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Sosa T, Galligan MM, Brady PW. J Hosp Med. 2022;17:199-202.
Situation awareness supports effective teamwork and safe care delivery. This commentary highlights the role of situation awareness in watching the condition of pediatric inpatients to reduce instances of unrecognized clinical deterioration. It features rapid response models enhanced by event review, psychological safety, and patient and family partnering as mechanisms improved through situation awareness.
Montgomery A, Lainidi O. Front Psychiatry. 2022;13:818393.
Difficulty speaking up about patient safety concerns and unprofessional behavior indicates a safety culture deficiency. This article discusses the relationship between silence, burnout, and quality of care, emphasizing how silence evolves during medical education and continues into clinical training, eventually impacting healthcare professional burnout, patient safety and quality of care.
Wailling J, Kooijman A, Hughes J, et al. Health Expect. 2022;25:1192-1199.
Harm resulting from patient safety incidents can be compounded if investigating responses ignore the human relationships involved. This article describes how compounded harm arises, and it recommends the use of a restorative practices. A restorative approach focuses on (1) who has been hurt and their needs, and who is responsible for addressing those needs, (2) how harms and relationships can be repaired, and avenues to prevent the incident from reoccurring.
Otachi JK, Robertson H, Okoli CTC. Perspect Psychiatr Care. 2022;Epub Apr 6.
Workplace violence in healthcare settings can jeopardize the safety of both patients and healthcare workers. This study found that over half of healthcare workers at one large academic medical center in the United States reported witnessing or experiencing workplace violence. Witnessing or experiencing workplace violence was most common in psychiatric settings and in the emergency department.  
Wojcieszak D. J Patient Saf Risk Manag. 2022;27:15-20.
Open disclosure and apology for errors is recommended in healthcare. In this study, 38 state medical boards responded to a survey regarding disclosure and apology practices after medical errors. Findings suggest that state medical boards have generally favorable views toward clinicians who disclose errors and apologize, and that these actions would not make the clinician a target for disciplinary action; respondents had less favorable views towards legislative initiatives regarding apologies and disclosure.
Fitzgerald KM, Banerjee TR, Starmer AJ, et al. Pediatr Qual Saf. 2022;7:e539.
I-PASS is a structured handoff tool designed to improve communication between teams at change-of-shift or between care settings. This children’s hospital implemented an I-PASS program to improve communication between attending physicians and safety culture. One year after the program was introduced, all observed handoffs included all five elements of I-PASS and the duration of handoff did not change. Additionally, the “handoff and transition score” on the Agency for Healthcare Quality (AHRQ) Hospital Survey on Patient Safety Culture improved.
Khansa I, Pearson GD. Plast Reconstr Surg Glob Open. 2022;10:e4203.
Some clinicians experience profound emotional distress following an adverse event, known as the “second victim” phenomenon. This study of surgical residents in the US found that most residents who reported being part of a medical error had subsequent emotional distress, including guilt, anxiety, and insomnia. Importantly, while three quarters of residents reported they did not get emotional support following the event, all those who did get support reported benefiting from it.
Tee QX, Nambiar M, Stuckey S. J Med Imaging Radiat Oncol. 2022;66:202-207.
Diagnostic errors in radiology can result in treatment delays and contribute to patient harm. This article provides an overview of the common cognitive biases encountered in diagnostic radiology that can contribute to diagnostic error, and strategies to avoid these biases, such as the use of a cognitive bias mitigation strategy checklist, peer feedback, promoting a just culture, and technology approaches including artificial intelligence (AI).
Dieckmann P, Tulloch S, Dalgaard AE, et al. BMC Health Serv Res. 2022;22:307.
When staff feel psychologically safe, they are more likely to speak up about safety concerns. This study sought to explore the link between psychological safety and improvement work, and whether an existing model captures all the relevant ‘antecedents’ and ‘consequences’ of psychological safety.
Gilmartin HM, Hess E, Mueller C, et al. Health Serv Res. 2022;57:385-391.
Ideal clinical learning environments (CLE) support employee engagement, satisfaction, and a culture of safety. The Learning Environment and High Reliability Practices Survey (LEHR) was used to determine the association between ideal CLE and job satisfaction, burnout, intent to leave, and staff turnover. Learning environments with higher average LEHR scores were associated with higher employee engagement, retention, and safety climate scores.
Lacson R, Khorasani R, Fiumara K, et al. J Patient Saf. 2022;18:e522-e527.
Root cause analysis is a commonly used tool to identify systems-related factors that contributed to an adverse event. This study assessed a system-based approach, (i.e., collaborative case reviews (CCR) co-led by radiology and an institutional patient safety program) to identify contributing factors and explore the strength of recommended actions in the radiology department at a large academic medical center. Stronger action items, such as standardization of processes, were implemented in 41% of events, and radiology had higher completion rates than other hospital departments.
Dawson R, Saulnier T, Campbell A, et al. Hosp Pediatr. 2022;12:407-417.
Voluntary error reporting remains underutilized in many clinical settings despite its importance for organizational learning and improved patient safety. This pediatric health system implemented a new safety event management system (SEMS) aimed at increased usability, de-centralized event follow-up, and closed-loop communication. The new SEMS resulted in more event reporting and less staff time spent on each report.
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.
Weiseth A, Plough A, Aggarwal R, et al. Birth. 2022;Epub Mar 1.
Labor and delivery is a high-risk care environment. This study evaluated a quality improvement initiative (TeamBirth) designed to promote shared decision-making and safety culture in labor and delivery. This mixed-methods study included both clinicians and patients at four hospitals and found that the program was feasible, increased the use of huddles, and had no negative effects on patient safety.
Logan‐Athmer AL. J Healthc Risk Manag. 2022;42:31-36.
High reliability organizations (HROs) often operate in complex, hazardous conditions and have fewer adverse events. Based on qualitative interviews with organizational leaders and front-line supervisors, the researchers of this study identified seven themes relating to necessary leadership skillsets for HRO adoption – nonhierarchical leadership; transparent, continuous communication; deference to expertise; ability to innovate; motivation through recognition; self-reflection; and commitment to visibility.
Wyner D, Wyner F, Brumbaugh D, et al. Pediatrics. 2021;148:e2021053091.
The dismissal of parental concerns is a known contributor to medical errors in children. This story illustrates how poor communication, lack of respect, and anchoring bias  contributed to failure in the care of a boy. The authors share actions being taken by the hospital involved in the tragedy to partner with the family to improve diagnosis practices throughout their organization.
Cribb A, O'Hara JK, Waring J. BMJ Qual Saf. 2022;31:327-330.
Patient safety advocates recommend a shift from a blame culture to a just culture. This commentary describes three types of justice that exist in healthcare - retributive, no blame or qualified blame, and restorative. The authors invite debate around the concept of just culture and its role in the “real world”.
Ito A, Sato K, Yumoto Y, et al. Nurs Open. 2021;9:467-489.
Ensuring that healthcare workers feel comfortable speaking up about concerns – also known as psychological safety – is an essential component of patient safety. This concept analysis identified five attributes of psychological safety in healthcare settings – (1) perceptions of consequences related to taking interpersonal risks; (2) strong interpersonal relationships; (3) group-level phenomenon; (4) safe work environments supporting interpersonal risks and (5) non-punitive culture.
Dempsey C, Batten P. J Nurs Adm. 2022;52:91-98.
Appropriate levels of nurse staffing have been shown to improve patient outcomes. This national study explored the effect of nurse staffing on clinical quality, nurse experience, and nurse engagement. Consistent with earlier research, nurse staffing was associated with improved clinical outcomes.