Changes in healthcare delivery due to the COVID-19 pandemic resulted in delays in care that can lead to patient harm. In this study using patient safety event data submitted to the VHA National Center of Patient Safety, researchers identified healthcare delays involving laboratory results, treatment and interventional procedures, and diagnosis.   

Rapid response systems (RRS) are widely used to identify signs of rapid deterioration among hospitalized patients.  Using in situ simulation, researchers identified obstacles to effective RRS execution, including inconsistent education and documentation, lack of interpersonal trust, and low psychological safety.

High-reliability organizations (HROs) are able to “manage the unexpected” while operating under challenging conditions. This article describes the U.S. Medical Department’s systemwide rollout of the Top Six HRO communication practices. The authors summarize how the Top Six campaign was developed and discuss the implementation of six systemwide initiatives to increase reliability – (1) daily safety briefings; (2) safety leadership rounds; (3) unit-based huddles; (4) Situation Background Assessment Recommendation (SBAR) for communication; (5) briefs and debriefs for surgical cases; and (6) Universal Protocol before every procedure.

Improving safe maternal care is an ongoing patient safety priority. This article outlines training strategies for providing safe obstetric care and improving communication among providers and patients.

Transporting critically ill patients within a hospital (e.g., to radiology for diagnostic procedures) is necessary but also poses safety threats. The authors conducted a systematic review and meta-analysis of all types of adverse events, critical or life-threatening adverse events, and death occurring during intra-hospital transport. Results indicate that adverse events can occur in intra-hospital transport, and that frequency of critical adverse events and death are low.

Situation, Background, Assessment, Recommendation (SBAR) is a mnemonic technique used to avoid communication failures during handoffs. This systematic review found that fidelity with SBAR is highest in classroom settings, but that studies in clinical contexts either did not achieve sufficient improvements in fidelity or did not assess fidelity.

This systematic review is an update of prior research characterizing the evidence base on team effectiveness in healthcare organizations. The review analyzed 297 publications focused on three types of interventions: (1) training, including crew resource management, TeamSTEPPS and simulations, (2) tools, including SBARs and checklists, and (3) organizational (re)designs, which involves intervening in structures which lead to improved team functioning (such as changing the physical environment or altering roles/responsibilities). The authors found that existing evidence base is limited to certain interventions, settings (primarily acute care), and outcomes (primarily non-technical skills). The authors call for more longitudinal research, particularly examining team functioning outside the hospital setting.

Handoffs in the emergency department are vulnerable to error. This commentary describes an improvement initiative that focused on structuring nurse shift change using situation, background, assessment, recommendation (SBAR) communication methods. Although safety culture scores improved, the authors note that resistance to change was a key barrier to implementation.

Situation, Background, Assessment, Recommendation (SBAR) is a mnemonic used to structure information sharing to avoid communication failures during handoffs. This review examines the challenges and benefits associated with SBAR use and provides a comparative assessment with other standardized communication tools in the field.

Patient handoffs are vulnerable to errors of omission. This quality improvement project designed and implemented a checklist as a way to standardize the process of pediatric handoffs. The program found the tool to be effective in uncovering problems and physicians felt the checklist supported situational awareness and patient safety.

SBAR has been widely implemented to improve communication in health care settings. This simulation study compared the use of SBAR with a newly developed Traffic Lights tool to assess the communication between anesthesia teams in different operating rooms in 12 validated clinical scenarios. The authors found that the new tool yielded more accurate information transfer, took less time to use, and was preferred by the majority of study participants.

The SBAR (situation-background-assessment-recommendation) method is commonly used to ensure high-quality communication between clinicians in acute situations. However, this study found that use of SBAR did not improve recall of critical communications during handover from the operating room to the postanesthesia care unit.

Use of a structured communication tool within an electronic medical record resulted in increased high-quality communication between nurses and physicians around critical patient events.

Introduction of the SBAR (situation-background-assessment-recommendation) communication tool at two anesthesia clinics led to significant improvements in perceptions of safety climate and between-group communication. By including a comparison group, this study used a more robust assessment design than most prior SBAR research.