Safety event reporting from both providers and patients is subject to bias. The authors of this commentary present several ways bias is introduced into reporting and offers strategies to ensure events are reported and analyzed in an equitable manner.

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.

… visitation, both during the pandemic and beyond. … Gandhi TK. Don't go to the hospital alone: ensuring safe, …

… safety, and continuous analysis of errors. … Adelman JS, Gandhi TK. COVID-19 and patient safety: time to tap into our …

… methods to prevent harm. … Singh H, Sittig DF, Gandhi TK. BMJ Qual Saf. 2021;30(2):141-145. …

The authors present a nomenclature to describe eight types of diagnostic errors anticipated in the COVID-19 pandemic (classic, anomalous, anchor, secondary, acute collateral, chronic collateral, strain and unintended diagnostic errors) and highlight mitigation strategies to reduce potentially preventable harm, including the use of electronic decision support, communication tactics such as visual aids, and huddles. Organizational strategies (e.g., peer-support, duty hour limits, and forums for transparent communication) and state/federal guidance around testing and monitoring diagnostic performance are also discussed.

Huddles are one technique to enhance team communication, identify safety concerns and built a culture of safety. This systematic review synthesized 24 studies examining the impact of either unit-based or hospital-wide/multiunit safety huddles. The majority of studies were uncontrolled pre-post study designs; only two studies were controlled and quantitatively measured intervention adoption and fidelity. Results for unit-based huddle programs appear positive. Given the limited number of studies evaluating hospital-wide huddle programs, the authors conclude that there is insufficient evidence to assess the benefit. Further research employing strong methodological designs is required to definitively assess the impact of huddle programs.

… , and (4) patient engagement and codesign of healthcare. … Gandhi TK, Feeley D, Schummers D. Zero harm in health care …

… training programs. In a past PSNet interview , Dr. Tejal Gandhi, president of the IHI/NPSF Lucian Leape Institute, …

Board and leadership engagement is considered critical for advancing patient safety. In this survey study, safety and quality leaders rated board and executive leaders as less engaged in patient safety and quality compared to executive and board member self-perceptions. These findings suggest room for enhanced executive engagement.

The copy-and-paste phenomenon represents one of the unintended consequences of electronic health record implementation and may introduce risks to patient care. The authors of this systematic review concluded that though copying and pasting information is common, the evidence supporting an adverse impact on patient safety remains limited.

System failures can remain undetected over time in large organizations. This perspective describes elements of a health care research environment that enabled lapses in safety, such as financial pressures and shifting priorities. The author calls for industry-wide learning from this example to ensure that patient safety remains a priority and that organizations invest and commit to an infrastructure that encourages safety.

This randomized controlled trial at two academic medical centers studied the potential benefits of providing pharmacist medication reconciliation and counseling, along with individualized telephone follow-up after discharge, for adult patients hospitalized with acute coronary syndrome or acute decompensated heart failure. This extensive intervention did not reduce readmissions or emergency department visits within 30 days of discharge, though there was a small positive effect seen in patients with low health literacy.

Adverse drug events (ADEs) are a common source of patient harm in the ambulatory setting. A substantial proportion of ADEs are caused by preventable errors in medication prescribing or monitoring. The introduction of computerized provider order entry (CPOE) has been shown to reduce the rate of medical errors in the inpatient setting. This before–after study examined rates of ADEs in primary care practices that implemented a CPOE system in Boston and Indianapolis. At baseline, the potential ADE rate was more than seven-fold greater in Indianapolis compared to Boston. Following CPOE implementation, this rate decreased by 56% in Indianapolis but increased by 104% in Boston, and there was no change overall in preventable ADEs. A recent PSNet annual perspective reviewed the relationship and current evidence linking CPOE and patient safety.

This commentary discusses findings from the National Patient Safety Foundation report investigating the state of patient safety in the 15 years after To Err Is Human. Focusing on the recommendation that leadership establish and sustain a culture of safety, the authors describe how leaders can engage board members and organizational leadership in this work and highlight the need to provide leaders with education and practical tools.

… of barcode technology systems. … Leung AA, Denham CR, Gandhi TK, et al. A safe practice standard for barcode …

Past commentaries have explored the tension between balancing no blame and individual accountability for medical errors. This commentary summarizes a debate exploring accountability in patient safety, with one argument describing the need for health care to differentiate individual failures from systems problems and an opposing perspective suggesting that incorporating blame would hinder progress in patient safety.

The communication of critical test results is a National Patient Safety Goal. This study describes an automated alert notification system for critical imaging results at a large academic medical center. The introduction of the system led to better closed-loop communication and appropriate documentation.

This commentary describes the development of a quality and safety clinical fellowship curriculum which focused on identifying core competencies and then incorporating training for these principles in an operational setting. A companion article explores the implementation of this curriculum at hospitals affiliated with Harvard Medical School.

An automated secure e-mail system successfully increased inpatient attending physicians' awareness of tests pending at hospital discharge.