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Ottawa, ON: Canadian Patient Safety Institute; 2008.
This initative defines competency domains for safe health care and outlines educational practices to achieve them. The 2nd edition of the Patient Safety Competencies was released in 2020. 
Kjaergaard-Andersen G, Ibsgaard P, Paltved C, et al. Int J Health Care Qual. 2021;33:mzaa148.
Simulation training is used by hospitals to improve patient care. This study describes the experience of one Danish hospital shifting from simulation training at external centers to in situ training. The shift to in situ training identified several latent safety threats (e.g., equipment access, lack of closed-loop communication, out-of-date checklists) and these findings led to practice changes.  
Kandasamy S, Vanstone M, Colvin E, et al. J Eval Clin Pract. 2021;27:236-245.
Physicians often experience considerable emotional distress, shame, and self-doubt after being involved in a medical error. Based on in-depth interviews with emergency, internal, and family medicine physicians, this qualitative study explores how physicians experience and learn from preventable medical errors. In addition to exploring themes around the physician’s emotional growth and professional development, the authors discuss the value of sharing and learning from these experiences for colleagues and trainees.  

This piece discusses the concept of Safety Across the Board and reviews the three key components necessary for successful implementation in a healthcare organization: culture, strong safety processes, and engagement.

Edwin Loftin, DNP, MBA, RN, NEA-BC-FACHE is the Senior Vice President of Integrated and Acute Care Services and the Chief Nursing Officer (CNO) at Parrish Medical Center in Titusville, Florida. We spoke with him about his experiences with the concept of safety across the board at his medical center.

A woman with acute myeloid leukemia presented to the emergency department (ED) with shortness of breath after receiving chemotherapy. As laboratory test results showed acute kidney injury and suggested tumor lysis syndrome, the patient was started on emergent hemodialysis. She experienced worsening dyspnea and was emergently intubated and transferred to the intensive care unit. There, her blood pressure began to drop, and she died despite aggressive measures.
Jones M, Scarduzio J, Mathews E, et al. Qual Health Res. 2019;29:1096-1108.
Simulation has been adopted as a valuable teaching tool in health care. In this study, researchers used relational dialectic theory and simulation to better understand the impact of interprofessional communication challenges on both team-based and individual disclosure of error.
Wright B, Faulkner N, Bragge P, et al. Diagnosis (Berl). 2019;6:325-334.
The hectic pace of emergency care detracts from reliability. This review examined the literature on evidence, practice, and patient perspectives regarding diagnostic error in the emergency room. A WebM&M commentary discussed an incident involving a diagnostic delay in the emergency department.
Krumwiede KH, Wagner JM, Kirk LM, et al. J Am Geriatr Soc. 2019;67:1273-1277.
Open disclosure of errors and adverse events is increasingly encouraged in health care. Researchers describe the development and impact of an educational program using simulation to promote learning regarding team-based error disclosure among medical students.
Boston, MA: Institute for Healthcare Improvement; 2019.
This toolkit provides access to nine key tools to help organizations improve teamwork, incident analysis, and communication as well as templates to support their use and instructions to begin associated processes. Featured tools include the Situation-Background-Assessment-Recommendation approach, huddle agendas, and failure modes and effects analysis.
Leslie M, Paradis E, Gropper MA, et al. Health Serv Res. 2017;52:1330-1348.
As implementation of comprehensive health information technology (IT) systems becomes more widespread, concern regarding the unintended consequences of such technologies has increased as well. Usability testing is helpful for optimizing implementation of health IT. Researchers analyzed the impact of health IT use on relationships among clinicians over a year-long period across three academic intensive care units. In the two units with higher health IT use, clinicians were more likely to work in an isolated manner, which was associated with an adverse effect on situational awareness, communication, and patient satisfaction. A previous PSNet perspective discussed some of the pitfalls in the development, implementation, and regulation of health IT and what can be learned to improve patient safety going forward.
Bates KE, Shea JA, Bird GL, et al. Jt Comm J Qual Patient Saf. 2016;42:562-AP4.
Hospitals rely on incident reporting systems to detect safety issues, but these systems are voluntary and do not capture all adverse events or near misses. Researchers developed and tested a prospective surveillance tool to identify teamwork errors in the pediatric intensive care unit. They found that this tool helped uncover safety issues not captured by the hospital's patient safety reporting system.
Farag AA, Anthony MK. J Perianesth Nurs. 2015;30:492-503.
This survey study of nurses across four ambulatory surgical wards in Ohio found that nursing managers' leadership styles and some aspects of the safety climate (such as teamwork and organizational learning) were associated with how willing nurses are to report medication errors.
Williams EA, Nikolai DA, Ladwig L, et al. Jt Comm J Qual Patient Saf. 2015;41:508-513.
Rapid teamwork has been highlighted as a mechanism to enhance response to patient deterioration, assess incidents, improve team feedback, and support high reliability. This commentary discusses the development and implementation of the SWARM tool—a unit-based mechanism to rapidly analyze problems and develop solutions—in a pediatric intensive care unit. The authors detail the results of the initiative and provide materials to enable organizations to implement a similar program.
Committee on Diagnostic Error in Health Care, National Academies of Science, Engineering, and Medicine. Washington, DC: National Academies Press; 2015. ISBN: 9780309377690.
The National Academy of Medicine (formerly the Institute of Medicine) launched the patient safety movement with the publication of its report To Err Is Human. The group has now released a report about diagnosis, which they describe as a blind spot in health care. Available evidence suggests that most Americans will experience a missed or delayed diagnosis in their lifetime. The committee made several recommendations to improve diagnosis, including promoting teamwork among interdisciplinary health care teams, enhancing patient engagement in the diagnostic process, implementing large-scale error reporting systems with feedback and corrective action, and improving health information technology (as recommended in prior reports). Longer-term recommendations include establishing a work system and safety culture that foster timely and accurate diagnosis, improving the medical liability system to foster learning from missed or delayed diagnoses, reforming the payment system to support better diagnosis, and increasing funding for research in diagnostic safety. The report emphasizes the need for much more effort, and far more resources, at the practice, policy, and research levels to address this pressing safety problem.
Valentine MA, Nembhard IM, Edmondson AC. Med Care. 2015;53:e16-e30.
According to this systematic review, few survey instruments for teamwork have been rigorously validated, and fewer still have been associated with nonself-reported outcomes. The authors suggest use of existing validated surveys to develop knowledge about teamwork, particularly AHRQ's Surveys on Patient Safety Culture as it is used to collect comparative data from hospitals across the United States. A previous AHRQ WebM&M interview with Dr. J. Bryan Sexton discussed teamwork and patient safety.