The perioperative setting is a high-risk environment. This publication discusses the clinical foundations and application of safety concepts in perioperative practice. Chapters cover topics such as human factors, error management, cognitive aids, safety culture, and teamwork.

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

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.

Teamwork can contribute to a healthy and respectful work environment. This discussion paper reviews evidence-based characteristics of high-functioning teams and barriers to their optimization in health care. Strategies to enhance teamwork and consequently clinician well-being include improvements in workflow, health information technologies, and financial models to train and sustain teams.

This online resource provides instructions and templates for implementing team-based, collaborative care. This group's collaborative care model has received a John M. Eisenberg Award for contributions to patient safety.

This guide and corresponding TeamStepps module address how to improve care for patients with limited English proficiency.

This book explores teamwork, including barriers to effective teamwork and tactics to enhance professional and organizational learning.

This book explores the complexity of patient safety improvement through the lens of human factors engineering and provides practical avenues for its application.

This report describes how teams participating in The Joint Commission’s Center for Transforming Healthcare hand hygiene initiative utilized techniques to examine hand hygiene processes and identified the most common reasons why clinicians don't wash their hands.

Dr. Charles Vincent, a psychologist by training, is unquestionably one of the founders of the modern patient safety movement and continues to publish groundbreaking research in the field. This essential textbook discusses the evolution of patient safety efforts, outlines current medical error reduction strategies, and emphasizes practical examples of initiatives to improve patient safety. Dr. Vincent was interviewed for AHRQ WebM&M in 2012, and discussed his career as well as the current state of patient safety in the United Kingdom.

This manual offers practical advice on how to plan for and implement care team rounds that involve a variety of health care providers.

Over the past decade, Johns Hopkins intensivist Dr. Peter Pronovost has emerged as the world's most influential patient safety researcher. In this book, written with Eric Vohr, Pronovost describes how his work was inspired by two deaths from medical mistakes: of young Josie King at Johns Hopkins Hospital (chronicled by her mother Sorrel in another book) and of his own father. The meat of the volume is a detailed chronicle of Pronovost's journey from neophyte faculty member to internationally acclaimed researcher and change agent. In earnest and plainspoken prose, he describes the inside story of interventions and studies that have transformed the safety world: the Comprehensive Unit-Based Safety Program (CUSP), the use of ICU goal cards, and most importantly, the use of checklists to reduce central line infections in more than 100 Michigan ICUs, a story also recently described by Dr. Atul Gawande in The Checklist Manifesto. Dr. Pronovost was the subject of an AHRQ WebM&M interview in 2005.

The pace, diversity, and scope of an emergency department (ED) create a setting particularly prone to medical error. This comprehensive textbook provides important information on developing and advancing patient safety in emergency medicine, including relevant content on the ED setting, medical errors, organizational approaches to safety, teamwork, education, and human performance. The target audience is primarily emergency physicians and administrators but likely would extend to other allied health professionals and patient safety advocates. This textbook sets a foundation for the establishment of patient safety practices within emergency medicine.

This guide introduces strategies for hospital managers to prevent avoidable readmissions.

This publication highlights AHRQ's patient safety research efforts in the 10 years since the Institute of Medicine report, To Err Is Human, was published.

This trio of modules provides ambulatory medical practices with tools to develop teamwork, assess culture and processes, and improve medication safety.