Perspectives on Safety
Narrow Results Clear All
- Communication Improvement
- Culture of Safety 6
Education and Training
- Students 1
- Error Reporting and Analysis 10
- Human Factors Engineering 6
- Legal and Policy Approaches 13
- Logistical Approaches 4
- Quality Improvement Strategies 10
- Research Directions 1
- Specialization of Care 1
- Teamwork 3
- Technologic Approaches 6
- Device-related Complications 1
- Diagnostic Errors 3
- Discontinuities, Gaps, and Hand-Off Problems 12
- Fatigue and Sleep Deprivation 2
- Medical Complications 4
- Medication Safety 5
- Psychological and Social Complications 5
- Family Members and Caregivers 2
- Health Care Executives and Administrators
- Health Care Providers 21
Non-Health Care Professionals
- Media 1
- Patients 3
with commentary by Rachel J. Stern, MD, and Urmimala Sarkar, MD, 2018
Patient engagement is widely acknowledged as a cornerstone of patient safety. Research in 2018 demonstrates that patient engagement, when done correctly, can help health care systems identify safety hazards, regain trust after they occur, and codesign sustainable solutions.
Post-Hospital Syndrome, April 2018
Dr. Krumholz is Professor of Medicine at the University of Yale School of Medicine and Director of the Yale-New Haven Hospital Center for Outcomes Research and Evaluation. We spoke with him about readmissions and post-hospital syndrome, a term he coined in an article in the New England Journal of Medicine to describe the risk of adverse health events in recently hospitalized patients.
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.
CLER and I-PASS, April 2016
Dr. Starmer is Director of Primary Care Quality Improvement and Assistant Professor of Pediatrics at Boston Children's Hospital and Harvard Medical School. We spoke with her about handoffs and the implementation and findings of the landmark I-PASS study.
Electronic Tools for Patient Safety: Engaging Patients and Providers, September 2015
Dr. Arora is Director of GME Clinical Learning Environment Innovation and Assistant Dean for Scholarship and Discovery at the University of Chicago Pritzker School of Medicine. We spoke with her about the intersection of health information technology and patient safety.
with commentary by Niraj Sehgal, MD, MPH, Handoffs and Patient Safety, 2014
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.
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.
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.
Handoffs and Patient Safety, March 2011
An Associate Professor at the University of Chicago, her research focuses on resident duty hours, handoffs, and professionalism.
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.
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 Anne Collins McLaughlin, PhD, Checklists, October 2010
The use of checklists is a primitive yet remarkably effective strategy for ensuring accuracy in complex tasks. Checklists have long been used in fields such as aviation and space exploration but have only recently made headway in medicine. The reluctance of medical professionals to adopt checklists is often framed as pushback against "more paperwork" and "cookbook medicine," or due to disbelief in their effectiveness. However, a rich literature has helped establish many best practices in checklist design, and health care now stands to benefit.
with commentary by David P. Sklar, MD; Cameron Crandall, MD, Patient Safety in Emergency Medicine, June 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.(1) The importance of rapid diagnosis and treatment of serious conditions (e.g., myocardial infarction, stroke, trauma, and sepsis) has made timeliness not simply a determinant of patient satisfaction but also a significant safety and quality concern—delays in care can be deadly.(2) Emergency physicians (EPs) have identified delays caused by crowding from boarding of admitted patients as their most significant safety problem.(3) We present a model for understanding emergency department (ED) patient safety and identify solutions by deconstructing care into three realms: individual provider, patient, and environmental system (Table).
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.
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?
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.(
Health Literacy and Safety, February-March 2009
Dean Schillinger, MD, is a Professor of Medicine at University of California, San Francisco, Director of the UCSF Center for Vulnerable Populations, and Chief of the California Diabetes Prevention and Control Program. His role as a practicing clinician at a safety net hospital (San Francisco General Hospital) has put him in a unique position to pursue influential and relevant research related to health literacy and improving care for vulnerable populations.