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Canadian Medical Protective Association. CMPA Perspective. September 2018;10:8-11.
Frontline leadership should model just culture behaviors to encourage reporting and discussion of error to facilitate improvement. This news article uses a medical administration error to examine whether human error, at-risk behavior, or reckless action on the part of a clinician led to the mistake and explores leadership response to the incident to determine accountability in each type of situation.
Journal Article > Commentary
Antunez AG, Shuman AG, Jagsi R, Dossett LA. J Am Coll Surg. 2018;227:543–547.
Learning from other organizations' errors is a recognized opportunity to engage in safety improvement. This commentary suggests that learning from others is an ethical responsibility. The authors describe a framework to build a culture that draws from quality, holism, collaboration, and accountability to enable cross-organizational learning. A past WebM&M commentary discussed the difficulties in disclosing mistakes that originated from a different hospital.
Williams N. Department of Health and Social Care. London, England: Crown Copyright; 2018.
Accountability for errors and organizational assessment of failures affect incident reporting. This policy review explores how potential legal ramifications stemming from investigations of negligence can hinder improvement efforts and outlines recommendations to support safety culture in health care.
Famolaro T, Yount N, Hare R, et al. Rockville, MD: Agency for Healthcare Research and Quality; April 2018. AHRQ Publication No. 18-0030-EF.
A vibrant culture of safety is critical to achieving high reliability in health care. Organizations with stronger safety culture boast lower in-hospital mortality and fewer surgical site infections. The AHRQ Medical Office Survey on Patient Safety Culture was designed to evaluate safety culture in outpatient clinics. The 2018 comparative database report assessed 10 safety culture domains in nearly 2500 ambulatory care practices. Respondents reported high rates of teamwork and strong systems for patient follow-up. Many practices identified productivity pressures and work pace as safety hazards. Although the practices surveyed are not nationally representative, they do allow leaders and scientists to compare safety culture across practices and time. A past WebM&M commentary examined safety hazards associated with productivity pressures in health care.
Patient Safety and the Invitational Conference on Contemporary Surgical Quality, Safety and Transparency.
Amer Surg. 2006;72:985-1149
This issue includes articles related to patient safety in the surgical environment and panel reports from a national symposium.