This review of national trends in medical malpractice claims explores the current environment, in which there has been a declining rate of paid claims as well as decreasing or flat compensation amounts. The authors discuss alternative approaches to malpractice. They predict the expansion of communication-and-resolution programs, where providers and health systems disclose errors, apologize, and offer compensation to patients and families if appropriate. The authors also expect that pre-suit notification (requiring patients and families to inform providers of intent to sue), apology laws (dictating that statements of fault or regret cannot be used in malpractice claims), and administrative compensation systems (which use an adjudication process rather than usual courts) will all play a larger role and lead to more rapid resolution following adverse events. They advocate for safe harbor legislation which would permit providers to use adherence to a clinical guideline as a defense. Formation of accountable care organizations may lead to reform in the liability system such that organizations rather than individuals are liable for malpractice. This data not only serves to underscore the shortcomings of the current malpractice environment in promoting patient safety, but suggests how alternative approaches might better serve all parties.