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Graber ML, Rusz D, Jones ML, et al. Diagnosis (Berl). 2017;4:225-238.
Teamwork has been highlighted as a key component of patient safety that also applies to improving diagnosis. This commentary describes how the team approach to diagnosis is anchored in patient-centered care and suggests that the diagnostic team must expand beyond the focus on physicians and involve a wide range of professionals, including pathologists, allied health practitioners, and medical librarians.
Taylor JR, Thompson PJ, Genzen JR, et al. Lab Med. 2017;48:97-103.
Diagnostic error represents a significant source of patient harm. In this study, researchers surveyed physicians to understand how to improve the involvement of laboratory professionals in assisting with diagnostic challenges. They conclude that there may be a greater role for laboratory professionals in the diagnostic process beyond providing test results.
Needleman J, Pearson ML, Upenieks V, et al. Jt Comm J Qual Patient Saf. 2016;42:61-69.
This evaluation of the Transforming Care at the Bedside initiative—a collaborative intended to drive engagement of bedside nurses in enhancing safety through unit-based quality improvement projects—found highly positive perceptions of the program and evidence of widespread implementation of new innovations.
Hicks CW, Rosen M, Hobson DB, et al. JAMA Surg. 2014;149:863-8.
Operating room briefings or time-outs are mandated by The Joint Commission as a strategy to prevent wrong-site surgery. This commentary explores the use of briefings both before and after surgery, evidence regarding their impact, and how a comprehensive unit-based safety program (CUSP) initiative designed and implemented a briefing and debriefing process.
Tennessee Center for Patient Safety.
This Web site summarizes patient safety improvement efforts in Tennessee, shares information on their patient safety organization activities and a calendar of training opportunities.
Gordon MB, Melvin P, Graham D, et al. Arch Pediatr Adolesc Med. 2011;165:424-8.
Improving teamwork and communication is a continued focus in the hospital setting. Targeted interventions to address noted gaps include adoption of interdisciplinary rounds, use of patient whiteboards, and structured tools such as SBAR. This study reorganized physicians into unit-based teams to evaluate the impact on nurse–physician communication. Following implementation of the new model, physicians were more likely to identify the nurse for their patients and experience increased frequency of direct communication with them. These changes also led to 42% fewer pages from nurses to physicians. While the study didn’t correlate these self-reported improvements in communication to clinical outcomes, it’s one of the first studies investigating the benefits of geographic organization as a potential safety strategy.
Romig M, Goeschel C, Pronovost P, et al. Hosp Pract (1995). 2010;38:114-21.
This commentary discusses the Comprehensive Unit-Based Safety (CUSP) and Translating Evidence Into Practice (TRIP) models and how they prevent error through culture of safety and teamwork improvements.
Kim MM, Barnato AE, Angus DC, et al. Arch Intern Med. 2010;170:369-76.
Efforts to improve the care of complex patients in intensive care units (ICUs) focus on many factors, including unit-based initiatives. This retrospective study evaluated the relationship between daily multidisciplinary rounds and 30-day mortality. Investigators discovered that the presence of daily rounds was associated with lower mortality among medical ICU patients. In addition, the survival benefits observed with intensivist staffing were in part explained by the presence of multidisciplinary care models. A related commentary [see link below] discusses this study's findings and the concept of health engineering as a systems science to study how we optimize staffing and patient outcomes in the ICU.
Gazarian PK, Henneman EA, Chandler GE. Clin Nurs Res. 2010;19:21-37.
This qualitative study explored the cues that nurses use to determine when a patient's clinical condition is worsening, with specific attention to factors influencing nurses' decisions to obtain assistance from the rapid response team or call a "code blue." Rather than relying on specific vital sign abnormalities, nurses relied on a combination of clinical findings (such as altered mental status), help from other experienced nurses, and their prior knowledge of the patient's baseline condition to determine when urgent physician assessment was needed. The study reveals the importance of a positive safety culture in ensuring that frontline staff feel empowered to enlist additional help when necessary.