True partnership with patients and families in safety work is an important yet elusive goal. This commentary outlines elements supporting engagement as part of an ambitious global plan and awareness campaign to ensure medical error reduction efforts are fully informed and enriched through the application of the patient and family experience in health care.

Analysis of closed malpractice claims can be used to identify potential safety hazards in a variety of clinical settings. This analysis of closed emergency department malpractice claims indicates that diagnostic errors dominate, and clinical judgment and documentation categories continue to be associated with a higher likelihood of payout. Subcategories and contributing factors are also discussed.

Strategies to reduce clinician burnout related to adverse events are critically needed. Physicians in the United States were surveyed on their experiences with adverse events to identify facilitators and barriers to reducing burnout. A common facilitator was peer support, and barriers included shame and a punitive work environment.

In response to concerns about COVID-19 transmission, many ambulatory care visits have transitioned to telehealth visits. This commentary describes the impact of telehealth on diagnostic errors and medication safety in ambulatory settings. Recommendations to further understand the impact of telemedicine on patient safety include: systematically measuring patient safety outcomes and increasing reporting of safety incidents; identifying the patients and clinical scenarios with the greatest risk of unsafe telehealth care; identifying and supporting best practices to ensure equal access to safe telehealth.

Physicians who experience emotional consequences after adverse events are referred to as second victims. In this survey study of 5782 physicians who identify as mothers, nearly half reported involvement in an error. Most of those respondents described feeling guilt and were more likely to report burnout. Participants reported a wide variety of errors; treatment errors were the most common but diagnostic errors were associated with more severe harm to patients. The authors conclude that strategies to mitigate burnout among second victims are urgently needed. A previous PSNet interview discussed the second victim phenomenon and interventions to address it.

Digital tools have the potential to improve diagnosis, patient self-care, and patient–clinician communication. This commentary argues that digital tools that alter diagnosis or treatment require examination to ensure safety. The authors provide recommendations such as involving experts in evaluating the tools, engaging information technologists, and continuous local review and assessment to identify and address risks associated with use of such tools in practice.

Although financial incentives have been widely adopted, they may not lead to organizational improvements. This commentary raises concerns about including hospital mortality in incentive programs, since patient deaths do not necessarily mean poor quality care. The authors suggest that further research is needed to enhance accuracy of risk-adjusted mortality and to account for differences in patient treatment preferences.

This review explores computerized physician order entry (CPOE), including its use with clinical decision support systems to enhance medication safety and its potential to increase risk of error. The authors also relate benefits and drawbacks one health system experienced when implementing CPOE.

Nights and weekends have been described as times when the quality of care is at risk for poor outcomes. However, this study found no associations between patients admitted during these times and worse clinical outcomes.