Safety event reporting is a primary method of gathering data to enhance learning from error. This commentary suggests that a broader approach is needed by engaging patients and gathering their perception of safety to provide a full picture of gaps in care that could result in harm.

… found that nearly 3% of respondents had experienced a patient safety event during the last 12 months. The authors … can influence measurement of patient experience. … Stahl K, Groene O. ASK ME!-routine measurement of patient experience with …

Polypharmacy in older adults puts them at risk for adverse drug events. In interviews with primary care clinicians, researchers found that working conditions and working in partnership with colleagues, patients, and family influenced medication evaluation. They also identified two main areas of action: working with a plan and collaborative problem-solving. 

The World Health Organization (WHO) surgical safety checklist is widely used in surgical settings to prevent errors. This multinational panel representing multiple clinical specialties identified 16 recommendations for checklist content modification and implementation during the COVID-19 pandemic. These recommendations exemplify how the checklist can be adapted to meet urgent and emerging needs of surgical units by targeting important processes and encouraging critical discussions.

This Swedish pediatric surgery team employed crew resource management training, which included checklists, communication training, and workflow redesign. The pre–post analysis showed sustained improvements in safety culture, checklist adherence, communication quality, and unplanned returns to surgery after laparoscopic appendectomy. Although this study design cannot control for secular trends, few crew resource management analyses include patient outcomes or such lengthy follow-up.

… Providers and Services patient satisfaction instrument. A significant proportion of narrative reviews raised concern …

The SQUIRE guidelines were developed to improve reporting on research and initiatives targeted toward improving quality and safety of health care. This commentary provides examples for authors who seek to apply the revised guidelines in safety improvement work and write about their experiences.

… Journal of clinical nursing … J Clin Nurs … This review examined nurses' role in detecting, … nurses may recover as many as one error each shift. A strong safety culture was an important organizational …

… medical students to identify patient safety hazards in a hospital room. Students demonstrated a wide range of accuracy in identifying hazards, with fall …

Codeine is considered a high-risk medication in children due to variability in its metabolization. Despite recommendations against its use, this analysis of national data over a 10-year period found only a slight decrease in codeine prescriptions for children seen in the emergency department.

… & safety … BMJ Qual Saf … Clinicians who are involved in a medical error experience considerable emotional distress, … doctors and nurses) who were involved in errors at a Swedish hospital. Interviews with the affected clinicians … researched this phenomenon, was interviewed by AHRQ WebM&M in 2011. …

This educational intervention applied high-fidelity simulation to teach patient safety principles to senior year medical students.

Malpractice claims in Sweden are compensated if an independent physician review confirms that harm resulted from physician error. Over the 8-year period covered in this study, compensation was provided in almost half of cases.

… the International Society for Quality in Health Care … Int J Qual Health Care … The implementation of an electronic health record at a Swedish hospital is analyzed through structured interviews, …

… AORN J … This article provides background on  crew resource … implementation at one medical center. … France DJ; Stiles R; Gaffney EA; Seddon MR; Grogan EL; Nixon WR Jr; Speroff T. …