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This quarterly commentary explores a wide range of subjects associated with patient safety, such as the impact of disruptive behavior on teams, the value of apologies, and safety challenges due to COVID-19. Older materials are available online for free.

Improving patient safety related to radiology and radiation oncology is an ongoing priority. This special issue explores themes related to radiology and radiation oncology, including monitoring and improving quality of care, promoting a culture of safety, and measuring, reporting, and learning from errors.

Otolaryngology-head and neck surgery is vulnerable to wrong site errors and other challenges present in surgical care. This series of articles highlights key areas of importance for the specialty as they work to enhance patient safety. The 2022 installment covers the role of simulation.

Research and error reporting are important strategies to uncover problems in health system performance. This special issue highlights vendor transparency and context as important areas of focus to ensure electronic health records (EHR) research and reporting help improve system reliability. The articles cover topics such as a framework for research reporting, design of randomized controlled trials for technology studies, and designing research on patient portal enhancement.

Medication safety is a worldwide challenge. This special issue discusses factors affecting the reliability of the ordering, dispensing, and administration of medications across a range of environments. Articles cover topics such as the need to deepen understanding of safety in community pharmacies, the use of smart pumps for high-alert medications, and the international effort to reduce medication-related harm.

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.

This news investigation chronicles a series of incidents in a transplant program that resulted in patient harm. The systemic nature of the problems such as insufficient whistleblower protection, accountability, and follow-up on patient concerns culminated in a change of hospital leadership. A previous PSNet interview with Charles Ornstein discussed the role of media in raising awareness of patient safety issues.

The Institute of Medicine report, To Err Is Human, marked the founding of the patient safety field. This special issue of Health Affairs, published 20 years after that report, highlights achievements and progress to date. One implementation study of evidence-based surgical safety checklists demonstrated that leadership involvement, intensive activities, and engagement of frontline staff are all critical to successful adoption of safety practices. Another study demonstrated that communication-and-resolution programs either decreased or did not affect malpractice costs, providing further support for implementing such programs. Experts describe the critical role of human factors engineering in patient safety and outline how to enhance the use of these methods. The concluding editorial by David Bates and Hardeep Singh points to progress in reducing hospital-acquired infections and improving medication safety in acute care settings and highlights remaining gaps in the areas of outpatient care, diagnostic errors, and electronic health record safety. In the related information, the Moore Foundation provides free access to five articles in this special issue.

Incidence of maternal harm is increasing in the United States. This news article series reports on factors that contribute to preventable maternal mortality, such as omission of recommended care processes, lack of patient-centeredness, and missed or delayed diagnoses of serious conditions.

Both organizational and national strategies are required to reduce opioid-related harm. This special issue section explores one health system's efforts to address the opioid epidemic. Articles discuss emergency department prescribing behaviors, use of clinical decision support to manage chronic noncancer pain, and the role of pain specialists as partners in improvement.

Maternal mortality is a sentinel event that affects mothers and families across a wide range of socioeconomic characteristics. This news series reports on the incidence of maternal death, individual stories of harm, and factors that contribute to the problem.

Iatrogenesis—an adverse effect of medical care—is an area of focus in patient safety. Articles in this special issue explore cases involving iatrogenic harm in pediatric care as learning opportunities for pediatricians. Topics covered include psychological harm following a neonatal intensive care unit stay and the etiology of iatrogenesis in pediatrics.

Improving diagnosis has recently been recognized as a primary focus for patient safety. This collection highlights particular clinical areas of concern such as neurology and infectious disease. The articles offer expert commentary and review strategies to avoid common reasoning errors.

Identifying and addressing organizational factors that enable individual missteps can generate lasting improvements. Exploring challenges to system-level efforts to learn from failure in health care, articles in this special issue discuss the importance of evaluation as a learning strategy, prioritization of improvement efforts, and leadership engagement to initiate innovation.

The NHS Safety Thermometer was a tool developed by the National Health Service to facilitate staff participation in measuring patient harm in various care environments. This report collection explores the data collected on four types of health care–acquired conditions (pressure ulcers, falls, catheter–associated urinary tract infections, and venous thromboembolisms) in NHS patients over a 5-year period. The NHS Safety Thermometer is no longer used as an official data type.