Perspectives on Safety
Narrow Results Clear All
- Communication Improvement 17
- Culture of Safety 23
- Education and Training 11
Error Reporting and Analysis
- Error Analysis 33
- Human Factors Engineering 7
- Legal and Policy Approaches 29
- Logistical Approaches 3
- Quality Improvement Strategies 27
- Research Directions 1
- Specialization of Care 1
- Teamwork 6
- Technologic Approaches 18
- Diagnostic Errors 10
- Fatigue and Sleep Deprivation 2
- Identification Errors 1
- Medical Complications 4
- Medication Safety 11
- Nonsurgical Procedural Complications 2
- Psychological and Social Complications 11
- Surgical Complications 7
- Family Members and Caregivers 3
- Health Care Executives and Administrators 64
- Health Care Providers 47
Non-Health Care Professionals
- Media 1
- Patients 5
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.
Safety in the Retail Pharmacy, October 2018
Dr. Cohen is President of the Institute for Safe Medication Practices, a nonprofit organization that operates the voluntary and confidential ISMP Medication Errors Reporting Program. He is also coeditor of the ISMP consumer website, chairperson of the International Medication Safety Network, and a consultant to the Food and Drug Administration. We spoke with him about patient safety in the community pharmacy, including challenges associated with production pressures and the importance of reporting concerns.
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.
Point-of-Care Ultrasound: Safety and Utility, June 2018
Dr. Hoppmann is the Dorothea H. Krebs Endowed Chair of Ultrasound Education, Professor of Medicine, and Director of the Ultrasound Institute of the University of South Carolina School of Medicine. He founded and served as the first President of the Society of Ultrasound in Medical Education. We talked to him about safety and usability of point-of-care ultrasound.
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 Sumant Ranji, MD, 2017
A considerable body of evidence demonstrates worsened clinical outcomes for patients admitted to the hospital on weekends compared to those admitted on weekdays. This Annual Perspective summarizes innovative studies published in 2017 that helped clarify the magnitude of this effect and identify possible mechanisms by which it occurs.
with commentary by Rachel J. Stern, MD, and Urmimala Sarkar, MD, 2017
Patient engagement in safety has evolved from obscurity to maturity over the past two decades. This Annual Perspective highlights emerging approaches to engaging patients and caregivers in safety efforts, including novel technological innovations, and summarizes the existing evidence on the efficacy of such approaches.
with commentary by Julia E. Szymczak, PhD, Presenteeism: A Patient Safety Challenge, October 2017
This piece explores the risks of presenteeism among health care workers and factors, such as cultural expectations, that contribute to its occurrence.
The Weekend Effect, June 2017
Professor Aylin is Professor of Epidemiology and Public Health at Imperial College London. We spoke with him about the weekend effect in health care—the observation that patients admitted to the hospital over the weekend often have worse outcomes than those admitted during the week.
with commentary by Vanessa K. Martin, DO, MS; Nasim Mirnateghi, PhD; and Mahdi Khoshchehreh, MD, MS, The Weekend Effect, June 2017
This piece explores the weekend effect in cardiology and recommends allowing invasive management for patients with non ST-elevation myocardial infarction to improve outcomes in this group.
Opioids and Patient Safety, May 2017
Dr. Juurlink is professor of medicine, pediatrics, and health policy at the University of Toronto, where he is also director of the Division of Clinical Pharmacology and Toxicology. We spoke with him about the opioid epidemic and strategies to address this growing patient safety concern.
with commentary by Irene Berita Murimi, PhD, MA, and G. Caleb Alexander, MD, MS, Opioids and Patient Safety, May 2017
This piece explores the opioid epidemic in the United States, including factors that led to increased opioid prescribing, its adverse effects, and tactics to reduce opioid-related harm.
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 Urmimala Sarkar, MD, and Kaveh Shojania, MD, 2016
Opioids are known to be high risk medications, and concerns about patient harm from prescription opioid misuse have been increasing in the United States. This Annual Perspective summarizes research published in 2016 that explored the extent of harm from their use, described problematic prescribing practices that likely contribute to adverse events, and demonstrated some promising practices to foster safer opioid use.
with commentary by Kiran Gupta, MD, MPH, and Audrey Lyndon, PhD, 2016
Root cause analysis is widely accepted as a key component of patient safety programs. In 2016, the literature outlined ongoing problems with the root cause analysis process and shed light on opportunities to improve its application in health care. This Annual Perspective reviews concerns about the root cause analysis process and highlights recommendations for improvement put forth by the National Patient Safety Foundation.
Root Cause Analysis: What Have We Learned?, December 2016
Dr. Bagian is Director of the Center for Healthcare Engineering and Patient Safety at the University of Michigan, and a former astronaut. He co-chaired the team that produced the influential NPSF report entitled, RCA2: Improving Root Cause Analyses and Actions to Prevent Harm.
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.
Patient Safety in Dentistry, July/August 2016
Dr. Perea-Pérez is Director of the Spanish Observatory for Dental Patient Safety. We spoke with him about patient safety in dentistry.
with commentary by Rachel Badovinac Ramoni, DMD, ScD; Muhammad Walji, PhD; and Elsbeth Kalenderian, DDS, MPH, PhD, Patient Safety in Dentistry, July/August 2016
This piece examines patient safety issues unique to dental care along with strategies to reduce risks.
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.