Perspectives on Safety
Narrow Results Clear All
- Communication Improvement 8
- Culture of Safety
- Education and Training 7
- Error Reporting and Analysis 10
- Human Factors Engineering 4
- Legal and Policy Approaches 7
- Logistical Approaches 1
- Quality Improvement Strategies 10
- Specialization of Care 3
- Teamwork 5
- Technologic Approaches 5
- Discontinuities, Gaps, and Hand-Off Problems 1
- Medical Complications 3
- Medication Safety 6
- Nonsurgical Procedural Complications 1
- Psychological and Social Complications 3
- Surgical Complications 2
- Family Members and Caregivers 1
- Health Care Executives and Administrators
Health Care Providers
- Nurses 2
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 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.
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.
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.
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.
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.(
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.
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.
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.
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...