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1 - 20 of 152
Institute for Healthcare Improvement.
This website provides resources for promoting patient safety during Patient Safety Awareness Week. The annual observance is held in March.

Rockville MD, Agency for Healthcare Quality and Research. December 7, 2021.

The TeamSTEPPS program is an established approach for improving teamwork and communication in health care. This announcement calls for feedback from healthcare teams and team members on how to update the current TeamSTEPPS training curriculum. 

Ariadne Labs, Brigham and Women’s Hospital, Harvard TH Chan School of Public Health.

Communication and Resolution Programs (CRP) are a promising strategy for managing the aftermath of medical harm. This 18-month collaborative will help participants engage leadership, implement CRP processes, build patient partnerships and establish measurement approaches to gauge the success of CRP efforts. The program will launch in 2022 and applicants will be informed of participation status no later than December 10, 2021.
Ottawa, ON: Canadian Patient Safety Institute; 2008.
This initative defines competency domains for safe health care and outlines educational practices to achieve them. The 2nd edition of the Patient Safety Competencies was released in 2020. 

Farnborough, UK: Healthcare Safety Investigation Branch; September 9, 2021.

In-depth failure investigations provide improvement insights for individuals and organizations alike. This report analyzes a collection of UK National Health Service incident examinations and provides recommendations for improvement on themes related to care transitions and access, decision making, communication, and point-of-care activity.
MedWatch Safety Alert. Silver Spring, MD: US Food and Drug Administration; August 20, 2021.
This announcement seeks to raise awareness of the potential risks associated with the use of robotic-assisted surgical devices in mastectomies or cancer-related care. Recommendations for patients who may seek to have robotically assisted surgery include asking about their surgeon's experience with these procedures and discussing benefits, risks, and alternatives regarding available treatment options with their health care provider. Suggestions for health care providers include completing specialized training on procedures they perform. A WebM&M commentary described the challenges and benefits associated with robotic surgery.

London, UK: Parliamentary and Health Service Ombudsman; 2021. ISBN 9781528627016. 

Lack of appropriate follow up of diagnostic imaging can result in care delays, patient harm, and death. This report summarizes an investigation of 25 imaging failures in the British National Health Service (NHS). The analysis identified communication and coordination issues resulting in lack of action and reporting of unanticipated findings to properly advance care. Recommendations to improve imaging in the NHS include use of previous analyses to enhance learning from failure.

Farnborough, UK: Healthcare Safety Investigation Branch; June 3, 2021.

Wrong site/wrong patent surgery is a persistent healthcare never event. This report examines National Health Service (NHS) reporting data to identify how ambulatory patient identification errors contribute to wrong patient care. The authors recommend that the NHS use human factors methods to design control processes to target and manage the risks in the outpatient environment such as lack of technology integration, shared waiting area space, and reliance on verbal communication at clinic.

Constellation, Society to Improve Diagnosis in Medicine. 

The processes supporting safe and accurate diagnosis involve many steps that are prone to human error. This collaborative will engage teams to explore test result management and follow-up coordination to improve timeliness, collaboration, and communication to support safe care. The launch of the collaborative has been delayed due to COVID-19.
BeMedWise Program at NeedyMeds, Gloucester, MA.
This Web site provides information and tools that support an educational campaign to encourage high-quality communication about medication use. The annual observance is in October and the last observance focused on the theme of "Medication Adherence – On track with your meds and your health".

MedWatch Safety Alert. Silver Spring, MD: US Food and Drug Administration. July 23, 2020.

Accidental misuse of prescription opiates for pain can result in addiction, overdose and death. This announcement outlines new federal labeling requirements for opiates and treatments for opioid use disorder. The FDA calls for health care professionals to educate patients about naloxone when prescribing opioid medications to improve the safety of patients taking opiates.     
This organization shares best practices to align and optimize efforts toward eliminating patient harm by the year 2030. The Foundation supports several awareness initiatives to drive improvements associated with its strategic aims that include promoting transparency, realigning safer care incentives, and informing patients and families about patient safety.

Circle Up for COVID-19 Training. Center for Medical Simulation.

Communication strategies are important for engaging staff in behaviors that support effective teamwork. This website highlights a process that involves briefings, supportive conversations, and debriefings as a communication structure for use during COVID-19 care episodes and other complex interactions.

NHS Improvement. Independent Mortality Review of Cardiac Surgery at St George’s University Hospitals NHS Foundation Trust. NHS England. March 2020.

In-depth incident investigations provide details of care process examinations to motivate learning and improvement. This report examines cardiac surgery patient mortality at a National Health Service Trust over a 5-year period. It highlights weakness in professionalism at the individual and organization level as a contributor to the preventable patient deaths catalogued over that time.
Maxwell J, Bourgoin A, Crandall J. Rockville, MD : Agency for Healthcare Research and Quality; 2020.
Project RED re-engineered discharge with the goal of reducing preventable readmissions. This report summarizes an Agency for Healthcare Research and Quality project to transfer the Project RED experience to the primary care environment. Areas of focus included enhancing the team leader role of primary care physicians in post-discharge care.

James G. House Commons Report 31. Department of Health and Social Care. London, England: Crown Copyright; 2020. ISBN 9781528617284.

Sharing information from large-scale failure investigations provides insights on latent factors that contribute to patient harm. This analysis discusses a criminal case involving one surgeon in the National Health Service. The examination uncovered problems perpetuated by culture, lack of respect for patient concerns, poor complaint follow-up and organizational blindness. The report summarizes recommendations to reduce similar situations through improving patient communication, organizational accountability and complaints management.
Massachusetts Sepsis Consortium.
Delayed diagnosis of sepsis is a primary patient safety concern. This campaign raises awareness of the symptoms of sepsis to engage patients in timely diagnosis and safe treatment of the condition.