Perspectives on Safety
Narrow Results Clear All
- Communication Improvement 16
- Culture of Safety 13
Education and Training
- Students 1
- Error Reporting and Analysis 14
- Human Factors Engineering 7
- Legal and Policy Approaches 17
- Logistical Approaches 8
- Policies and Operations 1
- Quality Improvement Strategies 22
- Specialization of Care 1
- Teamwork 3
- Technologic Approaches 6
- Device-related Complications 2
- Diagnostic Errors 2
- Discontinuities, Gaps, and Hand-Off Problems 6
- Fatigue and Sleep Deprivation 2
- Delirium 1
- Medication Errors/Preventable Adverse Drug Events 4
- Psychological and Social Complications 2
- Surgical Complications 3
- Family Members and Caregivers 2
- Health Care Executives and Administrators
Health Care Providers
- Nurses 4
Non-Health Care Professionals
- Media 1
- Patients 2
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 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.
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.
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.
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 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.
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 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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.