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Institute for Safe Medication Practices and the Just Culture Company. May 6, 2022.

Organizational factors can contribute to the occurrence of patient safety events and how health systems respond to such events. This webinar highlighted lessons learned in the aftermath of a fatal medication error, and strategies to improve patient safety at the organizational level through system design and accountability.
Amalberti R, Staines A, Vincent CA. Int J Qual Health Care. 2022;34:mzac006.
Leadership engagement is key to achieving patient safety goals. When it comes to improvement and innovation, healthcare organizations must balance multiple, sometimes conflicting, aims, such as cost, clinician wellbeing, and patient safety. This commentary outlines how healthcare organizations can manage multiple complex aims in relation to improvement and innovation projects. Four principles of managing multiple aims and five key strategies for practical action are described.
Sujan M, Bilbro N, Ross A, et al. Appl Ergon. 2022;98:103608.
Failure to rescue refers to delayed or missed recognition of a potentially fatal complication that results in a patient’s death. This single-center study sought to more effectively manage deteriorating patients after emergency surgery and reduce failure to rescue rates. Researchers used the functional resonance analysis method (FRAM) to develop recommendations for strengthening organizational resilience. Recommendations included improving team communication, organizational learning, and relationships.
Sotto KT, Burian BK, Brindle ME. J Am Coll Surg. 2021;233:794-809.e8.
The World Health Organization (WHO) Surgical Safety Checklist has been implemented in healthcare systems around the world. This systematic review and thematic analysis concluded that the surgical safety checklist positively impacts clinical outcomes (surgical outcomes and mortality), process measures, team dynamics, and communication, as well as safety culture. The authors note that the checklist was negatively associated with efficiency and workload; included studies often noted that checklist users felt the checklist slowed down processes within the operating room
Braverman A. Nurs Manage. 2021;52:30-34.
In high-consequence environments, differences of opinion can undermine teamwork and result in operational failure. This article discusses the application of crew resource management (CRM) to the clinical environment. The author outlines steps to translate the aviation CRM experience into the health care domain to improve communication and resolve conflicts in stressful situations.
Randall KH, Slovensky D, Weech-Maldonado R, et al. Pediatr Qual Saf. 2021;6:e470.
Achieving high reliability is an ongoing goal for health care. This survey of 25 pediatric organizations participating in a patient safety collaborative identified an inverse association between safety culture and patient harm, but found that elements of high-reliability, leadership, and process improvement were not associated with reduced patient harm.
Ottawa, ON: Canadian Patient Safety Institute; 2008.
This initative defines competency domains for safe health care and outlines educational practices to achieve them. The 2nd edition of the Patient Safety Competencies was released in 2020. 
Dhahri AA, Refson J. BMJ Leader. 2021;5:203-205.
Hierarchy and professional silos can disrupt collaboration. This commentary describes one hospital’s approach to shifting the surgical leadership role to facilitate communication and cross-organizational influence to affect quality and safety performance.
Bailey E, Dungarwalla M. Prim Dent J. 2021;10:89-95.
Research into patient safety culture in primary dental care remains limited. This commentary provides an overview of patient safety in dentistry and tools to develop a robust patient safety culture, including human factors and supporting second victims.
Sentinel Event Alert. 2010:1-3.
Revised June 2021. The Joint Commission issues sentinel event alerts to highlight areas of high risk and to promote rapid adoption of risk reduction strategies. This newly released alert focuses on violence in the health care setting, noting increasing rates of violent crimes such as assault, rape, and homicide, which are consistently among the top 10 types of sentinel events reported. Controlling access is viewed as a key protection strategy, and the alert also outlines techniques for identifying violent individuals and for training staff in violence management. The alert summarizes a series of suggested actions that will allow organizations to safeguard against these events. Adherence to sentinel event alert recommendations is assessed as part of Joint Commission accreditation surveys.
Isherwood P, Waterson P. J Patient Saf Risk Manag. 2021;26:64-73.
Investigating adverse events and identifying contributing factors is essential to organizational learning and improving patient safety. The authors of this article use three different methodologies – root cause analysis (RCA), human factors analysis classification system (HFACS), and AcciMap (which places emphasis on multiple levels of decision making important to risk management) – to analyze one near miss incident and illustrate how different methodologies generate different systems-level recommendations.
Weinger MB. BMJ Qual Saf. 2021;30:613-617.
Checklists are widely used strategies for error reduction and improved communication. This editorial discusses the limitations of checklists for perioperative safety (i.e., when used in isolation or implemented incorrectly) and suggests that safety initiatives taking a systems-oriented approach and organizational buy-in can lead to both perioperative and general safety improvements.
Aaberg OR, Hall-Lord ML, Husebø SIE, et al. BMC Health Serv Res. 2021;21:114.
TeamSTEPPS is a patient safety intervention designed to improve teamwork and communication in healthcare settings. One Norwegian hospital utilized TeamSTEPPS to improve professional and organizational outcomes in the urology and gastrointestinal surgery ward. Twelve months after implementation, researchers observed sustained improvements in three patient safety culture dimensions and three teamwork dimensions. Further studies with larger same size and stronger study designs are warranted.

Toccafondi G, Di Marzo F, Sartelli M, et al. Int J Qual Health Care. 2021;33(Supp 1):51-55. 

 

The impact of the COVID-19 pandemic on infection prevention efforts and healthcare-associated infections is unclear. This article discusses how the COVID-19 pandemic has led to adaptations to infection prevention and control and surveillance (IPCS) practices and a human factors and ergonomics perspective in surgery. Leveraging lessons learned from the pandemic, the authors use a human factors perspective to propose an enhanced infection prevention and control approach to prevent surgical site infections. 

Phipps D, Ashour A, Riste L, et al. The Pharmaceutical Journal. 2020;305(7943, 7944). November 10, December 1, 2020.

Dispensing mistakes are a common contributor to preventable adverse events in community pharmacies. Part 1 of this two-part series discusses factors that contribute to dispensing errors and summarizes methods for managing risks stemming from missteps. Part 2 focuses on preventing situations that enable errors and the role pharmacists have in minimizing dispensing errors in daily practice.

ISMP Medication Safety Alert! Acute Care Edition. October 8, 2020;25(20):1-4

In-depth investigations provide multidisciplinary insights that inform sustainable improvement opportunities. This newsletter story highlights a drug administration error examination by a dedicated office in the United Kingdom highlight the value of a commitment to deep, non-punitive analysis of patient safety incidents to enable transparency and learning.

Garman AN, McAlearney AS, Harrison MI, et al. Health Care Manag Rev. 2011-2020.

In this continuing series, high-performance work practices are explored and defined through literature review, case analysis, and research. The authors summarize findings and discuss how best practices can influence quality, safety, and efficiency outcomes. Topics covered include speaking up, central line infection prevention, and business case development.
Borshoff DC, Sadleir P. Curr Opin Anaesthesiol. 2020;33:554-560.
The COVID-19 pandemic has resulted in the delivery of anesthesia outside of operating rooms, such as in emergency departments, intensive care units, and makeshift field hospitals. This review examines challenges in maintaining patient safety while providing anesthesia services in nontraditional operating room environments.  
This primer describes stressors relevant to the healthcare response to the COVID-19 pandemic from the perspective of care deliverers and the significant personal toll the pandemic is taking on individuals who work in the healthcare system. This primer highlights foundational patient safety strategies – signage, workflow review and redesign, checklists and simulations – whose implementation is more important than ever for keeping patients and healthcare providers safe in the age of COVID-19.