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The dismissal of parental concerns is a known contributor to medical errors in children. This story illustrates how poor communication, lack of respect, and anchoring bias  contributed to failure in the care of a boy. The authors share actions being taken by the hospital involved in the tragedy to partner with the family to improve diagnosis practices throughout their organization.

Communication within teams is central to safe care delivery, crisis management, and staff well-being. This report shares the experience of one hospital that used technology to enhance information-sharing as a strategy to reduce clinician burnout in times of uncertainty and crisis.

Patients who have fallen in their homes and are found by a home healthcare worker are referred to as “found-on-floor” incidents. This study found that length of stay was a key theme in found-on-floor incidents and signaled underlying system-level issues, such as lack of informational continuity across the continuum of care (e.g., lack of standard documentation across settings, unclear messaging regarding clients’ home care needs), reliance on home healthcare workers instead of rehabilitation professionals, and lack of fall assessment follow-up. The authors recommend systems-level changes to improve fall prevention practices, such as use of electronic health records across the continuum of care and enhanced accountability in home safety.  

Before the emergence of COVID-19, the National Academy of Medicine had provided guidance on the reallocation of scarce medical resources – including ventilators – during extreme situations. Based on focus groups and key informant interviews conducted in 2018, this study sought to understand potential barriers arising from ethical conflicts to the implementation of these guidelines for ventilator allocation in the event of resource scarcity. Participants anticipated challenges reconciling this protocol with their roles and identities as health care providers, as well as concerns about emotional consequences, and fear of legal repercussions. These concerns raise questions about the performance of such a protocol in disaster scenarios and highlight the need for disaster preparedness drills and training.

This commentary reviews general aspects of the disclosure movement, supportive evidence, and challenges associated with liability concerns. The authors discuss barriers unique to radiology that have hindered acceptance of the practice and highlight how communication-and-resolution programs can support radiologist participation in disclosure conversations.

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.

Medication errors are common in inpatient and ambulatory environments. This commentary summarizes the research exploring the current status of medication safety incident reporting and reduction efforts in community pharmacies. The authors call for community pharmacy corporations to encourage the discussion and data sharing needed to increase transparency around incidents in this care setting. A recent PSNet interview discussed challenges to safety in the retail pharmacy environment.

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.

Effective apology behaviors improve opportunities for error resolution for clinicians, patients, and families. This commentary highlights the importance of expressing empathy, considering legal implications, and demonstrating individual, leadership, and organizational support of open disclosure.

Appropriate response to patient and family concerns after health care–associated harm is important. This commentary describes a seven-element approach to resolving family and patient issues following harmful error incidents. Strategies include providing immediate support to patients and families, rethinking legal action, committing to making changes required to address problems, and developing a communication-and-resolution program community.