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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.
Maher V, Cwiek M. Hosp Top. 2022;Epub Jul 20.
Fear of criminal liability may inhibit clinicians from reporting medical errors, thereby reducing opportunities for learning. This commentary discusses recent legal actions brought against clinicians, including Tennessee nurse RaDonda Vaught, and the negative impact such actions may have on the longstanding disclosure movement.
Ibrahim SA, Reynolds KA, Poon E, et al. BMJ. 2022;377:e063064.
Accreditation programs such as The Joint Commission are intended to improve patient safety and quality. Investigators evaluated the evidence base for 20 actionable standards issued by The Joint Commission. Standards were classified by the extent to which they were supported by evidence, evidence quality ratings, and the strength of the recommendation.

Clark C. MedPage Today. May 20, 2022.

Public reporting of safety measures is considered a hallmark of health care transparency. This article discusses a proposed change to reporting requirements in the Hospital-Acquired Condition Reduction Program (HACRP). The change would limit the sharing of patient safety indicator data that informs Care Compare and hospital Medicare reimbursements.

Jewett C. Kaiser Health News. November 4, 2021.

Nosocomial infection is a primary concern due to the COVID pandemic. This news story examines instances when inpatients contracted, and sometimes died of, COVID-19 while receiving care for a different condition. It summarizes the challenges associated with collecting adequate data that completely document nosocomial spread of COVID-19 and its impact on patient outcomes.

Ross NE, Newman WJ. J Am Acad Psychiatry Law. Epub 2021 May 21.

Open disclosure of errors and adverse events is increasingly encouraged in healthcare, but clinicians frequently cite fear of malpractice lawsuits as a reason to avoid apologizing for an error. This commentary summarizes the relationship between apologies and malpractice, the emergency of apology laws in the United States, and research exploring the impact of apology laws on malpractice claims and patient outcomes.
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.  

Washington DC; United States Government Accountability Office; November 26, 2020. Publication GAO-21-7SP.

Artificial intelligence (AI) has the potential to enhance the safety and reliability of clinical and administrative functions. This US Government Accountability Office report outlines barriers impacting the widespread use of AI, such as privacy concerns and lack of development transparency. Collaboration and oversight are areas of policy focus highlighted to address these challenges.
Yong E. The Atlantic. 2020;September.
This article takes a holistic view of the multiple preventable failures of the U.S. in managing the COVID-19 pandemic, raising several patient safety issues from the metasystems perspective. The piece highlights systemic problems such as lack of transparency, investment in public health and learning from experience.

Washington DC; National Quality Forum: 2019.

The Leapfrog Group announces their 2019 grading assigning “A,” “B,” “C,” “D” and “F” letter grades to general acute-care hospitals in the U.S. The report reveals states with highest percentages with “A” grades as well as states with no “A” grades. The Leapfrog Hospital Safety Grade is peer-reviewed, fully transparent and free to the public. It shares critical patient safety information to consumers.
Byju AS, Mayo K. J Med Ethics. 2019;45:821-823.
Managing errors that affect patients who lack decision-making capacity and a designated decision-maker is a new area of concern. This commentary discusses moral, ethical, legal, and clinical reasons for health care to examine how to respond when such a situation occurs. The authors hope to motivate development of needed protocols and best practices to ensure that this vulnerable patient population is respectfully and completely informed after medical errors.
Carmack HJ. Health Comm. 2020;35:1466-1474.
Large-scale system failures can damage an organization's credibility. This commentary analyzes how one organization responded after an incident that involved 76 patients who mistakenly received fatally high doses of radiation. The strategies discussed center on the importance of organizational communication to patients, navigating the blame response, and rapid efforts to prevent similar events.
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.
Palmer J. Patient Saf Qual Healthc. May/June 2019.
Organizations must learn from adverse events to prevent similar incidents. Reporting on lessons to be learned from the cascade of failures connected with the preventable death of a patient during an acute asthma attack at the door of a hospital emergency department, this magazine article outlines the importance of effective signage, appropriate security staff placement, and acceptance of the responsibility for failure.

Gabler E. New York Times. May 31, 2019.

Pediatric cardiac surgery is highly technical and risky. This newspaper article reports on a poorly performing pediatric cardiac surgery program, concerns raised by staff, and insufficient response from organizational leadership. Lack of data transparency, insufficient resources, and limited program capabilities to support a complex program contributed to poor outcomes for pediatric patients.
Jewett C. Kaiser Health News. May 3, 2019.
Transparency has been heralded as a cornerstone to improvement in health care. This news article reports on a government alternative summary reporting program that allowed medical device makers to conceal safety events and malfunction reports associated with medical devices. A new program that expands access to information about device-related failures will be put in place.