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Weenink J-W, Wallenburg I, Hartman L, et al. BMJ Open. 2022;12:e061321.
There is a long-standing tension between health care regulation and just culture principles. This qualitative study explored the experiences of mental health professionals, managers and other healthcare organization staff, as well as inspectors, regarding the role of healthcare inspectors in enabling a just culture. Three themes emerged – (1) the role of the inspector as both a catalyst for learning and a potential barrier, (2) just culture involves relationships between different layers within and outside the organization, and (3) to enable just culture in which inspectors would strike a balance between organizational responsibility and timely regulatory intervention.
Montgomery A, Lainidi O, Johnson J, et al. Health Care Manage Rev. 2022;Epub Jun 16.
When faced with a patient safety concern, staff need to decide whether to speak up or remain silent. Leaders play a crucial role in addressing contextual factors behind employees’ decisions to remain silent. This article offers support for leaders to create a culture of psychological safety and encourage speaking up behaviors.
Maher V, Cwiek M. Hosp Top. 2022;Epub Jul 20.
Fear of criminal liability may inhibit clinicians from reporting medical errors, thereby reducing opportunities for learning. This commentary discusses recent legal actions brought against clinicians, including Tennessee nurse RaDonda Vaught, and the negative impact such actions may have on the longstanding disclosure movement.
Mrayyan MT. BMJ Open Qual. 2022;11:e001889.
Strong patient safety culture is a cornerstone to sustained safety improvements. This cross-sectional study explored nurses’ perceptions about patient safety culture. Identified areas of strength included non-punitive responses to errors and teamwork, and areas for improvement focused on supervisor and manager expectations, responses, and actions to promote safety and open communication. The authors highlight the importance of measuring patient safety culture in order to improve hospitals’ patient safety improvement practices, overall performance and quality of healthcare delivery.
Walther F, Schick C, Schwappach DLB, et al. J Patient Saf. 2022;Epub May 4.
Historically, there have been many patient safety errors associated with healthcare workers’ failure to speak up and report when they notice a problem. Many studies have identified organizational culture as important in creating a safe environment for workers to report medical errors. This study reports on a multimodal program to educate and train healthcare workers resulting in improvements on speaking up behaviors.

Neft MW, Sekula K, Zoucha R, et al. AANA J. 2022;90(3):189-196. 

Healthcare workers who are involved in a patient safety incident may experience adverse psychological outcomes. This integrative review summarizes the importance of organizational safety culture and highlights strategies and programs (such as the RISE support program and peer support teams) for supporting healthcare professionals after involvement in a patient safety incident.
Niederhauser A, Schwappach DLB. Health Sci Rep. 2022;5:e631.
Ensuring that healthcare staff feel comfortable speaking up about safety concerns is an important component of safety culture. This cross-sectional study explored speaking up behaviors and perceptions among healthcare workers in rehabilitation clinics in Switzerland. Barriers to speaking up included expectations of a lack of productive response to the safety concern, presence of patients, and concerns about reactions from involved individuals.
Isaksson S, Schwarz A, Rusner M, et al. J Patient Saf. 2022;18:325-330.
Organizations may employ one or more methods for identifying and examining near misses and preventable adverse events, including structured record review, web-based incident reporting systems, and daily safety briefings. Using each of the three methods, this study identified the number and types of near misses and adverse events. Results indicate that each method identifies different numbers and types of adverse events, suggesting a multi-focal approach to adverse event data collection may more effectively inform organizations. 
Falcone ML, Van Stee SK, Tokac U, et al. J Patient Saf. 2022;18:e727-e740.
Adverse event reporting is foundational to improving patient safety, but many events go unreported. This review identified four key priorities in increasing adverse event reporting: understanding and reducing barriers; improving perceptions of adverse event reporting within healthcare hierarchies; improving organizational culture; and improving outcomes measurement.
Zebrak K, Yount N, Sorra J, et al. Int J Environ Res Public Health. 2022;19:6815.
AHRQ’s Hospital Survey on Patient Safety (SOPS) is used by hundreds of hospitals in the US to assess hospital patient safety culture. This study describes the development and testing of a “workplace safety supplement,” intended to be used in conjunction with the SOPS to assess how organizational culture supports workplace safety. Included survey items measured perceptions around protection from workplace hazards; moving, transferring, or lifting patients; workplace aggression; management and leadership support for workplace safety; and workplace safety reporting.
Khan A, Parente V, Baird JD, et al. JAMA Pediatr. 2022;176:776-786.
Parent or caregiver limited English proficiency (LPE) has been associated with increased risk of their children experiencing adverse events. In this study, limited English proficiency was associated with lower odds of speaking up or asking questions when something does not appear right with their child’s care. Recommendations for improving communication with limited English proficiency patients and families are presented.
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.
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.

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.
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.
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.
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.
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.