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.

… J Patient Saf Risk Manag … The July effect is a phenomenon that presumably results in poor care due to the … active, independent practice . The authors discuss how a systemic approach is required to situate these …

The COVID-19 pandemic has necessitated rapid adjustments in hospital operations to address patient care demands. This commentary discusses how one hospital system utilized their quality and safety staff during the pandemic, and how that experience informed the responsiveness of system-wide quality improvement operations.

In this editorial, patient safety experts discuss threats to healthcare safety and quality due to the COVID-19 pandemic (e.g., failures in infection prevention and control, diagnostic errors, issues with laboratory testing) and highlight positive changes and opportunities, such as improved care coordination, supply chain innovations, accelerated learning, expansion of telemedicine, and prioritizing the safety and well-being of health care workers.

… and showing gratitude for staff. … Wu AW, Buckle P, Haut ER, et al. Supporting the emotional well-being of health …

Determining which harms are truly preventable remains an ongoing challenge in the field of patient safety. In a 2016 report, the National Academies of Sciences, Engineering, and Medicine called for achieving zero preventable trauma deaths, but the actual number of preventable trauma deaths in the United States remains unknown. Analyzing administrative data from more than 18 million patients across 2198 hospitals, investigators determined that if low-performing hospitals could provide the same quality of trauma care as high-performing centers, 100,000 lives could be saved over a 5-year period.

Organizational infrastructure is important to ensure sustainability of safety improvements. This commentary describes how one academic medical center integrated structures, processes, and frameworks to build connections within the organization and throughout the community to facilitate success of improvement initiatives.

Program infrastructure that incorporates the knowledge of staff at executive and unit levels can enable system improvements to be sustained over time. This commentary describes how an academic medical center integrated departmental needs with overarching organizational concerns to inform safety and quality improvement work. The authors highlight the need for flexibility and structure to ensure success.

… This commentary describes the development and results of a multispecialty program to expand an existing academic …

Prevention of hospital-acquired venous thromboembolism (VTE) is a strongly recommended patient safety practice. This retrospective review of hospital-acquired VTE at one tertiary care hospital found that many patients who developed VTE while hospitalized were prescribed appropriate prophylaxis but did not receive all of the prescribed doses. The authors point out that since current quality metrics measure only prescription of VTE prophylaxis and not actual administration, they may overestimate hospital performance on this safety issue. Moreover, nearly half of the patients with VTE had received prophylaxis that is currently considered optimal, an important finding since VTE is often referred to as a "preventable adverse event."

… engagement. Higher levels of engagement (defined as a positive work-related mindset including dedication and absorption in one's work) was correlated with higher scores on the Safety …

This review examined the efficacy of different strategies for preventing venous blood clots during hospitalization. The most successful interventions combined education with computerized tools.

A mandatory computerized clinical decision support tool improved deep vein thrombosis (DVT) prophylaxis rates and decreased preventable DVTs in trauma patients.

Being admitted to the hospital on a weekend is potentially dangerous, as studies have shown that preventable complications and mortality are increased across a range of common diagnoses for weekend admissions compared with weekdays. One exception appears to be trauma, as a prior study found equal outcomes in patients with traumatic injuries regardless of the day of admission, a finding ascribed to the protocolized and closely supervised nature of trauma care. However, this study of older adults admitted with traumatic brain injury did find increased mortality for those patients admitted on the weekend, despite the fact that patients admitted on the weekend were less severely injured. A limitation of this study is that the authors were not able to analyze outcomes for patients cared for at specialized trauma centers. Nevertheless, the study adds to the considerable body of research documenting the dangers of weekend hospital admission.

This commentary addresses the Centers for Medicare and Medicaid Services' classification of venous thromboembolism as a never event.

… Annals of surgery … Ann Surg … Using AHRQ's Patient Safety Indicators , this study discovered that …