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Weiseth A, Plough A, Aggarwal R, et al. Birth. 2022;Epub Mar 1.
Labor and delivery is a high-risk care environment. This study evaluated a quality improvement initiative (TeamBirth) designed to promote shared decision-making and safety culture in labor and delivery. This mixed-methods study included both clinicians and patients at four hospitals and found that the program was feasible, increased the use of huddles, and had no negative effects on patient safety.
Alsabri M, Boudi Z, Lauque D, et al. J Patient Saf. 2022;18:e351-e361.
Medical errors are a significant cause of morbidity and mortality, and frequently result from potentially preventable human errors associated with poor communication and teamwork. This systematic review included 16 studies that were examined for assessment tools, training interventions, safety culture improvement, and teamwork intervention outcomes. The authors conclude that training staff on teamwork and communication improve the safety culture, and may reduce medical errors and adverse events in the Emergency Department.
Lyndon A, Simpson KR, Spetz J, et al. Appl Nurs Res. 2022;63:151516.
Missed nursing care appears to be associated with higher rates of adverse events. More than 3,600 registered nurses (RNs) were surveyed about missed care during labor and birth in the United States. Three aspects of nursing care were reported missing by respondents: thorough review of prenatal records, missed timely documentation of maternal-fetal assessments, and failure to monitor input and output.
Sosa T, Sitterding M, Dewan M, et al. Pediatrics. 2021;148:e2020034603.
Situational awareness during critical incidents is a key attribute of effective teams. This article describes the development of a situational awareness model, which included involving families and the interdisciplinary team in huddles, a shared mental model checklist, and an electronic health record (EHR) situational awareness navigator. Use of this new model decreased emergency transfers to the ICU and improved process measures, such as improved risk recognition before medical response team activation.
Polancich S, Hall AG, Miltner RS, et al. J Healthc Qual. 2021;43:137-144.
The COVID-19 pandemic has disrupted many aspects of health care delivery, including how hospitals prevent common hospital-acquired conditions such as pressure injuries. Based on retrospective data, the authors of this study did not identify a longitudinal increase in hospital-acquired pressure injuries between March and July 2020. The authors discuss how prior organizational efforts to reduce hospital-acquired pressure injuries allowed their hospital to quickly adapt existing workflows and processes to respond to the COVID-19 pandemic.
LaGrone LN, McIntyre LK, Riggle A, et al. J Trauma Acute Care Surg. 2020;89:1046-1053.
The authors examined contributors to error-associated deaths occurring between 1996-2004 and 2005-2014 and identified a shift from deaths occurring during the early phase of care (e.g., failed resuscitation and hemorrhage) to deaths occurring during the recovery phase (e.g., respiratory failure from aspiration). These findings demonstrate that successful implementation of system improvements can resolve process of care issues, but that ongoing evaluation is critical for continuous process improvement.
English M, Ogola M, Aluvaala J, et al. Arch Dis Child. 2021;106:326-332.
Health systems are encouraged to proactively identify patient safety risks. In the first of a two-part series, the authors draw on the  Systems Engineering Initiative for Patient Safety (SEIPS) framework  to discuss the strengths and challenge of a low-resource newborn unit from a systems perspective and SEIPS’ implications for patient safety.
Fransen AF, van de Ven J, Banga FR, et al. Cochrane Database Syst Rev. 2020;12:Cd011545.
Teamwork training simulation programs can improve communication and safety culture in obstetric teams. This systematic review found that simulation-based obstetric team training can improve team performance and may improve some maternal and perinatal outcomes. The authors note that future research should attempt to limit bias, improve precision, and pay attention to effect measurement at the patient outcome level.

Toccafondi G, Di Marzo F, Sartelli M, et al. Int J Qual Health Care. 2021;33(Supp 1):51-55. 

 

The impact of the COVID-19 pandemic on infection prevention efforts and healthcare-associated infections is unclear. This article discusses how the COVID-19 pandemic has led to adaptations to infection prevention and control and surveillance (IPCS) practices and a human factors and ergonomics perspective in surgery. Leveraging lessons learned from the pandemic, the authors use a human factors perspective to propose an enhanced infection prevention and control approach to prevent surgical site infections. 
Kozasa EH, Lacerda SS, Polissici MA, et al. Front Psych. 2020;11:570786.
Situational awareness during critical incidents is a key component of teamwork. This study found that a mutual care training can increase situational awareness for healthcare workers and consequently improve mental health and well-being before and during the COVID-19 pandemic.
Liberati EG, Tarrant C, Willars J, et al. BMJ Qual Saf. 2021;30:444-456.
Maternal harm is a sentinel event and improving maternal safety is receiving increased attention in both policy and clinical settings. The researchers used qualitative methods to generate a new plain language framework identifying safe behaviors and practices in inpatient maternity units. Several synergistic features were identified including a commitment to safety culture; technical competence; teamwork, cooperation, and positive working relationships.  
Rangachari P, L. Woods J. Int J Environ Res Public Health. 2020;17:4267.
This article discusses the impact of the lack of healthcare worker support on resilience, patient safety, and staff retention during the COVID-19 pandemic and provides recommendations for better supporting psychological safety among healthcare workers. 
Leveson N, Samost A, Dekker SWA, et al. J Patient Saf. 2020;16:162-167.
This article describes the use of a new accident analysis technique (CAST, or Causal Analysis based on Systems Theory), an alternative approach to root cause analysis. The CAST approach is based on the principle that accidents are not only the result of individual system component failures or errors but more generally result due to inadequate enforcement of constraints on the behavior of the system components (i.e., safety constraints enforced by controls, such as checklists).  Many adverse events (AEs) appear to be related to the design of the system involved and not attributable to unsafe individual behavior. This technique can be useful in identifying causal factors to help health care systems learn from mistakes and design systems-level changes to prevent future AEs.
Thull-Freedman J, Mondoux S, Stang A, et al. CJEM. 2020;22:738-741.
This commentary reviews the principles of high reliability organizations and their application to emergency department pandemic response and describes the experience of one children’s hospital in Alberta, Canada applying these principles in responding to the COVID-19 pandemic. Actions taken by the hospital included the use of an interprofessional ED quality council to identify processes where high reliability is essential in the context of the COVID-19 pandemic, such as resuscitations, intubations, donning and doffing of personal protective equipment (PPE), and preventing contamination.
Holdsworth LM, Safaeinili N, Winget M, et al. Implement Sci. 2020;15.
Rapid assessment procedures (RAP) describe a group of methods for studying organizational processes, practices and implementation. This study used RAP to evaluate the implementation of a package of patient safety interventions in intensive care units at four academic medical centers. The RAP approach included developing evaluation questions with stakeholder input, integrating implementation science into field guides and analytic tools, using a multidisciplinary evaluation team, building trust with the sites, engaging sites in participatory data collection, rapid team analysis of data sources, and validating findings with the sites. The RAP approach identified barriers and facilitators to successful intervention implementation and produced contextually-rich information using robust methods within a short timeframe. The authors conclude that this approach is particularly useful for learning health systems because it engages stakeholders in uncovering new insights.
DiCuccio MH, Colbert AM, Triolo PK, et al. J Nurs Admin. 2020;50:152-158.
Over 1,000 nurses across 40 medical/surgical or telemetry units throughout seven hospitals were surveyed about perceptions on safety culture, patient advocacy, patient experience, and fall and pressure ulcer rates. Survey results indicated a positive correlation between safety culture and advocacy; however, this relationship was moderated by nursing experience, with newer nurses being more positive about safety culture and advocacy compared to experienced nurses.
Profit J, Sharek PJ, Cui X, et al. J Patient Saf. 2020;16:e310-e316.
Prior research has shown that health care worker perceptions of safety culture may vary across different neonatal intensive care units (NICUs). Less is known as to how perceptions of NICU safety culture relate to NICU quality of care. In this cross-sectional study involving 44 NICUs, researchers found a significant relationship between safety climate and teamwork ratings and a lack of health care–associated infections, but no relationship with regard to the other performance metrics examined in the study.
Sarkar B, Brunsvold ME, Cherry-Bukoweic JR, et al. J Trauma. 2011;71:1447-53; discussion 1453-4.
A multifaceted program designed to optimize care of trauma patients resulted in a sustained improvement in trauma mortality over a 5-year period in this single-institution study. Part of the intervention included successful efforts to reduce health care–associated infections.