Perspectives on Safety
Narrow Results Clear All
- Communication Improvement 3
- Culture of Safety 5
- Education and Training 1
- Error Reporting and Analysis
- Human Factors Engineering 2
- Legal and Policy Approaches 5
- Quality Improvement Strategies 6
- Technologic Approaches 3
with commentary by Kiran Gupta, MD, MPH, and Audrey Lyndon, PhD, 2016
Root cause analysis is widely accepted as a key component of patient safety programs. In 2016, the literature outlined ongoing problems with the root cause analysis process and shed light on opportunities to improve its application in health care. This Annual Perspective reviews concerns about the root cause analysis process and highlights recommendations for improvement put forth by the National Patient Safety Foundation.
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.
Accreditation and Regulation, April 2009
Mark R. Chassin, MD, MPP, MPH, is president of The Joint Commission, the preeminent standard setting and accrediting organization in health care in the United States and, increasingly, the world. Over the course of his notable career, Dr. Chassin, an emergency medicine physician, has held a variety of key positions, including New York State Health Commissioner and chair of the department of health policy at Mt. Sinai. He has published several seminal papers and was a member of the team that authored the IOM report, "To Err Is Human." We asked him to speak with us about his role at The Joint Commission, as well as future directions for the organization.
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.
State Error Reporting Systems, June 2007
Diane Rydrych, MA, is Assistant Director of the Division of Health Policy at the Minnesota Department of Health, where she oversees their successful and influential adverse health events reporting system. We asked her to speak with us about the Minnesota initiative and some of the broader lessons for state error reporting systems.
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 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 Ashish K. Jha, MD, MPH, The Transformation of Patient Safety at the VA, September 2006
Five years after the landmark Crossing the Quality Chasm report by the Institute of Medicine (IOM), the quality and safety of health care in the United States remains far from ideal.(1) It is easy to feel pessimistic. Can health care organizations really...
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...