Background: Effective disaster preparedness requires coordination across multiple organizations. This article describes a detailed framework developed through the BioNet program to facilitate coordination of bioterrorism preparedness planning among military and civilian decision makers.

Methods: The authors and colleagues conducted a series of semistructured interviews with civilian and military decision makers from public health, emergency management, hazardous material response, law enforcement, and military health in the San Diego area. Decision makers used a software tool that simulated a hypothetical anthrax attack, which allowed them to assess the effects of a variety of response actions (eg, issuing warnings to the public, establishing prophylaxis distribution centers) on performance metrics. From these interviews, the authors characterized the information sources, technologies, plans, and communication channels that would be used for bioterrorism planning and responses. The authors used influence diagram notation to describe the key bioterrorism response decisions, the probabilistic factors affecting these decisions, and the response outcomes.

Results: The authors present an overview of the response framework and provide a detailed assessment of two key phases of the decision-making process:

1. pre-event planning and investment and
   
2. incident characterization and initial responsive measures.
   

The framework enables planners to articulate current conditions; identify gaps in existing policies, technologies, information resources, and relationships with other response organizations; and explore the implications of potential system enhancements.

Conclusions: Use of this framework could help decision makers execute a locally coordinated response by identifying the critical cues of a potential bioterrorism event, the information needed to make effective response decisions, and the potential effects of various decision alternatives. Key words: bioterrorism, decision making, organization and administration, regional health planning

BACKGROUND: Concern about patient safety has promoted efforts to improve safety climate. A better understanding of how patient safety climate differs among distinct work areas and disciplines in hospitals would facilitate the design and implementation of interventions. OBJECTIVES: To understand workers' perceptions of safety climate and ways in which climate varies among hospitals and by work area and discipline. RESEARCH DESIGN: We administered the Patient Safety Climate in Healthcare Organizations survey in 2004-2005 to personnel in a stratified random sample of 92 US hospitals. SUBJECTS: We sampled 100% of senior managers and physicians and 10% of all other workers. We received 18,361 completed surveys (52% response). MEASURES: The survey measured safety climate perceptions and worker and job characteristics of hospital personnel. We calculated and compared the percent of responses inconsistent with a climate of safety among hospitals, work areas, and disciplines. RESULTS: Overall, 17% of responses were inconsistent with a safety climate. Patient safety climate differed by hospital and among and within work areas and disciplines. Emergency department personnel perceived worse safety climate and personnel in nonclinical areas perceived better safety climate than workers in other areas. Nurses were more negative than physicians regarding their work unit's support and recognition of safety efforts, and physicians showed marginally more fear of shame than nurses. For other dimensions of safety climate, physician-nurse differences depended on their work area. CONCLUSIONS: Differences among and within hospitals suggest that strategies for improving safety climate and patient safety should be tailored for work areas and disciplines.

OBJECTIVES: In response to growing concerns about sexual violence as an underrecognized traumatic consequence of military service, Veterans Health Administration policy requires universal screening for sexual trauma sustained during military service. This prospective study, the first to evaluate national efforts to screen for military sexual trauma, investigated whether sexual trauma screening is associated with increased utilization of mental health services.

METHODS: This study examined data for all male (N=540,381) and female (N=33,259) veterans who had valid responses to screens for military sexual trauma in 2005. The use of mental health services during the three months after screening was examined for persons who screened positive for military sexual trauma and for those who screened negative. Findings were stratified by use of mental health services in the six months before the screening.

RESULTS: Compared with negative screens, positive screens were associated with significantly increased rates of postscreen mental health treatment. A more than twofold increase was observed for patients without previous use of mental health treatment (women: relative risk [RR]=2.52, 95% confidence interval [CI]= 2.38–2.66; men: RR=2.47, 95% CI=2.34–2.61). In this group, the number of positive screens needed for one additional patient to access treatment was 5.5 for women and 7.2 for men.

CONCLUSIONS: Our findings suggest that detection via screening is associated with increased rates of mental health treatment. An effective screening program that promotes detection of sexual trauma and access to mental health care can help to reduce the burden of psychiatric illness for those who have experienced military sexual trauma.

OBJECTIVE: Evaluate KNAVE-II, a knowledge-based framework for visualization, interpretation, and exploration of longitudinal clinical data, clinical concepts and patterns. KNAVE-II mediates queries to a distributed temporal-abstraction architecture (IDAN), which uses a knowledge-based problem-solving method specializing in on-the-fly computation of clinical queries. METHODS: A two-phase, balanced cross-over study to compare efficiency and satisfaction of a group of clinicians when answering queries of variable complexity about time-oriented clinical data, typical for oncology protocols, using KNAVE-II, versus standard methods: both paper charts and a popular electronic spreadsheet (ESS) in Phase I; an ESS in Phase II. The measurements included the time required to answer and the correctness of answer for each query and each complexity category, and for all queries, assessed versus a predetermined gold standard set by a domain expert. User satisfaction was assessed by the Standard Usability Score (SUS) tool-specific questionnaire and by a "Usability of Tool Comparison" comparative questionnaire developed for this study. RESULTS: In both evaluations, subjects answered higher-complexity queries significantly faster using KNAVE-II than when using paper charts or an ESS up to a mean of 255 s difference per query versus the ESS for hard queries (p=0.0003) in the second evaluation. Average correctness scores when using KNAVE-II versus paper charts, in the first phase, and the ESS, in the second phase, were significantly higher over all queries. In the second evaluation, 91.6% (110/120) of all of the questions asked within queries of all levels produced correct answers using KNAVE-II, opposed to only 57.5% (69/120) using the ESS (p<0.0001). User satisfaction with KNAVE-II was significantly superior compared to using either a paper chart or the ESS (p=0.006). Clinicians ranked KNAVE-II superior to both paper and the ESS. CONCLUSIONS: An evaluation of the functionality and usability of KNAVE-II and its supporting knowledge-based temporal-mediation architecture has produced highly encouraging results regarding saving of physician time, enhancement of accuracy of clinical assessment, and user satisfaction.

BACKGROUND: Strengthening hospital safety culture offers promise for reducing adverse events, but efforts to improve culture may not succeed if hospital managers perceive safety differently from frontline workers.

OBJECTIVES: To determine whether frontline workers and supervisors perceive a more negative patient safety climate (ie, surface features, reflective of the underlying safety culture) than senior managers in their institutions. To ascertain patterns of variation within management levels by professional discipline.

RESEARCH DESIGN: A safety climate survey was administered from March 2004 to May 2005 in 92 US hospitals. Individual-level cross sectional comparisons related safety climate to management level. Hierarchical and hospital-fixed effects modeling tested differences in perceptions.

SUBJECTS: Random sample of hospital personnel (18,361 respondents).

MEASURES: Frequency of responses indicating absence of safety climate (percent problematic response) overall and for 8 survey dimensions.

RESULTS: Frontline workers' safety climate perceptions were 4.8 percentage points (1.4 times) more problematic than were senior managers', and supervisors' perceptions were 3.1 percentage points (1.25 times) more problematic than were senior managers'. Differences were consistent among 7 safety climate dimensions. Differences by management level depended on discipline: senior manager versus frontline worker discrepancies were less pronounced for physicians and more pronounced for nurses, than they were for other disciplines.

CONCLUSIONS: Senior managers perceived patient safety climate more positively than nonsenior managers overall and across 7 discrete safety climate domains. Patterns of variation by management level differed by professional discipline. Continuing efforts to improve patient safety should address perceptual differences, both among and within groups by management level.

Objective: To assess variation in safety climate across VA hospitals nationally.

Study Setting: Data were collected from employees at 30 VA hospitals over a 6-month period using the Patient Safety Climate in Healthcare Organizations survey.

Study Design: We sampled 100 percent of senior managers and physicians and a random 10 percent of other employees. At 10 randomly selected hospitals, we sampled an additional 100 percent of employees working in units with intrinsically higher hazards (high-hazard units [HHUs]).

Data Collection: Data were collected using an anonymous survey design.

Principal Findings: We received 4,547 responses (49 percent response rate). The percent problematic response-lower percent reflecting higher levels of patient safety climate-ranged from 12.0-23.7 percent across hospitals (mean=17.5 percent). Differences in safety climate emerged by management level, clinician status, and workgroup. Supervisors and front-line staff reported lower levels of safety climate than senior managers; clinician responses reflected lower levels of safety climate than those of nonclinicians; and responses of employees in HHUs reflected lower levels of safety climate than those of workers in other areas.

Conclusions: This is the first systematic study of patient safety climate in VA hospitals. Findings indicate an overall positive safety climate across the VA, but there is room for improvement.

Patient safety has been a priority in health care since Hippocrates admonished physicians to "first do no harm." Even so, the Institute of Medicine found in 2000 that approximately 98 000 patients die from preventable medical errors each year. Recent US Centers for Disease Control and Prevention estimates project that 270 individuals die each day from hospital-acquired infections. Despite substantial efforts and investments, widespread and substantial improvement is not evident.

The problem is not in knowing what to do. Techniques, tools, and some best practices are available, and many health care organizations are making efforts to apply them. The importance of creating a "culture of safety" has also been noted. This involves continuous vigilance or mindfulness, learning, and accountability. A greater emphasis on safety over productivity and on teamwork over individual autonomy, increased standardization and simplification, and the implementation of an environment in which personnel are encouraged and feel comfortable to report errors and mistakes are needed.

Although creating a culture of safety is important, creating a culture of systems is a more fundamental challenge. In this Commentary, the term systems means systems of care that occur both within and across organizations. For example, in studies involving causes of adverse events in cardiac surgery, more than two-thirds were classified as nontechnical or systems-oriented issues including delays and missing equipment, and more of these problems occurred in cases with adverse outcomes than in successful cases. The greatest barrier to patient safety and safety culture is the inherent fragmentation of the US system of care. Safety will improve when the underlying system of care improves.