Vijayakumar S, Duggar WN, Packianathan S, et al. Front Oncol. 2019;9:302.
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.
Hessels AJ, Paliwal M, Weaver SH, et al. J Nurs Care Qual. 2019;34:287-294.
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.
Wolfe HA, Mack EH. Transl Pediatr. 2018;7:267-274.
Pediatric critical care patients are at greater risk for harm. This review examines how a culture of safety affects pediatric critical care delivery and highlights collaboratives as effective mechanisms to develop and test improvement strategies. The authors discuss the development of bundles to reduce hospital-acquired infections and standardize handoffs as promising safety improvement practices.
Campbell D, Dontje K. Journal of emergency nursing: JEN : official publication of the Emergency Department Nurses Association. 2019;45:149-154.
Handoffs in the emergency department are vulnerable to error. This commentary describes an improvement initiative that focused on structuring nurse shift change using situation, background, assessment, recommendation (SBAR) communication methods. Although safety culture scores improved, the authors note that resistance to change was a key barrier to implementation.
Emergency departments are high-risk environments due to the urgency of care needs and complexity of communication. This commentary explores challenges associated with medication administration, handoffs, discharge processes, and electronic health records in emergency medicine and recommends strategies to reduce risks.
Sheth S, McCarthy E, Kipps AK, et al. PEDIATRICS. 2016;137.
The I-PASS signout tool has become a widely used method of patient handoffs when transferring care from the primary clinician to a covering clinician. This study used the I-PASS framework to develop and implement a standardized signout process for transferring patients from the pediatric cardiac intensive care unit to the general ward. The new process significantly improved clinician workflow and perceived safety culture relating to handoffs.
Kitto S, Marshall SD, McMillan SE, et al. J Interprof Care. 2015;29:340-6.
Clinical staff often fail to call rapid response teams to evaluate deteriorating patients, even when objective criteria for calling the team are met. This qualitative study of physicians and nurses at an Australian hospital found that an impaired culture of safety can result in failure to use the rapid response team when appropriate and can also lead to using the team as a workaround to compensate for poor interdisciplinary communication.
Pannick S, Beveridge I, Wachter RM, et al. Eur J Intern Med. 2014;25:874-87.
This narrative review of safety efforts on general hospital wards found that most interventions encompass one or more of five areas: staffing levels, interprofessional collaboration, standardization of care such as use of checklists, rapid response to clinical deterioration, and safety culture. The authors advocate for increasing the evidence base in all of these areas, as gaps in implementation and sustainment are prevalent.
Cunningham FC, Ranmuthugala G, Plumb J, et al. BMJ Qual Saf. 2012;21:239-49.
Establishing a culture of safety is an essential component of improving safety within an organization. Analysis of programs that have successfully stimulated innovation to tackle safety issues, such as the Keystone ICU project or Kaiser Permanente, have found that a critical aspect of their success has been understanding the dynamics of how groups of professionals work together. This review explores how social network analysis—a method of examining relationships in complex systems, and how these relationships influence dissemination of knowledge and innovation—has been utilized to develop health professional networks for improving quality and safety. With the growing recognition of the role of context in determining the success of patient safety efforts, social network analysis provides an important tool for developing organizational approaches to improving safety.
Nasca TJ, Day SH, Amis S, et al. N Engl J Med. 2010;363:e3.
This article summarizes the Accreditation Council for Graduate Medical Education's proposed new regulations on housestaff duty hours. The recommendations are perhaps most notable for what they do not contain—a reduction in the 80-hour weekly limit. Rather than narrowly focusing on duty-hour restrictions, the recommendations take a broad approach to maximizing patient safety in training environments through targeted reductions in work hours for first-year residents, enhanced supervision by attending physicians, standardizing expectations around handoffs and signouts, and engaging residents in safety and quality improvement efforts. Although the current 80-hour work week will be preserved, the new regulations would eliminate extended-duration shifts for first-year residents (as was recommended in a 2008 Institute of Medicine report). The current regulations, implemented in 2003, have improved residents' quality of life but have not positively impacted patient safety or educational outcomes. The ACGME acknowledged this evidence in crafting recommendations that seek to establish a culture of safety within residency programs and focus more broadly on enhancing supervision for early-stage residents while allowing more autonomy for senior trainees.
Barber ND, Alldred DP, Raynor DK, et al. Qual Saf Health Care. 2009;18:341-346.
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.
Johnstone M-J, Kanitsaki O. Int J Qual Health Care. 2006;18:383-8.
The authors discuss the importance of understanding the relationship between culture, language, and patient safety and stress that not sufficiently addressing this relationship may put minority patients at risk for adverse events.
This commentary provides a broad overview of the issues facing health care systems in their efforts to promote quality and safety. The author discusses pervasive cultural barriers and process limitations that contribute to errors, while providing a series of anecdotes to demonstrate how easy and frequent these events can occur. Approaches for improvement that draw from the experiences of non-health care organizations, such as Toyota, are included. The strength of the commentary lies in the compelling stories shared and the perspectives offered to foster change.
Auerbach AD, Sehgal NL, Blegen MA, et al. BMJ Qual Saf. 2011;21.
Focused efforts to enhance teamwork and communication have led to improved safety culture, though the impact on clinical outcomes is mixed. This multicenter study evaluated the impact of a series of teamwork and communication interventions over a 2-year period. The interventions included a teamwork training program, the development of unit-based safety teams, and patient engagement through daily goals and whiteboard use. Although a related study demonstrated that the interventions led to improved safety culture, this study found no impact on readmission rates or length of stay. Interviewing patients both during and after hospitalization, investigators found that patients perceived greater team function, but that they also perceived more safety gaps. This raises the possibility that patients' heightened awareness regarding patient safety and teamwork may lead them to identify more flaws in the system.
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