Patient safety progress is dynamic, consistently producing evidence for application to generate improvements. This report is the fourth in a series funded by the Agency for Healthcare Research and Quality to track a prioritized set of emerging and existing safety approaches to confirm their value and effectiveness. This report will be compiled as new conclusions are formulated. Each review will be posted to the collection as they are completed. The first three Making Healthcare Safer reports, published in 2001, 2013, and 2020, have each served as a consolidated evidence source for clinicians, health system leadership, researchers, and government agencies. Chapter protocols and the results of an examination of harms associated with video-based telehealth are now available. 

Organizational efforts to collect and respond to the concerns of staff and patients are a cornerstone to patient safety improvement despite challenges to implement them. This annual report presents insights drawn from problems staff share with Freedom to Speak Up Guardians in the United Kingdom to capitalize on problems to drive improvement. The 2023 report summarized data collected from over 25,000 cases recorded.

Health information systems are fundamental tools for documenting adverse event trends within and across patient populations. This report highlights weaknesses in the web-based incident reporting system employed to track quality of care for American Indians and Alaska Natives. Recommendations for improvement focus on increasing leadership engagement and use of the data collected to examine instances of patient harm or near misses in the American Indians and Alaska Native patient population.

Delays in emergency care provision can contribute to patient harm. This analysis examined an instance of cardiopulmonary resuscitation (CPR) delay and the poor response once the emergency was identified at an outpatient clinic. System-level issues flagged include incomplete incident records and follow up. Staff training, emergency notification, CPR process compliance, and debrief results completion were among the recommendations for improvement.

Following an investigation into the death of 11-month-old Elizabeth Dixon in the UK’s National Health System (NHS), a report with 12 recommendations for system improvement was released. This report sets out the government’s response to each recommendation, including the agency responsible for each recommendation, where applicable.

Patient safety has long drawn from aviation safety strategies to inform improvement. This article examines the potential for transparency and learning should a National Patient Safety Board be established in the United States. Like the National Transportation Safety Board concept, the proposed agency would collect data on facilities where errors occurred, which is discussed as a barrier to acceptance of the safety board approach in health care.

This annual report shares the results of Western Australia's sentinel event reporting program. Medication errors were the highest recorded sentinel event in the latest period. The data is placed in the context of the overall data collected over the last 5 years of the program.

Emergency room failures are often rooted in system weaknesses. This series examines six patient deaths associated with emergency care that, while concerns were raised by nursing staff, have not been explored to initiate improvements at the facility. Factors contributing to the deaths discussed include nurse shortages, inconsistent oversight, and poor training.

The need for a national government-led patient safety effort has long been advocated for. This legislation outlines the structure of a federal agency to provide support for patient safety data collection, national incident analysis, and recommendation development.