A framework for patient safety: a defense nuclear industry-based high-reliability model.

David J Birnbach; Lisa F Rosen; Lorena Williams; Maureen Fitzpatrick; David A Lubarsky; John D Menna

Commentary

A framework for patient safety: a defense nuclear industry-based high-reliability model.

May 1, 2013

Birnbach DJ, Rosen LF, Williams L, et al. Jt Comm J Qual Patient Saf. 2013;39(5):233-240.

View more articles from the same authors.

This commentary describes how a seven-point high reliability framework used by the United States Department of Energy can be applied to health care delivery.

PubMed citation

Available at

Related Resources From the Same Author(s)

Introductions during time-outs: do surgical team members know one another's names?

May 24, 2017

An evaluation of hand hygiene in an intensive care unit: are visitors a potential vector for pathogens?

June 24, 2015

Double gloves: a randomized trial to evaluate a simple strategy to reduce contamination in the operating room.

June 4, 2014

Crisis management on surgical wards: a simulation-based approach to enhancing technical, teamwork, and patient interaction skills.

March 18, 2015

Randomized crossover study evaluating the effect of a hand sanitizer dispenser on the frequency of hand hygiene among anesthesiology staff in the operating room.

July 2, 2014

Intraoperative handoffs among anesthesia providers increase the incidence of documentation errors for controlled drugs.

August 9, 2017

Twitter as a tool to enhance student engagement during an interprofessional patient safety course.

May 21, 2014

The anatomy of health care team training and the state of practice: a critical review.

October 20, 2010

Patient safety begins with proper planning: a quantitative method to improve hospital design.

November 24, 2010

Errors and the burden of errors: attitudes, perceptions, and the culture of safety in pediatric cardiac surgical teams.

April 30, 2008

Simulation-based training for patient safety: 10 principles that matter.

March 26, 2008

Debriefing medical teams: 12 evidence-based best practices and tips.

September 3, 2008

Improving patient safety in the operating theatre and perioperative care: obstacles, interventions, and priorities for accelerating progress.

February 20, 2013

Role-modeling and medical error disclosure: a national survey of trainees.

February 12, 2014

Surgeons in difficulty: an exploration of differences in assistance-seeking behaviors between male and female surgeons.

October 14, 2015

Association of past and future paid medical malpractice claims.

March 1, 2023

Effects of teamwork training on adverse outcomes and process of care in labor and delivery: a randomized controlled trial.

January 17, 2007

Infection prevention in the operating room anesthesia work area.

January 30, 2019

Foundations for teaching surgeons to address the contributions of systems to operating room team conflict.

August 28, 2013

Electronic fetal heart rate monitoring: applying principles of patient safety.

May 16, 2012

Videos of simulated after action reviews: a training resource to support social and inclusive learning from patient safety events.

September 6, 2023

Composite measures for profiling hospitals on bariatric surgery performance.

October 30, 2013

Integrating the intensive care unit safety reporting system with existing incident reporting systems.

October 5, 2005

Intensive care unit safety incidents for medical versus surgical patients: a prospective multicenter study.

October 3, 2007

A system factors analysis of "line, tube, and drain" incidents in the intensive care unit.

August 24, 2005

Utilization of a role-based head covering system to decrease misidentification in the operating room.

August 7, 2019

Determining the skills needed by frontline NHS staff to deliver quality improvement: findings from six case studies.

June 8, 2022

Executive/senior leader checklist to improve culture and reduce central line–associated bloodstream infections.

November 3, 2010

View the world through a different lens: shadowing another provider.

October 8, 2008

Toward learning from patient safety reporting systems.

January 10, 2007

The Irish National Adverse Events Study (INAES): the frequency and nature of adverse events in Irish hospitals—a retrospective record review study.

February 8, 2017

'More than words' - interpersonal communication, cognitive bias and diagnostic errors.

August 11, 2021

Defining and measuring patient safety.

March 6, 2005

How to avoid the 'seven deadly sins of surgery.'

March 14, 2012

A leadership initiative to improve communication and enhance safety.

January 26, 2011

Unintended doses in radiotherapy—over, under and outside?

April 18, 2018

Management of anesthesia equipment failure: a simulation-based resident skill assessment.

August 19, 2009

Rate of occult specimen provenance complications in routine clinical practice.

February 27, 2013

Beam me up Scotty! Impact of personal wireless communication devices in the emergency department.

November 24, 2010

Quality and safety in surgical care.

April 5, 2006

Using potentially preventable severe maternal morbidity to monitor hospital performance.

February 8, 2023

Teamwork in healthcare: key discoveries enabling safer, high-quality care.

July 11, 2018

Prevalence of preventable medication-related hospitalizations in Australia: an opportunity to reduce harm.

May 2, 2012

A systems approach to patient-centered care.

January 3, 2007

Locating errors through networked surveillance: a multimethod approach to peer assessment, hazard identification, and prioritization of patient safety efforts in cardiac surgery.

April 23, 2014

A systematic review of teamwork in the intensive care unit: what do we know about teamwork, team tasks, and improvement strategies?

July 23, 2014

Using evidence, rigorous measurement, and collaboration to eliminate central catheter-associated bloodstream infections.

August 25, 2010

Getting doctors to report medical errors: project DISCLOSE.

July 5, 2006

Assessing hospital safety on nights and weekends: the SWAN tool.

June 3, 2009

Like night and day — shedding light on off-hours care.

May 21, 2008

Health information technology is a vehicle, not a destination: a conversation with David J. Brailer.

March 14, 2007

Do hospitals provide lower quality care on weekends?

July 18, 2007

Using a market model to track advances in patient safety.

March 6, 2005

Consensus-based recommendations for standardizing terminology and reporting adverse events for emergency department procedural sedation and analgesia in children.

May 13, 2009

Operating room briefings.

July 5, 2006

Sustaining reductions in catheter related bloodstream infections in Michigan intensive care units: observational study.

March 10, 2010

Transforming the medication regimen review process using telemedicine to prevent adverse events.

December 16, 2020

Reducing three infections across cardiac surgery programs: a multisite cross-unit collaboration.

May 22, 2019

Spinal surgery and patient safety: a systems approach.

May 10, 2006

Variation in hospital mortality associated with inpatient surgery.

October 14, 2009

Patient identification error among prostate needle core biopsy specimens—are we ready for a DNA time-out?

November 7, 2007

Decision making in trauma settings: simulation to improve diagnostic skills.

March 11, 2015

Teaching internal medicine residents quality improvement and patient safety: a lean thinking approach.

April 28, 2010

Effect of number of open charts on intercepted wrong-patient medication orders in an emergency department.

May 30, 2018

Operating room briefings: working on the same page.

June 14, 2006

Medication safety in a psychiatric hospital.

March 21, 2007

Developing process-support tools for patient safety: finding the balance between validity and feasibility.

October 8, 2008

Prospective evaluation of a multifaceted intervention to improve outcomes in intensive care: the Promoting Respect and Ongoing Safety through Patient Engagement Communication and Technology study.

May 24, 2017

Hospital discharge documentation and risk of rehospitalisation.

May 4, 2011

Patient safety informatics: meeting the challenges of emerging digital health.

July 20, 2022

Measuring communication in the surgical ICU: better communication equals better care.

February 24, 2010

Medication dosing safety for pediatric patients: recognizing gaps, safety threats, and best practices in the emergency medical services setting. A position statement and resource document from NAEMSP.

August 26, 2020

Evaluation of effectiveness and safety of pharmacist independent prescribers in care homes: cluster randomised controlled trial.

March 1, 2023

Assessment of teamwork during structured interdisciplinary rounds on medical units.

October 31, 2012

Identifying and categorising patient safety hazards in cardiovascular operating rooms using an interdisciplinary approach: a multisite study.

May 23, 2012

A trigger tool to identify adverse events in the intensive care unit.

October 4, 2006

Improving health care quality and patient safety through peer-to-peer assessment: demonstration project in two academic medical centers.

November 9, 2016

Hospital ethical climate and teamwork in acute care: the moderating role of leaders.

November 26, 2008

The poor state of health care quality in the U.S.: is malpractice liability part of the problem or part of the solution?

November 16, 2005

Establishing a rapid response team (RRT) in an academic hospital: one year's experience.

November 29, 2006

Patient Safety Innovations

Pharmacist-led mobile health intervention and transplant medication safety: a randomized controlled clinical trial.

April 7, 2022

Using incident reporting to improve patient safety: a conceptual model.

March 28, 2007

Improving teamwork: impact of structured interdisciplinary rounds on a medical teaching unit.

April 28, 2010

Effectiveness of acute care remote triage systems: a systematic review.

February 5, 2020

Systematic review and evaluation of physiological track and trigger warning systems for identifying at-risk patients on the ward.

March 14, 2007

Transitions from one electronic health record to another: challenges, pitfalls, and recommendations.

December 16, 2020

Hospital process compliance and surgical outcomes in Medicare beneficiaries.

October 27, 2010

Surgeon age and operative mortality in the United States.

October 25, 2006

It's not all about me: motivating hand hygiene among health care professionals by focusing on patients.

February 15, 2012

We meant no harm, yet we made a mistake; why not apologize for it? A student's view.

June 23, 2010

A team training program using human factors to enhance patient safety.

December 19, 2007

An investigation of the relationship between safety climate and medication errors as well as other nurse and patient outcomes.

December 13, 2006

Sample to sample carryover: a source of analytical laboratory error and its relevance to integrated clinical chemistry/immunoassay systems.

July 5, 2006

To err is human: quality and safety issues in spine care.

May 30, 2007

Making healthcare safer by understanding, designing and buying better IT.

July 22, 2015

Pediatric prehospital medication dosing errors: a national survey of paramedics.

March 29, 2017

Pediatric prehospital medication dosing errors: a mixed-methods study.

November 11, 2015

Perceptions of patient safety culture among physicians and RNs in the perioperative area.

January 23, 2008

Workarounds to hospital electronic prescribing systems: a qualitative study in English hospitals.

May 18, 2016

Safety risks associated with the lack of integration and interfacing of hospital health information technologies: a qualitative study of hospital electronic prescribing systems in England.

April 27, 2016

Related Resources

HANYS' Report on Report Cards.

November 20, 2019

Organizing Patient Safety: Failsafe Fantasies and Pragmatic Practices.

May 8, 2019

Improving safety for hospitalized patients: much progress but many challenges remain.

August 17, 2016

Lean Hospitals: Improving Quality, Patient Safety, and Employee Engagement, Third Edition.

June 22, 2016

Bundle interventions used to reduce prescribing and administration errors in hospitalized children: a systematic review.

May 25, 2016

Toward a safer health care system: the critical need to improve measurement.

April 27, 2016

A collaborative learning network approach to improvement: the CUSP learning network.

April 8, 2015

Human factors and ergonomics and quality improvement science: integrating approaches for safety in healthcare.

April 1, 2015

Disentangling quality and safety indicator data: a longitudinal, comparative study of hand hygiene compliance and accreditation outcomes in 96 Australian hospitals.

October 8, 2014

From harm to hope and purposeful action: what could we do after Francis?

July 23, 2014

Harnessing implementation science to improve care quality and patient safety: a systematic review of targeted literature.

May 21, 2014

How Does Hospital Quality Management Drive Quality? Results From the "Deepening Our Understanding of Quality Improvement (DUQuE)" Project.

May 21, 2014

Preventing health care–associated harm in children.

May 14, 2014

The relationship between patient safety culture and patient outcomes: a systematic review.

April 2, 2014

Medication administration errors in hospitals—challenges and recommendations for their measurement.

March 26, 2014

Evidence-based organization and patient safety strategies in European hospitals.

March 19, 2014

Learning from every death.

March 5, 2014

Evaluation of medium-term consequences of implementing commercial computerized physician order entry and clinical decision support prescribing systems in two 'early adopter' hospitals.

February 19, 2014

Healthcare-associated infections: a national patient safety problem and the coordinated response.

February 19, 2014

Hospital patient safety grades may misrepresent hospital performance.

February 12, 2014

Understanding the Role of Facility Design in the Acquisition and Prevention of Healthcare-Associated Infections.

February 5, 2014

Assessing the state of safe medication practices using the ISMP Medication Safety Self Assessment for Hospitals: 2000 and 2011.

February 5, 2014

Demonstrating high reliability on accountability measures at The Johns Hopkins Hospital.

December 4, 2013

A longitudinal study of clinical peer review's impact on quality and safety in US hospitals.

November 27, 2013

Increasing demands for quality measurement.

November 27, 2013

Patient Safety Collaboration.

November 27, 2013

Validity of AHRQ patient safety indicators derived from ICD-10 hospital discharge abstract data (chart review study).

November 6, 2013

Beyond crisis resource management: new frontiers in human factors training for acute care medicine.

October 30, 2013

An evidence-based toolkit for the development of effective and sustainable root cause analysis system safety solutions.

October 23, 2013

Around the Patient Bed: Human Factors and Safety in Health Care.

October 23, 2013

See More About The Topic

Hospitals

Health Care Executives and Administrators

Safety Scientists

General Internal Medicine

Hospital Medicine

A framework for patient safety: a defense nuclear industry-based high-reliability model.

Pharmacist-led mobile health intervention and transplant medication safety: a randomized controlled clinical trial.

Connect With Us

Sign up for Email Updates

Agency for Healthcare Research and Quality

A framework for patient safety: a defense nuclear industry-based high-reliability model.

Pharmacist-led mobile health intervention and transplant medication safety: a randomized controlled clinical trial.

Connect With Us

Sign up for Email Updates

Agency for Healthcare Research and Quality

PSNet Log in

Submit Your Innovations

Continue as a Guest

Continue Logged In

Submit Your Innovations

Continue as a Guest

Continue logged in

New Users to the PSNet site