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Redley B, Douglas T, Hoon L, et al. J Adv Nurs. 2022;Epub Jul 7.
Frontline care providers such as nurses play an important role in reducing preventable harm. This study used qualitative methods (direct observation and participatory workshops) to explore nurses’ experiences implementing harm prevention practices when admitting an older adult to the hospital. Researchers identified barriers (e.g., lack of resources, information gaps) and enablers (e.g., teamwork, reminders) to harm prevention during the admission process.
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in situ training identified several latent safety threats (e.g., equipment access, lack of closed-loop communication, out-of-date checklists) and these findings led to practice changes.  
Harper PG, Schafer KM, Van Riper K, et al. J Am Pharm Assoc (2003). 2021;61:e46-e52.
This article describes a systematic team-based care approach to medication reconciliation implemented in four family medicine residency clinics. After implementation, there was a significant increase in the number of visits with physician-documented medication reconciliation and this increase was sustained one year later.
Hendrickson MA, Schempf EN, Furnival RA, et al. Jt Comm J Qual Patient Saf. 2019;45:431-439.
This project report describes a novel procedure for handoffs from the emergency department to the inpatient service. The study team implemented a daily conference call that included nurses, residents, and attending physicians rather than separating physician and nursing handoff workflows. The overall reaction to the interdisciplinary workflow was positive.
Pettis AM. AORN J. 2018;108:644-650.
Failure to adhere to evidenced-based practices can result in patient harm. This article explores how high reliability concepts can support the reliable use of best practices to prevent surgical site infections. The authors suggest a framework focused on team engagement, education, implementation, and evaluation to encourage the use of evidence-based practice on the front line.
Clearfield C, Tilcsik A. New York, NY: Penguin Press; 2018. ISBN: 978-0735222632.
Complex systems are prone to failure. This book provides a multi-industry discussion of factors that contribute to failure. The authors highlight how complexity can exacerbate problems, small glitches can manifest themselves in large-scale failure, and poorly designed safety strategies can unintentionally contribute to harm. Recommended strategies to manage risks include those utilized in patient safety work, such as multidisciplinary teamwork, process design, and systems thinking.
Jones TS, Black IH, Robinson TN, et al. Anesthesiology. 2019;130:492-501.
Surgical fires, though uncommon, can result in serious harm. This review highlights three components to be managed in the operating room to prevent fires: an oxidizer, an ignition source, and a fuel. The authors provide recommendations to ensure each element is handled safely.
Green B, Mitchell DA, Stevenson P, et al. Br J Oral Maxillofac Surg. 2016;54:847-850.
Although leadership at the team and organizational level is considered crucial for safety, training to support this role is needed. Discussing how to improve leadership skills in maxillofacial surgery, this review describes key attributes that surgeons in leadership roles should develop—including professionalism, motivation, and innovation—to enhance quality of care.
Singer SJ, Molina G, Li Z, et al. J Am Coll Surg. 2016;223:568-580.e2.
Although checklists have been shown to improve safety and surgical mortality, they can be difficult to implement, which limits their effectiveness in clinical practice. This study examined whether perceptions of teamwork predicted checklist performance. Trained observers used standardized tools to rate the extent of checklist completion and quality of teamwork. They found that checklists were implemented as intended in only 3% of cases. Surgical teams with better surgeon buy-in to checklists, clinical leadership, communication, and overall teamwork completed more checklist components. Clinical factors, including older patient age and longer duration of surgery, were also associated with performing more of the checklist. The authors suggest that teamwork is critical to checklist implementation. A PSNet interview discussed the challenges of implementing checklists in health care.
Hertig JB, Hultgren KE, Weber RJ. Hosp Pharm. 2016;51:338-44.
Frontline and organizational leadership are key to implementing and sustaining safety improvement efforts. This commentary describes management principles that can prepare individuals as leaders in implementing a medication safety program, including skills in team-building, communication, tracking project progress, and encouraging innovation.
Epstein NE. Surg Neurol Int. 2014;5:S295-303.
Multidisciplinary teamwork is essential in developing appropriate treatment plans. This review summarizes the literature documenting the benefits of teamwork, including better communication, fewer adverse events, and increased job satisfaction. The author advocates for keeping teams that work well together to further optimize improvements.
Harrison R, McClean S, Lawton R, et al. J Patient Saf. 2014;10:159-67.
According to this interview study, clinical leaders perceive that appointing mentors to new attending physicians helps to improve patient safety. Mentors provided professional guidance, enhanced emotional well-being, and promoted organizational commitment which can contribute to a stronger safety culture. These findings add to literature advocating for leadership engagement in safety.
Richter JP, McAlearney AS, Pennell ML. Health Care Manage Rev. 2016;41:32-41.
Incomplete handoffs and insufficient communication regarding key clinical information may lead to adverse events or missed or delayed diagnoses. This analysis of data from the AHRQ Hospital Survey of Patient Safety Culture sought to determine how perceptions of organizational factors that affect safety can contribute to optimal handoffs. Perceived teamwork across units was a significant predictor for successful handoffs. Perceptions of staffing adequacy and management support for patient safety efforts were also related to good handoffs. Among frontline staff, open communication was associated with optimal handoffs, while among management safe handoffs were linked to a continuous learning culture. These findings add to existing studies which underscore the need for high-reliability organizations to promote safety efforts. The authors advocate for hospital leadership to promote teamwork and open communication to augment handoffs in their facilities. Dr. Vineet Arora discussed the challenges of handoffs in a prior AHRQ WebM&M interview.
Dietz AS, Pronovost PJ, Mendez-Tellez PA, et al. J Crit Care. 2014;29:908-14.
Improving teamwork and communication is a continued focus in the hospital setting. This systematic review revealed that although studies of teamwork in the intensive care unit abound, the field lacks common definitions and constructs. Teamwork usually entailed joint strategy and shared goals, and quality improvement approaches to enhance teamwork typically involve team training and development of structured protocols. Many interventions target rounds, during which interdisciplinary providers discuss each patient, or handoffs between clinicians. The authors suggest that communication is the most prominent aspect of teamwork and propose further study in conceptualizing teamwork to design effective interventions. The heterogeneity in defining and measuring teamwork may account for mixed results in improving safety outcomes. An AHRQ WebM&M perspective describes the Veterans Health Administration's medical team training program.
Li J, Young R, Williams M. Cleve Clin J Med. 2014;81:312-20.
Care transitions are a vulnerable time for patients as they move through various levels of care. Exploring factors that hinder safety during transitions, this review describes successful improvement initiatives and offers strategies to reduce readmissions, such as enhancing team communication, educating staff, and standardizing transition plans.
Bethune R, Blencowe NS. J Perioper Pract. 2014;24:56-58.
Briefings have been identified as a promising method to enhance team communication. This commentary describes an initiative to improve the use of preoperative briefings as a training mechanism through strategies like increased emphasis on identifying team members and assigning specific tasks.
Shuhaiber J. Bull Am Coll Surg. 2014;99:42-5.
Many studies have examined how checklists impact safety in surgical care, but this commentary focuses on the value of enhancing teamwork in this setting. The author describes the importance of individual team members' responsibility toward adopting behaviors that contribute to trust and transparency in surgical teams.
Burgess C, Curry MP. AORN J. 2014;99:529-39.
This commentary examines the role of nurses in contributing to and addressing disruptive behavior in health care. The authors describe an educational collaborative that used workshops to develop professional communication and leadership skills.