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The Joint Commission. R3 Report. August 21, 2019;24:1-6.
Maternal safety in the United States is gaining momentum as a system-level patient safety concern. This report reviews the new Joint Commission Provision of Care, Treatment, and Services (PC) standards developed to improve the reliability of maternal care. Actions for improvement include patient risk assessment for conditions at admission and role-specific education for staff and providers who treat maternal patients regarding hemorrhage processes and procedures.
Hilton K, Anderson A. Harv Bus Rev. May 20, 2019.
This commentary describes how one health system worked to combat resistance to change associated with implementation of a checklist initiative. The success of the program was built on empowering team members to drive the process, clinician motivation to provide safe care, and engaging leadership. A PSNet interview with Lucian Leape discussed surgical safety checklists.
Cheney C.
This news article describes how a 19-hospital health system successfully applied high reliability principles to emphasize a zero-tolerance focus on patient harm. The coordinated effort across the system achieved a drop in readmissions and physician burnout. Tactics used to improve reliability include huddles, purposeful redundancy, and leadership engagement.
van der Heijde R; Deichmann D.
Aviation continues to provide inspiration for patient safety innovation. This commentary describes a 10-minute team huddle exercise which involves team members rating their own mood status and the leader asking if there are any contextual concerns. In addition, two team members select "knowledge cards" that either test the person's knowledge or assign the person to proactively watch for improvement opportunities during the shift. The results encouraged sharing, situational awareness, and team building.
MacLean L, Coombs C, Breda K. Nursing management. 2016;47:30-4.
Bullying and disruptive conduct hinder teamwork and diminish the safety of care delivery. This article discusses how policies, organizational guidelines, and educational strategies can help nurse leaders develop the skills to address unprofessional behaviors in the workplace.
Diamond F. Managed care (Langhorne, Pa.). 2013;22:30-2.
Reporting on barriers to teamwork, this magazine article relates how hierarchy influences speaking up about concerns and recommends tactics to improve communication.
Boodman SG.
This newspaper article reports on a case of wrong-site surgery and explores initiatives to prevent such errors, including the Universal Protocol and Partnership for Patients program.
Kalb C.
This news piece describes adjustments made in medical training to enable safe, team-oriented practice during residency.
Feinmann J. BMJ. 2009;338:b420.
This news article highlights a National Patient Safety Agency campaign to achieve safer care through five interventions.