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de Bienassis K, Llena-Nozal A, Klazinga N for the Organisation for Economic Co-operation and Development. Paris, France: OECD Publishing; 2020. OECD Health Working Papers, No. 121.

Adverse events in long term care facilities are acerbated due to staffing, training and financial challenges. This report examined the costs of avoidable problems in long term care and suggests prevention strategies that center on workforce skill development and safety culture improvement.

Garman AN, McAlearney AS, Harrison MI, et al. Health Care Manag Rev. 2011-2020.

In this continuing series, high-performance work practices are explored and defined through literature review, case analysis, and research. The authors summarize findings and discuss how best practices can influence quality, safety, and efficiency outcomes. Topics covered include speaking up, central line infection prevention, and business case development.
Duke Center for Healthcare Safety and Quality.
Improving teamwork and communication is a continued focus in the hospital setting. This toolkit is designed to help organizations create a culture that embeds teamwork into daily practice routines. Topics covered include team leadership, learning and continuous improvement, clarifying roles, structured communication, and support for raising concerns.

GMS J Med Educ. 2019;36:Doc11-Doc22.

Patient safety has been described as an unmet need in physician training. This special issue covers areas of focus for a patient safety curriculum drawn from experience in the German medical education system. Topics covered include human error, blame, and responsibility. Articles also review the epidemiology of common problems such as medication safety, organizational contributors to failure, and diagnostic error.
A woman with a history of psychiatric illness presented to the emergency department with agitation, hallucinations, tachycardia, and transient hypoxia. The consulting psychiatric resident attributed the tachycardia and hypoxia to her underlying agitation and admitted her to an inpatient psychiatric facility. Over the next few days, her tachycardia persisted and continued to be attributed to her psychiatric disease. On hospital day 5, the patient was found unresponsive and febrile, with worsening tachycardia, tachypnea, and hypoxia; she had diffuse myoclonus and increased muscle tone.
Simmons-Ritchie D. Penn Live. November 15, 2018.
Nursing home patients are vulnerable to preventable harm due to poor safety culture, insufficient staffing levels, lack of regulation enforcement, and misaligned financial incentives. This news investigation reports on how poor practices resulted in resident harm in Pennsylvania nursing homes and discusses strategies for improvement, such as enhancing investigation processes.
Guttman OT, Lazzara EH, Keebler JR, et al. J Patient Saf. 2021;17:e1465-e1471.
Communication errors in health care are a persistent challenge to patient safety. This commentary advocates for studying behavioral, cognitive, linguistic, environmental, and technological factors to help understand barriers to effective information exchange in health care. The authors suggest that approaches targeting each set of barriers be developed and embedded into learning activities to generate lasting improvements.
Pronovost P, Johns MME, Palmer S, et al, eds. Washington, DC: National Academy of Medicine; 2018. ISBN: 9781947103122.
Although health information technology was implemented to improve safety, it has resulted in unintended consequences such as clinician burnout and perpetuation of incorrect information. This publication explores the barriers to achieving the interoperability needed to build a robust digital infrastructure that will seamlessly and reliably share information across the complex system of health care. The report advocates for adjusting purchasing behaviors to focus less on the price and features of each product and to instead look for interoperable technologies. The report outlines five action priorities to guide leadership decision-making around procurement, including championing systemwide interoperability and identifying goals and requirements. A PSNet interview discussed potential consequences of the digitization of health care.
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.
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.
van Noord I, de Bruijne MC, Twisk JWR. Int J Qual Health Care. 2010;22:162-169.
Safety culture surveys focus on respondents' perception of safety in specific contexts, and measurement of safety culture is recommended in order to identify problem areas and targets for improvement. However, this Dutch study, conducted in 33 emergency departments, found that positive safety culture perception may actually inhibit implementation of recommended safety practices. For example, hospitals where respondents felt that handoffs and signouts were carried out safely were less likely to have standardized protocols for supervision or case review. This finding raises the concern that, in some cases, important safety mechanisms may not be implemented due to a false sense of security regarding patient safety.
Oakbrook Terrace, IL: The Joint Commission; November 2008.
The quality of care delivered at US hospitals continues to improve, according to data gathered by the Joint Commission from nearly 1,500 institutions. Hospitals improved their provision of evidence-based care for patients with heart attacks, congestive heart failure, and pneumonia, and also improved at prevention of health care–associated infections in surgical patients. As in the 2007 report, adherence to the National Patient Safety Goals was more mixed. Although performance improved in some areas (including medication reconciliation and eliminating "do not use" abbreviations), many hospitals do not systematically perform time outs prior to procedures, or have reliable mechanisms for communicating critical test results.
The Healthcare Commission. London, UK: The Stationary Office; 2008.
This report shares findings from a 5-year analysis of the state of health care in the United Kingdom. It reveals that while awareness of patient safety has improved since the first report in the series, the UK health system needs to be more consistent in its application of patient-centeredness concepts to fully promote quality.
Following surgery, a woman on a patient-controlled analgesia pump is found to be lethargic and incoherent, with a low respiratory rate. The nurse contacted the attending physician, who dismisses the patient's symptoms and chastises the nurse for the late call.
On the day of a patient's scheduled electroconvulsive therapy, the clinic anesthesiologist called in sick. Unprepared for such an absence, the staff asked the very busy OR anesthesiologist to fill in on the case. Because the wrong drug was administered, the patient did not wake up as quickly as expected.