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
with commentary by David M. Gaba, MD, Point–Counterpoint: Simulation vs. Team Training, March 2006
Let’s take as a given that improving the ability of individuals and teams to function “as a team” is important in health care, especially in highly dynamic clinical environments.(1) How can this best be accomplished? In a comprehensive approach to teamwork...
with commentary by Stephen D. Pratt, MD and Benjamin P. Sachs, MB, Point–Counterpoint: Simulation vs. Team Training, March 2006
In recent years, the medical community has reached a near-consensus that team training and Crew Resource Management (CRM) techniques can improve patient safety. However, the most effective way to teach and implement these concepts is much less clear...
Disclosing Mistakes, February 2006
John Banja, PhD, is Assistant Director for Health Sciences and Clinical Ethics and Associate Professor of Clinical Ethics at Emory University School of Medicine. Dr. Banja, whose doctorate is in philosophy, is currently participating in AHRQ-funded studies designed to help clinicians communicate more effectively in emotionally charged situations after errors or unforeseen outcomes. His book, Medical Errors and Medical Narcissism, covers issues around the appropriate, ethical disclosure of medical errors by health care professionals.
with commentary by Eric J. Thomas, MD, MPH, Aviation and Patient Safety, January 2006
On August 2, 2005, Air France flight 358 crashed while landing in Toronto. In less than 2 minutes, the crew evacuated 309 passengers. Several minutes later, the plane burst into flames.(1) Crashes like this are remarkably rare, yet the crew was prepared to...
Aviation and Patient Safety, January 2006
Jack Barker, PhD, is Vice President of Research and Development for Mach One Leadership and a commercial pilot for a major airline. Dr. Barker began his career in the Air Force and proceeded to get his doctorate in cognitive psychology. His research has centered on high-performance teams, crew resource management (CRM), and training. He has trained hundreds of commercial airline pilots, as well as pilots and others working for NASA in the Space Shuttle program and Mars mission. His company, like several others, works with health care providers and organizations in an effort to translate aviation safety principles to health care.
The Law and Patient Safety, December 2005
Dr. Brennan is a Professor of Medicine at Harvard Medical School and Professor of Law and Public Health at the Harvard School of Public Health. As the lead investigator of the groundbreaking study that assessed the prevalence of adverse events in hospitalized patients, Dr. Brennan has contributed dramatically to our understanding of the epidemiology of medical errors. More recently, he has emerged as one of the world's most thoughtful and influential analysts of the complex interplay among medicine, ethics, law, and public health.
with commentary by Robert M. Wachter, MD, Patient Safety Initiatives, September 2005
Translational research is all the rage in biomedicine. In its purest form, the concept refers to the translation of basic research discoveries into clinical applications, followed by patient-oriented studies to demonstrate benefit.(1) Increasingly, it also...
with commentary by Linda H. Aiken, PhD, RN , Nursing and Patient Safety , July-August 2005
The goal set by the Institute of Medicine (IOM) in 1999 to reduce medical errors by half within 5 years has not been achieved. Opinion polls of consumers and health professionals show that concerns about patient safety remain high. Yet only 16% of hospital...
Nursing and Patient Safety , July-August 2005
Barbara A. Blakeney, MS, RN, is President of the 150,000-member American Nurses Association (ANA). A nurse practitioner and expert in public health practice, policy, and primary care, Ms. Blakeney is on leave from the Boston Public Health Commission, where she has been director of health care services for the homeless. She is the recipient of numerous awards and has been named to Modern Healthcare Magazine's list of the 100 most influential people in health care for the past 3 years.
with commentary by Kaveh G. Shojania, MD, Research in Patient Safety , June 2005
Five years ago, a widely publicized randomized trial reported a 90% reduction in the incidence of contrast dye-induced renal failure when patients were pretreated with acetylcysteine, an agent previously used to treat acetaminophen overdoses and bronchitis...
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.
Organizational Change in the Face of Highly Public Errors—I. The Dana-Farber Cancer Institute Experience
with commentary by James B. Conway; Saul N. Weingart, MD, PhD, Errors in the Media and Organizational Change, May 2005
A decade ago, two tragic medical errors rocked one of the world’s great cancer hospitals, Dana-Farber Cancer Institute (DFCI) in Boston, to its core. The errors led to considerable soul searching and, ultimately, a major change in institutional practices a...
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...