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Weenink J-W, Wallenburg I, Hartman L, et al. BMJ Open. 2022;12:e061321.
There is a long-standing tension between health care regulation and just culture principles. This qualitative study explored the experiences of mental health professionals, managers and other healthcare organization staff, as well as inspectors, regarding the role of healthcare inspectors in enabling a just culture. Three themes emerged – (1) the role of the inspector as both a catalyst for learning and a potential barrier, (2) just culture involves relationships between different layers within and outside the organization, and (3) to enable just culture in which inspectors would strike a balance between organizational responsibility and timely regulatory intervention.
Carrillo I, Mira JJ, Guilabert M, et al. J Patient Saf. 2021;17:e529-e533.
While prior research has shown patients want disclosure of adverse events, healthcare providers may still be hesitant to disclose and apologize. Factors that influence providers’ willingness to disclose errors and apologize include organizational support, experience in communicating errors, and expectations surrounding patient response. A culture of safety and a clear legal framework may increase providers’ willingness to disclose errors and apologize.
LeCraw FR, Stearns SC, McCoy MJ. J Patient Saf Risk Manag. 2021;26:34-40.
Healthcare systems have implemented communication-and-resolution programs (CRPs) to respond and disclose serious errors and adverse events. This article describes methods used by nine teams of CRP advocates to encourage adoption and endorsement by hospitals and national medical societies at the national, state, and local levels.  
Hendy J, Tucker DA. J Bus Ethics. 2020;2021;172:691–706.
Using the events at the United Kingdom’s Mid Staffordshire Trust hospital as a case study, the authors discuss the impact of ‘collective denial’ on organizational processes and safety culture. The authors suggest that safeguards allowing for self-reflection and correction be implemented early in the safety reporting process, and that employees be granted power to speak up about safety concerns.
Arora S, Tsang F, Kekecs Z, et al. J Patient Saf. 2021;17:e1884-e1888.
An analysis of over 500 survey responses of healthcare professionals working in patient safety education in the United Kingdom explored facilitators and barriers to effective safety education. Interactive and experience-focused (e.g., simulations) learning were identified as ideal learning modalities; learning was most effective when combined with standardized methods and assessments, dedicated funding, and a culture encouraging transparency and speaking up. Common barriers to effective education cited by survey respondents included staffing and workload pressures, lack of accessibility (due to inconvenient timing, location or unavailable technology) and lack of awareness and buy-in for the importance of patient safety education.
Sattar R, Johnson J, Lawton R. Health Expect. 2020;23:571-583.
This systematic review used meta-ethnographic synthesis to explore patients’ and healthcare professionals’ views on, and experiences with, error disclosure. The 15 included studies highlighted a misalignment in attitudes and expectations between patients and healthcare professionals regarding error disclosure. While patients and family members emphasized the importance of disclosure with sincere regret and actions to prevent future errors, healthcare professionals cited several barriers to disclosure (e.g., blame culture, avoidance of litigation, lack of disclosure training and guidance).
Cousins D, Accidents A against M.; 2020.
Health care organizations can learn from internal and external incidents to identify potential patient safety risks and incorporate care process improvements. This report suggests that England’s National Health Service has yet to build accountability and reliability into its response to practice alerts. The authors share 4 primary concerns and recommendations to address the alert compliance gaps that focus on clarity on action expected, transparency, communication and monitoring.

James G. House Commons Report 31. Department of Health and Social Care. London, England: Crown Copyright; 2020. ISBN 9781528617284.

Sharing information from large-scale failure investigations provides insights on latent factors that contribute to patient harm. This analysis discusses a criminal case involving one surgeon in the National Health Service. The examination uncovered problems perpetuated by culture, lack of respect for patient concerns, poor complaint follow-up and organizational blindness. The report summarizes recommendations to reduce similar situations through improving patient communication, organizational accountability and complaints management.
Polit Q. 2019;90:177-342.
The National Health Service strategy of publishing their inquiries into systematic poor care in the health service is a model of transparency. Articles in this special issue summarize this legacy and the learning that has been realized by the process. The authors discuss high-profile inquiries, quality of the investigations, and the need for the work to result in sustainable change.
Macrae C. J R Soc Med. 2019;112:365-369.
Incident investigations present important opportunities for process examination and redesign. This commentary recommends five strategies to ensure investigations inform patient safety improvement. The author emphasizes a focus on system risks, redesigning systems, examination process transparency, public accountability, and consideration of patient, family, and staff experiences.
Blease CR, Bell SK. Diagnosis (Berl). 2019;6:213-221.
Despite growing support for patient involvement in safety and quality improvement, little is known about engaging patients as partners in reducing diagnostic error. This commentary summarizes research on how sharing notes with patients can improve the timeliness of follow-up to confirm a diagnosis, identify documentation errors, and strengthen communication between the clinical team and the patient. The authors discuss challenges to the successful implementation of this strategy and areas of focus needed for future development. A PSNet interview discussed use of OpenNotes to engage patients in their care.
Toffolutti V, Stuckler D. Health Aff (Millwood). 2019;38:844-850.
Understanding the key factors underlying safety culture remains critical to improvement efforts. This cross-sectional study examined whether openness was associated with in-hospital mortality in the English National Health Service. Investigators measured openness with a composite measure derived from four questions from a staff survey: comfort with speaking up about safety concerns, disclosure of safety problems to staff, knowledge of reporting practices, and perceived security in reporting safety concerns. After adjustment for hospital size, the authors found that increased openness was associated with lower mortality. This relationship suggests that openness constitutes an important aspect of a positive safety culture. The results lend weight to calls for increased transparency in health systems. A past PSNet perspective discussed the evolution of patient safety and traced its development and progress in the United Kingdom.
Donaldson LJ, Lemer C, Titcombe J. BMJ. 2019;365:l2037.
This commentary recommends that health care structure the work environment to address conditions that allow for failure. The authors discuss how increased commitment to collective accountability for improvement will result in the robust infrastructure, proactive risk assessment, and cultural conditions needed to ensure patient safety.
Cullen A. Uitgeverij van Brug: The Hague, The Netherlands; 2019. ISBN: 9789065232236.
Patient stories offer important insights regarding the impact medical errors have on patients and their families. This book shares the author's experience with medical error and spotlights how lack of transparency in European health care can contribute to avoidable process failures that result in patient harm.
Ameratunga R, Klonin H, Vaughan J, et al. BMJ. 2019;364:l706.
Recent high-profile incidents in the United States and the United Kingdom have fueled debate on the impact of criminalizing medical mistakes that result in patient harm. This article compares how the United Kingdom and New Zealand respond when patients experience unintentional health care–related harm. The authors emphasize the importance of focusing on resolution and learning to improve patient safety.
Morgan L, Benson D, McCulloch P. BMJ. 2019;364:l1037.
Investigations into medical mistakes that result in patient harm should be fair, complete, and consider the context of the event. This commentary examines investigation processes in the United Kingdom and highlights the importance of understanding how human factors contribute to error to help effectively assess each incident and support transparency and improvement.
Ost S. J Med Ethics. 2019;45:151-155.
Labeling medical negligence as a criminal act can affect transparency and disclosure behaviors across professional health care communities. This commentary discusses two high-profile cases from the United Kingdom to explore the appropriateness of assigning criminality in either instance—one centered on human error that contributed to the death of a child and the other involved negligent actions but resulted in no permanent patient harm.
Elmontsri M, Banarsee R, Majeed A. JRSM Open. 2018;9:2054270418786112.
Health care safety is a global concern. This review examined the literature on improvement experience from developed countries and identified common themes. The authors recommend a patient-centered, systems-oriented approach built on leadership, teamwork, transparency, and communication as key elements for effectively implementing improvement efforts in developing countries.
Tigard DW. J Med Ethics. 2019;45:101-105.
Balancing between explicit calls for accountability for error and constructive discussion of mistakes in health care is challenging. This editorial discusses blame in the context of medical errors and suggests that healthy acceptance of responsibility for error enables the disclosure and apology needed to generate healing and learning.