Perspectives on Safety
Narrow Results Clear All
- Communication Improvement 7
- Culture of Safety 5
- Education and Training 9
- Error Reporting and Analysis 12
- Human Factors Engineering 1
- Legal and Policy Approaches 9
- Logistical Approaches 5
- Policies and Operations 1
- Quality Improvement Strategies 21
- Teamwork 1
- Technologic Approaches 5
- Alert fatigue 1
- Device-related Complications 1
- Diagnostic Errors 13
- Discontinuities, Gaps, and Hand-Off Problems 3
- Fatigue and Sleep Deprivation 3
- Delirium 2
- Medication Safety 5
- Nonsurgical Procedural Complications 1
- Psychological and Social Complications 2
- Surgical Complications 1
- Family Members and Caregivers 3
- Health Care Executives and Administrators 24
Health Care Providers
- Nurses 1
- Non-Health Care Professionals 15
- Patients 2
Improving Diagnosis, July 2018
Dr. Schiff is Associate Director of Brigham and Women's Center for Patient Safety Research and Practice, Associate Professor of Medicine at Harvard Medical School, and Quality and Safety Director for the Harvard Medical School Center for Primary Care. He was an invited expert and reviewer for the Improving Diagnosis in Health Care report of the National Academy of Medicine. We spoke with him about understanding and preventing diagnostic errors.
Improving Diagnosis, July 2018
Dr. Nundy is the Director of the Human Diagnosis Project, a nonprofit organization taking a unique crowdsourcing approach to improving medical diagnosis. He also practices primary care at a federally qualified health center for low-income and uninsured individuals in Washington, DC. We spoke with him about his work with the Human Diagnosis Project.
with commentary by Jane Ball, PhD, and Peter Griffiths, PhD, Nursing and Patient Safety, March 2018
This piece explores how missed nursing care may explain the association between low nurse staffing levels and increased mortality in hospital patients.
with commentary by Sumant Ranji, MD, 2016
The toll of medical errors is often expressed in terms of mortality attributable to patient safety problems. In 2016, there was considerable debate regarding the number of patients who die due to medical errors. This Annual Perspective explores the methodological approaches to estimating mortality attributable to preventable adverse events and discusses the benefits and limitations of existing approaches.
with commentary by Carl Macrae, PhD, Root Cause Analysis: What Have We Learned?, December 2016
This piece explores how strategies from aviation, such as just culture and monitoring technologies, can be applied in health care to improve patient safety.
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.
with commentary by Urmimala Sarkar, MD, and Kaveh Shojania, MD, 2015
Computerized provider order entry is a cornerstone of patient safety efforts, and the increasingly widespread implementation of electronic health records has made it a standard practice in health care. This Annual Perspective summarizes novel findings and research directions in computerized provider order entry in 2015.
Update on Diagnostic Errors, January 2016
Dr. Graber founded the Society to Improve Diagnosis in Medicine and the journal, Diagnosis. We spoke with him about the recent National Academy of Medicine (formerly Institute of Medicine) Improving Diagnosis in Health Care report, and about diagnostic errors more generally.
with commentary by Shams B. Syed, MD, MPH, Global Patient Safety, December 2014
This piece describes the evolution of the World Health Organization's African Partnerships for Patient Safety program and its implications for global patient safety improvement.
with commentary by Christopher Moriates, MD, Overuse as a Patient Safety Problem, September 2014
This piece describes the emergence of medical care overuse as a patient safety issue and relates efforts to change clinician behaviors to prevent overtreatment.
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.
Infection Prevention and Patient Safety, March 2014
Dr. Holmes is Director of Infection Prevention and Control and a professor at Imperial College London. We spoke with her about infection prevention and patient safety.
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.
Patient Safety Research, December 2013
Dr. Singh has conducted extensive multidisciplinary research supported by the VA, AHRQ, and NIH and is now a nationally recognized expert in electronic health record–related patient safety issues and diagnostic errors. We spoke with him about becoming a patient safety researcher.
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 Antonio Pinto, MD, PhD, Safety in Radiology, October 2013
This piece explores how to mitigate risks associated with radiology procedures.
Engaging the Patient and Family in Safety, February 2013
Beverley Johnson is President and Chief Executive Officer of the Institute for Patient- and Family-Centered Care.
Delirium as a Safety Target, December 2012
A leading expert in geriatrics research and innovation, Dr. Inouye developed and validated a widely used tool, the Confusion Assessment Method (CAM), to identify delirium.
The Demise of the Physical Exam, November 2012
A passionate advocate for the importance of the physical exam, Dr. Verghese is a Professor at Stanford University School of Medicine and a bestselling author.