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1 - 20 of 1998
Giardina TD, Shahid U, Mushtaq U, et al. J Gen Intern Med. 2022;Epub Jun 1.
Achieving diagnostic safety requires multidisciplinary approaches. Based on interviews with safety leaders across the United States, this article discusses how different organizations approach diagnostic safety. Respondents discuss barriers to implementing diagnostic safety activities as well as strategies to overcome barriers, highlighting the role of patient engagement and dedicated diagnostic safety champions.
Barnard C, Chung JW, Flaherty V, et al. Jt Comm J Qual Patient Saf. 2022;Epub Apr 28.
Organizations such as The Joint Commission and the Leapfrog Group require participating healthcare organizations to evaluate their patient safety culture, but surveys can represent a time burden on staff. An Illinois health system aimed to lessen this burden on staff by creating a shorter, revised survey. The final survey consisted of five questions with comparable measurement properties of the original 17-question survey; however, the authors caution the shorter survey will yield less detail than the longer version.

Agency for Healthcare Quality and Research. Fed Register. June 3, 2022;87: 33795-33796. 

Surveys are recognized tools to inform hospitals of the current status of their safety culture. This notice calls for public comment on the intention of the Agency for Healthcare Research and Quality to launch the Hospital Survey on Patient Safety Culture Comparative Database data collection process. The deadline for submitting comments on this notification is August 2, 2022.

Ferrere A, Rider C, Renerte B et al. Sloan Manag Rev. Summer 2022;39-43.

A baseline expectation in a safe organization is that employees feel comfortable and supported when sharing concerns. This article summarizes key results of a large workplace survey to identify cultural elements supporting the psychological safety required to encourage speaking up when ethical or other issues are identified in operations.
Rotteau L, Goldman J, Shojania KG, et al. BMJ Qual Saf. 2022;Epub Jun 1.
Achieving high reliability is a goal for every healthcare organization. Based on interviews with hospital leadership, clinicians, and staff, this study explored how healthcare professionals understand and perceive high-reliability principles. Findings indicate that some principles are more supported than others and identified inconsistent understanding of principles across different types of healthcare professionals.
Institute for Safe Medication Practices. August 4-5, 2022.
This virtual workshop will explore tactics to ensure medication safety, including strategic planning, risk assessment, and Just Culture principles.
Bamberger E, Bamberger P. BMJ Qual Saf. 2022;Epub Apr 15.
Disruptive behaviors are discouragingly present in health care. This commentary discusses evidence examining the impact of unprofessional behaviors on safety and clinical care. The authors suggest areas of exploration needed to design reduction efforts such as teamwork, the Safety I mindset and targeting of the root influences of impropriety.

Armstrong Center for Patient Safety and Quality. September 29, 2022.

The Resilience in Stressful Events (RISE) program provides peer assistance for healthcare workers who experience psychological effects after involvement in stressful adverse care events. This virtual session presents RISE implementation education and orientation for staff to respond when peer support is needed.
Appelbaum NP, Santen SA, Perera RA, et al. J Patient Saf. 2022;18:370-375.
Residents and trainees frequently report experiencing bullying and disrespectful behaviors in the workplace. This study explored the relationship between resident psychological safety, perceived organizational support, and humiliation. Results indicate resident perception of increased organizational support (e.g., help is available when they have a problem) reduces the negative impact of humiliation on their psychological safety.
Sonis J, Pathman DE, Read S, et al. J Healthc Manag. 2022;67:192-205.
Lack of organizational support can inhibit safety culture and increase risk of burnout among healthcare workers. Researchers surveyed internal medicine physicians to explore how institutional actions and policies influenced perceived organizational support (POS) during the COVID-19 pandemic. Higher POS was associated with opportunities to discuss ethnical issues related to COVID-19, adequate access to personal protective equipment, and leadership communication regarding healthcare worker concerns regarding COVID-19. High POS was also associated with lower odds of screening positive for burnout, mental health systems, and intention to leave the profession.

ISMP Medication Safety Alert! Acute care edition. May 19, 2022;27(10):1-5.

Challenging authority can be difficult but necessary in risky situations. This article examines a serial euthanasia overdose case and how the individuals interfacing with the physician involved sensed the medications ordered were inappropriate, yet said nothing. The piece discusses organizational and individual steps to encourage raising concerns in an appropriate and effective manner.

Famolaro T, Hare R, Tapia A, et al. Rockville, MD: Agency for Healthcare Research and Quality; April 2022. AHRQ Publication No. 22-0027.

A strong safety culture affects practice and learning in health care. This survey of over 1,000 clinicians and staff in 110 medical offices examined the extent to which elements of safety culture support safe diagnosis. Key findings demonstrate strengths in specialist consultation and test result communication. Identified weaknesses included lack of discussions about misdiagnoses when they occurred.
Rockville, MD: Agency for Healthcare Research and Quality; 2019.
The AHRQ Surveys on Patient Safety Culture™ (SOPS®) Hospital Survey and accompanying toolkit were developed to collect opinions of hospital staff on the safety culture at their organizations. An accompanying database serves as a central repository for hospitals to report their results. Participating hospitals will be able to measure patient safety culture in their institutions and compare results with other sites. Data will be collected for the latest submission period from June 1–July 22, 2022.

National Steering Committee for Patient Safety. Boston, MA: Institute for Healthcare Improvement; May 2022.

Leadership commitment is crucial to attaining sustainable improvement in patient safety. This “Declaration to Advance Patient Safety” call-to-action shares three steps to motivate work toward implementing change to enhance safe care. First, commit to a national plan for improvement. Second, identify and empower a senior leader and team to assess an organization’s existent safety status. Third, devise plans to measure, design, implement, and support adverse event reduction initiatives.
Feng T-ting, Zhang X, Tan L-ling, et al. J Nurs Adm. 2022;52:160-166.
When reported and investigated, near misses provide a unique learning opportunity for individuals and organizations. This scoping review of the literature on near misses identifies contributing factors (organizational, human, and technical); barriers and facilitators to reporting; and quality improvement projects to improve reporting of near misses.
Katz-Navon T, Naveh E. Health Care Manage Rev. 2022;47:e41-e49.
Balancing autonomy and supervision is an ongoing challenge in medical training. This study explored how residents’ networking with senior physicians influences advice-seeking behaviors and medical errors. Findings suggest that residents made fewer errors when they consulted with fewer senior physicians overall and consulted more frequently with focal senior physicians (i.e., physicians sought out by other residents frequently for consults).
Umoren R, Kim S, Gray MM, et al. BMJ Lead. 2022;6:15-19.
Organizational culture can influence willingness to speak up about patient safety concerns. Based on focus groups and interviews with nurses, advanced practice providers, and physicians, this study found that the hierarchical culture of medicine presents a barrier to speaking up about safety concerns, but that certain factors (institutional, interpersonal, and individual) can modulate the impact of hierarchy. Interventions to promote speaking up behaviors should focus on engaging leaders across the institution and within the hierarchy.

DePeau-Wilson M. MedPage Today. May 13, 2022. 

Disciplinary actions against clinicians who err continue despite awareness efforts to inhibit them. This article summarizes reaction to the sentencing of a nurse in a high-profile medication error case. It discusses reverberations throughout healthcare that will affect patient safety efforts.
Institute for Healthcare Improvement. Boston, MA and online. August 31-October 14, 2022.
Organization executives influence the success of patient safety improvement. This hybrid workshop will highlight how leaders can use assessments, planning, and evidence to improve the safety culture at their organizations.