Perspectives on Safety
Narrow Results Clear All
- Communication Improvement 32
- Culture of Safety 26
Education and Training
- Students 1
- Error Reporting and Analysis 33
- Human Factors Engineering 17
- Legal and Policy Approaches 37
- Logistical Approaches 15
- Policies and Operations 2
- Quality Improvement Strategies 46
- Research Directions 1
- Specialization of Care 5
- Teamwork 10
- Clinical Information Systems 12
- 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 8
- 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
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.
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.
Improving Transitions in Care, December 2007
Eric A. Coleman, MD, MPH, is Associate Professor of Medicine at the University of Colorado. Trained in both geriatrics and health services research, Dr. Coleman has emerged as one of the world's leading authorities on issues surrounding transitions of care, particularly between acute and postacute settings. His care model, the Care Transitions Intervention, is being adopted by leading health care organizations around the country. The Intervention has been associated with significant decreases in rehospitalization rates.
with commentary by Sunil Kripalani, MD, MSc, Improving Transitions in Care, December 2007
Hospital discharge is often viewed as the end of an acute medical event. Goodbyes are said as patients pack their belongings and return home. Physicians scratch the patient's name off their rounding list, and hospital staff remove the patient from the census as they clean out the room...
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 Rosemary Gibson, MSc, The Patient's Role in Safety, March 2007
Patients have three roles in improving patient safety: helping to ensure their own safety, working with health care organizations to improve safety at the organization and unit level, and advocating as citizens for public reporting and accountability of hospital and health system performance. The following case illustrates how patients can help ensure their own safety.
The Patient's Role in Safety, March 2007
Sorrel King is the mother of Josie King, who died tragically in 2001 at age 18 months because of medical errors during a hospitalization at Johns Hopkins Hospital. She has subsequently become one of the nation’s foremost patient advocates for safety, forming an influential foundation (the Josie King Foundation) and partnering with Johns Hopkins to promote the field of patient safety around the world.
Diagnostic Errors, February 2007
Joseph Britto, MD, is CEO and Co-founder of Isabel Healthcare Inc. Isabel, a clinical decision support system, was founded in 1999 by Britto and Jason and Charlotte Maude, whose daughter Isabel was harmed by a medical error. The company has been profiled in the Wall Street Journal, and the system has undergone several validation studies. We asked Dr. Britto to talk with us about eradicating diagnosis errors through diagnosis decision support systems.
Safety Culture, December 2006
J. Bryan Sexton, PhD, MA, is Assistant Professor, Department of Anesthesiology and Critical Care Medicine, at the Johns Hopkins University School of Medicine. Trained as a social psychologist, he has become one of the world's foremost authorities on the role of culture in patient safety. He developed the widely used Safety Attitudes Questionnaire and is one of the lead investigators of the Michigan Keystone ICU project, which aims to change practice and culture in intensive care units (ICUs) throughout the state. His research examines the connections between attitudes, behaviors, and outcomes in high-risk team environments, particularly aviation and medicine. We asked him to speak with us about safety climate surveys and efforts to change safety culture.
with commentary by Timothy J. Hoff, PhD, Safety Culture, December 2006
Safety cultures are the holy grail in any risky industry. Like all holy grails, they can never be fully realized. This is particularly the case in health care. Why? Health care organizations struggle with too many competing demands to make safety the only...
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.
with commentary by Jeffrey B. Cooper, PhD, Reflections on the History of the Patient Safety Movement, August 2006
My journey into patient safety began in 1972. It was born of serendipity enabled by the good fortune of extraordinary mentors, an environment that supported exploration and allowed for interdisciplinary teamwork, and my own intellectual curiosity. The...
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 Rainu Kaushal, MD MPH; Sekhar Upadhyayula, MD; David M. Gaba, MD; Lucian L. Leape, MD, Outpatient Safety, May 2006
Over the last decade, surgical operations and interventional procedures have been performed increasingly in offices with the administration of office-based anesthesia (OBA).(1) Economic considerations and convenience have driven this increase. Schultz...
with commentary by Nancy C. Elder, MD, MSPH, Outpatient Safety, May 2006
Dr. Jones was sure he had increased Mr. H's cholesterol-lowering medication to 80 mg 6 months ago, but, at his visit today, his pill bottle still says 40 mg. In reviewing Ms. B's chart in preparation for performing a well-woman examination, Dr. Smith find...
Pharmacy and Safety, April 2006
Michael Cohen, RPh, MS, ScD, is president of the Institute for Safe Medication Practices (ISMP) and co-editor of ISMP Medication Safety Alert!, a biweekly newsletter. A pharmacist by training, his ground-breaking work and commitment to patient safety and preventing medication errors has spanned three decades. He received one of the prestigious MacArthur Fellowships (informally known as the "genius awards") in 2005.