Perspectives on Safety
Our Perspectives on Safety section features expert viewpoints on current themes in patient safety, including interviews and written essays published monthly. Annual Perspectives highlight vital and emerging patient safety topics.
Narrow Results Clear All
Approach to Improving Safety
- Communication Improvement
- Culture of Safety 11
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Education and Training
17
- Students 1
- Error Reporting and Analysis 18
- Human Factors Engineering 10
- Legal and Policy Approaches 20
- Logistical Approaches 5
- Quality Improvement Strategies 14
- Research Directions 1
- Specialization of Care 2
- Teamwork 7
- Technologic Approaches 8
- Transparency and Accountability 2
Safety Target
- Device-related Complications 2
- Diagnostic Errors 4
- Discontinuities, Gaps, and Hand-Off Problems 13
- Fatigue and Sleep Deprivation 2
- Medical Complications 5
- Medication Safety 8
- Psychological and Social Complications 7
- Second victims 1
- Surgical Complications 1
Interview
In Conversation With… Timothy B. McDonald, MD, JD
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New Insights Into Apology and Disclosure Programs, April 2019
Dr. McDonald is President of the Center for Open and Honest Communication at the MedStar Institute for Quality and Safety, and Adjunct Professor of Law at Loyola University-Chicago School of Law and the Beazley Institute for Health Law and Policy. An internationally recognized patient safety expert, he served as a lead architect for the Communication and Optimal Resolution (CANDOR) toolkit, supported by AHRQ. We spoke with him about lessons learned over the years regarding event reporting and his insights about building and disseminating communication-and-resolution programs.
Interview
In Conversation With… … Jennifer Schulz Moore, LLB, MA, PhD
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New Insights Into Apology and Disclosure Programs, April 2019
Dr. Schulz Moore is the Director of Learning and Teaching at the University of New South Wales Faculty of Law and an Associate with the University of New South Wales School of Public Health and Community Medicine. Her research in health law draws from her unique training in public health, law, and health social sciences. We spoke with her about disclosure and apology in health care as well as the intersection between health and legal systems in Australia, New Zealand, and the United States.
Annual Perspective
Update: Patient Engagement in Safety
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with commentary by Rachel J. Stern, MD, and Urmimala Sarkar, MD, 2018
Patient engagement is widely acknowledged as a cornerstone of patient safety. Research in 2018 demonstrates that patient engagement, when done correctly, can help health care systems identify safety hazards, regain trust after they occur, and codesign sustainable solutions.
Interview
In Conversation With… Harlan Krumholz, MD, SM
Post-Hospital Syndrome, April 2018
Dr. Krumholz is Professor of Medicine at the University of Yale School of Medicine and Director of the Yale-New Haven Hospital Center for Outcomes Research and Evaluation. We spoke with him about readmissions and post-hospital syndrome, a term he coined in an article in the New England Journal of Medicine to describe the risk of adverse health events in recently hospitalized patients.
Perspective
Patient Safety During Hospital Discharge
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.
Interview
In Conversation With… Amy J. Starmer, MD, MPH
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.
Interview
In Conversation With… Vineet Arora, MD, MAPP
Electronic Tools for Patient Safety: Engaging Patients and Providers, September 2015
Dr. Arora is Director of GME Clinical Learning Environment Innovation and Assistant Dean for Scholarship and Discovery at the University of Chicago Pritzker School of Medicine. We spoke with her about the intersection of health information technology and patient safety.
Annual Perspective
Handoffs and Transitions
with commentary by Niraj Sehgal, MD, MPH, Handoffs and Patient Safety, 2014
Interview
In Conversation With… Dave deBronkart
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.
Perspective
Patient Engagement and Patient Safety
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.
Perspective
Medication Safety in Nursing Homes: What's Wrong and How to Fix It
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.
Perspective
The Second Victim Phenomenon: A Harsh Reality of Health Care Professions
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.
Interview
In Conversation with…Vineet Arora, MD, MA
Handoffs and Patient Safety, March 2011
An Associate Professor at the University of Chicago, her research focuses on resident duty hours, handoffs, and professionalism.
Perspective
What Have We Learned About Safe Inpatient Handovers?
with commentary by Sunil Kripalani, MD, MSc, Handoffs and Patient Safety, March 2011
This piece discusses how medical centers can improve handover quality and patient safety.
Interview
In Conversation with...Geri Amori, PhD
Risk Management and Patient Safety, December 2010
Geri Amori, PhD, is Vice President for the Education Center at The Risk Management and Patient Safety Institute, and a popular writer and speaker.
Perspective
Risk Management and Patient Safety
with commentary by Barry M. Manuel, MD; Jack L. McCarthy; William Berry, MD, MPH; Kathy Dwyer, Risk Management and Patient Safety, December 2010
In 1990, a Harvard-based research team reported the incidence of medical errors in the state of New York, based on the hospital discharge analysis of 30,121 cases.
Interview
In Conversation with...Peter J. Pronovost, MD, PhD
Checklists, October 2010
Peter J. Pronovost, MD, PhD, is a Professor of Anesthesia, Critical Care, and Health Policy at Johns Hopkins University and Director of the Johns Hopkins Quality and Safety Research Group. He may be best known for having led the Michigan Keystone project, which used checklists and other interventions to markedly reduce catheter-associated bloodstream infections in ICUs throughout the state. For this work and more, he received a MacArthur Foundation Fellowship, and Time Magazine named him as one of the 100 most influential people in the world. We asked him to speak with us about checklists and other thoughts about the science of improving patient safety.
Perspective
What Makes a Good Checklist
with commentary by Anne Collins McLaughlin, PhD, Checklists, October 2010
The use of checklists is a primitive yet remarkably effective strategy for ensuring accuracy in complex tasks. Checklists have long been used in fields such as aviation and space exploration but have only recently made headway in medicine. The reluctance of medical professionals to adopt checklists is often framed as pushback against "more paperwork" and "cookbook medicine," or due to disbelief in their effectiveness. However, a rich literature has helped establish many best practices in checklist design, and health care now stands to benefit.
Perspective
What Do We Know About Emergency Department Safety?
with commentary by David P. Sklar, MD; Cameron Crandall, MD, Patient Safety in Emergency Medicine, June 2010
Emergency medicine has evolved from a location, with variably trained and experienced providers ("the ER"), to a discipline with a well-defined knowledge base and skill set that focus on the diagnosis and care of undifferentiated acute problems.(1) The importance of rapid diagnosis and treatment of serious conditions (e.g., myocardial infarction, stroke, trauma, and sepsis) has made timeliness not simply a determinant of patient satisfaction but also a significant safety and quality concern—delays in care can be deadly.(2) Emergency physicians (EPs) have identified delays caused by crowding from boarding of admitted patients as their most significant safety problem.(3) We present a model for understanding emergency department (ED) patient safety and identify solutions by deconstructing care into three realms: individual provider, patient, and environmental system (Table).
Perspective
The Role of Graduate Medical Education (GME) in Improving Patient Safety
with commentary by Arpana R. Vidyarthi, MD; Robert B. Baron, MD, MS, Medical Education and Patient Safety, February 2010
Clear health communication is increasingly recognized as essential for promoting patient safety. Yet according to a recent Joint Commission report, What Did the Doctor Say? Improving Health Literacy to Protect Patient Safety, communication problems among health care providers, patients, and families are common and a leading root cause of adverse outcomes.(1) Addressing health literacy—the capacity of individuals to obtain, process, and understand basic health information and services needed to make appropriate health decisions—has become a primary objective for many health systems in order to protect patients from harm.