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Dinnen T, Williams H, Yardley S, et al. BMJ Support Palliat Care. 2019.
Advance care planning (ACP) allows patients to express and document their preferences about medical treatment; however, there are concerns about uptake and documentation due to human error. This study used patient safety incident reports in the UK to characterize and explore safety issues arising from ACP and to identify areas for improvement. Over a ten-year period, there were 70 reports of an ACP-related patient safety incident (due to incomplete documentation, inaccessible documentation or miscommunication, or ACP directives not being followed) which led to inappropriate treatment, transfer or admission. The importance of targeting the human factors of the ACP process to improve safety is discussed. A PSNet Human Factors Primer on human factors expands on these concepts.  
Scott J, Heavey E, Waring J, et al. BMC Health Serv Res. 2019;19:613.
This study reports the results of a survey measuring patients' experience of their own safety during care transitions. The survey data were perceived to be useful to physicians and hospital staff to identify potential safety risks and could be used to inform changes to improve care.
Ricciardi R, Shofer M. J Nurs Care Qual. 2019;34:1-3.
This commentary discusses the importance of the nurse-patient relationship and engagement with patients and their family members to improve patient safety practices. The article also provides an overview of AHRQ resources intended to facilitate engagement between providers and their patients and family members.
Tothy AS, Limper HM, Driscoll J, et al. Jt Comm J Qual Patient Saf. 2016;42:281-5.
This study reports on efforts to enhance communication between clinicians and patients in an urban pediatric emergency department. A rapid-change project resulted in significant improvement in patient perceptions of communication—clinicians were perceived as being more sensitive to patients' concerns and displayed better listening behaviors. Poor discharge communication in the emergency department has been linked to safety concerns in prior studies.
Stickney CA, Ziniel SI, Brett MS, et al. J Pediatr. 2014;165:1245-1251.e1.
In this study, health care providers and parents of children in a pediatric intensive care unit described their perceptions of family involvement in morning rounds. Although parents were overwhelmingly enthusiastic about being included in rounds, providers expressed some concerns and potential drawbacks, such as the avoidance of discussing uncomfortable topics due to presence of family.
Turner K, Frush K, Hueckel R, et al. J Nurs Care Qual. 2013;28:257-64.
The Josie King Care Journal is a tool intended to improve communication between the health care team and families of hospitalized children. This study reports on the implementation of the journal in a pediatric intensive care unit. Use of the tool was associated with perceived improvements in communication by both clinicians and parents.
Dunn D. J Perianesth Nurs. 2006;21:317-28; quiz 329-31.
The author explains the Joint Commission on Accreditation of Healthcare Organizations' Universal Protocol on surgical site verification in the context of its implementation in a New Jersey hospital.
Espin S, Levinson W, Regehr G, et al. Surgery. 2006;139:6-14.
This study discovered both similarities and differences in the way surgeons, nurses, anesthesiologists, and patients responded to four scripted clinical error scenarios. Findings suggested that all groups incorporated a negative outcome or a deviation from standard of practice into their error definition rather than analyzing the event independent of those factors. In addition, noted differences existed between patients who supported reporting for all negative events and nurses who believed in selective reporting. Similarly, persistent gaps existed between the full disclosure patients expect and the partial disclosure health professionals believe should occur. While the study represents a small sample size from two tertiary institutions, it does emphasize the importance of a safety culture and the need to redefine errors as opportunities for learning and improvement rather than individual or isolated events.
Winokur SC, Beauregard KJ. Front Health Serv Manage. 2005;22:17-32.
The authors describe the successful nurturing of a safety culture at William Beaumont Hospital in Royal Oak, Michigan. Their comments focus on several key challenges, including culture and behavior change, resource allocation, and the role of leadership and patients in contributing to safety.
Sachs BP. JAMA. 2005;294:833-840.
Part of a series in JAMA entitled Clinical Crossroads, this case study discusses the unfortunate events surrounding a 38-year-old woman’s presentation to a labor and delivery unit. The case details a seemingly routine full-term pregnancy that rapidly evolved into a course of complications, ultimately leading to a fetal death, a hysterectomy, and a prolonged hospital course. The discussion shares the experience through the eyes of the patient, her husband, and the primary obstetrician. Further exploration of the case identified several specific factors and broader systems issues that contributed to the events. The author shares how this particular institution responded with overarching changes, including a greater emphasis on teamwork, communication, and appropriate staffing of labor and delivery units to promote safety.
Porter SC, Kohane IS, Goldmann DA. J Am Med Inform Assoc. 2005;12:299-305.
This study examined the utility of a multimedia kiosk to capture parents’ knowledge of their children’s asthma medication history. Investigators compared the parental information with that documented by emergency department providers. Results suggested greatest accuracy in medication name followed by route of delivery, form of medication, and dose. The authors conclude that patient-derived data can be effective in improving current deficits in medication documentation during emergency department visits.