Perspectives on Safety
Narrow Results Clear All
- Communication Improvement 14
- Culture of Safety 12
- Education and Training 6
- Error Reporting and Analysis
- Human Factors Engineering 3
- Legal and Policy Approaches 16
- Quality Improvement Strategies 12
- Research Directions 1
- Specialization of Care 1
- Teamwork 4
- Technologic Approaches 9
- Diagnostic Errors 2
- Identification Errors 1
- Medical Complications 1
- Medication Safety 6
- Nonsurgical Procedural Complications 1
- Psychological and Social Complications 4
- Surgical Complications 3
- Family Members and Caregivers 3
- Health Care Executives and Administrators 26
- Health Care Providers 21
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.
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 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.
Organizations Working to Improve Quality and Safety, June 2015
Dr. Cassel, President and CEO of the National Quality Forum (NQF), is a leading expert in geriatric medicine, medical ethics, and quality of care. We spoke with her about NQF's work in developing and utilizing quality measures to improve safety in health care.
with commentary by Saul N. Weingart, MD, PhD, Engaging the Patient and Family in Safety, February 2013
This piece highlights the advantages to and limitations of engaging patients in patient safety.
Safety in the UK, June 2012
Professor Vincent, a psychologist by training, is one of the world’s leading patient safety researchers.
with commentary by Paul J. Sharek, MD, MPH, Trigger Tools, May 2012
This piece explains how the trigger tool approach identifies adverse events more efficiently than other detection methods such as voluntary incident reporting and patient safety indicators drawn from administrative data.
Disclosing Errors and Other Innovations in Risk Management, March 2012
An attorney and chief risk officer for the University of Michigan Health System, Mr. Boothman developed a pioneering approach to medical mistakes and risk management, emphasizing an honest approach to errors, early apology, and rapid settlement offers when the system was at fault.
with commentary by Allen Kachalia, MD, JD, Disclosing Errors and Other Innovations in Risk Management, March 2012
This piece describes how evidence-based improvements to the medical liability system could influence both accountability and compensation for errors.
The Second Victim, May 2011
A Professor at Johns Hopkins University, he coined the term “second victim” to describe the toll that errors take on providers.
Risk Management and Patient Safety, December 2010
Geri Amori, PhD, is Vice President for the Education Center at The Risk Management and Patient Safety Institute, and a popular writer and speaker.
Measuring Patient Safety, November 2010
Patrick S. Romano, MD, MPH, is Professor of Medicine and Pediatrics at the University of California, Davis, School of Medicine.
with commentary by Amy K. Rosen, PhD, Measuring Patient Safety, November 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.
High-Risk Physicians and Disruptive Behaviors, December 2009
Gerald B. Hickson, MD, is one of the world's leading experts on physician behavior and its connection to clinical outcomes and medical malpractice. He is a Professor at the Vanderbilt University School of Medicine, where he is also the Joseph C. Ross Chair in Medical Education and Administration, Associate Dean for Clinical Affairs, Director of the Vanderbilt Center for Patient and Professional Advocacy, and Director of Clinical Risk and Loss Prevention. We asked him to speak with us about high-risk physicians and malpractice.
Patient Disclosure and Apology, January 2009
Thomas H. Gallagher, MD, is Associate Professor in the Department of Medicine and the Department of Medical History and Ethics at the University of Washington in Seattle. Dr. Gallagher's current research covers the disclosure of medical errors, examining patients' and doctors' attitudes about disclosure, how best to train providers to disclose and apologize for errors, and how to create a system that promotes appropriate disclosure. We asked him to speak with us about new developments in the field of patient disclosure and apologies.
with commentary by Allen Kachalia, MD, JD, Patient Disclosure and Apology, January 2009
Disclosure of medical error is inextricably linked to today's patient safety efforts. Health care experts advocate that greater disclosure is necessary to achieve complete transparency and ameliorate barriers to error reporting.(1,2) Of course, the ethical obligations triggered by the occurrence of a medical error are not to be overlooked. Principles of fiduciary duty, patient autonomy, and equity all strongly support the ethical and moral mandate for physicians to disclose harmful errors to patients.(3) These principles weigh in favor of disclosure even if it is contrary to the physician's interests (e.g., malpractice risk or reputation). As a result, the issue of disclosure garners tremendous attention in today's medical literature.
Improving Safety in Large Systems, January 2008
Jennifer Daley, MD, is the Chief Medical Officer of Partners Community Healthcare Inc., the organization for the 6000 physicians employed/affiliated with Partners HealthCare System (which includes Massachusetts General and Brigham & Women's Hospitals). From 2002 to 2007, she was the Chief Medical Officer for Tenet Healthcare, one of the nation's largest hospital systems, where she was responsible for the development and implementation of Tenet's Commitment to Quality (C2Q). Her academic background (including her previous directorship of the Center for Health Systems Design and Evaluation in the Institute for Health Policy at Massachusetts General Hospital and Partners HealthCare) and her years of leadership at a huge multistate private sector system provide her with a unique perch from which to view patient safety implementation in complex systems.
International Perspectives on Safety, May 2007
Sir Liam Donaldson, MD, MSc, is England's Chief Medical Officer, a post often referred to as "the Nation's Doctor" (similar to the role of the U.S. Surgeon General). Trained as a surgeon, Sir Liam has been an inspirational leader in public health and health care quality in the United Kingdom for two decades. He has also emerged as a world leader in the patient safety field, authoring or commissioning dozens of influential reports, and serving as the founding chair of the World Health Organization's World Alliance for Patient Safety. We spoke to him about patient safety from an international perspective.
with commentary by Rosemary Gibson, MSc, The Patient's Role in Safety, March 2007
Patients have three roles in improving patient safety: helping to ensure their own safety, working with health care organizations to improve safety at the organization and unit level, and advocating as citizens for public reporting and accountability of hospital and health system performance. The following case illustrates how patients can help ensure their own safety.