Perspectives on Safety
Narrow Results Clear All
- Communication Improvement 6
- Culture of Safety 6
- Education and Training 6
- Error Reporting and Analysis 6
- Human Factors Engineering 7
- Legal and Policy Approaches 7
- Logistical Approaches 3
- Quality Improvement Strategies 17
- Specialization of Care 1
- Teamwork 3
- Technologic Approaches 6
- Device-related Complications 4
- Diagnostic Errors 2
- Discontinuities, Gaps, and Hand-Off Problems 3
- Fatigue and Sleep Deprivation 2
- Identification Errors 1
- Medical Complications 5
- Medication Safety 5
- Psychological and Social Complications 1
- Surgical Complications 2
- Family Members and Caregivers 1
- Health Care Executives and Administrators
- Health Care Providers 13
- Non-Health Care Professionals 16
with commentary by Margaret Plews-Ogan, MD, MS, Safety in the Ambulatory Setting, July-August 2014
This piece describes the new landscape of patient safety in outpatient care, including elements adapted from hospital settings and the growing evidence base for ambulatory-specific efforts.
with commentary by Helen Haskell, MA, Patient Advocacy, June 2014
This piece describes the evolution of the patient advocacy movement, including the events that spurred it, resulting reforms, and the impact of online access to medical information.
with commentary by Alexandre R. Marra, MD and Michael B. Edmond, MD, MPH, MPA , Hand Hygiene, May 2014
This piece describes barriers to hand hygiene compliance in health care along with strategies to enhance and measure it.
with commentary by Susan S. Huang, MD, MPH, Infection Prevention and Patient Safety, March 2014
This piece describes the history around efforts to address preventable health care–associated infections, including federal initiatives and further research avenues to consider.
Interruptions and Distractions in Health Care, February 2014
Dr. Coiera, a professor at the University of New South Wales, has extensively researched and written about clinical communication processes and information systems. We spoke with him about how interruptions and distractions in the clinical environment influence patient safety.
with commentary by Christopher Nemeth, PhD, Unintended Consequences, June 2011
This piece discusses how adopting new technology can have unintended effects.
Educating Practitioners in Safety and Quality, February 2011
Brent C. James, MD, MStat, is Chief Quality Officer and Executive Director of the Institute for Health Care Delivery Research at Intermountain Healthcare.
Patient Safety in Emergency Medicine, June 2010
Pat Croskerry, MD, PhD, is a professor in emergency medicine at Dalhousie University in Halifax, Nova Scotia, Canada. Trained as an experimental psychologist, Dr. Croskerry went on to become an emergency medicine physician, and found himself surprised by the relatively scant amount of attention given to cognitive errors. He has gone on to become one of the world's foremost experts in safety in emergency medicine and in diagnostic errors. We spoke to him about both.
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).
Health Literacy and Safety, February-March 2009
Dean Schillinger, MD, is a Professor of Medicine at University of California, San Francisco, Director of the UCSF Center for Vulnerable Populations, and Chief of the California Diabetes Prevention and Control Program. His role as a practicing clinician at a safety net hospital (San Francisco General Hospital) has put him in a unique position to pursue influential and relevant research related to health literacy and improving care for vulnerable populations.
with commentary by Michael S. Wolf, PhD, MPH; Stacy Cooper Bailey, MPH, Health Literacy and Safety, February-March 2009
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. 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.
Prevention of Urinary Tract Infections: Lessons for Patient Safety, November 2008
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.
with commentary by Lindsay E. Nicolle, MD , Prevention of Urinary Tract Infections: Lessons for Patient Safety, November 2008
Urinary tract infection (UTI) is the most common hospital-acquired infection, accounting for 40% of all hospital-acquired infections. More than 80% of these infections are attributable to use of an indwelling urethral catheter.(1) Catheter-acquired urinary infections (cUTIs) have received significantly less attention than other health care–acquired infections, such as surgical site infections, ventilator-associated pneumonia, and bacteremia.
with commentary by Susan Burnett and Charles Vincent, PhD, International Perspectives on Safety, May 2007
The dangers of health care in Britain have been long understood. Systematic data collection of the hazards of health care can be traced back at least to the time of Florence Nightingale's publications in the 1860s. In this short paper, we outline the evolution of patient safety and trace its development and progress over the last 10 years in Britain, where a nationalized health service and sustained commitment from Chief Medical Officer Sir Liam Donaldson and other senior figures have brought patient safety to considerable prominence.
with commentary by John Gosbee, MD, MS, Human Factors, November 2006
Certain phrases are famously oxymoronic: "jumbo shrimp," "military intelligence." We chuckle at such terms, but they do little harm. In the patient safety field, the term "expected complication" is both defeatist and ultimately self-fulfilling. For that...
Human Factors, November 2006
Don Norman, PhD, is well known for his books "The Design of Everyday Things" and "Emotional Design." Although not focused on health care, his work introduced many in health care to the concepts of human factors engineering and to the importance of thoughtful design in ensuring that technology is used for its intended purposes. He is cofounder of the Nielsen Norman Group, professor at Northwestern University, and former vice president of Apple Computer. Dr. Norman is now writing "The Design of Future Things," discussing the role that automation will play in our everyday lives. We asked Dr. Norman to speak with us about human-centered design.
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...
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.
with commentary by John Whittington, MD, Patient Safety Programs, July 2006
One of the most important interventions is for hospital leadership to get the hospital's board involved with safety and quality. Not only does the board have fiduciary responsibility for the organization, but they have responsibility for quality and safety...
with commentary by Rainu Kaushal, MD MPH; Sekhar Upadhyayula, MD; David M. Gaba, MD; Lucian L. Leape, MD, Outpatient Safety, May 2006
Over the last decade, surgical operations and interventional procedures have been performed increasingly in offices with the administration of office-based anesthesia (OBA).(1) Economic considerations and convenience have driven this increase. Schultz...