Commentary Transformation of health care at the front line. Citation Text: Conway PH, Clancy CM. Transformation of health care at the front line. JAMA. 2009;301(7):763-5. doi:10.1001/jama.2009.103. Copy Citation Format: DOIGoogle ScholarPubMedBibTeXEndNote X3 XMLEndNote 7 XMLEndnote taggedPubMedIdRIS Download Citation Save Save to your library Print Share Facebook Twitter Linkedin Copy URL February 25, 2009 Conway PH, Clancy CM. JAMA. 2009;301(7):763-5. View more articles from the same authors. This commentary emphasizes five key drivers to improve health care delivery and suggests next steps to accomplish such changes. PubMed citation Available at Save Save to your library Print Share Facebook Twitter Linkedin Copy URL Cite Citation Citation Text: Conway PH, Clancy CM. Transformation of health care at the front line. JAMA. 2009;301(7):763-5. doi:10.1001/jama.2009.103. Copy Citation Format: DOIGoogle ScholarPubMedBibTeXEndNote X3 XMLEndNote 7 XMLEndnote taggedPubMedIdRIS Download Citation Related Resources From the Same Author(s) Common formats allow uniform collection and reporting of patient safety data by patient safety organizations. January 13, 2010 New research highlights the role of patient safety culture and safer care. August 24, 2011 Alleviating "second victim" syndrome: how we should handle patient harm. December 14, 2011 Reengineering hospital discharge: a protocol to improve patient safety, reduce costs, and boost patient satisfaction. July 1, 2009 CMS's hospital-acquired condition lists link hospital payment, patient safety. March 25, 2009 Patient safety organizations ready for action. February 18, 2009 The importance of simulation: preventing hand-off mistakes. October 29, 2008 New patient safety organizations lower roadblocks to medical error reporting. August 13, 2008 Care transitions: a threat and an opportunity for patient safety. November 15, 2006 The intensive care unit, patient safety, and the Agency for Healthcare Research and Quality. October 4, 2006 AHRQ quality and safety initiatives. June 1, 2005 A call to excellence. March 6, 2005 The science of safety improvement: learning while doing. June 8, 2011 Complexity, bullying, and stress: analyzing and mitigating a challenging work environment for nurses. July 8, 2009 Nurses' role in patient safety. January 21, 2009 TeamSTEPPS: assuring optimal teamwork in clinical settings. June 27, 2007 Limiting nurse overtime, and promoting other good working conditions, influences patient safety. April 9, 2008 Medication therapy management programs: forming a new cornerstone for quality and safety in Medicare. August 2, 2006 Working conditions that support patient safety. October 12, 2005 Using the AHRQ Quality Indicators to improve health care quality. September 7, 2005 From HRO to HERO: making health equity a core system capability. November 24, 2021 Patient safety in nursing practice. October 3, 2007 Patient safety in nursing practice. July 20, 2005 Improving patient safety—five years after the IOM report. March 6, 2005 Utilising improvement science methods to optimise medication reconciliation. April 13, 2011 Utilizing improvement science methods to improve physician compliance with proper hand hygiene. March 29, 2012 Improving situation awareness to reduce unrecognized clinical deterioration and serious safety events. January 9, 2013 How useful are voluntary medication error reports? The case of warfarin-related medication errors. January 9, 2008 Addressing veteran health-related social needs: how Joint Commission standards accelerated integration and expansion of tools and services in the Veterans Health Administration. December 6, 2023 Identifying causes of adverse events detected by an automated trigger tool through in-depth analysis. October 20, 2010 Quality improvement project to reduce perioperative opioid oversedation events in a paediatric hospital. October 5, 2011 Could it happen here? Learning from other organizations' safety errors. November 12, 2008 Getting boards on board: engaging governing boards in quality and safety. April 2, 2008 Communicating with patients about diagnostic errors in breast cancer care: providers' attitudes, experiences, and advice January 22, 2020 Pathologists' perspectives on disclosing harmful pathology error. May 3, 2017 Reducing health care hazards: lessons from the Commercial Aviation Safety Team. April 15, 2009 Multidisciplinary approaches to reducing error and risk in a patient care setting. March 6, 2005 Medication errors in HIV-infected hospitalized patients: a pharmacist's impact. July 10, 2013 A qualitative study examining the influences on situation awareness and the identification, mitigation and escalation of recognised patient risk. January 29, 2014 Transforming healthcare: a safety imperative. December 9, 2009 Perceived discrimination in the community pharmacy: a cross-sectional, national survey of adults. May 10, 2023 Status of the implementation of the World Health Organization multimodal hand hygiene strategy in United States of America health care facilities. May 7, 2014 Providers' perceptions of communication breakdowns in cancer care. March 26, 2014 Incorporating harms into the weighting of the Revised AHRQ Patient Safety for Selected Indicators Composite (PSI 90). January 26, 2022 Enhancing communication in surgery through team training interventions: a systematic literature review. December 22, 2010 More than words: patients' views on apology and disclosure when things go wrong in cancer care. August 24, 2011 Toward patient-centered cancer care: patient perceptions of problematic events, impact, and response. May 2, 2012 Medication errors in hospitals: a literature review of disruptions to nursing practice during medication administration. September 23, 2015 Blind obedience and an unnecessary workup for hypoglycemia: a teachable moment. December 6, 2017 Patient safety event reporting in critical care: a study of three intensive care units. March 21, 2007 The Henry Ford Health System No Harm Campaign: a comprehensive model to reduce harm and save lives. July 11, 2012 Delivering the truth: challenges and opportunities for error disclosure in obstetrics. February 26, 2014 Classifying errors in preventable and potentially preventable trauma deaths: a 9-year review using the Joint Commission's standardized methodology. October 15, 2014 Nurse interrupted: development of a realistic medication administration simulation for undergraduate nurses. August 26, 2015 Residency training at a crossroads: duty-hour standards 2010. November 3, 2010 Medication reconciliation at an academic medical center: implementation of a comprehensive program from admission to discharge. December 9, 2009 Maintaining perioperative safety in uncertain times: COVID-19 pandemic response strategies. November 18, 2020 A critical review of the systems approach within patient safety research. October 14, 2009 A simple checklist for preventing major complications associated with cesarean delivery. January 5, 2011 Using the Agency for Healthcare Research and Quality Patient Safety Indicators for targeting nursing quality improvement. November 23, 2011 Huddling for high reliability and situation awareness. July 24, 2013 Talking with patients about other clinicians' errors. November 6, 2013 Can positivity promote safety? Psychological capital development combats cynicism and unsafe behavior. July 10, 2019 The future of engaging patients and families for patient safety. October 18, 2023 Improving the reliability of verbal communication between primary care physicians and pediatric hospitalists at hospital discharge. June 24, 2015 Analysis of medical malpractice claims to improve quality of care: cautionary remarks. June 12, 2019 Mortality among patients in VA hospitals in the first 2 years following ACGME resident duty hour reform. September 12, 2007 Failure-to-rescue: comparing definitions to measure quality of care. October 10, 2007 How valid is the ICD-9-CM based AHRQ Patient Safety Indicator for postoperative venous thromboembolism? January 13, 2010 Making infection prevention and control everyone's business? Hospital staff views on patient involvement. June 5, 2019 Recognizing and responding to the "toxic" work environment: worker safety, patient safety, and abuse/neglect in nursing homes. September 20, 2017 Predictors of unit-level medication administration accuracy: microsystem impacts on medication safety. August 27, 2014 Disclosing adverse events to patients: international norms and trends. April 30, 2014 Human factors in healthcare: welcome progress, but still scratching the surface. June 29, 2016 Maintaining maternal-newborn safety during the COVID-19 pandemic. May 26, 2021 To err is system: a comparison of methodologies for the investigation of adverse outcomes in healthcare. May 5, 2021 Considering the safety and quality of artificial intelligence in health care. September 16, 2020 An unsuspected MR projectile: a "wooden" chair with metal bracing. May 3, 2006 Shepherding change: how the market, healthcare providers, and public policy can deliver quality care for the 21st century. March 1, 2006 Preliminary assessment of pediatric health care quality and patient safety in the United States using readily available administrative data. August 13, 2008 A national profile of patient safety in U.S. hospitals. March 6, 2005 Positive predictive value of the AHRQ accidental puncture or laceration patient safety indicator. January 20, 2010 Prolonged hospital stay and the resident duty hour rules of 2003. January 13, 2010 Families’ experiences of central-line infection in children: a qualitative study. September 7, 2022 Effect of social influences on pharmacists' intention to report adverse drug events. October 17, 2012 Weekend specialist intensity and admission mortality in acute hospital trusts in England: a cross-sectional study. November 29, 2017 An organization-specific and modifiable inpatient safety composite measure. May 8, 2019 The relationship between resident physician burnout and its’ effects on patient care, professionalism, and academic achievement: a review of the literature. October 5, 2022 Characterising ICU–ward handoffs at three academic medical centres: process and perceptions. March 20, 2019 Surgical simulation: a systematic review. March 8, 2006 Low perfusion and missed diagnosis of hypoxemia by pulse oximetry in darkly pigmented skin: a prospective study. March 6, 2024 Junior doctors' views on reporting concerns about patient safety: a qualitative study. June 17, 2015 Measurement of harms in community care: a qualitative study of use of the NHS Safety Thermometer. August 1, 2018 Improving medication administration safety: using naïve observation to assess practice and guide improvements in process and outcomes. January 7, 2015 Safe work-hour standards for parents of children with medical complexity. January 29, 2020 Did duty hour reform lead to better outcomes among the highest risk patients? November 4, 2009 Measuring and managing quality of surgery. Statistical vs incidental approaches. March 6, 2005 Detection of postoperative respiratory failure: how predictive is the Agency for Healthcare Research and Quality's Patient Safety Indicator? September 29, 2010 Disclosing harmful pathology errors to patients. January 6, 2010 Malpractice reform—opportunities for leadership by health care institutions and liability insurers. April 14, 2010 View More Related Resources Patient Safety Awareness Week. March 10, 2024 - March 16, 2024 Mark Graber Diagnostic Quality & Safety Award. August 30, 2023 Electronic health record legal settlements in the US since the 2009 Health Information Technology for Economic and Clinical Health Act. December 21, 2022 The impact of meaningful use and electronic health records on hospital patient safety. November 2, 2022 Combined impact of Medicare's hospital pay for performance programs on quality and safety outcomes is mixed. August 10, 2022 Complexity bias in the prevention of iatrogenic injury: why specific harms may inhibit performance. March 16, 2022 Incorporating harms into the weighting of the Revised AHRQ Patient Safety for Selected Indicators Composite (PSI 90). January 26, 2022 Alternatives to opioid education and a prescription drug monitoring program cumulatively decreased outpatient opioid prescriptions. December 16, 2020 Safe use of the EHR by medical scribes: a qualitative study. November 18, 2020 Unintended consequences of health care reform: impact of changes in payor mix on patient safety indicators, October 7, 2020 Patient Safety September 17, 2020 The confused and bewildered hospital: adverse event discovery, pay-for-performance, and big data tools as halfway technologies. July 29, 2020 Improvement in patient safety may precede policy changes: trends in patient safety indicators in the United States, 2000-2013. June 3, 2020 Hospital-acquired Conditions Reduction Program, patient safety, and Magnet designation in the United States. May 13, 2020 Adverse events present on arrival to the emergency department: the ED as a dual safety net. March 11, 2020 A model for improving health care quality for transgender and gender nonconforming patients. January 23, 2020 Validation of new ICD-10-based patient safety indicators for identification of in-hospital complications in surgical patients: a study of diagnostic accuracy. September 11, 2019 Patient Safety Primers Detection of Safety Hazards September 7, 2019 Recommendations from a national panel on quality improvement in obstetrics. April 24, 2019 Pursuing patient safety at the intersection of design, systems engineering, and health care delivery research: an ongoing assessment. February 27, 2019 Unintended harm associated with the Hospital Readmissions Reduction Program. January 16, 2019 Patient safety in inpatient psychiatry: a remaining frontier for health policy. January 9, 2019 Selected medication safety risks that can easily fall off the radar screen—part 1, part 2, and part 3. December 19, 2018 Toolkit to Promote Safe Surgery. January 17, 2018 Interview In Conversation With… Karl Bilimoria, MD, MS August 1, 2017 Safe practices for copy and paste in the EHR. Systematic review, recommendations, and novel model for health IT collaboration. February 8, 2017 Agency for Healthcare Research and Quality (AHRQ) Patient Safety Indicator for Postoperative Respiratory Failure (PSI 11) does not identify accurately patients who received unsafe care. November 16, 2016 Building a highway to quality health care. September 7, 2016 Transformational leadership in nursing and medication safety education: a discussion paper. June 1, 2016 Validity of the Agency for Healthcare Research and Quality Patient Safety Indicators and the Centers for Medicare and Medicaid Hospital-acquired Conditions: a systematic review and meta-analysis. May 18, 2016 View More See More About The Topic Quality and Safety Professionals Policy Makers Quality Improvement Strategies Incentives Education and Training View More
Common formats allow uniform collection and reporting of patient safety data by patient safety organizations. January 13, 2010
Reengineering hospital discharge: a protocol to improve patient safety, reduce costs, and boost patient satisfaction. July 1, 2009
The intensive care unit, patient safety, and the Agency for Healthcare Research and Quality. October 4, 2006
Complexity, bullying, and stress: analyzing and mitigating a challenging work environment for nurses. July 8, 2009
Limiting nurse overtime, and promoting other good working conditions, influences patient safety. April 9, 2008
Medication therapy management programs: forming a new cornerstone for quality and safety in Medicare. August 2, 2006
Utilizing improvement science methods to improve physician compliance with proper hand hygiene. March 29, 2012
Improving situation awareness to reduce unrecognized clinical deterioration and serious safety events. January 9, 2013
How useful are voluntary medication error reports? The case of warfarin-related medication errors. January 9, 2008
Addressing veteran health-related social needs: how Joint Commission standards accelerated integration and expansion of tools and services in the Veterans Health Administration. December 6, 2023
Identifying causes of adverse events detected by an automated trigger tool through in-depth analysis. October 20, 2010
Quality improvement project to reduce perioperative opioid oversedation events in a paediatric hospital. October 5, 2011
Communicating with patients about diagnostic errors in breast cancer care: providers' attitudes, experiences, and advice January 22, 2020
A qualitative study examining the influences on situation awareness and the identification, mitigation and escalation of recognised patient risk. January 29, 2014
Perceived discrimination in the community pharmacy: a cross-sectional, national survey of adults. May 10, 2023
Status of the implementation of the World Health Organization multimodal hand hygiene strategy in United States of America health care facilities. May 7, 2014
Incorporating harms into the weighting of the Revised AHRQ Patient Safety for Selected Indicators Composite (PSI 90). January 26, 2022
Enhancing communication in surgery through team training interventions: a systematic literature review. December 22, 2010
More than words: patients' views on apology and disclosure when things go wrong in cancer care. August 24, 2011
Toward patient-centered cancer care: patient perceptions of problematic events, impact, and response. May 2, 2012
Medication errors in hospitals: a literature review of disruptions to nursing practice during medication administration. September 23, 2015
Patient safety event reporting in critical care: a study of three intensive care units. March 21, 2007
The Henry Ford Health System No Harm Campaign: a comprehensive model to reduce harm and save lives. July 11, 2012
Delivering the truth: challenges and opportunities for error disclosure in obstetrics. February 26, 2014
Classifying errors in preventable and potentially preventable trauma deaths: a 9-year review using the Joint Commission's standardized methodology. October 15, 2014
Nurse interrupted: development of a realistic medication administration simulation for undergraduate nurses. August 26, 2015
Medication reconciliation at an academic medical center: implementation of a comprehensive program from admission to discharge. December 9, 2009
Maintaining perioperative safety in uncertain times: COVID-19 pandemic response strategies. November 18, 2020
A simple checklist for preventing major complications associated with cesarean delivery. January 5, 2011
Using the Agency for Healthcare Research and Quality Patient Safety Indicators for targeting nursing quality improvement. November 23, 2011
Can positivity promote safety? Psychological capital development combats cynicism and unsafe behavior. July 10, 2019
Improving the reliability of verbal communication between primary care physicians and pediatric hospitalists at hospital discharge. June 24, 2015
Mortality among patients in VA hospitals in the first 2 years following ACGME resident duty hour reform. September 12, 2007
How valid is the ICD-9-CM based AHRQ Patient Safety Indicator for postoperative venous thromboembolism? January 13, 2010
Making infection prevention and control everyone's business? Hospital staff views on patient involvement. June 5, 2019
Recognizing and responding to the "toxic" work environment: worker safety, patient safety, and abuse/neglect in nursing homes. September 20, 2017
Predictors of unit-level medication administration accuracy: microsystem impacts on medication safety. August 27, 2014
To err is system: a comparison of methodologies for the investigation of adverse outcomes in healthcare. May 5, 2021
Shepherding change: how the market, healthcare providers, and public policy can deliver quality care for the 21st century. March 1, 2006
Preliminary assessment of pediatric health care quality and patient safety in the United States using readily available administrative data. August 13, 2008
Positive predictive value of the AHRQ accidental puncture or laceration patient safety indicator. January 20, 2010
Effect of social influences on pharmacists' intention to report adverse drug events. October 17, 2012
Weekend specialist intensity and admission mortality in acute hospital trusts in England: a cross-sectional study. November 29, 2017
The relationship between resident physician burnout and its’ effects on patient care, professionalism, and academic achievement: a review of the literature. October 5, 2022
Characterising ICU–ward handoffs at three academic medical centres: process and perceptions. March 20, 2019
Low perfusion and missed diagnosis of hypoxemia by pulse oximetry in darkly pigmented skin: a prospective study. March 6, 2024
Measurement of harms in community care: a qualitative study of use of the NHS Safety Thermometer. August 1, 2018
Improving medication administration safety: using naïve observation to assess practice and guide improvements in process and outcomes. January 7, 2015
Detection of postoperative respiratory failure: how predictive is the Agency for Healthcare Research and Quality's Patient Safety Indicator? September 29, 2010
Malpractice reform—opportunities for leadership by health care institutions and liability insurers. April 14, 2010
Electronic health record legal settlements in the US since the 2009 Health Information Technology for Economic and Clinical Health Act. December 21, 2022
The impact of meaningful use and electronic health records on hospital patient safety. November 2, 2022
Combined impact of Medicare's hospital pay for performance programs on quality and safety outcomes is mixed. August 10, 2022
Complexity bias in the prevention of iatrogenic injury: why specific harms may inhibit performance. March 16, 2022
Incorporating harms into the weighting of the Revised AHRQ Patient Safety for Selected Indicators Composite (PSI 90). January 26, 2022
Alternatives to opioid education and a prescription drug monitoring program cumulatively decreased outpatient opioid prescriptions. December 16, 2020
Unintended consequences of health care reform: impact of changes in payor mix on patient safety indicators, October 7, 2020
The confused and bewildered hospital: adverse event discovery, pay-for-performance, and big data tools as halfway technologies. July 29, 2020
Improvement in patient safety may precede policy changes: trends in patient safety indicators in the United States, 2000-2013. June 3, 2020
Hospital-acquired Conditions Reduction Program, patient safety, and Magnet designation in the United States. May 13, 2020
Adverse events present on arrival to the emergency department: the ED as a dual safety net. March 11, 2020
A model for improving health care quality for transgender and gender nonconforming patients. January 23, 2020
Validation of new ICD-10-based patient safety indicators for identification of in-hospital complications in surgical patients: a study of diagnostic accuracy. September 11, 2019
Pursuing patient safety at the intersection of design, systems engineering, and health care delivery research: an ongoing assessment. February 27, 2019
Selected medication safety risks that can easily fall off the radar screen—part 1, part 2, and part 3. December 19, 2018
Safe practices for copy and paste in the EHR. Systematic review, recommendations, and novel model for health IT collaboration. February 8, 2017
Agency for Healthcare Research and Quality (AHRQ) Patient Safety Indicator for Postoperative Respiratory Failure (PSI 11) does not identify accurately patients who received unsafe care. November 16, 2016
Transformational leadership in nursing and medication safety education: a discussion paper. June 1, 2016
Validity of the Agency for Healthcare Research and Quality Patient Safety Indicators and the Centers for Medicare and Medicaid Hospital-acquired Conditions: a systematic review and meta-analysis. May 18, 2016