Parent or caregiver limited English proficiency (LPE) has been associated with increased risk of their children experiencing adverse events. In this study, limited English proficiency was associated with lower odds of speaking up or asking questions when something does not appear right with their child’s care. Recommendations for improving communication with limited English proficiency patients and families are presented.

This interview study with second victims—physicians who had made a serious medical error—found that although the majority disclosed the error to patient or family, less than 10% had received disclosure training. Disclosure and apology, forgiveness, and preventing recurrence helped physicians cope with medical errors.

Clinicians who commit a medical error experience a wide range of emotional responses, including loss of confidence in their job performance, job dissatisfaction, and even overt depression and burnout. This qualitative study used in-depth interviews to explore the coping strategies that physicians used to deal with these emotions. Physicians experienced fundamental changes in both personal and professional relationships, describing themselves as having increased compassion, humility, and tolerance for uncertainty as a result of being involved in an error. Interestingly, few reported utilizing institutional resources to help with the recovery process, instead relying on informal support from colleagues. This study illustrates the second victim phenomenon that affects many clinicians who are involved in medical errors, which is explored in more detail in an AHRQ WebM&M interview.

Through semi-structured interviews, this study identified strategies that pediatric nurses have developed to manage interruptions and avoid errors during medication administration.

This qualitative study examines the coping strategies that physicians used after being involved in a medical error.

This commentary describes a template to standardize handoff education to drive safety improvement.

… Journal of general internal medicine … J Gen Intern Med … Using direct observation and peer …

Despite increased focus on safety and quality in health care, prior studies have documented that residency programs miss opportunities to engage trainees in learning about patient safety. This study describes the successful implementation of a longitudinal curriculum in patient safety and quality improvement for internal medicine residents, centered around root cause analysis of adverse events.

… Commission journal on quality and patient safety … Jt Comm J Qual Patient Saf … The investigators surveyed internal …