Dr. Schulz Moore is the Director of Learning and Teaching at the University of New South Wales Faculty of Law and an Associate with the University of New South Wales School of Public Health and Community Medicine. Her research in health law draws from her unique training in public health, law, and health social sciences. We spoke with her about disclosure and apology in health care as well as the intersection between health and legal systems in Australia, New Zealand, and the United States.

Dr. McDonald is President of the Center for Open and Honest Communication at the MedStar Institute for Quality and Safety, and Adjunct Professor of Law at Loyola University-Chicago School of Law and the Beazley Institute for Health Law and Policy. An internationally recognized patient safety expert, he served as a lead architect for the Communication and Optimal Resolution (CANDOR) toolkit, supported by AHRQ. We spoke with him about lessons learned over the years regarding event reporting and his insights about building and disseminating communication-and-resolution programs.

Dr. Krumholz is Professor of Medicine at the University of Yale School of Medicine and Director of the Yale-New Haven Hospital Center for Outcomes Research and Evaluation. We spoke with him about readmissions and post-hospital syndrome, a term he coined in an article in the New England Journal of Medicine to describe the risk of adverse health events in recently hospitalized patients.

This piece explores the risks patients face after hospital discharge and strategies to address them, such as patient education, Project RED, and the Care Transitions Intervention.

Patient engagement is widely acknowledged as a cornerstone of patient safety. Research in 2018 demonstrates that patient engagement, when done correctly, can help health care systems identify safety hazards, regain trust after they occur, and codesign sustainable solutions.

This piece highlights the advantages to and limitations of engaging patients in patient safety.

This piece, written by a national leader in safe use of medications in elderly patients, discusses strategies for improving the quality and safety of medication use in the nursing home setting.

This piece discusses how medical centers can improve handover quality and patient safety.

An Associate Professor at the University of Chicago, her research focuses on resident duty hours, handoffs, and professionalism.

In 1990, a Harvard-based research team reported the incidence of medical errors in the state of New York, based on the hospital discharge analysis of 30,121 cases.

Peter J. Pronovost, MD, PhD, is a Professor of Anesthesia, Critical Care, and Health Policy at Johns Hopkins University and Director of the Johns Hopkins Quality and Safety Research Group. He may be best known for having led the Michigan Keystone project, which used checklists and other interventions to markedly reduce catheter-associated bloodstream infections in ICUs throughout the state. For this work and more, he received a MacArthur Foundation Fellowship, and Time Magazine named him as one of the 100 most influential people in the world.

Clear health communication is increasingly recognized as essential for promoting patient safety. Yet according to a recent Joint Commission report, What Did the Doctor Say?

Frontline health care providers are challenged by poorly performing work systems. Required equipment is broken, patient medications are in the wrong dose, key information fails to get communicated, and essential supplies are out of stock.(

Workarounds

Dean Schillinger, MD, is a Professor of Medicine at University of California, San Francisco, Director of the UCSF Center for Vulnerable Populations, and Chief of the California Diabetes Prevention and Control Program. His role as a practicing clinician at a safety net hospital (San Francisco General Hospital) has put him in a unique position to pursue influential and relevant research related to health literacy and improving care for vulnerable populations.

Clear health communication is increasingly recognized as essential for promoting patient safety. Yet according to a recent Joint Commission report, What Did the Doctor Say? Improving Health Literacy to Protect Patient Safety, communication problems among health care providers, patients, and families are common and a leading root cause of adverse outcomes.

Disclosure of medical error is inextricably linked to today's patient safety efforts. Health care experts advocate that greater disclosure is necessary to achieve complete transparency and ameliorate barriers to error reporting.(1,2) Of course, the ethical obligations triggered by the occurrence of a medical error are not to be overlooked.