Perspectives on Safety
Narrow Results Clear All
- Communication Improvement 3
- Culture of Safety 2
- Education and Training 3
- Error Reporting and Analysis 3
- Human Factors Engineering 4
- Legal and Policy Approaches 4
- Logistical Approaches 2
- Quality Improvement Strategies
- Research Directions 1
- Technologic Approaches 4
- Device-related Complications 1
- Diagnostic Errors 7
- Discontinuities, Gaps, and Hand-Off Problems 1
- Fatigue and Sleep Deprivation 1
- Delirium 3
- Medication Errors/Preventable Adverse Drug Events 2
- Nonsurgical Procedural Complications 1
- Psychological and Social Complications 2
- Surgical Complications 1
- Family Members and Caregivers 1
- Health Care Executives and Administrators 11
Health Care Providers
- Nurses 1
Non-Health Care Professionals
- Media 1
- Patients 1
with commentary by Rachel J. Stern, MD, and Urmimala Sarkar, MD, 2018
Patient engagement is widely acknowledged as a cornerstone of patient safety. Research in 2018 demonstrates that patient engagement, when done correctly, can help health care systems identify safety hazards, regain trust after they occur, and codesign sustainable solutions.
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.
Safety in Radiology, October 2013
Dr. Smith-Bindman is a national leader in the impact of radiologic testing on patient outcomes, and in the safety of radiographic imaging.
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.
Quality and Safety Challenges in Critical Care: Preventing and Treating Delirium in the Intensive Care Unit
with commentary by Eduard E. Vasilevskis, MD; E. Wesley Ely, MD, MPH; Robert S. Dittus, MD, MPH, Delirium as a Safety Target, December 2012
This piece details a number of evidenced-based practices to help detect, prevent, and treat delirium, which is now seen as a patient safety hazard.
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 Eric J. Thomas, MD, MPH; Jan Patterson, MD, MS; Sherry Martin, MEd; Doris Quinn, PhD; Gary Reed, MD; Ken Shine, MD, Educating Practitioners in Safety and Quality, February 2011
Health care in the United States is undergoing profound changes due to societal demands to improve the quality of care and simultaneously reduce costs.
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 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 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.
Not Paying for Errors: A Policy Perspective, October 2008
At the University of California, San Francisco, Robert M. Wachter, MD, is Professor and Chief of the Division of Hospital Medicine; Associate Chairman of the Department of Medicine; Lynne and Marc Benioff Endowed Chair in Hospital Medicine; and Chief of the Medical Service at UCSF Medical Center. He is also Editor of AHRQ WebM&M and AHRQ Patient Safety Network.
with commentary by Gary A. Noskin, MD, MRSA and Patient Safety, April 2008
Methicillin-resistant Staphylococcus aureus (MRSA) has received a great deal of media attention over the past few months following the release of a study indicating that, on an annual basis, approximately 94,000 patients develop serious MRSA infections resulting in 18,650 deaths. Email to a colleague Digg This Printable View Methicillin-Resistant Staphylococcus aureus Perspective by Gary A. Noskin, MD Methicillin-resistant Staphylococcus aureus (MRSA) has received a great deal of media attention over the past few months following the release of a study indicating that, on an annual basis, approximately 94,000 patients develop serious MRSA infections resulting in 18,650 deaths.(
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...
with commentary by Nancy C. Elder, MD, MSPH, Outpatient Safety, May 2006
Dr. Jones was sure he had increased Mr. H's cholesterol-lowering medication to 80 mg 6 months ago, but, at his visit today, his pill bottle still says 40 mg. In reviewing Ms. B's chart in preparation for performing a well-woman examination, Dr. Smith find...
Organizational Change in the Face of Highly Public Errors—I. The Dana-Farber Cancer Institute Experience
with commentary by James B. Conway; Saul N. Weingart, MD, PhD, Errors in the Media and Organizational Change, May 2005
A decade ago, two tragic medical errors rocked one of the world’s great cancer hospitals, Dana-Farber Cancer Institute (DFCI) in Boston, to its core. The errors led to considerable soul searching and, ultimately, a major change in institutional practices a...