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Although it is assumed that information about patient safety and adverse events will be used for improvement and organizational learning, we know little about how this actually happens in patient care settings. This study examines how organizational and professional practices and beliefs related to patient safety influence (1) how health care providers and managers make sense of patient safety risks and adverse events, and (2) the flow and use of information for making improvements. The research is based on an ethnographic case study of a medical unit in a large tertiary care hospital in Canada. The study found that front-line staff are task driven, coping with heavy workloads that limit their attention to and recognition of potential information needs and knowledge gaps. However, a surrogate in an informationrelated role-an "information/change agent"-may intervene successfully with staff and engage in preventive maintenance and repair of routines. The article discusses four key functions of the information/change agent (i.e., boundary spanner, information seeker, knowledge translator, and change champion) in the context of situated practice and learning. All four functions are important for facilitating changes to practice, routines, and the work environment to improve patient safety.

Learning to communicate research well through posters involves far more than formatting issues such as font size. The conventions of poster presentations as social practices are part of academic apprenticeship in many health disciplines. This case study examines doctoral students’ poster presentations as a research-process genre. The article maps genre knowledge required of novice researchers: poster form, creation processes, presentation practices, and underlying values. Complexity arises from the multiple roles that posters must fulfill, combined with formatting restrictions, the nature of audience interaction, and prestige issues. Posters are often considered as second class compared to oral presentations, perhaps unfairly. The reuse of posters raises questions about publication as academic currency and appropriate knowledge-exchange practices. Poster presentations are evolving with digital media, which may affect competence development in this multimodal form of research communication. Future research should consider how posters’ technology-influenced evolution affects interaction, communicative purposes, and the texts themselves.

Two sets of research-to-practice gaps are portrayed in the journal: the gap between clinical research and practice and the gap between research and practice in CEHP. To close the first gap, authors have asserted that the second gap must be addressed, ensuring that CEHP practices themselves are evidence based, driven by theory-based research. This is a variation on prior debates regarding the need to define CEHP as a discipline, which uses the language of professionalization. The increased focus of continuing education on the contexts of health care providers' practices has multiplied the topics that are potentially relevant to CEHP practice.

The passage of the Excellent Care for All Act, 2010 (ECFA Act) in Ontario has confirmed the responsibilities of hospital boards for quality of care and reinforced expectations that they will monitor performance and establish strategic aims in this area. Quality of care and patient safety have created a new agenda for many healthcare boards that had only a limited focus on these issues. Here, we report on interviews with five Ontario healthcare organizations identified by experts as having high-performing boards. Our question was, how has the ECFA Act influenced Ontario healthcare organizations' governance practices relating to quality and safety? While the act has raised the profile of these issues, in the short-term it may have blunted the effectiveness of some boards that had already developed a clear strategic focus on quality and patient safety. Executive compensation was the most contentious issue; the introduction of pay for performance was considered poor timing, given the Ontario government's pay freeze. Overall, the act is an important step in increasing responsible governance and has helped align governance activities with the core work of hospitals-delivering high-quality care. However, effective policy must create an environment where all organizations focus on improvement, but where regulation does not limit the capabilities of leading organizations to achieve even higher performance. Visit the Ministry of Health and long-term care www.health.gov.on.ca