Root cause analysis (RCA) may not be an ideal process, but it still creates opportunities for learning and improvement after a sentinel event. This article posits why perioperative nurses may not report problems to avoid engagement in RCA activities. Increasing nurse awareness of RCA as a multidisciplinary and systems-focused improvement method is a suggested educational tactic to increase nurse RCA participation.

Preventing inpatient falls is a patient safety target. This study used one health system’s incident reporting tool in the United Kingdom to ascertain the incidence and characteristics of inpatient falls among patients under 1:1 or “cohorting” supervision. Findings indicate that nearly one in five falls occurred while the patient was under enhanced supervision and most commonly occurred in the patient’s bathroom or bedside.

The World Health Organization's (WHO) Surgical Safety Checklist (SSC) has resulted in improved surgical outcomes; however, use of the checklist varies. In this study, surgical personnel (surgeons, anesthesiologists, nurse anesthetists, surgical nurses, and assistant nurses) were surveyed about use of the SCC in their hospital, including who was responsible for ensuring its use. Although most groups reported it was not clear who was responsible for implementing the SSC prior to surgery, they believed it was the assistant nurse.

Structured handoffs are recognized as a method to ensure that complete, accurate information is shared between teams. This article describes the impact of the Handoffs and Transitions in Critical Care (HATRICC) study on accuracy and completeness of handoff before and after implementation of a structured handoff tool. Post-intervention, the accuracy and completeness of handoffs improved. Omissions, mortality, and length of intensive care unit (ICU) stay were reported in a 2019 study.

Numerous organizations promote communication with patients and families after harm has occurred due to medical error. This commentary reflects on perceived barriers to patient disclosure and describes the patient and family perspectives and needs following harm. The authors promote the use of Communication and Resolution Programs (CRP) such as the learning community Pathway to Accountability, Compassion, and Transparency (PACT) to advance research, policy, and transparency regarding patient harm.

Simulation training is commonly used by hospitals to identify threats to safety and improve patient care. This article describes the development and implementation of an in situ simulation to improve acute airway management during the COVID-19 pandemic across five emergency departments. The simulation protocol helped identify latent safety threats involving equipment, infection control, and communication. The simulation process also helped staff identify interventions to reduce latent safety threats, including improved accessibility of airway management equipment, a designated infection control cart, and role identification cards to improve team function.

The Measurement and Monitoring of Safety Framework (MMSF) draws on principles of high-reliability to increase patient safety at the organizational level. This commentary describes the Canadian Learning Collaborative’s experience implementing MMSF and highlights several key elements for successful implementation.

Encouraging frontline healthcare workers to voice concerns is an important component of safety culture. This systematic review of 76 qualitative studies explored how speaking up behaviors and silence are measured in healthcare. The authors identified several evidence gaps, including a reliance on self-reported data and overrepresentation of certain demographic characteristics.

Health care workers’ perception of safety is an important indicator of safety culture. Using data from the 2021 AHRQ Hospital Survey on Patient Safety Culture™ (SOPS®), these researchers examined individual and organizational factors influencing perceived patient safety ratings. Findings indicate that nurses have lower patient safety perceptions compared to other job types and that organizational factors such as organizational learning, leadership support, and ease of handoffs and information exchange, were all associated with higher perceived patient safety. 

Labor and delivery units are high-risk care environments. This article describes the development and implementation of a weekly obstetrics and gynecology Safety Call at one large health system. The Safety Call provides leadership across the 10 maternity hospitals an opportunity to promote proactive preparation, improve communication, increase situational awareness, and share safety concerns or other issues facing each hospital. Implementation of the Safety Call contributed to a 19% decrease in a composite measure of adverse events.

The emergency department is a busy and complex environment that can present challenges to patient safety. This survey of emergency medicine professionals from 101 countries identified several patient safety concerns, including workflow and staffing, overcrowding and perceived lack of leadership support. Two PSNet WebM&M commentaries highlight the impact of boarding and overcrowding in the emergency department on patients with a postoperative infection and ruptured abdominal aortic aneurysm.

The COVID-19 pandemic challenged infection prevention and control practices. Findings from this survey of infection prevention professionals from acute care hospitals in the United States found that while CLABSI and VAE preventive practices either increased or remained consistent, use of CAUTI preventive practices decreased during the pandemic.

A “just culture” balances organizational responsibility and individual accountability after an error occurs. This integrative review of 16 articles identified four concepts critical to implementing a “just culture” in healthcare settings – leadership commitment, education and training, accountability, and open communication.

Effective teamwork is critical in healthcare settings. This qualitative study explored experiences with personality, psychological safety and perceived stressors among emergency and critical care department staff working in the United Kingdom. Findings underscore the ways in which personality traits can influence team performance.