Lack of respect for the concerns of patients and sensitivity to their situation detract from their safety and trust in the health care system. This story relates firsthand experience of maternal mistreatment of those harmed while receiving care.

This compendium of editorials and opinion pieces discuss “Martha’s Rule,” a new policy in the United Kingdom motivated by the death of a pediatric patient to sepsis and the systemic weaknesses contributing to the adverse outcome. The policy is intended to encourage patients and caregivers to request a second opinion if a patient’s health condition is deteriorating and they feel their concerns are not being taken seriously by the healthcare team. The articles discuss the importance effective communication between clinicians, caregivers, and patients, mitigating adverse impacts of hierarchies, and the role of patient and caregiver engagement in the design of safe healthcare systems.

Patient and family engagement can improve individual health outcomes and may help identify potential safety hazards. This report describes the economic impact of patient engagement, results of pilot data collection to measure patient-reported experiences of safety, and the status of patient engagement in 21 countries.

Engaging patients to capture their insights after diagnostic error is one of the top patient safety strategies. This pair of issue briefs describes how organizations can use patient experience to inform improvements in diagnosis. Volume 1: Why Patient Narratives Matter highlights how patient perspectives offer unique information about the impacts of diagnosis-related events on patient care trajectories through the healthcare system. Volume 2: Eliciting Patient Narratives emphasizes that rigorous methods are needed to elicit patient experiences. Both briefs identify areas in which more research is needed about patients’ diagnostic experience.

Lack of accountability for systemic contributions to failure degrades efforts to generate improvement. This report discusses gaps in the British National Health Service patient safety culture. It calls for governmental oversight and commitment as the central activation lever necessary to achieve collective, coordinated effort and motivate large-scale action to support lasting change.

Unnecessary medication infusions indicate weaknesses in medication service processes. While no harm was noted in the case discussed, the actions by the patient’s family to initiate an examination of the incident were rebuffed, patient disrespect was demonstrated, a near miss incident report was absent, and data omissions took place. The piece discusses how these detractors from safety were all present at the hospital involved.