Perspectives on Safety
Narrow Results Clear All
- Communication Improvement 43
- Culture of Safety 47
Education and Training
- Students 2
- Error Reporting and Analysis 64
- Human Factors Engineering 27
Legal and Policy Approaches
- Regulation 14
- Logistical Approaches 19
- Policies and Operations 1
- Quality Improvement Strategies 85
- Research Directions 1
- Specialization of Care 5
- Teamwork 17
- Clinical Information Systems 21
- Alert fatigue 2
- Device-related Complications 5
- Diagnostic Errors 14
- Discontinuities, Gaps, and Hand-Off Problems 16
- Fatigue and Sleep Deprivation 10
- Identification Errors 2
- Delirium 1
- Medication Errors/Preventable Adverse Drug Events 11
- Nonsurgical Procedural Complications 5
- Psychological and Social Complications 15
- Surgical Complications 14
- Gynecology 52
- Surgery 12
- Nursing 11
- Pharmacy 7
- Family Members and Caregivers 4
- Health Care Executives and Administrators
Health Care Providers
- Nurses 7
- Physicians 18
Non-Health Care Professionals
- Educators 23
- Media 1
- Patients 3
with commentary by Timothy J. Hoff, PhD, Safety Culture, December 2006
Safety cultures are the holy grail in any risky industry. Like all holy grails, they can never be fully realized. This is particularly the case in health care. Why? Health care organizations struggle with too many competing demands to make safety the only...
with commentary by John Gosbee, MD, MS, Human Factors, November 2006
Certain phrases are famously oxymoronic: "jumbo shrimp," "military intelligence." We chuckle at such terms, but they do little harm. In the patient safety field, the term "expected complication" is both defeatist and ultimately self-fulfilling. For that...
Human Factors, November 2006
Don Norman, PhD, is well known for his books "The Design of Everyday Things" and "Emotional Design." Although not focused on health care, his work introduced many in health care to the concepts of human factors engineering and to the importance of thoughtful design in ensuring that technology is used for its intended purposes. He is cofounder of the Nielsen Norman Group, professor at Northwestern University, and former vice president of Apple Computer. Dr. Norman is now writing "The Design of Future Things," discussing the role that automation will play in our everyday lives. We asked Dr. Norman to speak with us about human-centered design.
The Transformation of Patient Safety at the VA, September 2006
James P. Bagian, MD, is the Director of the Department of Veterans Affairs National Center for Patient Safety. Dr. Bagian began his career as a mechanical engineer, then became a physician, trained in surgery and anesthesia. A NASA Astronaut for 15 years, he flew on two space shuttle flights. In 2001, the American Medical Association awarded him the Nathan S. Davis Award for outstanding public service in the advancement of public health. We asked Dr. Bagian to speak with us about his experience transforming safety at in Veterans Affairs hospitals nationwide.
with commentary by Ashish K. Jha, MD, MPH, The Transformation of Patient Safety at the VA, September 2006
Five years after the landmark Crossing the Quality Chasm report by the Institute of Medicine (IOM), the quality and safety of health care in the United States remains far from ideal.(1) It is easy to feel pessimistic. Can health care organizations really...
Reflections on the History of the Patient Safety Movement, August 2006
Lucian Leape, MD, is generally known as the father of the modern patient safety movement in the United States. A Harvard professor, Leape shifted his career two decades ago from his clinical practice as a pediatric surgeon to a focus on understanding how medical errors occur and how patient safety can be improved. The result was several groundbreaking studies and commentaries that helped shift the paradigm from "bad people" to "bad systems," and which paved the way for the Institute of Medicine report, "To Err is Human," which he helped write. He has received dozens of honors, including the John M. Eisenberg patient safety award, the duPont Award for Excellence in Children's Health Care, and the Robert Wood Johnson Foundation Investigator's Award in Health Policy Research. He spoke to us about his remarkable career and his thoughts about the patient safety movement.
with commentary by Jeffrey B. Cooper, PhD, Reflections on the History of the Patient Safety Movement, August 2006
My journey into patient safety began in 1972. It was born of serendipity enabled by the good fortune of extraordinary mentors, an environment that supported exploration and allowed for interdisciplinary teamwork, and my own intellectual curiosity. The...
Patient Safety Programs, July 2006
Allan Frankel, MD, is Director of Patient Safety for Partners HealthCare, the merged entity of Harvard hospitals and clinics that includes Massachusetts General and Brigham and Women's Hospital. Dr. Frankel, an anesthesiologist by training, has been a key member of the faculty of the Institute for Healthcare Improvement, co-chairing numerous Adverse Drug Events and Patient Safety Collaboratives. Dr. Frankel's work in patient safety focuses on leadership training, high reliability in health care, teamwork development, and cultural change. We asked Dr. Frankel to speak with us about developing a comprehensive patient safety program.
with commentary by John Whittington, MD, Patient Safety Programs, July 2006
One of the most important interventions is for hospital leadership to get the hospital's board involved with safety and quality. Not only does the board have fiduciary responsibility for the organization, but they have responsibility for quality and safety...
with commentary by Rainu Kaushal, MD MPH; Sekhar Upadhyayula, MD; David M. Gaba, MD; Lucian L. Leape, MD, Outpatient Safety, May 2006
Over the last decade, surgical operations and interventional procedures have been performed increasingly in offices with the administration of office-based anesthesia (OBA).(1) Economic considerations and convenience have driven this increase. Schultz...
with commentary by Nancy C. Elder, MD, MSPH, Outpatient Safety, May 2006
Dr. Jones was sure he had increased Mr. H's cholesterol-lowering medication to 80 mg 6 months ago, but, at his visit today, his pill bottle still says 40 mg. In reviewing Ms. B's chart in preparation for performing a well-woman examination, Dr. Smith find...
Pharmacy and Safety, April 2006
Michael Cohen, RPh, MS, ScD, is president of the Institute for Safe Medication Practices (ISMP) and co-editor of ISMP Medication Safety Alert!, a biweekly newsletter. A pharmacist by training, his ground-breaking work and commitment to patient safety and preventing medication errors has spanned three decades. He received one of the prestigious MacArthur Fellowships (informally known as the "genius awards") in 2005.
with commentary by David M. Gaba, MD, Point–Counterpoint: Simulation vs. Team Training, March 2006
Let’s take as a given that improving the ability of individuals and teams to function “as a team” is important in health care, especially in highly dynamic clinical environments.(1) How can this best be accomplished? In a comprehensive approach to teamwork...
with commentary by Stephen D. Pratt, MD and Benjamin P. Sachs, MB, Point–Counterpoint: Simulation vs. Team Training, March 2006
In recent years, the medical community has reached a near-consensus that team training and Crew Resource Management (CRM) techniques can improve patient safety. However, the most effective way to teach and implement these concepts is much less clear...
Disclosing Mistakes, February 2006
John Banja, PhD, is Assistant Director for Health Sciences and Clinical Ethics and Associate Professor of Clinical Ethics at Emory University School of Medicine. Dr. Banja, whose doctorate is in philosophy, is currently participating in AHRQ-funded studies designed to help clinicians communicate more effectively in emotionally charged situations after errors or unforeseen outcomes. His book, Medical Errors and Medical Narcissism, covers issues around the appropriate, ethical disclosure of medical errors by health care professionals.
with commentary by Eric J. Thomas, MD, MPH, Aviation and Patient Safety, January 2006
On August 2, 2005, Air France flight 358 crashed while landing in Toronto. In less than 2 minutes, the crew evacuated 309 passengers. Several minutes later, the plane burst into flames.(1) Crashes like this are remarkably rare, yet the crew was prepared to...
Aviation and Patient Safety, January 2006
Jack Barker, PhD, is Vice President of Research and Development for Mach One Leadership and a commercial pilot for a major airline. Dr. Barker began his career in the Air Force and proceeded to get his doctorate in cognitive psychology. His research has centered on high-performance teams, crew resource management (CRM), and training. He has trained hundreds of commercial airline pilots, as well as pilots and others working for NASA in the Space Shuttle program and Mars mission. His company, like several others, works with health care providers and organizations in an effort to translate aviation safety principles to health care.
The Law and Patient Safety, December 2005
Dr. Brennan is a Professor of Medicine at Harvard Medical School and Professor of Law and Public Health at the Harvard School of Public Health. As the lead investigator of the groundbreaking study that assessed the prevalence of adverse events in hospitalized patients, Dr. Brennan has contributed dramatically to our understanding of the epidemiology of medical errors. More recently, he has emerged as one of the world's most thoughtful and influential analysts of the complex interplay among medicine, ethics, law, and public health.
Patient Safety Initiatives, September 2005
Dr. Carolyn Clancy has been the Director of the Agency for Healthcare Research and Quality (AHRQ) since 2003. Prior to becoming AHRQ Director, she led the Agency's Center for Outcomes and Effectiveness Research. A general internist and health services researcher, she has published widely in the peer reviewed literature on a variety of topics, ranging from quality improvement to primary care. She is a member of the Institute of Medicine and a Master of the American College of Physicians.
with commentary by Robert M. Wachter, MD, Patient Safety Initiatives, September 2005
Translational research is all the rage in biomedicine. In its purest form, the concept refers to the translation of basic research discoveries into clinical applications, followed by patient-oriented studies to demonstrate benefit.(1) Increasingly, it also...