Using the events at the United Kingdom’s Mid Staffordshire Trust hospital as a case study, the authors discuss the impact of ‘collective denial’ on organizational processes and safety culture. The authors suggest that safeguards allowing for self-reflection and correction be implemented early in the safety reporting process, and that employees be granted power to speak up about safety concerns.

Incomplete communication regarding patient information can diminish the safety of care delivery. This commentary describes how a quality improvement project applied plan–do–study–act cycles to enhance collection of patient data. Researchers developed, tested, and refined a ward round template in a United Kingdom urology service and increased compliance in the recording of patient care measures.

Communication failures at the time of patient handoffs have been frequently implicated in adverse events. Comparing how narrative modes of communication such as storytelling and structured tools like checklists can be utilized to augment information transfers in health care, this commentary advocates for more research into strategies to improve narrative thinking.

This commentary describes a checklist to help ensure comprehensive information gathering by medical trainees during rounds.

Implementing a checklist for post-surgical handoffs resulted in more information being included in the handoff, but on average, only about half of the checklist items were specifically discussed. Prior studies have also found lower than expected checklist adherence in real-world settings.

Color-coded wristbands are often used to identify patients and alert providers to specific safety considerations, such as allergies. This study used human factors engineering principles to examine how wristbands were used for safety purposes at two British hospitals.

Implementation of an electronic medication reconciliation tool reduced drug discrepancies at the time of hospital admission.

Radiologists frequently receive inadequate or unclear clinical information from referring clinicians and must engage in workarounds to ensure patient safety.

Handovers, or handoffs, in patient care are a continued and problematic safety concern that were further elevated by The Joint Commission into a National Patient Safety Goal. Despite guidelines and past efforts to standardize the process with computerized tools, there are remaining opportunities for improvement. This study adopted a handover assessment instrument in the intensive care setting to evaluate the degree of information corruption in handover exchanges. Investigators discovered variances in information retained during a handover compared with actual facts from the medical record, and noted the potential for these variations to contribute to errors in care. The authors share their tool and advocate its use as a screening method to identify areas for improvement in the quality of handovers. A past AHRQ WebM&M case commentary discussed a fumbled handoff resulting from poor communication and lack of standardization in the process.

This study found a remarkably high incidence of medication errors—nearly two errors per patient—in skilled nursing facilities. Interviews with staff revealed several underlying factors: polypharmacy, overworked staff, poor communication between nursing home staff and physicians, lack of a culture of safety, and lack of reliable systems for medication ordering and administration. Recognition of the high potential for medication errors in nursing facilities has led to the development of toolkits for improving medication safety. A serious medication administration error at a nursing facility is discussed in this AHRQ WebM&M case commentary.