Perspectives
Our Perspectives on Safety section features expert viewpoints on current themes in patient safety, including interviews and written essays published monthly. Annual Perspectives highlight vital and emerging patient safety topics.
Latest Perspectives
Monika Haugstetter, MHA, MSN, RN, CPHQ, is a Health Science Administrator with AHRQ, leading AHRQ’s TeamSTEPPS® initiative. Stephen Hines, PhD, is a Senior Research Scientist at the Arbor... Read More
This piece discusses the impact of AHRQ’s TeamSTEPPS training curriculum on patient safety and highlights updates made to the curriculum in 2023 with the launch of TeamSTEPPS 3.0.
This perspective discusses patient safety in office-based care settings, where most patients get their healthcare. We discuss patient safety events that arise in routine office-based settings and those more particular to procedures performed in office... Read More
Richard Ricciardi is the associate dean for clinical practice and community engagement and the executive director of the Center for Health Policy and Media Engagement at the George Washington University. He has served as the... Read More
This perspective discusses the impact of climate change on human health and healthcare delivery, and how the healthcare system has contributed to pollution and climate change. Initiatives to decrease waste and emissions from... Read More
Jodi Sherman is an associate professor of anesthesiology at Yale School of Medicine and is the director of the Yale Program on Healthcare Environmental Sustainability. She also serves as the medical director for the Yale New... Read More
All Perspectives (192)
This piece discusses the impact of AHRQ’s TeamSTEPPS training curriculum on patient safety and highlights updates made to the curriculum in 2023 with the launch of TeamSTEPPS 3.0.
Monika Haugstetter, MHA, MSN, RN, CPHQ, is a Health Science Administrator with AHRQ, leading AHRQ’s TeamSTEPPS® initiative. Stephen Hines, PhD, is a Senior Research Scientist at the Arbor Research Collaborative for Health. While at Abt Associates, he co-led the TeamSTEPPS 3.0 revisions in collaboration with AHRQ. We spoke with Monika and Stephen about the newly released TeamSTEPPS 3.0 curriculum.
This perspective discusses patient safety in office-based care settings, where most patients get their healthcare. We discuss patient safety events that arise in routine office-based settings and those more particular to procedures performed in office-based ambulatory surgery centers. Communication strategies can mitigate safety risks and can be applied in many healthcare settings.
Richard Ricciardi is the associate dean for clinical practice and community engagement and the executive director of the Center for Health Policy and Media Engagement at the George Washington University. He has served as the director of the Division of Practice Improvement and senior advisor for nursing at AHRQ, and he maintains a part-time clinical practice at Mercy Health Clinic. We spoke to him on patient safety in office-based settings.
This perspective discusses the impact of climate change on human health and healthcare delivery, and how the healthcare system has contributed to pollution and climate change. Initiatives to decrease waste and emissions from healthcare can reduce the harm that healthcare pollution inflicts on population health while achieving safer, more resilient care.
Jodi Sherman is an associate professor of anesthesiology at Yale School of Medicine and is the director of the Yale Program on Healthcare Environmental Sustainability. She also serves as the medical director for the Yale New Haven Health System Center for Sustainable Healthcare. We spoke to her on patient safety and sustainable healthcare.
This piece discusses how undergraduate professional nursing education integrates the topic of patient safety into classroom and clinical instruction, and how this affects patient safety as a whole.
Joan Stanley is the chief academic officer at the American Association of Colleges of Nursing (AACN). We spoke to her about how undergraduate professional nursing education integrates the topic of patient safety into classroom and clinical instruction, and how this affects patient safety as a whole.
This piece focuses on workplace violence trends in healthcare settings and strategies for creating a safer healthcare environment.
Cheryl B. Jones is a professor, director of the Hillman Scholars Program, and interim associate dean of the School of Nursing’s PhD program at the University of North Carolina at Chapel Hill. We spoke to her about workplace violence trends in healthcare settings and how we can create a safer work environment for healthcare staff.
This piece focuses on the importance of patient safety following the end of the public health emergency and how organizations can move beyond the pandemic.
Patricia McGaffigan is the Vice President for Safety Programs at the Institute for Healthcare Improvement and President of the Certification Board for Professionals in Patient Safety. We spoke to Patricia about patient safety trends and how patient safety will move beyond the pandemic.
This piece discusses virtual nursing, an approach to care that incorporates an advanced practice nurse into hospital-based patient care through telehealth. Virtual nursing increases patient safety and may enable expert nurses to continue to meet patient needs in future staffing shortages.
Kathleen Sanford is the chief nursing officer and an executive vice president at CommonSpirit. Sue Schuelke is an assistant professor at the College of Nursing–Lincoln Division, University of Nebraska Medical Center. They have pioneered and tested a new model of nursing care that utilizes technology to add experienced expert nurses to care teams, called Virtual Nursing.
This piece focuses on the importance of building the capacity of the workforce and organizations for patient safety using patient safety education.
Regina Hoffman is the executive director of the Pennsylvania Patient Safety Authority. We spoke to her about her experience in collaborative learning, sharing information across healthcare facilities, and patient safety education.
This piece discusses how family presence and participation in healthcare at all levels can improve patient safety as well as how the COVID-19 pandemic affected partnership with patients and families, ultimately highlighting the critical importance of family presence and participation.
Beverley H. Johnson is the president and CEO of the Institute for Patient- and Family-Centered Care (IPFCC). We spoke to her about her experience in patient and family engagement and improving patient safety, including how to continue to partner with families during pandemics and through technology.
Throughout 2022, AHRQ PSNet has shared research that elucidates the complex nature of misdiagnosis and diagnostic safety. This Year in Review explores recent work in diagnostic safety and ways that greater safety may be promoted using tools developed to improve diagnostic practices.
This piece discusses surveillance monitoring of patients in low-acuity units of the hospital to prevent failure to rescue events, its difference from high-acuity continuous monitoring, and its potential applications in other settings.
Drs. Susan McGrath and George Blike discuss surveillance monitoring and its challenges and opportunities.
In the past several decades, technological advances have opened new possibilities for improving patient safety. Using technology to digitize healthcare processes has the potential to increase standardization and efficiency of clinical workflows and to reduce errors and cost across all healthcare settings.1 However, if technological approaches are designed or implemented poorly, the burden on clinicians can increase. For example, overburdened clinicians can experience alert fatigue and fail to respond to notifications. This can lead to more medical errors. As a testament to the significance of this topic in recent years, several government agencies [(e.g. the Agency for Healthcare Research and Quality (AHRQ) and the Centers for Medicare and Medicaid services (CMS)] have developed resources to help healthcare organizations integrate technology, such as the Safety Assurance Factors for EHR Resilience (SAFER) guides developed by the Office of the National Coordinator for Health Information Technology (ONC).2,3,4 However, there is some evidence that these resources have not been widely used.5 Recently, the Centers for Medicare & Medicaid Services (CMS) started requiring hospitals to use the SAFER guides as part of the FY 2022 Hospital Inpatient Prospective Payment Systems (IPPS), which should raise awareness and uptake of the guides.6
This piece focuses on perinatal mental health and efforts to improve maternal safety.
Christie Allen is the Senior Director of Quality Improvement at the American College of Obstetrics and Gynecology (ACOG). We spoke to her about her experience in maternal safety and improving perinatal mental healthcare, which is care for mental health conditions during pregnancy and the twelve months following delivery
Throughout 2022, the impact of system failures on healthcare workers was a recurrent theme of articles on AHRQ PSNet. This Year in Review explores these impacts and ways to support healthcare workers involved in a system failure.
This piece discusses the evolution of remote patient monitoring, emergence into use with acute conditions, patient safety considerations, and the continued challenges of telehealth implementation.
Dr. Neal Sikka and Dr. Colton Hood are emergency medicine physicians who work in the Innovative Practice & Telemedicine section at George Washington University Hospital (GW). We spoke with them about their experience implementing remote patient monitoring (RPM) programs, GW’s Maritime Medical Access program, and patient safety considerations in the remote environment.
This piece discusses patient safety concerns among members of the LGBTQ+ community which may inhibit access to needed healthcare and potential ways to provide patient-centered care and mitigate the risk of adverse events.
Connor Wesley, RN, BSN, is a registered nurse in Tacoma, WA. In addition to his role as the Assistant Nurse Manager of the Emergency Department at MultiCare Allenmore Hospital, Connor lectures locally and nationally on providing healthcare to members of the lesbian, gay, bisexual, transgender, and queer or questioning (LGBTQ+) community. We interviewed Connor to discuss patient safety and the LGBTQ+ community.
This piece discusses resilient healthcare and the Safety-I and Safety-II approaches to patient safety.
Ellen Deutsch, MD, MS, FACS, FAAP, FSSH, CPPS is a Medical Officer in the Center for Quality Improvement and Patient Safety at the Agency for Healthcare Research and Quality. Dr. Deutsch is a pediatric otolaryngologist and has vast experience in simulation and resilience engineering. We spoke with her about resilient healthcare and how resilient engineering principles are applied to improve patient safety.
This collaborative piece with the Centers for Medicare & Medicaid Services discusses the current state of patient safety measurement, advancements in measuring patient safety, and explores future directions.
Michelle Schreiber, MD, is the Deputy Director of the Center for Clinical Standards and Quality and the Director of the Quality Measurement and Value-Based Incentives Group at the Centers for Medicare & Medicaid Services. We spoke with her about measuring patient safety, the CMS National Quality Strategy, and the future of measurement.
This piece focuses on human factors engineering including application of the SEIPS model to implement care transitions rooted in patient safety and the processes of care.
Dr. Pascale Carayon, PhD, is a professor emerita in the Department of Industrial and Systems Engineering and the founding director of the Wisconsin Institute for Healthcare Systems Engineering (WIHSE). Dr. Nicole Werner, PhD, is an associate professor in the Department of Health and Wellness Design at the Indiana University School of Public Health-Bloomington. We spoke with both of them about the role of human factors engineering has in improving healthcare delivery and its role in patient safety.
Special thanks to Freya Spielberg, MD, MPH, Founder and CEO of Urgent Wellness LLC in Washington, DC; and Jack Westfall, MD, MPH, Director of the Robert Graham Center for Policy Studies in Family Medicine and Primary Care, for their thoughtful interviews on the topic of Primary Care and Patient Safety, which helped lay the groundwork for this Perspective.
Freya Spielberg MD, MPH, is the Founder and CEO of Urgent Wellness LLC, a social enterprise dedicated to improving the health of Individuals living in low-income housing in Washington, DC. Previously, as an Associate Professor at George Washington University, and at the University of Texas Dell Medical School, and School of Public Health, she developed a curriculum in Community Oriented Quality Improvement, to train the next generation of healthcare providers how to integrate population health into primary care to achieve the quintuple aim of better health outcomes, better patient experience, better provider experience, lower health care costs, and decreased health disparities. We spoke with her about her ongoing work in low-income communities to improve access to primary care and its impact on patient safety.