From its early days in the 1980s and 90s, the patient safety movement has been blessed with high quality, accessible writing. Many of the early contributors—Michael Millenson, Bob Wachter, Atul Gawande, to name only a few—continue to contribute and update their research and reflections. Millenson and Wachter have recently commented on their earlier works and reflected on what if any progress they have seen over the years.

With the launch of the VNNA Blueprint for Excellence, the Visiting Nurse Associations of America offers the home health industry, policymakers, payers, and others an invaluable tool to support better, safer and smoother care transitions.

Experts say the most risky time for patients in the ER is when physicians transfer care of patients from one doctor to another. Communication failures are the most common cause of problems inside our hospitals and often are the root cause of errors and adverse events. February’s 2013 BMJ Quality and Safety Journal found team training can transform a hospital’s culture of safety. Safer Sign Out is a patient-centered, team-based innovation that was developed by emergency physicians to improve the safety and reliability of end of shift patient “handoffs.”

By Karlene M. Kerfoot, PhD, RN, NEA-BC, FAAN

Ineffective staffing programs are often the invisible factors that cause the best intentioned patient safety programs to collapse. Positive patient care outcomes are dependent upon a “point of excellence” where the clinician and the patient interact synergistically every time. Variability between clinicians because of nurse turnover blocks the chances of achieving excellence—which is particularly harmful when it involves the new nurse.