We have moved away from blaming individuals for mistakes to determining systemic flaws that contribute to an error and redesigning processes to prevent future mistakes.

Poor communication during hand-offs, hierarchical organizations that prevent frontline caregivers from voicing concerns, lack of patient education, and reluctance to take responsibility for errors can all have dangerous consequences for patients.

Health courts using a "no-fault" model have been proposed as a less expensive and more time-effective alternative to medical malpractice litigation, but their legality and the fairness of the verdicts they produce remains to be seen.

When a physician’s mother was hospitalized, she learned firsthand that not until safety is an emphasized part of everyone’s job description can we hope to reduce the great number of preventable errors taking place in our hospitals.

Do some pernicious patient safety problems remain unresolved, even after systems changes, because health care professionals are not personally held accountable for their failure to meet standards?

Asking for forgiveness may be oppressive to a patient or family still grappling with the fact of the harm, the impact of the harm, and their own emotional response to the harm.

Acknowledging errors and the manner in which they occur both enables doctors to hold themselves accountable and promotes understanding that can lead to error prevention.

Winner of the 2010 Bander Essay Contest, this essay discusses how primary care physicians should manage the fact that their patients visit retail clinics for some medical needs.

Medical educators can incorporate improvement science and patient safety training into existing curricula using a variety of methods and models, including the continuous longitudinal integrated clerkship model, in which students follow patients across time and care sites.

PSOs are not required to share their data, which limits the ability to achieve a much-needed national perspective. Regardless, the are a step in the right direction.