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JAMA. 2021-2022. 

Diagnostic excellence achievement is becoming a primary focus in health care. This article series covers diagnosis as it relates to the Institute of Medicine quality domains, clinical challenges, and priorities for improvement across the system.
Shapiro J. BMJ. 2018;360:k1025.
Unprofessional behavior detracts from teamwork and safety culture. This commentary discusses the impact of unprofessional behavior in health care and provides suggestions to address the problem, such as establishing expectations for behaviors, training providers in conflict management, and developing processes to report concerns.
Green MJ, Rieck R. Ann Intern Med. 2013;158:357-61.
This piece uses a graphic novel format to depict a story of a diagnostic error that resulted in a patient’s death. The attention-grabbing design is an innovative method for demonstrating the context and emotional aspects related to an adverse event. The story implicitly illustrates the hidden curriculum of medical training that often rewards trainee autonomy and places retrospective blame on individuals. The final frame closes with the author reflecting on how this adverse event had a lasting effect on his psyche - a well-recognized phenomenon known as the second victim of a medical error. A prior AHRQ WebM&M perspective explored many issues related to diagnostic errors.
Halpin HA, McMenamin SB, Simon LP, et al. Am J Infect Control. 2013;41:307-11.
This study demonstrated that hospitals participating in the California Healthcare-Associated Infection Prevention Initiative (CHAIPI) had significant improvements in adoption and implementation of evidence-based patient safety practices. However, there were no differences in health care–associated infection rates compared with non-CHAIPI hospitals.
Schneider EB, Hirani SA, Hambridge HL, et al. J Surg Res. 2012;177:295-300.
Being admitted to the hospital on a weekend is potentially dangerous, as studies have shown that preventable complications and mortality are increased across a range of common diagnoses for weekend admissions compared with weekdays. One exception appears to be trauma, as a prior study found equal outcomes in patients with traumatic injuries regardless of the day of admission, a finding ascribed to the protocolized and closely supervised nature of trauma care. However, this study of older adults admitted with traumatic brain injury did find increased mortality for those patients admitted on the weekend, despite the fact that patients admitted on the weekend were less severely injured. A limitation of this study is that the authors were not able to analyze outcomes for patients cared for at specialized trauma centers. Nevertheless, the study adds to the considerable body of research documenting the dangers of weekend hospital admission.
Berenholtz SM, Pham JC, Thompson DA, et al. Infect Control Hosp Epidemiol. 2011;32:305-14.
The landmark Keystone ICU project, a statewide quality improvement initiative that used interventions grounded in safety culture and human factors engineering to improve safety in the intensive care unit, stands as one of the seminal achievements of the patient safety field. The success of the Keystone ICU project at reducing central line–associated bloodstream infections has been widely publicized, and this study reports a similar success in reducing rates of ventilator-associated pneumonia. As with the prior results, this article emphasizes that the success of the study was attributable to the multifaceted quality improvement approach used and the cultural change it engendered in participating ICUs.
Nagpal K, Arora S, Abboudi M, et al. Ann Surg. 2010;252:171-6.
This qualitative study interviewed 18 providers and found that postoperative handovers are informal, unstructured, and fraught with inconsistent and incomplete information transfer. These data were used to develop and validate a formal handover protocol. Prior studies have used insights from Formula One auto racing to inform improvement strategies for postoperative handoffs, and the World Health Organization's Surgical Safety Checklist explicitly emphasizes structured handoffs at the time of patient transfer from the operating room to the postoperative area.
Donaldson N, Shapiro S, Scott M, et al. J Nurs Adm. 2009;39:176-81.
Rapid response teams (RRTs) have proven to be very popular among bedside nursing staff, contributing to their widespread implementation despite equivocal evidence of clinical benefits. This study carried out interviews with nurses, chief nursing officers, and RRT members at 18 hospitals to obtain insights on how to successfully implement RRTs. Themes that predicted successful implementation included clear organizational support for the RRT, support for bedside nurses when the team is called, and less resistance from physicians to using the RRT.