Perspectives on Safety
Narrow Results Clear All
- Communication Improvement 12
- Culture of Safety 3
Education and Training
- Students 1
- Error Reporting and Analysis 12
- Human Factors Engineering 7
- Legal and Policy Approaches 15
- Logistical Approaches 6
- Policies and Operations 1
- Quality Improvement Strategies 24
- Specialization of Care 2
- Teamwork 2
- Clinical Information Systems 6
- Device-related Complications 3
- Diagnostic Errors 2
- Discontinuities, Gaps, and Hand-Off Problems 5
- Fatigue and Sleep Deprivation 5
- Identification Errors 1
- Medical Complications 16
- Medication Safety 5
- Nonsurgical Procedural Complications 4
- Psychological and Social Complications 1
- Surgical Complications 3
- Family Members and Caregivers 1
- Health Care Executives and Administrators
- Health Care Providers 32
- Non-Health Care Professionals 28
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.
Organizations Working to Improve Quality and Safety, June 2015
Maureen Bisognano is President and CEO of the Institute for Healthcare Improvement (IHI). We spoke with her about IHI's efforts to improve health care on a global level.
Organizations Working to Improve Quality and Safety, June 2015
Dr. Cassel, President and CEO of the National Quality Forum (NQF), is a leading expert in geriatric medicine, medical ethics, and quality of care. We spoke with her about NQF's work in developing and utilizing quality measures to improve safety in health care.
with commentary by Yan Xiao, PhD; Colin F. Mackenzie, MB, ChB; and F. Jacob Seagull, PhD, Using Video to Assess Quality and Safety, May 2015
This piece explores the advantages of using video in clinical practice and health care education to augment safety and quality.
with commentary by Niraj Sehgal, MD, MPH, Handoffs and Patient Safety, 2014
Risk-Adjusted Mortality as a Safety/Quality Measure, March 2015
Sir Brian Jarman designed the methodology for hospital standardized mortality ratios, a widely used method of measuring quality and safety, and was involved with the Bristol Royal Infirmary Inquiry. We spoke with him about the development of the HSMR and their role in monitoring performance.
with commentary by Ian Scott, MBBS, MHA, MEd, Risk-Adjusted Mortality as a Safety/Quality Measure, March 2015
This piece discusses risk-adjusted hospital mortality rates as a measure of hospital safety, including why they've become popular, major flaws such as low sensitivity, and alternative ways to use them.
Lean and Patient Safety, January 2015
Mr. Graban is an internationally recognized expert in Lean Healthcare. We spoke with him about applying Lean in hospitals to improve safety and decrease waste.
with commentary by Paul E. Plsek, MS, Lean and Patient Safety, January 2015
This book excerpt describes how integrating innovation and Lean concepts at Virginia Mason enhances clinical performance and the patient experience.
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.
with commentary by Alexandre R. Marra, MD and Michael B. Edmond, MD, MPH, MPA , Hand Hygiene, May 2014
This piece describes barriers to hand hygiene compliance in health care along with strategies to enhance and measure it.
National Organizations in Safety, April 2014
Dr. Gandhi is President of the National Patient Safety Foundation and Associate Professor of Medicine at Harvard Medical School. We spoke with her about NPSF's evolving role in enhancing health care at a national level.
National Organizations in Safety, April 2014
Leah Binder is President and CEO of the Leapfrog Group. We spoke with her about Leapfrog's efforts to address key health policy issues and the development of the Hospital Safety Score.
Infection Prevention and Patient Safety, March 2014
Dr. Holmes is Director of Infection Prevention and Control and a professor at Imperial College London. We spoke with her about infection prevention and patient safety.
with commentary by Susan S. Huang, MD, MPH, Infection Prevention and Patient Safety, March 2014
This piece describes the history around efforts to address preventable health care–associated infections, including federal initiatives and further research avenues to consider.
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.
with commentary by Suzanne Beyea, RN, PhD, Interruptions and Distractions in Health Care, February 2014
This piece describes the research around the effect of interruptions and distractions on health care safety and advocates for promoting and teaching mindfulness to address risks.
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.
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.
Pay-for-Performance: Implications for Patient Safety, May 2013
Harvard internist Dr. Jha is a national leader in policy issues related to safety and quality.
Update on Sleep Deprivation, April 2013
Christopher P. Landrigan, MD, MPH, of Brigham and Women's Hospital has performed key studies on how sleep deprivation affects clinicians and strategies to mitigate such fatigue to improve patient safety, including seminal articles published in the New England Journal of Medicine in 2004 and 2010.
with commentary by Kathlyn E. Fletcher, MD, MA; Darcy A. Reed, MD, MPH, Update on Sleep Deprivation, April 2013
This article discusses evidence surrounding the impact of resident duty hour limits on safety in health care.
with commentary by Saul N. Weingart, MD, PhD, Engaging the Patient and Family in Safety, February 2013
This piece highlights the advantages to and limitations of engaging patients in patient safety.
Designing for Safety, October 2012
Dr. Reiling consults with hospitals nationwide regarding facility designs that emphasize safety, error reduction, and quality.
with commentary by Anjali Joseph, PhD, EDAC; Eileen B. Malone, RN, MSN, MS, EDAC, Designing for Safety, October 2012
This piece discusses how environmental factors contribute to adverse events in health care and describes how evidence-based design principles can improve safety.
Safety in the UK, June 2012
Professor Vincent, a psychologist by training, is one of the world’s leading patient safety researchers.
Trigger Tools, May 2012
One of the pioneers of the trigger tool methodology for detecting adverse events, Dr. Classen is Chief Medical information Officer at Pascal Metrics and Associate Professor of Medicine at the University of Utah.
with commentary by Paul J. Sharek, MD, MPH, Trigger Tools, May 2012
This piece explains how the trigger tool approach identifies adverse events more efficiently than other detection methods such as voluntary incident reporting and patient safety indicators drawn from administrative data.
Disclosing Errors and Other Innovations in Risk Management, March 2012
An attorney and chief risk officer for the University of Michigan Health System, Mr. Boothman developed a pioneering approach to medical mistakes and risk management, emphasizing an honest approach to errors, early apology, and rapid settlement offers when the system was at fault.
Resident Supervision and Patient Safety, February 2012
The founding Dean of Hofstra North Shore-LIJ School of Medicine, Dr. Smith has held numerous senior leadership positions within the field of medical education and residency training.
with commentary by C. Jessica Dine, MD, MA; and Jennifer S. Myers, MD, Resident Supervision and Patient Safety, February 2012
This piece discusses how increased supervision influences the educational experience for trainees.
with commentary by Frances Healey, RN, PhD, Fall Prevention, December 2011
This piece discusses the multiple, complex causes of falls in hospitalized patients along with prevention strategies.
with commentary by Sunil Kripalani, MD, MSc, Handoffs and Patient Safety, March 2011
This piece discusses how medical centers can improve handover quality and patient safety.
Measuring Patient Safety, November 2010
Patrick S. Romano, MD, MPH, is Professor of Medicine and Pediatrics at the University of California, Davis, School of Medicine.
with commentary by Amy K. Rosen, PhD, Measuring Patient Safety, November 2010
Emergency medicine has evolved from a location, with variably trained and experienced providers ("the ER"), to a discipline with a well-defined knowledge base and skill set that focus on the diagnosis and care of undifferentiated acute problems.
Checklists, October 2010
Peter J. Pronovost, MD, PhD, is a Professor of Anesthesia, Critical Care, and Health Policy at Johns Hopkins University and Director of the Johns Hopkins Quality and Safety Research Group. He may be best known for having led the Michigan Keystone project, which used checklists and other interventions to markedly reduce catheter-associated bloodstream infections in ICUs throughout the state. For this work and more, he received a MacArthur Foundation Fellowship, and Time Magazine named him as one of the 100 most influential people in the world. We asked him to speak with us about checklists and other thoughts about the science of improving patient safety.
with commentary by Arpana R. Vidyarthi, MD; Robert B. Baron, MD, MS, Medical Education and Patient Safety, February 2010
Clear health communication is increasingly recognized as essential for promoting patient safety. Yet according to a recent Joint Commission report, What Did the Doctor Say? Improving Health Literacy to Protect Patient Safety, communication problems among health care providers, patients, and families are common and a leading root cause of adverse outcomes.(1) Addressing health literacy—the capacity of individuals to obtain, process, and understand basic health information and services needed to make appropriate health decisions—has become a primary objective for many health systems in order to protect patients from harm.
Workarounds, August 2009
with commentary by Anita L. Tucker, DBA, MS, Workarounds, August 2009
Frontline health care providers are challenged by poorly performing work systems. Required equipment is broken, patient medications are in the wrong dose, key information fails to get communicated, and essential supplies are out of stock.(
Prevention of Urinary Tract Infections: Lessons for Patient Safety, November 2008
Sanjay Saint, MD, MPH, is Professor of Medicine at the University of Michigan and the Ann Arbor VA Medical Center in Ann Arbor, Michigan. Dr. Saint's research has focused on reducing health care–associated infections, with a particular focus on preventing catheter-related urinary tract infections (UTIs). We asked him to speak with us about how research on UTI prevention provides broader lessons for patient safety.
with commentary by Lindsay E. Nicolle, MD , Prevention of Urinary Tract Infections: Lessons for Patient Safety, November 2008
Urinary tract infection (UTI) is the most common hospital-acquired infection, accounting for 40% of all hospital-acquired infections. More than 80% of these infections are attributable to use of an indwelling urethral catheter.(1) Catheter-acquired urinary infections (cUTIs) have received significantly less attention than other health care–acquired infections, such as surgical site infections, ventilator-associated pneumonia, and bacteremia.
with commentary by James M. Naessens, ScD, Not Paying for Errors: A Policy Perspective, October 2008
Interest is growing in the use of existing data sources to identify opportunities to improve the delivery and safety of medical care, to measure and compare quality and patient safety, and even to change provider incentives through pay for performance initiatives.
Not Paying for Errors: A Policy Perspective, October 2008
At the University of California, San Francisco, Robert M. Wachter, MD, is Professor and Chief of the Division of Hospital Medicine; Associate Chairman of the Department of Medicine; Lynne and Marc Benioff Endowed Chair in Hospital Medicine; and Chief of the Medical Service at UCSF Medical Center. He is also Editor of AHRQ WebM&M and AHRQ Patient Safety Network.
Bar Coding for Medication Safety, September 2008
Eric G. Poon, MD, MPH, is Director of Clinical Informatics at Brigham and Women’s Hospital and Assistant Professor of Medicine at Harvard Medical School. Dr. Poon’s research has focused on using health information technology to improve patient safety. He oversees the development and implementation of clinical applications including computerized physician order entry (CPOE) and barcode-assisted electronic medication administration record, and was lead author on the first rigorous study demonstrating the impact of a bar coding system in a hospital pharmacy. We asked him to speak with us about how such technology can augment medication safety.
with commentary by Jeffrey M. Rothschild, MD, MPH; Carol Keohane, RN, BSN, Bar Coding for Medication Safety, September 2008
Medication safety in hospitals depends on the successful execution of a complex system of scores of individual tasks that can be categorized into five stages: ordering or prescribing, preparing, dispensing, transcribing, and monitoring the patient's response. Many of these tasks lend themselves to technologic tools. Over the past 20 years, technology has played an increasingly larger role toward achieving the five rights of medication safety: getting the right dose of the right drug to the right patient using the right route and at the right time. While several of these technologies may incur significant upfront and maintenance costs, the net impact over time may be reduced overall institutional costs and improvements in work efficiency. Examples of technologic tools commonly seen in many hospitals today include computerized provider order entry (CPOE) with decision support and automatic dispensing carts, also known as medication dispensing robots. While outside the scope of this Perspective, it is important to emphasize that many nontechnologic interventions, such as clinical pharmacists on physician rounds, can be equally effective in improving medication safety.
with commentary by Gary A. Noskin, MD, MRSA and Patient Safety, April 2008
Methicillin-resistant Staphylococcus aureus (MRSA) has received a great deal of media attention over the past few months following the release of a study indicating that, on an annual basis, approximately 94,000 patients develop serious MRSA infections resulting in 18,650 deaths. Email to a colleague Digg This Printable View Methicillin-Resistant Staphylococcus aureus Perspective by Gary A. Noskin, MD Methicillin-resistant Staphylococcus aureus (MRSA) has received a great deal of media attention over the past few months following the release of a study indicating that, on an annual basis, approximately 94,000 patients develop serious MRSA infections resulting in 18,650 deaths.(
MRSA and Patient Safety, April 2008
The voices of patients are often missing from discussions of the impact of medical errors and adverse events. Ms. Constance Lehfeldt is a former nurse who developed a methicillin-resistant Staphylococcus aureus (MRSA) infection, which ultimately led to a devastating series of complications. Connie bravely describes her story, with understated eloquence, in the video interview. The voices of patients are often missing from discussions of the impact of medical errors and adverse events. Ms. Constance Lehfeldt is a former nurse who developed a methicillin-resistant Staphylococcus aureus (MRSA) infection, which ultimately led to a devastating series of complications.
Improving Safety in Large Systems, January 2008
Jennifer Daley, MD, is the Chief Medical Officer of Partners Community Healthcare Inc., the organization for the 6000 physicians employed/affiliated with Partners HealthCare System (which includes Massachusetts General and Brigham & Women's Hospitals). From 2002 to 2007, she was the Chief Medical Officer for Tenet Healthcare, one of the nation's largest hospital systems, where she was responsible for the development and implementation of Tenet's Commitment to Quality (C2Q). Her academic background (including her previous directorship of the Center for Health Systems Design and Evaluation in the Institute for Health Policy at Massachusetts General Hospital and Partners HealthCare) and her years of leadership at a huge multistate private sector system provide her with a unique perch from which to view patient safety implementation in complex systems.
with commentary by Loran Hauck, MD, and Jan Jacob, MBA, RN, Improving Safety in Large Systems, January 2008
Hospitals and health systems across the United States are struggling to put strategies and structures in place to improve patient safety at their institutions. This article will share the safety and quality journey of Adventist Heath System (AHS), the largest Protestant not-for-profit health care system in the United States.