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.

High reliability organization (HRO) principles used in other high-risk industries (such as aviation) can be applied patient safety. This article provides an overview of how HRO principles (preoccupation with failure, situational awareness, reluctance to simplify, deference to expertise, and commitment to resilience) can be successfully applied in dentistry.

Assessing risk and learning from adverse events are core components of patient safety improvement. The authors propose a method which leverages a radiation oncology incident learning system with a simplified failure mode and effects analysis (FMEA) to analyze safety events and monitor the success of workflow changes to improve patient safety and address high-risk errors.

Communication-and-resolution programs (CRP) emphasize early disclosure of adverse events and proactive approaches to resolving patient safety issues. This editorial discusses strategies for successful implementation of CRPs highlighted in prior research, including its prioritization by institutional leadership, investment in tools and resources necessary for implementation, and the use of metrics to track CRP functioning. 

Health care systems have implemented communication-and-resolution programs (CRPs) to respond to serious errors and adverse events. Rather than a deny-or-defend strategy, CRPs facilitate full error disclosure, investigation into the cause, an apology, and early compensation. Some systems have had great success with CRPs and most see them as a morally wise approach to errors. However, concerns that CRPs will increase malpractice costs has limited widespread implementation. Investigators analyzed malpractice costs at four hospitals that implemented CRPs compared with matched control hospitals. Communication-and-resolution programs had either a positive or neutral effect on all metrics including new claims rate, paid claims rate, and total liability costs. This analysis is the most robust to date supporting CRP programs as previous studies have lacked a control group. A previous PSNet interview with Michelle Mello discussed other intersections between patient safety and the law.

Communication-and-resolution programs, in which health systems and liability insurers disclose errors, apologize, and offer compensation to patients and families, led to declines in malpractice costs in prior studies. However, some have raised concerns that actual implementation of these programs may not have the same benefits. This prospective observational study reports results following implementation of a communication-and resolution-program at four hospitals in Massachusetts. Investigators report that the program was largely implemented as intended. Less than 10% of events met criteria for compensation, and the median payment was $75,000, allaying concerns about high costs of these programs. Lawsuits occurred in 5% of cases. The authors conclude that these results support further implementation and evaluation of communication-and-resolution programs. A recent PSNet interview with Michelle Mello, the lead author of this study, discussed legal issues in patient safety.

Patient safety problems can be difficult to detect. This study used electronic health record data—such as diagnostic codes, laboratory test values, and pharmacy information—to identify adverse events in an automated fashion. The authors conclude that the administrative harm measurement tool can detect adverse events accurately enough for internal quality improvement purposes, but the tool is insufficient to compare harm across institutions.

Researchers in this study reviewed patient feedback posted on a hospital's Facebook page to determine whether social media may be a helpful mechanism for identifying patient safety and quality improvement issues. In this small sample of 37 respondents over a 3-week period, insights from social media comments did not seem to add much to the feedback already collected by more traditional methods, such as patient satisfaction surveys.

This article examines unique challenges and approaches for teamwork communication on a general medical unit, where team members are often physically separated in space and time.

This commentary proposes a model for implementation of a disclosure program drawn from the experience of a three-hospital health system.

Hospitalists are the fastest-growing medical specialty in the US, but their effect on quality of inpatient care has not been comprehensively assessed. This large observational study compared outcomes of patients cared for by hospitalists, general internists, and primary care physicians. Inpatient mortality and readmission rates were similar across all three groups of patients, and while hospitalists' patients had a slightly shorter length of stay, costs of care were also similar across groups. The study also did not find a relationship between case volume and outcomes. 

This piece outlines steps taken by a large academic tertiary care facility to reduce surgical complications. Through its participation in a Surgical Infection Prevention (SIP) collaborative project, the hospital now places greater emphasis on improved reliability of processes, particularly in the use of antibiotics.

… of computerized physician order entry (CPOE) in U.S. hospitals has remained slow , and most prior research has …

The investigators studied an incentive-based voluntary reporting system in an emergency department and found that approximately half of errors were recovered, mainly by nurses, and that unrecovered errors impacted patients, most often with a delay in hospital stay.