While choosing the top articles published in BMJ Quality and Safety is a challenge every year, 2021 saw a higher number of submissions than those seen prior to 2020. Nearly one in five submissions related to COVID-19. The editors and editorial board of the journal therefore had some difficult choices to make in selecting the top articles of the year, taking into account downloads, citations, Altmetrics scores and other information, as well as expert judgement. We thank all authors for their contributions to the journal and congratulate those who appear on the list (in no particular order) below. As well as those involved in this process, we are also hugely grateful to all of our reviewers who give their time and expertise to peer-reviewing submissions: none of this would be possible without you.

-Bryony Dean Franklin & Eric Thomas

• Socioeconomic deprivation and ethnicity inequalities in disruption to NHS hospital admissions during the COVID-19 pandemic: a national observational study by M Warner et al. Published Online First: 25 November 2021.

• Smart agent system for insulin infusion protocol management: a simulation-based human factors evaluation study by MA Rosen (@Mike_Rosen_) et al. BMJ Quality & Safety 2021;30:893-900.

• Visual mapping of team dynamics and communication patterns on surgical ward rounds: an ethnographic study by C Bonaconsa (@chbonaconsa76) et al. BMJ Quality & Safety 2021;30:812-824.

• Impact of COVID-19 restrictions on diabetes health checks and prescribing for people with type 2 diabetes: a UK-wide cohort study involving 618,161 people in primary care by MJ Carr et al. Published Online First: 12 October 2021.

• Improving surgical quality in low-income and middle-income countries: why do some health facilities perform better than others? by S Alidina et al. BMJ Quality & Safety 2021;30:937-949.

• Should electronic differential diagnosis support be used early or late in the diagnostic process? A multicentre experimental study of Isabel by M Sibbald (@SibbaldMatt) et al. Published Online First: 05 October 2021.

• Overuse of diagnostic testing in healthcare: a systematic review by JLJM Müskens et al. BMJ Quality & Safety 2022;31:54-63.

• Determining the skills needed by frontline NHS staff to deliver quality improvement: findings from six case studies by D Wright et al. Published Online First: 27 August 2021.

• Improving diagnostic performance through feedback: the Diagnosis Learning Cycle by C Fernandez Branson et al. BMJ Quality & Safety 2021;30:1002-1009.

• Incidence, origins and avoidable harm of missed opportunities in diagnosis: longitudinal patient record review in 21 English general practices by S Cheraghi-Sohi (@Dr_Sudeh) et al. BMJ Quality & Safety 2021;30:977-985.

• Outcomes for surgical procedures funded by the English health service but carried out in public versus independent hospitals: a database study by H Crothers et al. Published Online First: 07 September 2021.

• Timeout procedure in paediatric surgery: effective tool or lip service? A randomised prospective observational study by OJ Muensterer et al. BMJ Quality & Safety 2021;30:622-627.

• Effects of a refined evidence-based toolkit and mentored implementation on medication reconciliation at 18 hospitals: results of the MARQUIS2 study by JL Schnipper (@drjschnip) et al. Published Online First: 29 April 2021.

• Filling a gap in safety metrics: development of a patient-centred framework to identify and categorise patient-reported breakdowns related to the diagnostic process in ambulatory care by SK Bell et al. Published Online First: 16 October 2021.

• Effectiveness of a multifaceted intervention to improve emergency department care of low back pain: a stepped-wedge, cluster-randomised trial by DM Coombs et al. BMJ Quality & Safety 2021;30:825-835.

• Exploring the actionability of healthcare performance indicators for quality of care: a qualitative analysis of the literature, expert opinion and user experience by E Barbazza et al. BMJ Quality & Safety 2021;30:1010-1020.

• Impact of COVID-19 on opioid use in those awaiting hip and knee arthroplasty: a retrospective cohort study by L Farrow (@docfarrow) et al. Published Online First: 14 September 2021.

• Concordance with urgent referral guidelines in patients presenting with any of six ‘alarm’ features of possible cancer: a retrospective cohort study using linked primary care records by B Wiering et al. Published Online First: 04 October 2021.

• Using a dark logic model to explore adverse effects in audit and feedback: a qualitative study of gaming in colonoscopy by J Catlow (@DrJamieC) et al. Published Online First: 10 December 2021.

• Use of patient complaints to identify diagnosis-related safety concerns: a mixed-method evaluation by TD Giardina (@TDGiardina) et al. BMJ Quality & Safety 2021;30:996-1001.

• Evaluating the safety of mental health-related prescribing in UK primary care: a cross-sectional study using the Clinical Practice Research Datalink (CPRD) by WY Khawagi (@khawagi) et al. Published Online First: 25 August 2021.