Surgical specimen and laboratory process problems can affect diagnosis. This publication examines factors that contribute to errors across the surgical pathology process and reviews strategies to reduce their impact on care. Chapters discuss areas of focus to encourage process improvement and error response, such as information technology, specimen tracking, root cause analysis, and disclosure.

Reducing adverse medication events is a worldwide challenge. This collection of technical reports explores key areas of concern that require action at a system level to improve: high-alert medications, polypharmacy, and medication use at care transitions. Each monograph provides an overview of the topic as well as practical improvement approaches for patients, clinicians, and organizations.

Cognitive biases contribute to diagnostic missteps, delays, and errors. This publication uses case-based illustrations to explore the effect of common cognitive biases (e.g., confirmation, anchoring, and overconfidence) on care. The author suggests feedback, healthy skepticism, and open discussion as tactics to reduce errors stemming from bias in decision-making.

Disrespectful and unprofessional behaviors are a common problem in health care. The report examines cultural issues at a National Health Service trust that affected the transparency needed to report disruptive behaviors and that limited conversation needed to facilitate local actions and improvement. Recommendations for the leadership, organizational, and system levels are provided to enable constructive change.

This draft 5-year framework aims to guide the activities in Canada to focus action, resources, and policy development on supporting care improvement. The document is structured around five goals: people-centered care, safe care, accessible care, appropriate care, and continuous care. The authors invited Canadian patients, families, clinicians, organization leaders, and policymakers to provide input on the material to ensure its applicability across the country. 

This publication provides various strategies to drive innovation in patient safety, including how to eliminate unsafe practices.

The Agency for Healthcare Research and Quality conducts safety culture surveys in a wide variety of clinical settings and makes the results publicly available on a regular basis. This report contains responses to the Community Pharmacy Survey on Patient Safety Culture from 331 participating pharmacies, most of which were chain drugstores or pharmacies within integrated health systems. The areas of strength were similar to the 2015 report, with most community pharmacies scoring well for patient counseling and openness of communication regarding unsafe situations. Inadequate staffing and production pressures were the commonly identified barriers to safety. A PSNet perspective explored safety issues in the community pharmacy setting in detail.

Physical demands and technical complexities can affect surgical safety. This resource is designed to capture frontline perceptions of surgeons in the United Kingdom regarding concerning behaviors exhibited by their peers during practice to facilitate awareness of problems, motivate improvement, and enable learning.

Programs are in place to address hospital discharge process gaps that contribute to readmissions. This report summarizes research on primary care perspectives on reducing readmissions. Interventions identified include automated alerting to primary care providers when patients are hospitalized and the patient-centered medical home model.

Health literacy affects patients' ability to comprehend information about their health and participate effectively with clinicians to ensure their care is safe, appropriate, and effective. This workshop report summarizes discussions about health literacy programs and provides case studies of health organizations that have adopted such programs. A PSNet perspective discusses the intersection of patient safety and health literacy.

Implicit biases can affect diagnostic decision-making. This book discusses biases and cultural limitations that influence the safety of women's health care. Systemic problems are highlighted, such as lack of respect for patient concerns and insufficient biomedical research examining treatments and their effect on women.

This annual publication provides common cause analyses of incidents submitted to a pediatric patient safety organization and highlights the successful outcomes of the collaborative's activities, such as safe table meetings and a policy revision to guide retained surgical item reduction efforts.

Transitions are known to be vulnerable to communication errors. This toolkit focuses on patient transitions between ambulatory care environments and encourages staff to engage patients and families in their care to prevent errors during care transitions.

Missed and delayed diagnoses can stem from problems in the outpatient referral process. The Institute for Healthcare Improvement convened an expert panel aimed at addressing safety vulnerabilities in the current referral process. The report delineates nine steps in the referral process, starting from the primary care provider ordering the referral and ending with communication of the treatment plan to patients and families. Recommendations to improve this process include interoperability between primary care and subspecialty electronic health records, standardizing handoffs between providers, clear standards of accountability for patient follow-up, and use of evidence-based communication methods like teach-back with patients and families. The report concludes that prioritizing the safety of the referral process is important to reduce diagnostic errors.

Patient safety in the ambulatory setting is gaining traction as a focus for research, intervention, and policy. This position paper highlights seven recommendations to address patient safety challenges in the ambulatory environment, including enhancing patient health literacy, utilizing team-based care models, and establishing a national effort to reduce patient harm across all settings of health care.

Patient health literacy is a known challenge in health care safety. This publication reports on results of a multidisciplinary workshop that explored health literacy improvement strategies and tools to enhance the clarity of labels, patient instructions, and decision aids to support safe medication use.