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
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.
Certification in Patient Safety, June 2016
Dr. Meyer is Chief Clinical Officer of Partners Healthcare System, the large Boston-based system that includes Massachusetts General and Brigham and Women's Hospitals. We spoke with him about training and certification in patient safety.
with commentary by Karen Frank, DNP, RN, MSHA, Certification in Patient Safety, June 2016
This piece offers a nurse's viewpoint on the benefits of acquiring certification in patient safety.
with commentary by Urmimala Sarkar, MD, and Kaveh Shojania, MD, 2015
Computerized provider order entry is a cornerstone of patient safety efforts, and the increasingly widespread implementation of electronic health records has made it a standard practice in health care. This Annual Perspective summarizes novel findings and research directions in computerized provider order entry in 2015.
Ten years of AHRQ Patient Safety Network: A Window Into the Evolution of the Patient Safety Literature, November 2015
Dr. Shojania is Editor-in-Chief of BMJ Quality and Safety and Director of the Centre for Quality Improvement and Patient Safety at the University of Toronto. We spoke with him about the evolution of patient safety research over the past 15 years.
Ten years of AHRQ Patient Safety Network: A Window Into the Evolution of the Patient Safety Literature, November 2015
Ms. Zipperer was a founding staff member of the National Patient Safety Foundation as their information projects manager and has also been Cybrarian for AHRQ Patient Safety Network since its inception. We spoke with her about the role of librarians in patient safety.
with commentary by Robert M. Wachter, MD, Ten years of AHRQ Patient Safety Network: A Window Into the Evolution of the Patient Safety Literature, November 2015
This editorial provides an overview of how PSNet and WebM&M have evolved in the past decade.
New Insights on Safety and Health IT, July/August 2015
Dr. Wachter is Professor and the Interim Chairman of the Department of Medicine at UCSF. We talked with him about his new book, The Digital Doctor: Hope, Hype, and Harm at the Dawn of Medicine's Computer Age.
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.
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.
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.
Risk-Adjusted Mortality as a Safety/Quality Measure, March 2015
Sir Brian Jarman designed the methodology for hospital standardized mortality ratios, a widely used method of measuring quality and safety, and was involved with the Bristol Royal Infirmary Inquiry. We spoke with him about the development of the HSMR and their role in monitoring performance.
with commentary by Ian Scott, MBBS, MHA, MEd, Risk-Adjusted Mortality as a Safety/Quality Measure, March 2015
This piece discusses risk-adjusted hospital mortality rates as a measure of hospital safety, including why they've become popular, major flaws such as low sensitivity, and alternative ways to use them.
Lean and Patient Safety, January 2015
Mr. Graban is an internationally recognized expert in Lean Healthcare. We spoke with him about applying Lean in hospitals to improve safety and decrease waste.
with commentary by Paul E. Plsek, MS, Lean and Patient Safety, January 2015
This book excerpt describes how integrating innovation and Lean concepts at Virginia Mason enhances clinical performance and the patient experience.
Global Patient Safety, December 2014
Dr. Kelley, PhD, is Director of Service Delivery and Safety for the World Health Organization (WHO). We spoke with him about his work with WHO and the global impact of the organization on patient safety.
with commentary by Shams B. Syed, MD, MPH, Global Patient Safety, December 2014
This piece describes the evolution of the World Health Organization's African Partnerships for Patient Safety program and its implications for global patient safety improvement.
Overuse as a Patient Safety Problem, September 2014
Ms. Gibson is Senior Advisor to The Hastings Center, an editor for JAMA Internal Medicine, and co-author of Wall of Silence and The Treatment Trap. We spoke with her about overuse of medical care and its effect on patient safety.
Safety in the Ambulatory Setting, July-August 2014
Dr. Sarkar is an associate professor of medicine at UCSF whose research has focused on ambulatory patient safety, including missed and delayed diagnosis, adverse drug events, and monitoring failures for outpatients with chronic diseases. We spoke with her about patient safety in the ambulatory setting.
National Organizations in Safety, April 2014
Dr. Gandhi is President of the National Patient Safety Foundation and Associate Professor of Medicine at Harvard Medical School. We spoke with her about NPSF's evolving role in enhancing health care at a national level.
Infection Prevention and Patient Safety, March 2014
Dr. Holmes is Director of Infection Prevention and Control and a professor at Imperial College London. We spoke with her about infection prevention and patient safety.
with commentary by Susan S. Huang, MD, MPH, Infection Prevention and Patient Safety, March 2014
This piece describes the history around efforts to address preventable health care–associated infections, including federal initiatives and further research avenues to consider.
Interruptions and Distractions in Health Care, February 2014
Dr. Coiera, a professor at the University of New South Wales, has extensively researched and written about clinical communication processes and information systems. We spoke with him about how interruptions and distractions in the clinical environment influence patient safety.
Update on Simulation in Health Care, March 2013
Stanford anesthesiologist David M. Gaba, MD, helped introduce the modern full-body patient simulator and the concept of crew resource management training to health care.
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.
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.
Nurse Staffing and Patient Safety, September 2012
Prof. Needleman has performed some of the key studies on how the nursing workforce influences health outcomes, including seminal articles published in the New England Journal of Medicine in 2002 and 2011.
with commentary by Peter I. Buerhaus, PhD, RN, Nurse Staffing and Patient Safety, September 2012
This piece describes federal initiatives aimed at preparing the nursing workforce needed to match future demand and to navigate changes vital to improving health care.
with commentary by Jerry Gurwitz, MD, Safety in Nursing Homes, August 2012
This piece, written by a national leader in safe use of medications in elderly patients, discusses strategies for improving the quality and safety of medication use in the nursing home setting.
Disclosing Errors and Other Innovations in Risk Management, March 2012
An attorney and chief risk officer for the University of Michigan Health System, Mr. Boothman developed a pioneering approach to medical mistakes and risk management, emphasizing an honest approach to errors, early apology, and rapid settlement offers when the system was at fault.
with commentary by Allen Kachalia, MD, JD, Disclosing Errors and Other Innovations in Risk Management, March 2012
This piece describes how evidence-based improvements to the medical liability system could influence both accountability and compensation for errors.
Resident Supervision and Patient Safety, February 2012
The founding Dean of Hofstra North Shore-LIJ School of Medicine, Dr. Smith has held numerous senior leadership positions within the field of medical education and residency training.
with commentary by C. Jessica Dine, MD, MA; and Jennifer S. Myers, MD, Resident Supervision and Patient Safety, February 2012
This piece discusses how increased supervision influences the educational experience for trainees.
Fall Prevention, December 2011
A leading expert on health care–associated falls, Dr. Hendrich developed one of the most widely used risk assessment tools.
with commentary by Frances Healey, RN, PhD, Fall Prevention, December 2011
This piece discusses the multiple, complex causes of falls in hospitalized patients along with prevention strategies.
Update on Teamwork, November 2011
Dr. Salas is one of the world’s leading experts in the use of simulation and teamwork training, having studied these areas extensively in a variety of fields.
with commentary by Julia Neily, RN, MS, MPH; Peter D. Mills, PhD, MS; Lisa M. Mazzia, MD; and Douglas E. Paull,MD, Update on Teamwork, November 2011
This piece describes how the Medical Team Training program has improved safety, staff morale, and patient outcomes in the VA.
with commentary by Dr. John Øvretveit, The Role of Context in Safety Research, October 2011
This piece discusses how observations from social sciences have implications for patient safety.
with commentary by Teryl K. Nuckols, MD, MSHS, Incident Reporting, September 2011
This piece discusses incident reporting systems as tools for improving patient safety.
Unintended Consequences, June 2011
His seminal work in patient safety is generally credited with introducing the concept of unintended consequences.
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.
Educating Practitioners in Safety and Quality, February 2011
Brent C. James, MD, MStat, is Chief Quality Officer and Executive Director of the Institute for Health Care Delivery Research at Intermountain Healthcare.
with commentary by Barry M. Manuel, MD; Jack L. McCarthy; William Berry, MD, MPH; Kathy Dwyer, Risk Management and Patient Safety, December 2010
In 1990, a Harvard-based research team reported the incidence of medical errors in the state of New York, based on the hospital discharge analysis of 30,121 cases.
Measuring Patient Safety, November 2010
Patrick S. Romano, MD, MPH, is Professor of Medicine and Pediatrics at the University of California, Davis, School of Medicine.
with commentary by Amy K. Rosen, PhD, Measuring Patient Safety, November 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.
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.
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.
Medical Education and Patient Safety, February 2010
Thomas J. Nasca, MD, is the executive director and chief executive officer of the Accreditation Council for Graduate Medical Education (ACGME). Prior to joining the ACGME in 2007, Dr. Nasca, a nephrologist, was dean of Jefferson Medical College and Senior Vice President for Academic Affairs of Thomas Jefferson University. We asked him to speak with us about the role of the ACGME in patient safety.
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.
The Role of the Media in Patient Safety, October 2009
Charles Ornstein is a senior reporter at ProPublica, a nonprofit news organization in New York. Formerly with the Los Angeles Times, he co-wrote a series of articles about medical errors at Martin Luther King Jr./Drew Medical Center, which closed in 2007; the series earned the newspaper a Pulitzer Prize for Public Service. He is also the president of the Association of Health Care Journalists. We asked him to speak with us about the role of the media in patient safety. This interview was conducted while he was still at the Times.
with commentary by Robert M. Wachter, MD, The Role of the Media in Patient Safety, October 2009
December 1 marks the tenth anniversary of the Institute of Medicine (IOM) report To Err Is Human, the blockbuster that launched the modern patient safety movement.(1) The anniversary provides an opportunity to reflect on the forces that have promoted safety efforts over the past decade. They include a more robust accreditation environment, increased reporting of adverse events to state and other regulatory bodies, growing implementation of information technology, skill-building support by organizations such as Institute for Healthcare Improvement, and a maturing research field supported by AHRQ and others.
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.
with commentary by Michael S. Wolf, PhD, MPH; Stacy Cooper Bailey, MPH, Health Literacy and Safety, February-March 2009
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. 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.
Patient Disclosure and Apology, January 2009
Thomas H. Gallagher, MD, is Associate Professor in the Department of Medicine and the Department of Medical History and Ethics at the University of Washington in Seattle. Dr. Gallagher's current research covers the disclosure of medical errors, examining patients' and doctors' attitudes about disclosure, how best to train providers to disclose and apologize for errors, and how to create a system that promotes appropriate disclosure. We asked him to speak with us about new developments in the field of patient disclosure and apologies.
with commentary by Allen Kachalia, MD, JD, Patient Disclosure and Apology, January 2009
Disclosure of medical error is inextricably linked to today's patient safety efforts. Health care experts advocate that greater disclosure is necessary to achieve complete transparency and ameliorate barriers to error reporting.(1,2) Of course, the ethical obligations triggered by the occurrence of a medical error are not to be overlooked. Principles of fiduciary duty, patient autonomy, and equity all strongly support the ethical and moral mandate for physicians to disclose harmful errors to patients.(3) These principles weigh in favor of disclosure even if it is contrary to the physician's interests (e.g., malpractice risk or reputation). As a result, the issue of disclosure garners tremendous attention in today's medical literature.
Prevention of Urinary Tract Infections: Lessons for Patient Safety, November 2008
Sanjay Saint, MD, MPH, is Professor of Medicine at the University of Michigan and the Ann Arbor VA Medical Center in Ann Arbor, Michigan. Dr. Saint's research has focused on reducing health care–associated infections, with a particular focus on preventing catheter-related urinary tract infections (UTIs). We asked him to speak with us about how research on UTI prevention provides broader lessons for patient safety.
with commentary by Lindsay E. Nicolle, MD , Prevention of Urinary Tract Infections: Lessons for Patient Safety, November 2008
Urinary tract infection (UTI) is the most common hospital-acquired infection, accounting for 40% of all hospital-acquired infections. More than 80% of these infections are attributable to use of an indwelling urethral catheter.(1) Catheter-acquired urinary infections (cUTIs) have received significantly less attention than other health care–acquired infections, such as surgical site infections, ventilator-associated pneumonia, and bacteremia.
with commentary by James M. Naessens, ScD, Not Paying for Errors: A Policy Perspective, October 2008
Interest is growing in the use of existing data sources to identify opportunities to improve the delivery and safety of medical care, to measure and compare quality and patient safety, and even to change provider incentives through pay for performance initiatives.
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.