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.

Huddles are increasingly being used to improve safety in hospitals. This commentary describes how one hospital implemented structured multidisciplinary prospective peer review of radiation oncology patient treatment plans to help prevent harm and reduce errors. The authors discuss safety culture and minimizing clinical hierarchy as drivers of success.

This cross-sectional study examined associations between safety culture, missed nursing care, and adverse events. Investigators found significant associations between worse ratings of safety culture and more reports of missed nursing care. They recommend enhancing safety culture to reduce missed nursing care and improve safety.

The review reveals shortcomings associated with do-not-resuscitate orders and suggests strategies to improve communication and hospital culture.

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.

The Concord Hospital has been recognized for its effective use of teamwork and communication, and the Concord Collaborative Care Model draws from successful efforts in the aviation industry, human factors science, and high-reliability organizations.