Reducing harm to patients. Using patient safety dashboards at the board level.

Michael Pugh; James L Reinertsen

Newspaper/Magazine Article

Reducing harm to patients. Using patient safety dashboards at the board level.

December 5, 2007

Pugh M, Reinertsen JL. Healthcare executive. 2007;22(6):62, 64-5.

View more articles from the same authors.

This commentary describes how hospital and health care system board members can develop facility-specific "dashboards" to spur whole-system improvements.

PubMed citation

Related Resources From the Same Author(s)

Rounding to influence.

September 29, 2010

The 100,000 Lives Campaign: crystallizing standards of care for hospitals.

November 23, 2005

Decoding laboratory test names: a major challenge to appropriate patient care.

January 16, 2013

The Patient Safety Leadership Academy at the University of Pennsylvania: the first cohort's learning experience.

June 13, 2007

A professional development course improves unprofessional physician behavior.

February 12, 2020

Standard practices for computerized clinical decision support in community hospitals: a national survey.

July 11, 2012

Understanding differences in electronic health record (EHR) use: linking individual physicians' perceptions of uncertainty and EHR use patterns in ambulatory care.

June 19, 2013

Error training: missing link in surgical education.

April 11, 2012

Relationships within inpatient physician housestaff teams and their association with hospitalized patient outcomes.

January 7, 2015

Declines in hospitalizations for acute cardiovascular conditions during the COVID-19 pandemic: a multicenter tertiary care experience.

July 1, 2020

Color coding to reduce errors.

September 7, 2005

Health care huddles: managing complexity to achieve high reliability.

March 26, 2014

Studying critical values: adverse event identification following a critical laboratory values study at the Ohio State University Medical Center.

October 17, 2007

Examining the effects of an obstetrics interprofessional programme on reductions to reportable events and their related costs.

December 5, 2018

Advancing the future of patient safety in oncology: implications of patient safety education on cancer care delivery.

June 10, 2015

Systematic review: antimicrobial urinary catheters to prevent catheter-associated urinary tract infection in hospitalized patients.

January 31, 2006

Use of specific indicators to detect warfarin-related adverse events.

August 24, 2005

Leadership oversight for patient safety programs: an essential element.

January 17, 2018

Faculty member review and feedback using a sign-out checklist: improving intern written sign-out.

September 19, 2012

Facility-level variation in potentially inappropriate prescribing for older veterans.

August 15, 2012

The effect of clinical history on accuracy of electrocardiograph interpretation among doctors working in emergency departments.

September 26, 2012

Resident duty-hour reform associated with increased morbidity following hip fracture.

October 7, 2009

Competition and health plan performance: evidence from health maintenance organization insurance markets.

April 27, 2005

Board of pharmacy practices related to medication errors and their potential impact on patient safety.

August 1, 2018

The impact of a nursing-led intervention bundle with a bedside checklist to reduce mortality during the initial COVID-19 pandemic and implications for future emergencies.

May 24, 2023

The Ask Me to Explain campaign: a 90-day intervention to promote patient and family involvement in care in a pediatric emergency department.

June 1, 2016

Quality and variability of patient directions in electronic prescriptions in the ambulatory care setting.

April 18, 2018

An analysis of near misses identified by anesthesia providers in the intensive care unit.

July 15, 2015

Using proactive risk assessment (HFMEA) to improve patient safety and quality associated with intraocular lens selection and implantation in cataract surgery.

September 18, 2019

Use of error management theory to quantify and characterize residents' error recovery strategies.

January 15, 2020

A multiobserver study of the effects of including point-of-care patient photographs with portable radiography: a means to detect wrong-patient errors.

October 8, 2014

Inpatient suicide and suicide attempts in Veterans Affairs hospitals.

August 20, 2008

Clinical and safety impact of an inpatient pharmacist-directed anticoagulation service.

August 24, 2011

Analysis of consistency in emergency department physician variation in propensity for admission across patient sociodemographic groups.

October 13, 2021

Awareness and use of a cognitive aid for anesthesiology.

September 19, 2007

Medical team training: applying crew resource management in the Veterans Health Administration.

May 30, 2007

Potentially inappropriate prescribing in elderly veterans: are we using the wrong drug, wrong dose, or wrong duration?

August 24, 2005

The incidence and nature of adverse events during pediatric sedation/anesthesia with propofol for procedures outside the operating room: a report from the Pediatric Sedation Research Consortium.

March 18, 2009

July 20, 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

Performance of vascular exposure and fasciotomy among surgical residents before and after training compared with experts.

March 22, 2017

Development of a trigger tool to identify adverse events and harm in emergency medical services.

September 20, 2017

Interactive questioning in critical care during handovers: a transcript analysis of communication behaviours by physicians, nurses and nurse practitioners.

May 28, 2014

The effect of a rapid response team on major clinical outcome measures in a community hospital.

September 5, 2007

Association of hydrocodone schedule change with opioid prescriptions following surgery.

September 5, 2018

Postoperative opioid prescribing and the pain scores on Hospital Consumer Assessment of Healthcare Providers and Systems survey.

June 7, 2017

One size fits all? Mixed methods evaluation of the impact of 100% single-room accommodation on staff and patient experience, safety and costs.

October 21, 2015

Incidence and nature of adverse events during pediatric sedation/anesthesia for procedures outside the operating room: report from the Pediatric Sedation Research Consortium.

October 18, 2006

Development of a high-value care culture survey: a modified Delphi process and psychometric evaluation.

November 16, 2016

ASHP guidelines on preventing medication errors with chemotherapy and biotherapy.

April 22, 2015

ACGME duty-hour recommendations—a national survey of residency program directors.

August 11, 2010

Active surveillance of vaccine safety: a system to detect early signs of adverse events.

May 4, 2005

Adverse drug event detection in pediatric oncology and hematology patients: using medication triggers to identify patient harm in a specialized pediatric patient population.

May 14, 2014

Pediatric patient safety in emergency departments: unit characteristics and staff perceptions.

August 19, 2009

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

October 20, 2010

The morbidity and mortality meeting: time for a different approach?

December 2, 2015

Creating an infrastructure for safety event reporting and analysis in a multicenter pediatric emergency department network.

April 3, 2013

Characteristics of medical professional liability claims in patients with cardiovascular diseases.

April 21, 2010

Medical team training improves team performance: AOA critical issues.

October 18, 2017

A piece of my mind. Despite my best intentions.

November 22, 2017

A new, evidence-based estimate of patient harms associated with hospital care.

August 7, 2013

Patient Safety.

February 8, 2012

A piece of my mind. I'm sorry.

July 1, 2015

The future of graduate medical education: a systems-based approach to ensure patient safety.

July 22, 2015

Using information to optimize medical outcomes.

June 17, 2009

Getting boards on board: engaging governing boards in quality and safety.

April 2, 2008

Could it happen here? Learning from other organizations' safety errors.

November 12, 2008

Patient safety: lessons learned.

March 1, 2006

The evolution of the apology.

February 7, 2007

When incidents happen.

August 2, 2006

How I minimize mistransfusion risk in my hospital.

July 26, 2006

Patient safety: what is really at issue?

October 26, 2005

Quality and safety implications of emergency department information systems.

July 17, 2013

February 13, 2008

Racial and ethnic differences in emergency department pain management of children with fractures.

April 22, 2020

Evaluation of a patient-centered fall-prevention tool kit to reduce falls and injuries: a nonrandomized controlled trial.

December 2, 2020

A policy-based intervention for the reduction of communication breakdowns in inpatient surgical care: results from a Harvard surgical safety collaborative.

July 13, 2011

Clinical decision-making: heuristics and cognitive biases for the ophthalmologist.

January 31, 2018

Medication-administration errors in an urban mental health hospital: a direct observation study.

March 11, 2015

Adverse events and comparison of systematic and voluntary reporting from a paediatric intensive care unit.

July 14, 2010

Random safety auditing, root cause analysis, failure mode and effects analysis.

May 19, 2010

A learning health care system using computer-aided diagnosis.

March 22, 2017

Speaking up: an ethical action exercise.

April 11, 2018

The impact of transitioning from a 24-hour to a 16-hour call model amongst a cohort of Canadian anesthesia residents at McMaster University—a survey study.

October 7, 2015

The Swiss cheese model of adverse event occurrence—closing the holes.

January 13, 2016

Diagnostic errors in interpretation of pediatric musculoskeletal radiographs at common injury sites.

June 25, 2014

From tasks to processes: the case for changing health information technology to improve health care.

April 1, 2009

Organisational failure: rethinking whistleblowing for tomorrow's doctors.

September 7, 2022

The effect of contact precautions on frequency of hospital adverse events.

December 9, 2015

Embedding quality and safety in otolaryngology–head and neck surgery education.

January 21, 2015

Self-Reported Learning (SRL), a voluntary incident reporting system experience within a large health care organization.

May 12, 2021

Functional health literacy and understanding of medications at discharge.

July 16, 2008

A systematic review of trauma crew resource management training: what can the United States and the United Kingdom learn from each other?

September 2, 2020

Animated stories of medical error as a means of teaching undergraduates patient safety: an evaluation study.

July 24, 2019

Measuring the rate of manual transcription error in outpatient point-of-care testing.

March 13, 2019

Using a spare medication vial to store multiple medications: a potentially fatal in-home medication error.

March 6, 2019

Increasing trainee reporting of adverse events with monthly, trainee-directed review of adverse events.

January 31, 2018

Overuse of medical imaging and its radiation exposure: who’s minding our children?

September 28, 2016

Sharing the process of diagnostic decision making.

August 9, 2017

Using simulation to improve systems.

September 27, 2017

Related Resources

Are you well positioned to resolve conflicts with the safety of an order? Learning from a physician’s homicide trial and the firing of multiple healthcare workers.

June 1, 2022

Collaborative case review: a systems-based approach to patient safety event investigation and analysis.

March 30, 2022

Can hospitals learn about safety from airlines?

September 15, 2021

10 Leadership mindsets for high reliability organizations. How to empower caregivers and engage patients in patient safety.

April 14, 2021

Survey shows room for improvement with two new ISMP Targeted Medication Safety Best Practices.

August 12, 2020

Predictors of nursing home nurses' willingness to report medication near-misses.

May 13, 2020

A systematic review of factors that enable psychological safety in healthcare teams.

May 13, 2020

Choosing a Patient Safety Organization

March 1, 2020

CUSP Toolkit.

September 26, 2019

PC standards for maternal safety.

September 11, 2019

How organisations contribute to improving the quality of healthcare.

June 12, 2019

Bringing perioperative emergency manuals to your institution: a "How To" from concept to implementation in 10 steps.

April 3, 2019

IV push medications survey results—part 1 and part 2.

November 28, 2018

Partnering with pediatric patients and families in high reliability to identify and reduce preventable safety events.

September 26, 2018

Surgical fires: decreasing incidence relies on continued prevention efforts.

July 18, 2018

Transgender patients and diagnostic safety: back to basics.

March 14, 2018

High-alert medications: the safeguards that you should put in place to reduce risks.

November 1, 2017

So much care it hurts: unneeded scans, therapy, surgery only add to patients' ills.

November 1, 2017

Improving patient care through improved caregiver support.

September 13, 2017

Death due to pharmacy compounding error reinforces need for safety focus.

June 28, 2017

Creating a Pediatric Joint Council to promote patient safety and quality, governance, and accountability across Johns Hopkins Medicine.

May 3, 2017

Building a highway to quality health care.

September 7, 2016

The next wave of hospital innovation to make patients safer.

August 17, 2016

Reporting and second-order problem solving can turn short-term fixes into long-term remedies.

June 1, 2016

Radically redesigning patient safety.

May 4, 2016

Nurses say stress interferes with caring for their patients.

April 27, 2016

Is misdiagnosis inevitable?

April 13, 2016

Reducing preventable harm in hospitals.

February 3, 2016

Sustaining reliability on accountability measures at the Johns Hopkins Hospital.

January 27, 2016

The persistent problem of diagnostic error.

December 16, 2015

See More About The Topic

Health Care Executives and Administrators

Quality Improvement Strategies

Institutional Patient Safety Plan

Reducing harm to patients. Using patient safety dashboards at the board level.

Connect With Us

Sign up for Email Updates

Agency for Healthcare Research and Quality

Reducing harm to patients. Using patient safety dashboards at the board level.

Connect With Us

Sign up for Email Updates

Agency for Healthcare Research and Quality

PSNet Log in

Submit Your Case

Continue as a Guest

Continue Logged In

Submit Your Case

Continue as a Guest

Already have a PSNet

Account?

New Users

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