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1 - 20 of 1962
Alsabri M, Boudi Z, Lauque D, et al. J Patient Saf. 2022;18(1):e351-e361.
Medical errors are a significant cause of morbidity and mortality, and frequently result from potentially preventable human errors associated with poor communication and teamwork. This systematic review included 16 studies that were examined for assessment tools, training interventions, safety culture improvement, and teamwork intervention outcomes. The authors conclude that training staff on teamwork and communication improve the safety culture, and may reduce medical errors and adverse events in the Emergency Department.
Etherington C, Kitto S, Burns JK, et al. BMC Health Serv Res. 2021;21(1):1357.
Gender bias has been implicated in negatively affecting patient safety. The authors conducted semi-structured interviews to explore how gender and other social identify factors impact experiences and teamwork in the operating room. Researchers found that women being routinely challenged or ignored or perceived negatively when assertive may hinder their pursuit of leadership positions or certain specialties. Implicit gender bias and stereotypes along with deeply entrenched structural barriers persist and complicate hierarchical relations between professions – all contributing to breakdowns in communication, increased patient safety risks, and poor team morale.  
Bacon CT, McCoy TP, Henshaw DS, et al. J Nurs Adm. 2021;51(11):e20-e26.
Organizational safety climate (OSC) has been associated with positive nurse outcomes. This study compared the association between organizational climate and job enjoyment in two surgical units, one that received crew resource management (CRM) training and the other that did not. The study used the Hospital Culture of Safety framework as a theoretical basis and found that job enjoyment and organizational safety climate scores were higher in the hospitals that received CRM training compared with those that did not.
Samuels A, Broome ME, McDonald TB, et al. J Patient Saf Risk Manage. 2021;26(6):251-260.
Healthcare systems have implemented communication-and-resolution programs (CRPs) (aka CANDOR) to encourage early disclosure of adverse events. This evaluation found that CRP training participants demonstrated improvements in self-reported empathy and communication skills.

Cohen M, Degnan D, McDonnell P, eds. Patient Saf. 2022;4(s1):1-45

Pharmacists play a unique role in patient safety that educational methods are shifting to address. This special issue covers several topics including strategies to reduce the susceptibility of hospitalized infants and children to medication errors, and infusing safety culture into pharmacy school curriculum.
Gampetro PJ, Segvich JP, Hughes AM, et al. J Pediatr Nurs. 2021;63:20-27.
Communicating and reporting patient safety incidents relies on a robust safety culture wherein health care providers feel supported, not blamed, for errors. Using pediatric registered nurses’ responses from the 2016 and 2018 Hospital Survey on Patient Culture, researchers explored (1) associations between the communication of RNs within their teams and the frequency that they reported safety events; (2) associations between RNs’ communication within their health care teams and their perceptions of safety within the hospital unit; and (3) whether RNs’ communication had improved from 2016 to 2018.
Lyndon A, Simpson KR, Spetz J, et al. Appl Nurs Res. 2022;63:151516.
Missed nursing care appears to be associated with higher rates of adverse events. More than 3,600 registered nurses (RNs) were surveyed about missed care during labor and birth in the United States. Three aspects of nursing care were reported missing by respondents: thorough review of prenatal records, missed timely documentation of maternal-fetal assessments, and failure to monitor input and output.
Dixon-Woods M, Aveling EL, Campbell A, et al. J Health Serv Res Policy. 2022;Epub Jan 3.
A key aspect of patient safety culture is the perception that all team members should speak up about safety concerns. In this study of 165 frontline and senior leader participants, deciding to report a safety event (referred to as a “voiceable concern”) is influenced by four factors: certainty that something is wrong and is an occasion for voice; system versus conduct concerns, forgivability, and normalization. Organizational culture and context effect whether an incident is considered a voiceable concern.
Noor Arzahan IS, Ismail Z, Yasin SM. Safety Sci. 2022;147:105624.
A culture of safety is a key component to successful patient safety initiatives. This systematic review explored the relationship between safety culture and safety climate dimensions and safety performance measures. The most common dimensions used to assess this relationship were the involvement of leadership, safety resources, risk management and communication, safety rules and procedures, and involvement of healthcare workers.

Famolaro T, Hare R, Tapia A, Yount et al. Rockville, MD: Agency for Healthcare Research and Quality; December 2021. AHRQ Publication No. 22-0004.

Ambulatory surgery centers harbor unique characteristics that affect safety culture. This analysis from the Agency for Healthcare Research and Quality (AHRQ) shares results of 235 ambulatory surgery centers (ASCs) participating in the Surveys on Patient Safety Culture (SOPS) Ambulatory Surgery Center Survey. Most respondents (92%) rated their organization as committed to learning and continuous improvement.
Institute for Healthcare Improvement. March 17-23, 2022, Boston, MA.
Organization executives influence the success of patient safety improvement. This onsite workshop will highlight how leaders can use assessments, planning, and evidence to improve the safety culture at their organizations.
Institute for Safe Medication Practices. January 27-28, 2022.
This virtual workshop will explore tactics to ensure medication safety, including strategic planning, risk assessment, and Just Culture principles.
Rockville, MD: Agency for Healthcare Research and Quality.
In this annual publication, AHRQ reviews the results of the National Healthcare Quality Report and National Healthcare Disparities Report. This 2021 report highlights that a wide range of quality measures have shown improvement in quality, access, and cost.

Rockville, MD: Agency for Healthcare Research and Quality; December 2021. AHRQ Publication No. 22-0009.

In consultation with AHRQ, the U.S. Department of Health and Human Services delivered a final report on effective strategies to improve patient safety and reduce medical errors to Congress. Required by the Patient Safety Act of 2005, the report was made available for public review and comment, and review by the National Academy of Medicine. It outlined several strategies to accelerate progress in improving patient safety, including using analytic approaches in patient safety research, measurement, and practice improvement to monitor risk; implementing evidence-based practices in real-world settings through clinically useful tools and infrastructure; encouraging the development of learning health systems that integrate continuous learning and improvement in day-to-day operations; and encouraging the use of patient safety strategies outlined in the National Action Plan by the National Steering Committee for Patient Safety.
Brenner MJ, Boothman RC, Rushton CH, et al. Otolaryngol Clin North Am. 2021;55(1).
This three-part series offers an in-depth look into the core values of honesty, transparency, and trust. Part 1, Promoting Professionalism, introduces interventions to increase provider professionalism. Part 2, Communication and Transparency, describes the commitment to honesty and transparency across the continuum of the patient-provider relationship. Part 3, Health Professional Wellness, describes the impact of harm on providers and offers recommendations for restoring wellness and joy in work.
Hannawa AF, Wu AW, Kolyada A, et al. Patient Educ Couns. 2021;Epub Oct 30.
In this qualitative study, researchers explore physician, nurse, and patient perspectives about what features constitute “good” and “poor” care episodes. Participants highlighted the importance of quickly identifying and responding to errors and failures as one key component of good quality care.

Rockville, MD: Agency for Healthcare Research and Quality. January 12, 2:00-3:00 PM (eastern).

An organization’s understanding of its culture is foundational to patient safety. This webinar will introduce the AHRQ Surveys on Patient Safety Culture™ (SOPS®) program. The session will cover the types of surveys available and review resources available to best use the data to facilitate conversations and comparisons to inform improvement efforts.