Perspectives on Safety
Narrow Results Clear All
- Communication Improvement 34
- Culture of Safety 27
Education and Training
- Students 1
- Error Reporting and Analysis 35
- Human Factors Engineering 17
- Legal and Policy Approaches 38
- Logistical Approaches 15
- Policies and Operations 2
- Quality Improvement Strategies 46
- Research Directions 1
- Specialization of Care 5
- Teamwork 10
- Clinical Information Systems 12
- Transparency and Accountability 2
- Alert fatigue 1
- Device-related Complications 3
- Diagnostic Errors 6
- Discontinuities, Gaps, and Hand-Off Problems 12
- Fatigue and Sleep Deprivation 5
- Identification Errors 1
- Delirium 1
- Medication Errors/Preventable Adverse Drug Events 10
- Nonsurgical Procedural Complications 2
- Psychological and Social Complications 10
- Second victims 1
- Surgical Complications 8
- Gynecology 33
- Surgery 9
- Nursing 11
- Pharmacy 7
- Family Members and Caregivers 2
- Health Care Executives and Administrators
Health Care Providers
- Nurses 7
- Physicians 20
Non-Health Care Professionals
- Educators 11
- Media 1
- Patients 3
New Insights Into Apology and Disclosure Programs, April 2019
Dr. McDonald is President of the Center for Open and Honest Communication at the MedStar Institute for Quality and Safety, and Adjunct Professor of Law at Loyola University-Chicago School of Law and the Beazley Institute for Health Law and Policy. An internationally recognized patient safety expert, he served as a lead architect for the Communication and Optimal Resolution (CANDOR) toolkit, supported by AHRQ. We spoke with him about lessons learned over the years regarding event reporting and his insights about building and disseminating communication-and-resolution programs.
New Insights Into Apology and Disclosure Programs, April 2019
Dr. Schulz Moore is the Director of Learning and Teaching at the University of New South Wales Faculty of Law and an Associate with the University of New South Wales School of Public Health and Community Medicine. Her research in health law draws from her unique training in public health, law, and health social sciences. We spoke with her about disclosure and apology in health care as well as the intersection between health and legal systems in Australia, New Zealand, and the United States.
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.
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 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.
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.
Nursing and Patient Safety, March 2018
Dr. Aiken is Claire M. Fagin Leadership Professor of Nursing, Professor of Sociology, and Director of the Center for Health Outcomes and Policy Research at University of Pennsylvania. She is generally considered the nation's foremost expert on health policy as it relates to the nursing workforce. We spoke with her about how nurse staffing and the work environment can affect patient safety and outcomes.
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.
Presenteeism: A Patient Safety Challenge, October 2017
Dr. Starke is Professor of Pediatrics–Infectious Disease at Baylor College of Medicine and previously served as Infection Control Officer at Texas Children's Hospital. We spoke with him about "presenteeism" (coming to work while ill) in health care and its impact on provider and patient safety.
Approaching Safety Culture in New Ways, March 2017
Dr. Dixon-Woods is RAND Professor of Health Services Research at Cambridge University, Deputy Editor-in-Chief of BMJ Quality and Safety, and one of the world's leading experts on the sociology of health care. We spoke with her about new ways to approach safety culture.
with commentary by Sumant Ranji, MD, 2016
The toll of medical errors is often expressed in terms of mortality attributable to patient safety problems. In 2016, there was considerable debate regarding the number of patients who die due to medical errors. This Annual Perspective explores the methodological approaches to estimating mortality attributable to preventable adverse events and discusses the benefits and limitations of existing approaches.
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.
Workplace Safety, January 2017
Mr. O'Neill served as the United States Secretary of the Treasury under President George W. Bush and, prior to that, chairman and CEO of Alcoa. We spoke with him about workplace safety and its relationship to patient safety and organizational excellence.
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 Urmimala Sarkar, MD, and Kaveh Shojania, MD, 2016
Opioids are known to be high risk medications, and concerns about patient harm from prescription opioid misuse have been increasing in the United States. This Annual Perspective summarizes research published in 2016 that explored the extent of harm from their use, described problematic prescribing practices that likely contribute to adverse events, and demonstrated some promising practices to foster safer opioid use.
Root Cause Analysis: What Have We Learned?, December 2016
Dr. Bagian is Director of the Center for Healthcare Engineering and Patient Safety at the University of Michigan, and a former astronaut. He co-chaired the team that produced the influential NPSF report entitled, RCA2: Improving Root Cause Analyses and Actions to Prevent Harm.
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.
New Leaders in Safety and Quality, November 2016
Dr. Bindman, an expert in health policy in underserved populations, was appointed as director of the Agency for Healthcare Research and Quality (AHRQ) in May 2016. We spoke with him about his new role at AHRQ.