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.

Parents of children with medical complexity can offer unique perspectives on hospital quality and safety. Prior to their child's discharge, parents were surveyed about their child's care, medications, safety, and other concerns experienced during their stay. Parents reported experiencing miscommunication with the providers and providers seemingly not communicating with each other. They also reported inconsistency in care/care plans, unmet expectations, lack of transparency, and a desire for their expertise to be taken seriously.

Parents of children with medical complexity are an important part of the care team and can raise awareness of safety concerns. This study included parents of children with medical complexity who had reported safety concerns to members of their child's healthcare team. Parents whose concerns were validated and addressed felt increased trust in the team and hospital, whereas those whose concerns were invalidated or ignored felt disrespected and judged.

Numerous organizations promote communication with patients and families after harm has occurred due to medical error. This commentary reflects on perceived barriers to patient disclosure and describes the patient and family perspectives and needs following harm. The authors promote the use of Communication and Resolution Programs (CRP) such as the learning community Pathway to Accountability, Compassion, and Transparency (PACT) to advance research, policy, and transparency regarding patient harm.

Previous research has identified gender and racial disparities in the burden of diagnostic errors. In this study, researchers conducted a series of human-centered design workshops with a diverse set of stakeholders who generated a set of design challenges, principles, and solutions for addressing diagnostic disparities, improving healthcare quality, and promoting equity and inclusion of marginalized patients. Participants also identified two prototypes for the solutions – a visit preparation guide to teach patients how to advocate for themselves and a tool for identifying patients who may be at increased risk for experiencing a diagnostic error.

This commentary, authored by patients and families who have experienced medical errors, argues current patient safety efforts in the United States lack urgency and commitment, even as the World Health Organization is increasing its efforts. They call on policy makers and safety agencies to collaborate with the Patients for Patient Safety US organization to move improvement efforts forward.

Children with serious medical conditions are vulnerable to medical errors. This prospective study examined safety reporting behaviors among parents of children with medical complexity and hospital staff caring for these patients in one tertiary children’s hospital. Findings indicate that parents frequently identify medical errors or quality issues, despite not being routinely advised on how to report safety concerns.

… buy-in on the value of parent engagement. … Khan A, Baird J, Kelly MM, et al. Family safety reporting in medically …

This study analyzed self-reported adverse events captured on a national online questionnaire to determine the association between patient-reported contributory factors and patient-reported physical, emotional or financial harm. Contributory factors identified in the analysis focused on issues with health care personnel communication, fatigue, or response (e.g., doctor was slow to arrive, nurse was slow to respond to call button). These patient-reported contributory factors increased the likelihood of reporting any type of harm.

Patient safety is a global concern across the economic spectrum. This commentary summarizes activities associated with the first World Patient Safety Day and emphasizes how patient engagement is key to generating lasting improvements around the world to enhance patient safety.

The term "second victim," coined by Dr. Albert Wu, has engendered mixed responses from patients and health care professionals. This commentary raises concerns that the term negates the sense of responsibility for errors that result in harm and advocates for abandoning it.

Patient engagement in safety takes many forms: patients may report unique safety incidents, encourage adherence to best medical practice, and coproduce improvement initiatives. Family-centered rounding in pediatrics invites families to express concerns, clarify information, and provide real-time input to the health care team. This pre–post study explored the safety impact of Patient and Family Centered (PFC) I-PASS rounds on 3106 admissions in pediatric units at 7 hospitals. Family-centered rounds reduced both preventable and nonpreventable adverse events. They also improved family experience without substantially lengthening rounding time. A past PSNet interview discussed the safety benefits of structured communication between health care providers and family members.

Reducing harm related to diagnostic error remains a major focus within patient safety. While significant effort has been made to engage patients in safety, such as encouraging them to report adverse events and errors, little is known about patient and family experiences related specifically to diagnostic error. Investigators examined adverse event reports from patients and families over a 6-year period and found 184 descriptions of diagnostic error. Contributing factors identified included several manifestations of unprofessional behavior on the part of providers, e.g., inadequate communication and a lack of respect toward patients. The authors suggest that incorporating the patient voice can enhance knowledge regarding why diagnostic errors occur and inform targeted interventions for improvement. An Annual Perspective discussed ongoing challenges associated with diagnostic error. The Moore Foundation provides free access to this article.

Lack of transparency regarding errors in patient care contributes to harm, mistrust, and inclination toward legal action. This commentary offers insights from a parent whose daughter died from medical error and the resistance she faced when trying to understand what happened. The author encourages health care to embrace strategies that improve dialogue and explanation regarding errors including communication-and-resolution programs.

Engaging patients in their care is gaining recognition as a strategy to improve diagnosis. This commentary explores the role of shared decision making in building patient and clinician relationships that enable patient-centered diagnosis.

Detecting adverse events remains a challenge across health care settings. This prospective study conducted in multiple pediatric inpatient settings used medical record review, clinician reports, and hospital incident reports to identify adverse events. Investigators compared adverse events detected with these mechanisms to adverse events identified through interviews with parents and caregivers of pediatric patients. As with previous studies, two physicians reviewed all incidents and rated the severity and preventability of all incidents. About half the incidents reported by family members were determined to be safety concerns; fewer than 10% of these incidents were felt to be preventable adverse events. Family-reported error rates were similar to error rates drawn from actively eliciting error reports from clinicians. Families were able to identify preventable adverse events that were not detected by any other method. Error rates calculated from hospital incident reports were much lower than those drawn from either clinician or family reports, consistent with prior studies. These results demonstrate that families can identify otherwise undetected adverse events and their input should be elicited in safety surveillance systems.

This commentary discusses patient safety education during medical school and describes a framework for integrating this topic into curriculum.

This commentary reviews the death of a patient to identify factors that contributed to the incident, including cognitive biases and poor communication between clinicians, and recommends strategies to address them.