Recently I sat patiently in an examination room while my physician typed notes into a computer terminal. After a few moments, he paused and asked, “You know what electronic medical records are good at?” I smiled politely. “Federal compliance and billing,” he said. I didn’t have to wait long for the follow-up I knew was coming. “You know what they’re bad at? Caring for patients.”

Earlier this year, the National Patient Safety Foundation’s Lucian Leape Institute released a report calling for greater transparency in healthcare as a means of improving patient safety. Defining transparency as “the free, uninhibited flow of information available to the scrutiny of others,” the report argues for transparency across all areas of healthcare: between clinicians and patients; among clinicians; between organizations; and with the public (NPSF Lucian Leape Institute, 2015).

In our cover feature, Deborah Wachenheim tells the story of a grassroots effort in Massachusetts that resulted in a mandate for every hospital in the state to have a patient and family advisory council (PFAC). Now, five years after the mandate went into effect, PFACs are in use in many hospitals across the country. Deborah, who was involved in the Massachusetts movement, also describes experiences and lessons learned in two hospitals—an academic medical center and a community hospital.

In 1996, the Institute for Safe Medication Practices (ISMP) began describing cases of inadvertent intravenous (IV) administration of liquid substances meant for administration via feeding tubes (Using oral syringes, 1996). Of course, incidents had been happening long before that time, putting patients who simultaneously have IV lines and small-bore nasogastric (NG) feeding tubes or percutaneously inserted gastric tubes at risk.

Announcing our 39th Annual Health Care Quality & Patient Safety Conference

Although recent publications have enhanced our understanding of the second victim phenomenon, many questions remain unanswered. In an effort to explain this possible career-ending circumstance, the vast majority of the literature focuses on describing the second victim experience.

A medical malpractice claims review identifies key contributing factors related to harm in the diagnosis and treatment of breast cancer.

The National Practitioner Data Bank (NPDB or Data Bank)—the nation’s leading source for verifying practitioners’ licensure, clinical privileges, disciplinary events, and malpractice payment histories—opened its doors a quarter century ago, on September 1, 1990. It now contains well over one million reports, more than 40% of which concern physicians. Other reports concern dentists, nurses, pharmacists, chiropractors, and all other types of licensed practitioners. The Data Bank’s information is rated as accurate, timely, and appropriate by almost all users, whether they are required by law to obtain Data Bank information or do so voluntarily.

The modern concept of informed consent was born barely a century ago in Schloendorff v. Society of New York Hospital—a 1914 case establishing that procedures performed on a person without the patient’s explicit permission are a form of battery. The notion that risks and alternatives must be disclosed to a patient was established in 1957 in Salgo v. Leland Stanford Jr. University Board of Trustees. That idea was further refined in 1972 in Canterbury v. Spence to specify that the risks disclosed should include those that a reasonable patient might want to know.

As decreasing reimbursement rates continue to flog hospital budgets, organizations struggle to find ways to reduce their costs. As labor represents approximately 60% of hospital expenditures, staffing remains a prime target for reductions.