Perspectives on Safety
Narrow Results Clear All
- Communication Improvement 11
- Culture of Safety
- Education and Training 10
- Error Reporting and Analysis 21
- Human Factors Engineering 6
- Legal and Policy Approaches 17
- Logistical Approaches 1
- Quality Improvement Strategies 18
- Specialization of Care 3
- Teamwork 10
- Technologic Approaches 7
- Transparency and Accountability 1
- Discontinuities, Gaps, and Hand-Off Problems 1
- Identification Errors 1
- Medical Complications 4
- Medication Safety 6
- Nonsurgical Procedural Complications 1
- Psychological and Social Complications 7
- Second victims 1
- Surgical Complications 3
- Family Members and Caregivers 1
- Health Care Executives and Administrators
Health Care Providers
- Nurses 2
Non-Health Care Professionals
- Media 1
- Patients 2
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.
with commentary by Paul E. Phrampus, MD, Health System Consolidation and Patient Safety, March 2019
This piece outlines how large integrated health care systems can implement effective patient safety programs and spotlights the importance of leadership engagement and a just culture.
with commentary by Audrey Lyndon, RN, PhD, 2018
This perspective examines the troubling decline in maternal health outcomes in the United States and summarizes recent national initiatives to improve safety in maternity care.
New Thinking About High Reliability, April 2017
Dr. Chassin is president and chief executive officer of The Joint Commission. He is also president of the Joint Commission Center for Transforming Healthcare, a center he began to promote high reliability and transformative practice. We spoke with him about new thinking in high reliability.
New Thinking About High Reliability, April 2017
Professor Sutcliffe is a Bloomberg Distinguished Professor of Business and Medicine at Johns Hopkins University. She studies organizational adaptability, reliability, resilience, and safety in health care. We spoke with her about high reliability in health care organizations.
Approaching Safety Culture in New Ways, March 2017
Dr. Dixon-Woods is RAND Professor of Health Services Research at Cambridge University, Deputy Editor-in-Chief of BMJ Quality and Safety, and one of the world's leading experts on the sociology of health care. We spoke with her about new ways to approach safety culture.
with commentary by Sara J. Singer, MBA, PhD, Approaching Safety Culture in New Ways, March 2017
This piece discusses the importance of strengthening safety culture in health care and offers insights for organizations seeking to achieve culture change.
with commentary by Christopher Moriates, MD, and Robert M. Wachter, MD, 2015
While the patient safety world has largely embraced the concept of a just culture for many years, in 2015 the discussion moved toward tackling some of the specifics and many gray areas that must be addressed to realize this ideal. This Annual Perspective reviews the context of the "no blame" movement and the recent shift toward a framework of a just culture, which incorporates appropriate accountability in health care.
What We've Learned About Leveraging Leadership and Culture to Affect Change and Improve Patient Safety
with commentary by Sara J. Singer, MBA, PhD, Update on Just Culture, September 2013
This piece explores how leaders can promote cultural changes to improve patient safety.
Update on Safety Culture, July-August 2013
J. Bryan Sexton, PhD, is director of the Patient Safety Center for the Duke University Health System and an international expert in safety culture and clinician burnout.
with commentary by Allan Frankel, MD, and Michael Leonard, MD, Update on Safety Culture, July-August 2013
This piece explores how safety culture work has evolved over the past decade.
Safety in Nursing Homes, August 2012
An expert on patient safety in nursing homes, Dr. Castle is a Professor at the University of Pittsburgh in the Department of Health Policy and Management.
Fall Prevention, December 2011
A leading expert on health care–associated falls, Dr. Hendrich developed one of the most widely used risk assessment tools.
with commentary by Frances Healey, RN, PhD, Fall Prevention, December 2011
This piece discusses the multiple, complex causes of falls in hospitalized patients along with prevention strategies.
The Role of Context in Safety Research, October 2011
An international leader in evidence-based medicine and quality improvement, Dr. Shekelle led an AHRQ-funded effort to better define the role of context in patient safety.
with commentary by Dr. John Øvretveit, The Role of Context in Safety Research, October 2011
This piece discusses how observations from social sciences have implications for patient safety.
Incident Reporting, September 2011
A leading expert on evidence-based patient safety strategies and translating research into practice, Dr. Shojania is the Director of the University of Toronto Centre for Patient Safety and the new editor of BMJ Quality and Safety.
with commentary by Teryl K. Nuckols, MD, MSHS, Incident Reporting, September 2011
This piece discusses incident reporting systems as tools for improving patient safety.
Patient Safety Organizations, July 2011
In charge of implementing the PSO initiative for AHRQ, Dr. Munier is Director of the Center for Quality Improvement and Patient Safety.
with commentary by Rory Jaffe, MD, MBA, Patient Safety Organizations, July 2011
This piece discusses the process by which one professional organization became a PSO.