes the validation of the Checklist Performance Observation for Improvement (CheckPOINT) tool to assess SSC implementation fidelity. Based on testing in simulated and real-life clinical practice, researchers found that that the tool can reliably assess implementation fidelity and identify opportunities for improvement.

The opioid epidemic has prompted national and institutional guidelines for safe opioid prescribing. This paper describes the development, implementation, and sustainment of a toolkit for safer opioid prescribing for chronic pain in primary care. The authors describe organizational, technical, and external barriers to implementation along with attempted solutions and their effects. The toolkit is available as supplemental material.

… safe delivery of patient care. This commentary presents a framework for new physician managers to address disruptive … future disruption though intentional training and building a culture of safety. … Goodwin C, Haas S, Berry W. What I wish I’d known: how experienced physician …

Patient safety learning laboratories (PSLL) encourage a cross-disciplinary, collaborative approach to problem solving. This study reports on how a learning ecosystem supported the success of three distinct PSLLs. Qualitative and quantitative results reveal four types of alignment and supporting practices that contribute to the success of the learning laboratories.

… buy-in on the value of parent engagement. … Khan A, Baird J, Kelly MM, et al. Family safety reporting in …

Work conditions can impact clinician satisfaction and the quality and safety of the care they provide. This study sought to identify the combination of systems features (team dynamics, provider-perceived safety culture, patient care coordination) that positively impact work satisfaction in primary care practices. Results showed a strong culture of safety combined with more effective team dynamics were sufficient to lead to improved work satisfaction.

… Birth … Labor and delivery is a high-risk care environment. This study evaluated a quality improvement initiative (TeamBirth) designed to … effects on patient safety. … Weiseth A, Plough A, Aggarwal R, et al. Improving communication and teamwork during labor: …

… J Patient Saf … Medical errors are a significant cause of morbidity and mortality, and … culture and patient safety in emergency departments: a systematic review. J Patient Saf. 2022;18(1):e351-e361. …

The WHO surgical safety checklist has been implemented in healthcare systems around the world. Survey responses from 2,032 surgical team members from high-income countries suggest that most respondents perceive the checklist as enhancing patient safety, but that not all team members are engaging with its use or feel confident in their role in the checklist process.

As part of a quality improvement initiative to enhance surgical onboarding, the authors used semi-structured interviews with 20 physicians to understand potential areas of risk when a physician begins working in an unfamiliar setting. Qualitative analysis found that three key findings: (1) physicians often receive little to no onboarding when starting to practice in a new setting, which can limit their ability to provide safe care; (2) physicians felt onboarding inadequately fostered strong interpersonal relationships among health care teams, which impedes psychological safety and team cohesion, and; (3) physicians noted an increased risk of patient harm during emergency situations in new settings due to lack of understanding of culture, workflow, roles/responsibilities and available equipment.

… BMJ (Clinical research ed.) … BMJ … Checklists are a popular yet controversial strategy for improving the safety … debate the weaknesses and strengths of checklists through a discussion of the evidence . …

… Journal of clinical medicine research … J Clin Med Res … Ambulatory surgery centers are increasingly … environment. Researchers describe efforts to implement a surgical safety checklist and infection control techniques …

This study in the Health Affairs patient safety theme issue examines the implementation of surgical safety checklists. Checklists have been shown to improve patient outcomes in randomized control trials, but implementation studies have not consistently demonstrated similar improvements. In this statewide initiative, implementation of the checklist varied significantly among sites. Factors associated with more successful implementation included greater leadership participation, frontline engagement, and more frequent activities for all involved groups, including surgeons, nurses, technicians, and administrators. Sites that invested more funding and time also saw greater checklist implementation. The authors conclude that hospitals that participated more did better. Past PSNet interviews with Lucian Leape and David Urbach discussed their perspectives on surgical safety checklists.

Checklists have been shown to improve surgical outcomes in clinical trials, but their effectiveness in real-world settings is variable. This implementation study examined factors related to checklist use in the operating room for crises rather than routine practice. Investigators surveyed individuals who downloaded a checklist from two websites about whether they used a checklist regularly in specific clinical situations. Thorough checklist implementation, leadership support, and dedicated staff training time led to more regular use of the checklist. Conversely, frontline resistance and lack of clinical champions undermined checklist use. The authors conclude that optimizing organizational conditions should increase the use of checklists during crises in operating rooms. Past PSNet interviews with Lucian Leape and David Urbach discussed their perspectives on surgical safety checklists.

Changes in organizational process and governance can create downstream conditions that result in failures. This commentary explored how system expansion affects safety. The authors highlight the need for leadership to use system data to plan for and manage the impact of the resultant infrastructure and patient population changes on care delivery.

… 360-degree reviews, in which team members evaluate a range of professional attributes and behaviors, were … informing others, and considering others' suggestions had a significantly higher risk for malpractice claims. Surgeons … behaviors among surgeons could mitigate malpractice risk. A previous WebM&M commentary discussed patient complaints as …

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.

… Annals of surgery … Ann Surg … Establishing a robust culture of safety , in which all staff feel free to … culture. This study reports on the baseline results of a program that sought to improve surgical safety at hospitals … among operating room personnel in 31 hospitals using a validated instrument. The investigators found a relatively …

A recent AHRQ technical brief on ambulatory safety found that evidence for effective interventions is lacking. This cluster-randomized controlled trial examined whether participation in a multimodal quality improvement intervention enhanced safety processes at primary care clinics compared to usual practice. Using chart review, investigators determined that clinics receiving the intervention—which included a learning network, webinars, in-person meetings, and coaching—improved documentation and patient notification for abnormal test results overall. Also, time between test date and treatment plan was shorter in intervention sites. Through pre–post surveys, they learned that patient perceptions of quality and safety improved modestly for coordination and communication but were otherwise similar between the sites. Staff perceptions of safety and quality were similar pre–post and between intervention and control sites. Barriers to improvement included time and resource constraints, staff turnover, health information technology, and local practice variation. The authors recommend further study to determine the potential for multimodal practice-level interventions to enhance outpatient safety.