Organizational evaluations often reveal opportunities to address persistent quality and safety issues. This extensive inspection report shares findings from examinations at 45 Veterans Health Administration care facilities that focused on assessing oversight, system redesign and surgical programs. Recommendations drawn from the analysis call for improvements in protected peer review, surgical work structure and surgical adverse incident examination.

Pre-hospital emergency care can be vulnerable to timing, information, and task failures that compromise safety. This investigation explores how computerized decision support system access played a roles in an emergency call-center program incident where erroneous information was transmitted to a pregnant patient that contributed to infant harm.

Organizational assessments often provide insights that address overarching quality and safety challenges. This extensive inspection report shares findings from inspections of 36 Veterans Health Administration care facilities. Recommendations drawn from the analysis call for improvements in suicide death review, root cause analysis result application, and safety committee action item implementation.

Antibiotic overuse is a long-standing safety concern due to the potential global public health impact of the practice in supporting drug-resistant bacteria. This news article discusses the overprescribing of antibiotics in context of viral disease pandemics. 

Post-mortem examination is an important tool for determining if misdiagnosis occurs. The authors discuss the value of assessing cause of death for patients thought to have died from COVID-19 to understand disease spread and true impact.   

This bill submits amendments to existing US federal law to strengthen state-organized efforts to improve health care-associated infection control efforts, pediatric safety initiatives, care transitions, reporting systems and antimicrobial stewardship programs.

Maternal care during and after childbirth is at risk for never events including retained foreign objects. This analysis of a sentinel event involving a retained surgical tampon after childbirth discusses communication, fatigue, and process factors that contributed to the incident. The report suggests improved handoffs as one improvement strategy.

Local efforts that draw from the experience of its leaders serve an important role in generating patient safety improvement. This collaboration merges the efforts of three organizations as participants in the federal Partnerships for Patients initiative to engage their constituents in regionally focused safety and quality improvement.