Perspectives on Safety
Narrow Results Clear All
- Communication Improvement 5
- Culture of Safety 14
- Education and Training 2
- Error Reporting and Analysis 6
- Human Factors Engineering 3
- Legal and Policy Approaches 8
- Policies and Operations 1
- Quality Improvement Strategies 8
- Teamwork 5
- Technologic Approaches 4
- Identification Errors 1
- Medical Complications 3
- Medication Safety 2
- Nonsurgical Procedural Complications 1
- Psychological and Social Complications 5
- Surgical Complications 2
- Health Care Executives and Administrators
- Health Care Providers 7
Non-Health Care Professionals
- Media 1
- Patients 1
Resilience Engineering and Patient Safety, June 2019
Dr. Hollnagel is Senior Professor of Patient Safety at the University of Jönköping (Sweden) as well as Visiting Professorial Fellow at Macquarie University in Sydney (Australia). We spoke with him about his work studying safety in health care and the differences between designing safety improvements in health care versus other industries.
Health System Consolidation and Patient Safety, March 2019
Dr. Haas is an obstetrician–gynecologist and co-Principal Investigator for Ariadne Labs' work focused on health care system expansion. We spoke with her about the trend of health systems getting larger and more integrated, the risks to patient safety, and ways to mitigate these risks.
Patient Advocacy, June 2014
Dave deBronkart, known as e-Patient Dave, is a co-founder and co-chair of the Society for Participatory Medicine and coauthor of Let Patients Help: A Patient Engagement Handbook. We spoke with him about engaging patients in their care and allowing patients to access their medical records.
Hand Hygiene, May 2014
Dr. Pittet is Director of the Infection Control Programme and WHO Collaborating Centre on Patient Safety at the University of Geneva Hospitals, Switzerland. We spoke with him about hand hygiene in health care, including how to implement culture change and improve safety.
Interruptions and Distractions in Health Care, February 2014
Dr. Coiera, a professor at the University of New South Wales, has extensively researched and written about clinical communication processes and information systems. We spoke with him about how interruptions and distractions in the clinical environment influence patient safety.
Update on Just Culture, September 2013
Professor Sidney Dekker has done revolutionary work on human error and safety and written several bestselling books on system failure and just culture.
What We've Learned About Leveraging Leadership and Culture to Affect Change and Improve Patient Safety
with commentary by Sara J. Singer, MBA, PhD, Update on Just Culture, September 2013
This piece explores how leaders can promote cultural changes to improve patient safety.
Update on Safety Culture, July-August 2013
J. Bryan Sexton, PhD, is director of the Patient Safety Center for the Duke University Health System and an international expert in safety culture and clinician burnout.
with commentary by Allan Frankel, MD, and Michael Leonard, MD, Update on Safety Culture, July-August 2013
This piece explores how safety culture work has evolved over the past decade.
with commentary by Susan D. Scott RN, MSN, The Second Victim, May 2011
This piece discusses efforts to ameliorate the impact of errors on providers, including an innovative program to counsel second victims.
High-Risk Physicians and Disruptive Behaviors, December 2009
Gerald B. Hickson, MD, is one of the world's leading experts on physician behavior and its connection to clinical outcomes and medical malpractice. He is a Professor at the Vanderbilt University School of Medicine, where he is also the Joseph C. Ross Chair in Medical Education and Administration, Associate Dean for Clinical Affairs, Director of the Vanderbilt Center for Patient and Professional Advocacy, and Director of Clinical Risk and Loss Prevention. We asked him to speak with us about high-risk physicians and malpractice.
with commentary by Alan H. Rosenstein, MD, MBA; Michelle O'Daniel, MSG, MHA, High-Risk Physicians and Disruptive Behaviors, December 2009
The 1999 Institute of Medicine report highlighted the need for health care providers to address the serious concerns raised about the quality and safety of patient care being provided in our health care organizations. Organizations responded by looking at new ways to fix the system, mostly through the introduction of new technologies and system/process redesign. Advances have been made, but there are still significant opportunities for improvement. Is the barrier poor system or process design, or is it related to addressing basic human behaviors?
Just Culture, October 2007
An engineer and an attorney by training, David Marx, JD, is president of Outcome Engineering, a risk management firm. After a career focused on safety assessment and improvement in aviation, he has spent the last decade focusing on the interface between systems engineering, human factors, and the law. In 2001, he wrote a seminal paper describing the concept of just culture, which became a focal point for efforts to reconcile notions of "no blame" and "accountability." He has gone on to form the "Just Culture Community" to address these issues at health care institutions around the country.
with commentary by Alison H. Page, MS, MHA, Just Culture, October 2007
We've all been there...something goes wrong, a patient is harmed, and we, as medical directors, managers, and administrators, are forced to judge the behavioral choices of another human being. Most of the time, we conduct this complex leadership function guided by little more than vague policies, personal beliefs, and intuition. Frequently, we are frustrated by the fact that many other providers have made the same mistake or behavioral choice, with no adverse outcome to the patient, and the behavior was overlooked. Quite understandably, the staff is frustrated by what appears to be inconsistent, irrational decision-making by leadership. The "just culture" concept teaches us to shift our attention from retrospective judgment of others, focused on the severity of the outcome, to real-time evaluation of behavioral choices in a rational and organized manner.
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...
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...
Organizational Change in the Face of Highly Public Errors—I. The Dana-Farber Cancer Institute Experience
with commentary by James B. Conway; Saul N. Weingart, MD, PhD, Errors in the Media and Organizational Change, May 2005
A decade ago, two tragic medical errors rocked one of the world’s great cancer hospitals, Dana-Farber Cancer Institute (DFCI) in Boston, to its core. The errors led to considerable soul searching and, ultimately, a major change in institutional practices a...
with commentary by Karen Frush, MD, Errors in the Media and Organizational Change, May 2005
In February 2003, 17-year-old Jessica Santillan died at Duke University Medical Center due to a mismatched heart-lung transplantation. As with the Dana-Farber experience, the death made headlines around the world and devastated the leaders and providers at...