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Journal Article > Commentary
The Swiss Cheese Conference: integrating and aligning quality improvement education with hospital patient safety initiatives.
Durstenfeld MS, Statman S, Dikman A, et al. Am J Med Qual. 2019 Jan 18; [Epub ahead of print].
Academic medical centers are working to increase resident engagement in patient safety work. Building on Reason's system failure investigation model, this commentary describes the integration of monthly educational opportunities into actual improvement efforts. Core elements of the program rely on effective case selection, root cause analysis, and resident-led discussion.
Journal Article > Study
A multidisciplinary model for reviewing severe maternal morbidity cases and teaching residents patient safety principles.
Ogunyemi D, Hage N, Kim SK, Friedman P. Jt Comm J Qual Patient Saf. 2019;45:423-430.
The rise in maternal morbidity and mortality is one of the most pressing patient safety issues in the United States. Formal debriefing after adverse events is an important method for analyzing and improving safety. In this study, an academic hospital adopted a systems-based morbidity and mortality conference model to review cases of serious maternal harm and implemented several safety measures (including teamwork training) to address issues that were identified through structured review.