The National Quality Forum has defined 29 never events—patient safety problems that should never occur, such as wrong-site surgery. Since 2003, Minnesota hospitals have been required to report such incidents. The 2022 report summarizes information about 572 adverse events that were reported, representing a significant increase in the year covered. Earlier reports prior to the last two years reflect a fairly consistent count of adverse events. The rise documented here is likely due to demands on staffing and care processes associated with COVID-19 and general increases in patient complexity and subsequent length of stay. Pressure ulcers and fall-related injuries were the most common incidents recorded. Reports from previous years are available.

This reoccurring report compiles patient safety data collected by Massachusetts hospitals. The 2022 numbers document an increase in serious reportable events recorded in acute care hospitals, from 1430 the previous year to 1632. This presentation also includes events from ambulatory surgery centers. Older reports are also available.

In this annual publication, AHRQ reviews the results of the National Healthcare Quality Report and National Healthcare Disparities Report. The 2022 report discusses a decrease in life expectancy due to the COVID-19 pandemic. It also reviews the current status of special areas of interest such as maternity care, child and adolescent mental health, and substance abuse disorders. 

Checklists are integrated into error reduction strategies and healthcare team communication efforts worldwide but implementation and impact of the tool varies widely. This report examines the use of the WHO Surgical Safety Checklist and barriers to its uptake which include lack of effective staff introduction to the content, misperceptions about the time needed to use the tool and ineffective local contextualization of the content and process.

The Partnership for Patients program has supported the Hospital Engagement Networks since 2011. This report reviews the results of the second round of funded effort, which involved more than 1500 hospitals in the United States that prevented 34,000 harms from September 2015 to September 2016. Areas of improvement included reductions in surgical site infections, adverse drug events, and postoperative complications. The authors also highlight core strategies of the program, such as evidence dissemination and coaching.

This intensely personal memoir by the famed British neurosurgeon Henry Marsh is no hagiography or recitation of his many accomplishments. Instead, Marsh relates many errors he has committed or witnessed, and the personal toll these errors have taken on his patients and himself. He recreates these stories in vivid detail, acknowledging the effect that his own emotional state had on committing both cognitive and technical errors. Marsh was inspired to write this book in part by reading the work of Daniel Kahneman, the Nobel Prize–winning psychologist whose research established the mechanisms by which humans commit cognitive errors. Along with Atul Gawande's Complications, this book stands as an essential human perspective on error in medicine.

This report provides background on the Minnesota Never Events reporting initiative, tips for patients on how to receive the safest care possible, and a table of events reported by all hospitals in the state.

This analysis of patient safety in Medicare patients from 2005–2007 concludes that while modest improvements have been made, patient safety incidents still account for nearly 100,000 preventable deaths and nearly $7 billion in excess costs yearly. The report also recognizes the best performing hospitals with a "Patient Safety Excellence Award"—hospitals scoring in the top 15% according to a ranking methodology developed by the authors. As with prior HealthGrades reports, the study uses the Agency for Healthcare Research and Quality (AHRQ) Patient Safety Indicators (PSIs) to measure the incidence of patient safety problems and compare hospitals. The limitations of using PSIs as a performance measure have been discussed in a prior study and AHRQ WebM&M commentary, and it is important to note that this report did not undergo external peer review.

Using survey data as well as information on patient safety indicators, this report provides an update on the frequency of certain types of errors and incidents in Canada.

This book includes essays on the social and professional conventions that can affect a physician's ability to provide safe and effective care. Gawande, a surgeon and frequent contributor to The New Yorker, previously wrote the acclaimed book Complications and received a 2006 MacArthur Fellowship.

This collection of reports provides annual findings on the number and rate of health care-acquired infections in Pennsylvania hospitals. The 2010 analysis found the most common HAI to be surgical site infections and urinary tract infections and a slight reduction in patient iatrogenic infections from the previous year.

In Complications, Gawande reprises and builds on a series of feature articles, several written for the New Yorker during his surgical residency at Harvard, exploring the imperfect science of medicine. Part I, Fallibility, explores several patient safety issues. Part II, Mysteries, presents a series of remarkable cases that perplex even the most seasoned clinicians. Lastly, Uncertainty explores the common situations in medicine in which even highly trained physicians are required to act with imperfect knowledge. Written for both practitioners and patients, Complications effectively opens up the fascinating, previously hidden world of surgery to its readers.

In this seminal study, Bosk, a medical sociologist at the University of Pennsylvania, spent a year observing the surgical residents and faculty at an unnamed hospital, in the process exploring the balance between autonomy and oversight in medical training, how physicians deal with their errors, and the nature of accountability in the medical profession. This edition, published more than two decades after Forgive and Remember was first published, includes a new prologue, epilogue, and list of appendices. The book is informative for both lay readers and clinicians.