Parents of children with medical complexity can offer unique perspectives on hospital quality and safety. Prior to their child's discharge, parents were surveyed about their child's care, medications, safety, and other concerns experienced during their stay. Parents reported experiencing miscommunication with the providers and providers seemingly not communicating with each other. They also reported inconsistency in care/care plans, unmet expectations, lack of transparency, and a desire for their expertise to be taken seriously.

Learning from mistakes is an important component of medical education. In this study, medical residents at one large Canadian hospital participated in semi-structured interviews exploring how residents experience and learn from medical errors. Residents described learning to differentiate errors from complications, how the work environment and workload creates vulnerabilities, approaches to manage errors, and identifying avenues for support in order to move past an error.

Patients who experience life-changing adverse events due to errors, and their families, typically want disclosure of the error and appropriate accountability. This systematic review identified 41 studies exploring the views of those affected by adverse events. Four themes were identified: transparency, person-centeredness, trustworthiness, and restorative justice. Applying these themes to investigations may result in ensuring the process and outcomes are experienced as "fair" to those impacted.

Numerous organizations promote communication with patients and families after harm has occurred due to medical error. This commentary reflects on perceived barriers to patient disclosure and describes the patient and family perspectives and needs following harm. The authors promote the use of Communication and Resolution Programs (CRP) such as the learning community Pathway to Accountability, Compassion, and Transparency (PACT) to advance research, policy, and transparency regarding patient harm.

While medical trainees and residents agree that disclosing errors to patients is important, they also perceive barriers to doing so. In this study, surgical trainees described factors influencing their decisions not to disclose errors despite their intention to do so. Even with formal communication trainings throughout the program, participants reported a lack of sufficient education in error disclosure. Workplace culture and role-modelling influenced their own disclosure practices both positively and negatively.

Reporting and learning from adverse events are core components of patient safety. In this qualitative study involving 15 surgeons from four academic hospitals in Norway, researchers identified several individual and structural factors influencing serious adverse events as well as both positive and negative implications of transparency regarding adverse events. The authors highlight the importance of systemic learning and structural changes to foster psychological safety and create space for safe discussions after adverse events.

Effective apology for medical mistakes is a cornerstone for healing and improvement. This piece discusses the impact sincere and complete apologies may have on legal resolutions of patient harm. They discuss the current presence of apology laws at the state level and the limited role they play in protecting clinicians who err and apologize in a court of law.

Medical errors in the neonatal intensive care unit (NICU) are common and can result in significant patient harm. This prospective observational study conducted at 10 NICUs in France found that approximately 41% of the 1,822 errors (among 1,019 patients) were disclosed to the patient’s parents. Providers cited parental absence (i.e., the error occurred overnight) and perceived lack of serious consequences for the infant as the most frequent reason for non-disclosure.

Patients and families expect full, timely disclosure after incidents. This realist synthesis examines research on patient disclosure to inform what is required to strengthen disclosure in maternity care. Five key themes were identified, including meaningful acknowledgment of harm and opportunities for patients and families to be involved in the follow-up.

Disclosure of adverse events to patients and families is an important component of safety culture. AHRQ's Communication and Optimal Resolution (CANDOR) program provides tools to guide the disclosure process as well as peer support for healthcare providers (HCP) involved in the adverse event. This study aimed to identify associations with CANDOR implementation and HCP job satisfaction. Results indicate implementation of CANDOR increased some measures of HCP job satisfaction and trust in leadership, a novel finding not previously reported.

Trust between patients and providers is essential to safe, effective healthcare. This survey of German patients undergoing implant surgeries (e.g., hip and knee replacements, dental implants, cochlear implants) found that adverse events negatively impact patient trust in their physicians, but effective patient-provider communication can mitigate the impacts.

Reducing diagnostic errors is a primary patient safety concern. This qualitative study based on interviews with 17 providers and two focus group with seven patient advisors found broad agreement that diagnostic errors pose a significant threat to patient safety, as participants had difficulty defining and describing, and correctly identifying. the frequency of diagnostic errors in acute care settings. Participants cited issues such as communication failures, diagnostic uncertainty, and cognitive load as the primary factors contributing to diagnostic errors.