Perspectives on Safety
Narrow Results Clear All
- Communication Improvement 18
- Culture of Safety 23
Education and Training
- Students 1
- Error Reporting and Analysis 27
- Human Factors Engineering 13
- Legal and Policy Approaches 29
- Logistical Approaches 11
- Policies and Operations 1
- Quality Improvement Strategies 38
- Specialization of Care 1
- Teamwork 7
- Clinical Information Systems 7
- Device-related Complications 3
- Diagnostic Errors 5
- Discontinuities, Gaps, and Hand-Off Problems 7
- Fatigue and Sleep Deprivation 5
- Identification Errors 1
- Delirium 1
- Medication Errors/Preventable Adverse Drug Events 4
- Nonsurgical Procedural Complications 2
- Psychological and Social Complications 6
- Surgical Complications 6
- Family Members and Caregivers 3
- Health Care Executives and Administrators
Health Care Providers
- Nurses 4
Non-Health Care Professionals
- Media 1
- Patients 2
with commentary by Paul E. Phrampus, MD, Health System Consolidation and Patient Safety, March 2019
This piece outlines how large integrated health care systems can implement effective patient safety programs and spotlights the importance of leadership engagement and a just culture.
with commentary by Joseph O. Lopreiato, MD, MPH, Update on Simulation, August 2018
This piece explores health care simulation including the four main methods used and the evidence base for its impact on learning and patient care.
with commentary by Katherine Liang and Eric Alper, MD, Post-Hospital Syndrome, April 2018
This piece explores the risks patients face after hospital discharge and strategies to address them, such as patient education, Project RED, and the Care Transitions Intervention.
with commentary by Jane Ball, PhD, and Peter Griffiths, PhD, Nursing and Patient Safety, March 2018
This piece explores how missed nursing care may explain the association between low nurse staffing levels and increased mortality in hospital patients.
with commentary by Robert M. Wachter, MD, Surgical Safety, December 2017
This piece explores progress of patient safety in the surgical field and where further improvement can be made, such as ongoing assessment of procedural skills along with video recording and review of surgical procedures.
with commentary by Julia E. Szymczak, PhD, Presenteeism: A Patient Safety Challenge, October 2017
This piece explores the risks of presenteeism among health care workers and factors, such as cultural expectations, that contribute to its occurrence.
with commentary by Dean F. Sittig, PhD, and Hardeep Singh, MD, MPH, Health Information Technology and Safety, September 2017
This piece highlights four key lessons that the authors believe are useful for clinicians and health care organizations that seek to identify, prevent, and mitigate electronic health record–related safety issues.
with commentary by Kathy Malloy; Timothy P. Brigham, PhD; Thomas J. Nasca, MD, Resident Duty Hours Policy Changes, August 2017
This piece reviews how changes to the ACGME requirements emphasize patient safety and quality improvement, address physician well-being, strengthen expectations around team-based care, and create flexibility for work hours within the maximum 80-hour workweek.
with commentary by David Studdert, LLB, ScD, Legal Issues and Patient Safety, July 2017
This piece explores the risk of recurring medicolegal events among providers who have received unsolicited patient complaints, faced disciplinary actions by medical boards, or accumulated malpractice claims.
with commentary by Vanessa K. Martin, DO, MS; Nasim Mirnateghi, PhD; and Mahdi Khoshchehreh, MD, MS, The Weekend Effect, June 2017
This piece explores the weekend effect in cardiology and recommends allowing invasive management for patients with non ST-elevation myocardial infarction to improve outcomes in this group.
with commentary by Irene Berita Murimi, PhD, MA, and G. Caleb Alexander, MD, MS, Opioids and Patient Safety, May 2017
This piece explores the opioid epidemic in the United States, including factors that led to increased opioid prescribing, its adverse effects, and tactics to reduce opioid-related harm.
with commentary by Sara J. Singer, MBA, PhD, Approaching Safety Culture in New Ways, March 2017
This piece discusses the importance of strengthening safety culture in health care and offers insights for organizations seeking to achieve culture change.
with commentary by David P. Baker, PhD; James B. Battles, PhD; Heidi B. King, MS, Update on Teamwork, February 2017
This piece outlines 10 insights about team training in health care learned from experience with the AHRQ-supported teamwork training program, TeamSTEPPS.
with commentary by Ross W. Simon and Elena G. Canacari, RN, Workplace Safety, January 2017
This piece explores how a team at Beth Israel Deaconess Medical Center combined tools and techniques used in manufacturing along with continuous improvement to develop a process to identify, prioritize, and mitigate hazards in health care settings.
with commentary by Carl Macrae, PhD, Root Cause Analysis: What Have We Learned?, December 2016
This piece explores how strategies from aviation, such as just culture and monitoring technologies, can be applied in health care to improve patient safety.
with commentary by Alvin Rajkomar, MD, Big Data and Patient Safety, October 2016
This piece explores the role for a clinician data scientist in utilizing clinical datasets to improve health care quality and safety.
with commentary by Karen Frank, DNP, RN, MSHA, Certification in Patient Safety, June 2016
This piece offers a nurse's viewpoint on the benefits of acquiring certification in patient safety.
with commentary by Mark Friedberg, MD, MPP, Joy in Practice, February 2016
This piece highlights the importance of focusing on physician professional satisfaction as a way to determine potential patient safety hazards and improve health care quality.
with commentary by Hardeep Singh, MD, MPH, Update on Diagnostic Errors, January 2016
This piece discusses momentum in the field of diagnostic error over the past several years (culminating in the recent Improving Diagnosis in Health Care report) and outlines future avenues to ensure progress in diagnostic safety.
with commentary by Robert M. Wachter, MD, Ten years of AHRQ Patient Safety Network: A Window Into the Evolution of the Patient Safety Literature, November 2015
This editorial provides an overview of how PSNet and WebM&M have evolved in the past decade.