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Although recommended as a patient safety improvement strategy, the value of root cause analysis has been debated. This commentary suggests a three-step approach for optimizing root cause analysis results to detect factors that contribute to adverse events. The author applies philosophical principles to identify and prioritize interventions to enhance benefit from root cause analysis.

Read-backs are widely recommended in order to improve communication of critical clinical information. This simulation study found that anesthesiologists who immediately read back clinical data during simulated emergencies were eight times more likely to retain and use the information appropriately.

Handoffs between care settings can lead to adverse events. This literature review analyzed 17 studies of handoffs between prehospital first responders and emergency department (ED) staff. Safety gaps detected included communication barriers, lack of a structured communication tool, and unclear identification of the receiving clinical staff. The authors suggest that a structured handoff tool could improve first responder–ED handoffs. A past AHRQ WebM&M commentary discussed communication failures between providers and highlighted a need for standard handoff protocols.

In this mixed-methods study of nursing handoffs in the emergency department, 96% of participants felt that they received adequate information. Participating nurses believed that the essential data included demographics, presenting problems, nursing observations, and future care plans.

Provision of visual reminders improved intensive care unit nurses' ability to remember and perform key clinical tasks immediately after receiving a handoff.

Prior research has documented errors in handoffs between ambulance and emergency department personnel. This study reports on the development and initial implementation of a structured tool for use at this handoff.

Poor care coordination has been shown to be a risk factor for preventable errors in the ambulatory setting, and patients consistently voice concern about care coordination problems. This survey, which builds on prior Commonwealth Fund reports, found that care coordination was a major determinant of patient-reported medication errors in all seven countries studied. The study reinforces the role of health systems in ambulatory patient safety, and the need for improved communication between providers and better integration of health systems to reduce preventable errors for outpatients.

Interviews with clinicians who committed medication errors helped to identify contributing factors, which included understaffing and lack of access to prescribing information at the point of care.