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This article aims to analyze morbidity and mortality conferences (M&MCs) in a university‐affiliated hospital, notably their format and progression since the 1990s.

A cross‐sectional study was conducted and M&MC characteristics were collected using three methods: a questionnaire to all department heads to identify past M&MCs; semi‐structured interviews with each M&MC leader; and when available, meeting reports were analyzed.

Of 189 questionnaires sent to department heads, 105 were completed and returned (55.6 per cent). A total of 27 M&MCs were identified; five times more than in 1994. The M&MC format varied greatly between departments. In surgical units, cases per conference tended to be higher than in intensive care or medical units and paramedical staff were invited less often. Compared with 1998, head nurses (70.4 vs 27.3 percent, p=0.03) and paramedical staff (63.0 vs 18.2 percent, p=0.03) attendance increased significantly. Physicians considered M&MCs important for improving service quality, patient safety and enhancing team cohesion.

Patient outcomes were not assessed.

Although undefined formats allowed leaders to conduct M&MCs according to their objectives, how these conferences are conducted should impact healthcare quality and safety.

Results indicate that M&MCs have evolved over the past 20 years, showing them to be valuable quality and safety improvement methods.

The purpose of this paper is to systematically describe the types of non-clinical rounds implemented in hospital settings.

This scoping review was conducted and reported in accordance with the PRISMA. The review followed the four stages of conducting scoping review as defined by Arskey and O’Malley (2005).

Initially, 978 articles were identified through database search from which only 24 studies were considered relevant and included in the final review. Overall, eight types of non-clinical rounds were identified (death rounds, grand rounds, morbidity and mortality conferences, multidisciplinary rounds, patient safety rounds, patient safety huddles, walkarounds and Schwartz rounds) that independently of their format, goal, participants and type of outcomes aimed to enhance patient safety and improve quality of healthcare delivery in hospital settings, either by focusing on physician, patient or organizational system.

To the authors’ knowledge this is the first review that aims to provide a comprehensive summary to the types of non-clinical rounds that has been applied in clinical settings.

Mental health providers will be increasingly called on to lead psychiatric efforts to improve care and care redesign. The Accreditation Council for Graduate Medical Education (ACGME) in the USA requires residency programs to teach quality improvement (QI) and systems-based practice (SBP) to all trainees as part of training requirements. However, teaching QI and SBP concepts without a clinical context can be challenging with low trainee engagement. The paper aims to discuss these issues.

The authors describe curricular redesign with a specialized educator faculty task force that aimed to create a longitudinal curriculum that integrated abstract QI concepts into clinical practice settings, and helped trainees apply SBP concepts throughout residency. In addition, the authors describe the utilization of resident prescriber profiles to contextualize clinical practice habits, and the implementation of an educational case conference series with emphasis on QI-specific educational tools such as root cause analysis (RCA).

Formal resident feedback from 2016 to 2018 has demonstrated improved trainee satisfaction. The resulting curricular change has also led to a new chief resident role and sustained engagement in QI and SBP education by trainees.

The faculty task force and curricular design changes described in this paper were implemented at one large academic institution. Thus, additional assessment and research is necessary to address the generalizability of the interventions described.

Since QI and SBP are becoming more prominent requirements for medical education accrediting bodies such as the ACGME, the innovative curricular design can benefit other residency and medical student education programs that attempt to integrate clinical practice with education incorporating QI and SBP concepts.

Although adverse events are less studied in the prehospital setting, the evidence is beginning to paint an alarming picture. Consequently, improvements in Emergency Medical Services (EMS) demand a paradigm shift regarding the way care is conceptualized. The chapter aims to (1) support the dialogue on near-misses and adverse events as a learning opportunity and (2) to provide insights on applications of multiteam systems (MTSs).

To offer discussion on near-misses and adverse events and knowledge on how MTSs are applicable to emergency medical care, we review and dissect a complex patient case.

Throughout this case discussion, we uncover seven pertinent issues specific to this particular MTS: (1) misunderstanding with number of patients and their locations, (2a) lack of context to build a mental model, (2b) no time or resources to think, (3) expertise-facilitated diagnosis, (4) lack of communication contributing to a medication error, (5) treatment plan selection, (6) extended time on scene, and (7) organizational culture impacting treatment plan decisions.

By dissecting a patient case within the prehospital setting, we can highlight the value in engaging in dialogue regarding near-misses and adverse events. Further, we can demonstrate the need to expand the focus from simply teams to MTSs.

The purpose of this paper is to investigate how professionals, like doctors, deal with their ignorance? Which strategies do they apply? How can the organization support activities that encourage dealing with ignorance in a positive way? The paper shows how ignorance can be managed in professional organizations like hospitals.

To explore this touchy subject, the research follows a sequential mixed method design. The advantage of combining research methods is the opportunity to explore an uninvestigated research field. In the first exploratory research sequence (empirical study 1) preliminary questions were defined by means of 43 qualitative semi-structured interviews with hospital physicians and literature analysis. The results of the qualitative content analysis also served as a starting point for the development of a Germany-wide online-questionnaire survey with more than 2,500 physicians (empirical study 2).

The results show that breaks, a lack of negative organizational constraints, collective learning, positive role models and intrinsic motivation have the highest impact on ignorance sharing of physicians in hospitals. In reverse, negative organizational constraints, distrust, a lack of intrinsic motivation and omitting the implementation of evidence-based insights in terms of collective learning have the highest impact on hiding ignorance. These findings help to manage ignorance in a positive way.

Physicians all over the world have to deal with incomplete information and ignorance in their daily work. Mostly, they have no time and/or resources to gather all relevant information before they make a diagnosis or administer a therapy. It is quite evident that scientific discourses on knowledge management and professions mostly emphasize the power of expertise and knowledge, whereas research on ignorance is currently more or less neglected. This paper is one of the first attempts to overcome this research gap.

Governance of healthcare organisations and health systems requires many different competencies, with a great emphasis on evidence and information governance, which are traditional fields of librarians’ expertise. However, stakeholders are unaware of how health and hospital libraries are contributing with specific activities and what are the trends in library support for health/clinical governance in Europe, mainly because traditional methods of measuring impact are restricted to specific library activities or are not showing direct impact long term. The paper aims to discuss these issues.

A model combining components of clinical and health governance (C/HG), related library activity types, and the possible impact was developed based on a literature review and tested by a European expert panel. A web-based survey was offered to the members of the European Association for Health Information and Libraries (EAHIL) to offer further insight into activities and examples of contribution to C/HG.

Librarians from 25 European countries participated in the survey. The model proves that librarians in Europe are involved in supporting most identified components of C/HG, with examples of clinical effectiveness and research, education and training, patient and public involvement, partnership engagement, formulating strategic direction, etc.

The authors were unable to cover the roles of libraries in all European countries in this paper, but dialogue and research will continue within the EAHIL group.

No such comparative research has been undertaken before, looking at what activities and tasks libraries undertake to support C/HG. This research has highlighted valuable services and tools that can be replicated in libraries across health care organisations and at the same time promote libraries and librarians as significant actors in organisational governance.

The purpose of this study is to demonstrate how action learning can be practically applied to quality and safety challenges at a large academic medical health system and become fundamentally integrated with an institution’s broader approach to quality and safety.

The authors describe how the fundamental principles of action learning have been applied to advancing quality and safety in health care at a large academic medical institution. The authors provide an academic contextualization of action learning in health care and then transition to how this concept can be practically applied to quality and safety by providing detailing examples at the unit, cross-functional and executive levels.

The authors describe three unique approaches to applying action learning in the comprehensive unit-based safety program, clinical communities and the quality management infrastructure. These examples, individually, provide discrete ways to integrate action learning in the advancement of quality and safety. However, more importantly when combined, they represent how action learning can form the basis of a learning health system around quality and safety.

This study represents the broadest description of action learning applied to the quality and safety literature in health care and provides detailed examples of its use in a real-world context.

The purpose of this paper is to apply Bow-tie methodology, a proactive risk assessment technique based on systemic approach, for prospective analysis of the risks threatening patient safety in intensive care unit (ICU).

Bow-tie methodology was used to manage clinical risks threatening patient safety by a multidisciplinary team in the ICU. The Bow-tie analysis was conducted on incidents related to high-alert medications, ventilator associated pneumonia, catheter-related blood stream infection, urinary tract infection, and unwanted extubation.

In total, 48 potential adverse events were analysed. The causal factors were identified and classified into relevant categories. The number and effectiveness of existing preventive and protective barriers were examined for each potential adverse event. The adverse events were evaluated according to the risk criteria and a set of interventions were proposed with the aim of improving the existing barriers or implementing new barriers. A number of recommendations were implemented in the ICU, while considering their feasibility.

The application of Bow-tie methodology led to practical recommendations to eliminate or control the hazards identified. It also contributed to better understanding of hazard prevention and protection required for safe operations in clinical settings.

The purpose of this paper is to assess the association between shift schedule realignment and patient safety culture.

Using difference in differences model, BIMC Hospitals and Siloam Hospital Bali were compared before and after shift schedule realignment to test the association between shift schedule realignment and patient safety culture.

Shift schedule realignment was associated with a significant improvement in staffing (coefficient 1.272; 95% CI 0.842 – 1.702; p<0.001), teamwork within units (coefficient 1.689; 95% CI 1.206 – 2.171; p<0.001), teamwork across units (coefficient 1.862; 95% CI 1.415 – 2.308; p<0.001), handoffs and transitions (coefficient 0.999; 95% CI 0.616 – 1.382; p<0.001), frequency of error reported (coefficient 1.037; 95% CI 0.581 – 1.493; p<0.001), feedback and communication about error (coefficient 1.412; 95% CI 0.982 – 1.841; p<0.001) and communication openness (coefficient 1.393; 95% CI 0.968 – 1.818; p<0.001).

With positive impact on patient safety culture, shift schedule realignment should be considered as quality improvement initiative. It stretches the compressed workload suffered by staff while maintaining 40 h per week in accordance with applicable laws and regulations.

Shift schedule realignment, designed to improve patient safety culture, has never been implemented in any Indonesian private hospital. Other hospital managers might also appreciate knowing about the shift schedule realignment to improve the patient safety culture.