Patients and caregivers are important partners in promoting safe care. Findings from this cross-sectional study reinforce the importance of patients’ perceived roles in ensuring safe surgery and highlight the importance of patient engagement in mitigating surgical site errors.

This analysis of medical malpractice claims identified four leading causes of anesthesia-related claims involving ambulatory surgery centers – dental injuries, pain, nerve damage, and death. The authors discuss the role of preoperative risk assessment, use of routine dental and airway assessment, adequate treatment of perioperative pain, and improving communication between patients and providers.

This article draws on interviews and observations to explore medical iatrogenesis in obstetric care. The authors discuss how various factors – such as universal management plans, labor and delivery interventions, and informed consent – contribute to iatrogenic harm and worse perinatal outcomes for racial/ethnic minority patients.

This study explored views, practices, and needs related to patient counseling on medication safety in obstetrics and gynecology. Survey responses from over 500 OB/GYNs indicate opportunities to improve available resources and information sharing, such as developing new tools to communicate about teratogenic medications and pregnancy-safe over-the-counter medications and dietary supplements.

This article discusses the challenges COVID-19 poses for shared decision making (such as physical distancing and health service reallocation, communicating uncertainty, delivering allergy/immunology care) and opportunities to evolve incorporation of shared decision making into clinical practice during and after the pandemic.

Advanced Directives (AD) and Physician Orders for Life-Sustaining Therapy (POLST) are intended to improve end-of-life care by ensuring that patient's wishes are honored by health care providers. This perspective presents two cases in which preventable errors allowed for the use of unwanted life-sustaining therapies. Root cause analyses for these cases found that haste, inadequate communication, EMR discrepancies, knowledge deficits contributed to these errors. 

The process of informed consent is designed to ensure that patients fully understand risks, benefits, and alternatives when receiving certain treatments. In this mixed-methods study, researchers examined the impact of two Agency for Healthcare Research and Quality informed consent training modules across four hospitals.

By employing improvement science methods, a quality improvement initiative virtually eliminated surgical consent errors at a pediatric academic medical center.

Written consent forms often introduce issues related to legibility and completeness. A Web-based system for booking elective surgical procedures improved the rate of obtaining and documenting informed consent in a community hospital system.

This observational study explored nurses' dynamic and complex interactions on maternity wards.

In this study of simulated cholecystectomies, surgical residents felt ill-trained to disclose both complications (common bile duct injury) and serious incidental findings (gallbladder cancer) encountered during a cholecystectomy. Most concerning, a large proportion of residents did not adequately describe potential complications when obtaining informed consent.

The Leapfrog Group has been a major driver of patient safety efforts—more than 1000 hospitals have committed to implementing its recommendations for computerized provider order entry, intensivist coverage for critically ill patients, evidence-based referral for certain diagnoses, and implementation of the National Quality Forum's (NQF) Safe Practices. A prior study found that hospitals that had implemented at least one Leapfrog practice tended to provide higher quality of care for specific diagnoses. However, in this study, adoption of the NQF safe practices did not correlate with reduced inpatient mortality. The authors note that many hospitals could score highly on the Leapfrog Hospital Survey but not fully implement or consistently follow safety recommendations, as the survey only measures a hospital's self-reported implementation of safety practices.

This case report describes an error in which physicians mistook a patient's living will for a do-not-resuscitate (DNR) order. The authors discuss common misunderstandings about advanced directives and DNR orders as well as how such mix-ups may affect patient care and safety.