Perspectives on Safety
Narrow Results Clear All
- Communication Improvement 3
- Education and Training 4
- Error Reporting and Analysis 4
- Legal and Policy Approaches 3
- Logistical Approaches 2
- Quality Improvement Strategies 4
- Teamwork 1
- Technologic Approaches 2
with commentary by Chris Moore, MD, Point-of-Care Ultrasound: Safety and Utility, June 2018
This piece highlights how point-of-care ultrasound can improve and expedite diagnosis and advocates for having an individual responsible for overseeing point-of-care ultrasound use within a health care delivery organization.
with commentary by Zahra Khudeira, PharmD, Certification in Patient Safety, June 2016
In this piece, a pharmacist highlights the importance of earning patient safety certification.
with commentary by Hardeep Singh, MD, MPH, Update on Diagnostic Errors, January 2016
This piece discusses momentum in the field of diagnostic error over the past several years (culminating in the recent Improving Diagnosis in Health Care report) and outlines future avenues to ensure progress in diagnostic safety.
with commentary by P. Jeffrey Brady, MD, MPH; William B. Munier, MD, MBA; Irim Azam, MPH, Patient Safety Research, December 2013
This piece, written by three leaders in AHRQ's research portfolio, covers future avenues for patient safety research and reviews current AHRQ projects.
with commentary by Steven McGee, MD, The Demise of the Physical Exam, November 2012
This piece details the benefits of an evidenced-based approach to physical examination and diagnosis.
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.
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).
with commentary by Richard J. Baron, MD, The Business Case for Improving Safety, May 2009
Most patient interactions with the health care system occur in the outpatient setting. Many potential and actual safety problems occur there as well.(1) Yet patient safety literature and practice do not seem to have reached deeply into ambulatory care. This is likely due to a combination of factors: in most practices, there is no layer of administration providing a second look at routine policies and procedures; there is no accrediting agency, like The Joint Commission, to mandate safe practices (2); and those of us in office practice are so consumed with simply getting through the day that it is difficult to recognize the problems, large and small, that can lead to major safety hazards. The business case for safety, such as it is, relies almost entirely on the malpractice rate-setting process: errors that result in litigation lead to higher premiums and personal and professional misery. However, as Studdert (3) has argued, relying on the malpractice system to identify and "correct" errors is unlikely to be timely or productive.
with commentary by James M. Naessens, ScD, Not Paying for Errors: A Policy Perspective, October 2008
Interest is growing in the use of existing data sources to identify opportunities to improve the delivery and safety of medical care, to measure and compare quality and patient safety, and even to change provider incentives through pay for performance initiatives.
with commentary by Mark L. Graber, MD, Diagnostic Errors, February 2007
Strike 3—You're OUT! Many a baseball game hinges on the accuracy of calls made by the men in black behind home plate. Umpires make crucial split-second decisions under conditions of substantial pressure and uncertainty, a challenge familiar to front-line...