Now is the time to routinely ask patients about safety.

Tejal K. Gandhi

Commentary

Now is the time to routinely ask patients about safety.

March 15, 2023

Gandhi TK. Jt Comm J Qual Patient Saf. 2023;49(4):235-236.

View more articles from the same authors.

Safety event reporting is a primary method of gathering data to enhance learning from error. This commentary suggests that a broader approach is needed by engaging patients and gathering their perception of safety to provide a full picture of gaps in care that could result in harm.

PubMed citation

Available at

Related Resources From the Same Author(s)

Don't go to the hospital alone: ensuring safe, highly reliable patient visitation.

January 12, 2022

Medication rounds: a tool to promote medication safety for children with medical complexity.

March 8, 2023

The effect of a system-level tiered huddle system on reporting patient safety events: an interrupted time series analysis.

October 12, 2022

An infrastructure to provide safer, higher quality, and more equitable telehealth.

March 1, 2023

Lessons learned from a systems approach to engaging patients and families in patient safety transformation.

February 12, 2020

COVID-19 and patient safety: time to tap into our investment in high reliability.

May 12, 2021

A program to provide clinicians with feedback on their diagnostic performance in a learning health system.

October 28, 2020

Keeping patients at risk for self-harm safe in the emergency department: a protocolized approach.

December 2, 2020

Harnessing event report data to identify diagnostic error during the COVID-19 pandemic.

December 15, 2021

Developing the Safer Dx Checklist of Ten Safety Recommendations for Health Care Organizations to address diagnostic errors.

October 12, 2022

Communication with patients and families regarding health care-associated exposure to coronavirus 2019: a checklist to facilitate disclosure.

August 12, 2020

Hospital at Home: setting a regulatory course to ensure safe, high-quality care.

February 2, 2022

Communication with health care workers regarding health care-associated exposure to coronavirus 2019: a checklist to facilitate disclosure.

June 24, 2020

How to mitigate the effects of cognitive biases during patient safety incident investigations.

September 28, 2022

A contemporary analysis of closed claims related to wrong site surgery.

March 29, 2023

Teamwork is associated with reduced hospital staff burnout at military treatment facilities: findings from the 2019 Department of Defense Patient Safety Culture Survey.

March 22, 2023

Building a program of expanded peer support for the entire health care team: no one left behind.

October 13, 2021

Rapid-cycle improvement during the COVID-19 pandemic: using safety reports to inform incident command.

October 7, 2020

Time to take hearing loss seriously.

February 19, 2020

Providers' and patients' perspectives on diagnostic errors in the acute care setting.

February 15, 2023

Changes in safety and teamwork climate after adding structured observations to patient safety WalkRounds.

October 27, 2021

Potentially harmful medication dispenses after a fall or hip fracture: a mixed methods study of a commonly used quality measure.

March 9, 2022

Reducing surgical specimen errors through multidisciplinary quality improvement.

June 16, 2021

Using participatory design to engage physicians in the development of a provider-level performance dashboard and feedback system.

February 2, 2022

Resilience vs. vulnerability: psychological safety and reporting of near misses with varying proximity to harm in radiation oncology.

November 18, 2020

What safety events are reported for ambulatory care? Analysis of incident reports from a patient safety organization.

October 21, 2020

Advanced medication reconciliation: a systematic review of the impact on medication errors and adverse drug events associated with transitions of care.

June 16, 2021

Development and validation of a brief culture-of-safety survey.

June 22, 2022

Self-reported adherence to high reliability practices among participants in the Children's Hospitals' Solutions for Patient Safety Collaborative.

December 12, 2018

Adverse events present on arrival to the emergency department: the ED as a dual safety net.

March 11, 2020

Variation in the reporting of elective surgeries and its influence on patient safety indicators.

July 6, 2022

Patient safety and ethical implications of healthcare sick leave policies in the pandemic era.

September 15, 2021

Considering the safety and quality of artificial intelligence in health care.

September 16, 2020

Medication errors in overweight and obese pediatric patients: a systematic review.

February 9, 2022

Assessing patients 2019 experiences with medical injury reconciliation processes: item generation for a novel survey questionnaire.

May 5, 2021

A multicenter collaborative effort to reduce preventable patient harm due to retained surgical items.

November 30, 2022

Novel telephone-based interactive voice response system for incident reporting.

November 17, 2021

A simulation systems testing program using HFMEA methodology can effectively identify and mitigate latent safety threats for a new on-site helipad.

January 12, 2022

A handoff protocol from the cardiovascular operating room to cardiac ICU is associated with improvements in care beyond the immediate postoperative period.

July 17, 2013

Using potentially preventable severe maternal morbidity to monitor hospital performance.

February 8, 2023

Design and implementation of an analgesia, sedation, and paralysis order set to enhance compliance of pro re nata medication orders with Joint Commission medication management standards in a pediatric ICU.

December 9, 2020

Referrals of infection control breaches to public health authorities: ambulatory care settings experience, 2017.

September 23, 2020

Improving medication reconciliation with comprehensive evaluation at a Veterans Affairs skilled-nursing facility.

July 21, 2021

Focus on the Quadruple Aim: development of a resiliency center to promote faculty and staff wellness initiatives.

June 6, 2018

Bracing for the storm: one health care system's planning for the COVID-19 surge.

November 11, 2020

Lessons from walking the medical distancing tightrope.

July 22, 2020

Standardized orders for titrating vasopressors: do efforts to improve safety slow delivery of care?

September 11, 2019

Safety checklists for emergency response driving and patient transport: experiences from emergency medical services.

July 7, 2021

Identifying electronic medication administration record (eMAR) usability issues from patient safety event reports.

November 3, 2021

A safe practice standard for barcode technology.

June 3, 2015

Inaccurate penicillin allergy labeling, the electronic health record, and adverse outcomes of care.

August 24, 2022

Physician task load and the risk of burnout among US physicians in a national survey.

December 2, 2020

Root cause analysis of adverse events involving opioid overdoses in the Veterans Health Administration.

June 23, 2021

Detecting and assessing suicide ideation during the COVID-19 pandemic.

May 26, 2021

Leadership behavior associations with domains of safety culture, engagement, and healthcare worker well-being.

February 1, 2023

The cost of quality: an academic health center's annual costs for its quality and patient safety infrastructure.

July 25, 2018

A model for improving health care quality for transgender and gender nonconforming patients.

January 23, 2020

Implementation of peer messengers to deliver feedback: an observational study to promote professionalism in nursing.

January 18, 2023

Wrong-patient blood transfusion error: leveraging technology to overcome human error in intraoperative blood component administration.

January 9, 2019

A longitudinal study of a multifaceted intervention to reduce newborn falls while preserving rooming-in on a mother-baby unit.

October 5, 2022

Building patient trust in hospitals: a combination of hospital-related factors and health care clinician behaviors.

October 27, 2021

A multisite study of interprofessional teamwork and collaboration on general medical services.

November 25, 2020

Deficiencies in provider-reported interpreter use in a clinical trial comparing telephonic and video interpretation in a pediatric emergency department.

October 14, 2020

Incident reporting systems: what will it take to make them less frustrating and achieve anything useful?

December 1, 2021

CHaMP: A model for building a center to support health care worker well-being after experiencing an adverse event.

April 5, 2023

Prompting rounding teams to address a daily best practice checklist in a pediatric intensive care unit.

August 14, 2019

Anesthesiology patient handoff education interventions: a systematic review.

March 29, 2023

Factors associated with malpractice claim payout: an analysis of closed emergency department claims.

July 13, 2022

Reporting of unsafe conditions at an academic women and children's hospital.

September 29, 2021

Health system leaders' role in addressing racism: time to prioritize eliminating health care disparities.

February 10, 2021

Systems-level factors affecting registered nurses during care of women in labor experiencing clinical deterioration.

April 20, 2022

Preferences and perceptions of medical error disclosure among marginalized populations: a narrative review.

August 10, 2022

Intraoperative code blue: improving teamwork and code response through interprofessional, in situ simulation.

October 26, 2022

An asset-based quality improvement tool for health care organizations: cultivating organization wide quality improvement and health care professional engagement.

October 19, 2022

Diagnostic trajectories in primary care at 12 months: an observational cohort study.

June 15, 2022

Factors that affect opioid quality improvement initiatives in primary care: insights from ten health systems.

December 14, 2022

Nurses' perceived causes of medication administration errors: a qualitative systematic review.

November 25, 2020

Assessing and supporting late career practitioners: four key questions.

September 30, 2020

A comprehensive departmental care review model: requirements, structure, and flow.

June 30, 2021

Prevalence and characteristics of interruptions and distractions during surgical counts.

July 28, 2021

Disparities after discharge: the association of limited English proficiency and postdischarge patient-reported issues.

December 8, 2021

Interprofessional training and communication practices among clinicians in the postoperative ICU handoff.

April 28, 2021

Universal protection: operationalizing infection prevention guidance in the COVID-19 era.

May 12, 2021

Improving responses to safety incidents: we need to talk about justice.

February 23, 2022

Compensation claims in Danish emergency care: identifying hot spots and blind spots in the quality of care.

May 11, 2022

Increasing naloxone prescribing in the emergency department through education and electronic medical record work-aids.

April 21, 2021

A comprehensive estimation of the costs of 30-day postoperative complications using actual costs from multiple, diverse hospitals.

October 14, 2020

Root cause analysis of ICU adverse events in the Veterans Health Administration.

August 30, 2017

Improving timely recognition and treatment of sepsis in the pediatric ICU.

May 27, 2020

Quality and safety in surgery: challenges and opportunities.

September 8, 2021

The effect of transitions intervention to ensure patient safety and satisfaction when transferred from hospital to home health care-a systematic review.

March 8, 2023

Didactic and simulation nontechnical skills team training to improve perinatal patient outcomes in a community hospital.

August 10, 2011

Assessment of patient retention of inpatient care information post-hospitalization.

February 22, 2023

Patient and family engagement in catheter-associated urinary tract infection (CAUTI) prevention: a systematic review.

July 14, 2021

Partnering with patients and families living with chronic conditions to coproduce diagnostic safety through OurDX: a previsit online engagement tool.

February 15, 2023

Longitudinal evaluation of a pediatric rapid response system with realist evaluation framework.

April 27, 2022

Improving handoff by deliberate cognitive processing: results from a randomized controlled experimental study.

April 28, 2021

Fighting a common enemy: a catalyst to close intractable safety gaps.

August 5, 2020

Combined proactive risk assessment: unifying proactive and reactive risk assessment techniques in health care.

June 29, 2022

Clinician distress and inappropriate antibiotic prescribing for acute respiratory tract infections: a retrospective cohort study.

May 11, 2022

Related Resources

National Action Alliance to Advance Patient and Workforce Safety Webinar Series.

August 20, 2024 - August 20, 2024

AHRQ-Funded Patient Safety Project Highlights: Improving Patient Safety by Enhancing Care Coordination.

July 17, 2024

Artificial intelligence in the provision of health care: an American College of Physicians policy position paper.

June 12, 2024

Patient Safety Research Summaries.

April 9, 2024

Patient Experience, Patient Safety, and Provider Well-Being: Associations and Paths for Quality Improvement.

February 6, 2024

Responding to medical errors — implementing the modern ethical paradigm.

January 31, 2024

Reconceptualizing patient safety beyond harm: insights from a mixed-methods qualitative inquiry.

January 24, 2024

When mistakes multiply: how inadequate responses to medical mishaps erode trust in American medicine.

December 6, 2023

Rethinking Patient Safety: A Discussion Guide for Patients, Healthcare Providers and Leaders.

November 1, 2023

Improving patient safety by shifting power from health professionals to patients.

October 25, 2023

The future of engaging patients and families for patient safety.

October 18, 2023

Patient Engagement for Patient Safety: The Why, What, and How of Patient Engagement for Improving Patient Safety.

October 11, 2023

Reduced postdischarge incidents after implementation of a hospital-to-home transition intervention for children with medical complexity.

October 4, 2023

Five strategies for how patients and families can improve patient safety: World Patient Safety Day 2023.

October 4, 2023

Disclosing medical errors: prioritising the needs of patients and families.

July 5, 2023

Measurement and Monitoring of Safety Framework (MMSF): learning from its implementation in Canada.

June 28, 2023

Context matters: toward a multilevel perspective on context in clinical reasoning and error.

June 21, 2023

Patient Safety Innovations

Preventing Falls Through Patient and Family Engagement to Create Customized Prevention Plans

May 31, 2023

The Patient Safety Adoption Framework: a practical framework to bridge the know-do gap.

May 31, 2023

Clinical Investigation Booking Systems Failures: Written Communications in Community Languages.

May 31, 2023

Effects of a multimodal transitional care intervention in patients at high risk of readmission: the TARGET-READ randomized clinical trial.

May 17, 2023

Roadmap to Health Care Safety for Massachusetts.

May 3, 2023

Events that inspired change: the importance of sharing what happened to stop it from happening again.

May 3, 2023

Annual Perspective

Improving Diagnostic Safety and Quality

April 26, 2023

Interview

In Conversation with... Susan McGrath, PhD and George Blike, MD about Surveillance Monitoring

April 26, 2023

Perspective

Surveillance Monitoring to Improve Patient Safety in Acute Hospital Care Units

April 26, 2023

Economic evaluations of interventions to prevent and control health-care-associated infections: a systematic review.

April 26, 2023

Racism and electronic health records (EHRs): perspectives for research and practice.

April 12, 2023

CHaMP: A model for building a center to support health care worker well-being after experiencing an adverse event.

April 5, 2023

Patient generated research priorities to improve diagnostic safety: a systematic prioritization exercise.

April 5, 2023

See More About The Topic

Hospitals

Ambulatory Clinic or Office

Facility and Group Administrators

Quality and Safety Professionals

Medicine

Now is the time to routinely ask patients about safety.

Preventing Falls Through Patient and Family Engagement to Create Customized Prevention Plans

Connect With Us

Sign up for Email Updates

Agency for Healthcare Research and Quality

Now is the time to routinely ask patients about safety.

Preventing Falls Through Patient and Family Engagement to Create Customized Prevention Plans

Connect With Us

Sign up for Email Updates

Agency for Healthcare Research and Quality

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