Perspectives on Safety
Narrow Results Clear All
- Communication Improvement 5
- Culture of Safety 4
- Education and Training 6
- Error Reporting and Analysis 9
- Human Factors Engineering 1
- Legal and Policy Approaches 8
- Logistical Approaches 3
- Policies and Operations 1
- Quality Improvement Strategies 12
- Teamwork 1
- Technologic Approaches 4
- Alert fatigue 1
- Device-related Complications 1
- Diagnostic Errors 4
- Discontinuities, Gaps, and Hand-Off Problems 2
- Fatigue and Sleep Deprivation 2
- Medical Complications 3
- Medication Safety 4
- Psychological and Social Complications 1
- Surgical Complications 1
- Family Members and Caregivers 2
- Health Care Executives and Administrators
Health Care Providers
- Nurses 1
- Non-Health Care Professionals 10
- Patients 2
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 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 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.
CLER and I-PASS, April 2016
Dr. Starmer is Director of Primary Care Quality Improvement and Assistant Professor of Pediatrics at Boston Children's Hospital and Harvard Medical School. We spoke with her about handoffs and the implementation and findings of the landmark I-PASS study.
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.
Update on Diagnostic Errors, January 2016
Dr. Graber founded the Society to Improve Diagnosis in Medicine and the journal, Diagnosis. We spoke with him about the recent National Academy of Medicine (formerly Institute of Medicine) Improving Diagnosis in Health Care report, and about diagnostic errors more generally.
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 Margaret Plews-Ogan, MD, MS, Safety in the Ambulatory Setting, July-August 2014
This piece describes the new landscape of patient safety in outpatient care, including elements adapted from hospital settings and the growing evidence base for ambulatory-specific efforts.
with commentary by Helen Haskell, MA, Patient Advocacy, June 2014
This piece describes the evolution of the patient advocacy movement, including the events that spurred it, resulting reforms, and the impact of online access to medical information.
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.
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.
with commentary by P. Jeffrey Brady, MD, MPH; William B. Munier, MD, MBA; Irim Azam, MPH, Patient Safety Research, December 2013
This piece, written by three leaders in AHRQ's research portfolio, covers future avenues for patient safety research and reviews current AHRQ projects.
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.
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.
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.
Workarounds, August 2009
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.
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 Alison H. Page, MS, MHA, Just Culture, October 2007
We've all been there...something goes wrong, a patient is harmed, and we, as medical directors, managers, and administrators, are forced to judge the behavioral choices of another human being. Most of the time, we conduct this complex leadership function guided by little more than vague policies, personal beliefs, and intuition. Frequently, we are frustrated by the fact that many other providers have made the same mistake or behavioral choice, with no adverse outcome to the patient, and the behavior was overlooked. Quite understandably, the staff is frustrated by what appears to be inconsistent, irrational decision-making by leadership. The "just culture" concept teaches us to shift our attention from retrospective judgment of others, focused on the severity of the outcome, to real-time evaluation of behavioral choices in a rational and organized manner.