Perspectives on Safety
Narrow Results Clear All
- Communication Improvement 2
- Culture of Safety 6
- Education and Training 1
- Error Reporting and Analysis 5
- Human Factors Engineering 2
- Legal and Policy Approaches 4
- Quality Improvement Strategies 5
- Teamwork 1
- Technologic Approaches 2
- Health Care Executives and Administrators
- Health Care Providers 4
Non-Health Care Professionals
- Media 1
- Patients 1
Patient Advocacy, June 2014
Dave deBronkart, known as e-Patient Dave, is a co-founder and co-chair of the Society for Participatory Medicine and coauthor of Let Patients Help: A Patient Engagement Handbook. We spoke with him about engaging patients in their care and allowing patients to access their medical records.
Hand Hygiene, May 2014
Dr. Pittet is Director of the Infection Control Programme and WHO Collaborating Centre on Patient Safety at the University of Geneva Hospitals, Switzerland. We spoke with him about hand hygiene in health care, including how to implement culture change and improve safety.
Update on Just Culture, September 2013
Professor Sidney Dekker has done revolutionary work on human error and safety and written several bestselling books on system failure and just culture.
Does Root Cause Analysis Work?, July 2008
Albert Wu, MD, MPH, is Professor of Health Policy and Management at the Johns Hopkins School of Public Health and is presently working with the World Health Organization's World Alliance for Patient Safety, based in Geneva. He is a leading expert on several aspects of patient safety, including disclosure and evaluation. He recently wrote a commentary on the use of root cause analysis in patient safety in the Journal of the American Medical Association (JAMA).
with commentary by Patrice Spath, BA, RHIT, and William Minogue, MD, Does Root Cause Analysis Work?, July 2008
Throughout most of his life, 19th century French chemist Louis Pasteur insisted that germs were the cause of disease, not the body. It wasn't until Pasteur was nearing the end of his life that he came to believe just the opposite. After reaching this conclusion, he declined treatment for potentially curable pneumonia, reportedly saying, "It is the soil, not the seed."(1) In other words, a germ (the seed) causes disease when our bodies (the soil) provide a hospitable environment.
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.
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.
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...