Perspectives on Safety

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.

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.

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.

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.

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.

An Associate Professor at the University of Chicago, her research focuses on resident duty hours, handoffs, and professionalism.

This piece discusses how medical centers can improve handover quality and patient safety.

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.

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.

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.

The 1999 Institute of Medicine report highlighted the need for health care providers to address the serious concerns raised about the quality and safety of patient care being provided in our health care organizations. Organizations responded by looking at new ways to fix the system, mostly through the introduction of new technologies and system/process redesign. Advances have been made, but there are still significant opportunities for improvement. Is the barrier poor system or process design, or is it related to addressing basic human behaviors?

Frontline health care providers are challenged by poorly performing work systems. Required equipment is broken, patient medications are in the wrong dose, key information fails to get communicated, and essential supplies are out of stock.(

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.

Jennifer Daley, MD, is the Chief Medical Officer of Partners Community Healthcare Inc., the organization for the 6000 physicians employed/affiliated with Partners HealthCare System (which includes Massachusetts General and Brigham & Women's Hospitals). From 2002 to 2007, she was the Chief Medical Officer for Tenet Healthcare, one of the nation's largest hospital systems, where she was responsible for the development and implementation of Tenet's Commitment to Quality (C2Q). Her academic background (including her previous directorship of the Center for Health Systems Design and Evaluation in the Institute for Health Policy at Massachusetts General Hospital and Partners HealthCare) and her years of leadership at a huge multistate private sector system provide her with a unique perch from which to view patient safety implementation in complex systems.

Eric A. Coleman, MD, MPH, is Associate Professor of Medicine at the University of Colorado. Trained in both geriatrics and health services research, Dr. Coleman has emerged as one of the world's leading authorities on issues surrounding transitions of care, particularly between acute and postacute settings. His care model, the Care Transitions Intervention, is being adopted by leading health care organizations around the country. The Intervention has been associated with significant decreases in rehospitalization rates.

Hospital discharge is often viewed as the end of an acute medical event. Goodbyes are said as patients pack their belongings and return home. Physicians scratch the patient's name off their rounding list, and hospital staff remove the patient from the census as they clean out the room...

Sorrel King is the mother of Josie King, who died tragically in 2001 at age 18 months because of medical errors during a hospitalization at Johns Hopkins Hospital. She has subsequently become one of the nation’s foremost patient advocates for safety, forming an influential foundation (the Josie King Foundation) and partnering with Johns Hopkins to promote the field of patient safety around the world.

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.

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...