Perspectives on Safety
Our Perspectives on Safety section features expert viewpoints on current themes in patient safety, including interviews and written essays published monthly. Annual Perspectives highlight vital and emerging patient safety topics.
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Annual Perspective
Maternal Safety
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with commentary by Audrey Lyndon, RN, PhD, 2018
This perspective examines the troubling decline in maternal health outcomes in the United States and summarizes recent national initiatives to improve safety in maternity care.
Interview
In Conversation With… Karl Bilimoria, MD, MS
Surgical Safety, December 2017
Dr. Bilimoria is the Director of the Surgical Outcomes and Quality Improvement Center of Northwestern University, which focuses on national, regional, and local quality improvement research and practical initiatives. He is also the Director of the Illinois Surgical Quality Improvement Collaborative and a Faculty Scholar at the American College of Surgeons. In the second part of a two-part interview (the earlier one concerned residency duty hours), we spoke with him about quality and safety in surgery.
Perspective
The Evolution of Patient Safety in Surgery
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.
Interview
In Conversation With… John D. Birkmeyer, MD
Using Video to Assess Quality and Safety, May 2015
Dr. Birkmeyer is Chief Academic Officer and Executive Vice President at Dartmouth-Hitchcock Medical Center. We spoke with him about his seminal New England Journal of Medicine video study that found a link between practicing surgeons' directly observed technical skills and surgical outcomes.
Interview
In Conversation With… Lucian Leape, MD
Surgical Checklists, April 2015
A pioneer in patient safety, Dr. Leape is Adjunct Professor of Health Policy at the Harvard School of Public Health and Chairman of the Lucian Leape Institute of the National Patient Safety Foundation. His groundbreaking research has focused on patient safety and quality of care. We spoke with him about checklists and the field of patient safety.
Interview
In Conversation With… David Urbach, MD, MSc
Surgical Checklists, April 2015
Dr. Urbach is Professor of Surgery and Health Policy, Management and Evaluation at the University of Toronto. We spoke with him about his study evaluating the effectiveness of checklists in Ontario, Canada and its implications for a variety of safety interventions.
Perspective
Quality and Safety Challenges in Critical Care: Preventing and Treating Delirium in the Intensive Care Unit
with commentary by Eduard E. Vasilevskis, MD; E. Wesley Ely, MD, MPH; Robert S. Dittus, MD, MPH, Delirium as a Safety Target, December 2012
This piece details a number of evidenced-based practices to help detect, prevent, and treat delirium, which is now seen as a patient safety hazard.
Perspective
The Second Victim Phenomenon: A Harsh Reality of Health Care Professions
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.
Interview
In Conversation with…Pat Croskerry, MD, PhD
Patient Safety in Emergency Medicine, June 2010
Pat Croskerry, MD, PhD, is a professor in emergency medicine at Dalhousie University in Halifax, Nova Scotia, Canada. Trained as an experimental psychologist, Dr. Croskerry went on to become an emergency medicine physician, and found himself surprised by the relatively scant amount of attention given to cognitive errors. He has gone on to become one of the world's foremost experts in safety in emergency medicine and in diagnostic errors. We spoke to him about both.
Perspective
What Do We Know About Emergency Department Safety?
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).
Interview
In Conversation with...James P. Bagian, MD
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.
Perspective
What Can the Rest of the Health Care System Learn from the VA's Quality and Safety Transformation?
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...
Interview
In Conversation with…Peter J. Pronovost, MD, PhD
Research in Patient Safety , June 2005
Peter J. Pronovost, MD, PhD, is Medical Director of the Johns Hopkins Center for Innovation in Quality Patient Care. A practicing anesthesiologist and critical care physician, he has appointments in both The Johns Hopkins University School of Medicine and its Bloomberg School of Public Health. Dr. Pronovost's research, which has focused on how to improve patient safety and quality in the ICU setting, has been characterized by a blend of methodologic sophistication and practical attention to the details of making change happen and making it stick. His many contributions include studies of the value of intensivists, of the use of daily goal cards on safety and communication, of an executive adopt-a-unit strategy, and of a comprehensive unit-based safety program. For this work, much of which has been supported by AHRQ, he was awarded the John M. Eisenberg Award in Research Achievement in 2004.
Perspective
Organizational Change in the Face of Highly Public Errors—II. The Duke Experience
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...