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The Hospital Survey on Patient Safety Culture and Nursing Home Survey on Patient Safety Culture were used in one Finish healthcare organization to assess 1) differences in employee perceptions of safety culture in their respective settings, and 2) differences between professionals’ and managers’ views. Managers assessed safety culture higher than professionals in both settings. Acute care patient safety scores were significantly positive in 8 out of twelve domains, compared to only one in long-term care.

A systems approach provides a framework to analyze errors and improve safety. This study uses the Systems Theoretic Process Analysis (STPA) to analyze risks related to pediatric sepsis treatment process. Fifty-four safety recommendations were identified, the majority of which were organizational factors (e.g., communication, organizational culture).

Patients and families are essential partners in identifying and preventing safety events. This systematic review characterizes patient engagement along a continuum of engagement that includes consultation (e.g., patients are invited to provide input about a specific safety issue), involvement (e.g., patients are asked about their preferences/concerns and given the opportunity to engage with practitioners about a specific issue), and partnership/leadership (e.g., patients ‘work’ with practitioners to improve the safety of their care, often using tools designed to empower patients to alert practitioners to concerns).

The World Health Organization (WHO) released the International Classification of Diseases, 11th Revision (ICD-11) in 2018. In addition to the medical entities such as disease and injury, it contains a second component, the ICD-11 Mortality and Morbidity Statistics (MMS) linearization. The authors evaluated whether the ICD-11 MMS is appropriate for use in patient safety and quality or if a USA-specific clinical modification is necessary. 

The safety climate in nursing homes influences patient safety. This study of frontline staff and managers from 56 US Veterans Health Administration community living centers found that organizational readiness to change predicted safety climate. The authors suggest that nursing home leadership explore readiness for change in order to help nursing homes improve their safety climate.

Information technology (IT) is prevalent across healthcare settings. This study used publicly available nursing home data and a survey on IT sophistication to identify the relationship between nursing home health deficiencies and IT sophistication. Results indicate health deficiencies decreased as IT sophistication increased, suggesting investment in IT could lead to further patient safety benefits in nursing homes.

Healthcare providers who are involved in a medical error and feel guilt, remorse, shame, and anger are sometimes referred to as “second victims”. This mixed-methods study surveyed medical residents about their well-being, coping strategies, and support following a self-perceived medical error. Residents reported feeling fear, shame, and feeling judged, and many used maladaptive strategies to cope.

Massive online open courses (MOOCs) have the ability to reach a broad audience of learners. The Science of Safety in Healthcare MOOC was delivered in 2013 and 2014. At completion of the course, participants reported increased confidence on all six measured domains (teamwork, communication, managing risk, human environment, recognizing and responding, and culture). At 6 months post-completion, the majority agreed the content was useful and positively influenced their clinical practice, demonstrating that MOOCs are an effective interprofessional learning format.

This systematic review provides an update to McDonald et al’s 2013 review of strategies to reduce diagnostic error.  Technique (e.g., changes in equipment) and technology-based (e.g. trigger tools) interventions were the most studied intervention types. Future research on educational and personnel changes would be useful to determine the value of these types of interventions.

The July Effect is a belief that the quality of care delivered in academic medical centers decreases during July and August due to the arrival of new trainees. Using data from the Medicare Patient Safety Monitoring System, this retrospective cohort, including over 185,000 hospital admissions from 2010 to 2017, found that patients admitted to teaching hospitals in July and August did not experience higher rates of adverse events compared to patients admitted to non-teaching hospitals.

In this qualitative study, researchers interviewed 40 clinicians in high- and low-performing hospitals to better understand the barriers to effective organizational learning from medical errors. Findings from these interviews suggest that the primary barriers to active learning stem from social issues post-reporting – e.g., lack of trust or proactive engagement from management. The authors highlight the importance of fostering an organizational culture that encourages cooperation and collaboration between management and clinicians.

Staff willingness to speak up about patient safety enables organizations to implement improvements to prevent patient harm. The author describes barriers that trainees face when presented with an opportunity to speak up as well as barriers faced by those who receive the reports. Initiatives to improve trainee speaking up behavior are discussed.

Cognitive biases and poor communication among providers can lead to diagnostic errors. This commentary presents the links between biases, provider communication, and diagnostic error, and proposes how patient engagement and health communication research can improve the diagnostic process.