Perspectives on Safety
Narrow Results Clear All
- Communication Improvement 7
- Culture of Safety 5
Education and Training
- Students 2
- Error Reporting and Analysis 9
- Human Factors Engineering 4
- Legal and Policy Approaches 9
- Logistical Approaches 4
- Quality Improvement Strategies 10
- Research Directions 1
- Specialization of Care 1
- Teamwork 1
- Clinical Information Systems
- Alert fatigue 1
- Device-related Complications 2
- Diagnostic Errors 5
- Discontinuities, Gaps, and Hand-Off Problems 3
- Fatigue and Sleep Deprivation 1
- Identification Errors 2
- Medical Complications 1
- Medication Errors/Preventable Adverse Drug Events 6
- Psychological and Social Complications 3
- Surgical Complications 3
- Family Members and Caregivers 1
- Health Care Executives and Administrators 21
- Health Care Providers 19
- Non-Health Care Professionals 23
- 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.
A Decade After HITECH, May 2018
Dr. Blumenthal is President of the Commonwealth Fund and served as the National Coordinator for Health Information Technology from 2009-2011, during early implementation of the Health Information Technology for Economic and Clinical Health (HITECH) Act and the accompanying Meaningful Use program. We spoke with him about the HITECH Act and lessons learned in health care since it was enacted.
A Decade After HITECH, May 2018
Dr. Halamka is the International Healthcare Innovation Professor at Harvard Medical School, Chief Information Officer of Beth Israel Deaconess Medical Center, and an emergency physician. He is widely known as one of the most thoughtful and provocative experts on the subject of health IT. We spoke with him about the HITECH Act and the consequences—anticipated and otherwise—of the digitization of health care.
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.
Clinical Documentation in the Modern Era, January 2018
Dr. Hirschtick is Associate Professor of Medicine at Northwestern Medicine, and the author of a number of prominent articles—many quite amusing—about the changes in medical practice wrought by information technology. We spoke with him about what it means to be a clinician in the modern era, particularly how digitization of health records has affected clinicians' notes.
with commentary by Shannon M. Dean, MD, Clinical Documentation in the Modern Era, January 2018
This piece explores concerns regarding the use of copy and paste in electronic health records and offers potential strategies to improve clinical documentation accuracy.
Surgical Safety, December 2017
Dr. Bilimoria is the Director of the Surgical Outcomes and Quality Improvement Center of Northwestern University, which focuses on national, regional, and local quality improvement research and practical initiatives. He is also the Director of the Illinois Surgical Quality Improvement Collaborative and a Faculty Scholar at the American College of Surgeons. In the second part of a two-part interview (the earlier one concerned residency duty hours), we spoke with him about quality and safety in surgery.
Health Information Technology and Safety, September 2017
Dr. Gettinger is the Chief Medical Information Officer and the Executive Director of the Office of Clinical Quality and Safety for the Office of the National Coordinator (ONC). He led the development of an electronic health record (EHR) system at Dartmouth and was the senior physician leader during their transition to a vendor-based EHR. We spoke with him about safety and health information technology.
with commentary by Dean F. Sittig, PhD, and Hardeep Singh, MD, MPH, Health Information Technology and Safety, September 2017
This piece highlights four key lessons that the authors believe are useful for clinicians and health care organizations that seek to identify, prevent, and mitigate electronic health record–related safety issues.
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 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.
Electronic Tools for Patient Safety: Engaging Patients and Providers, September 2015
Dr. Arora is Director of GME Clinical Learning Environment Innovation and Assistant Dean for Scholarship and Discovery at the University of Chicago Pritzker School of Medicine. We spoke with her about the intersection of health information technology and patient safety.
with commentary by A. Zach Hettinger, MD, MS; Raj Ratwani, PhD; Rollin J. (Terry) Fairbanks, MD, MS, New Insights on Safety and Health IT, July/August 2015
This piece provides an overview of health IT usability design, including persisting challenges and progress in the field.
National Organizations in Safety, April 2014
Dr. Gandhi is President of the National Patient Safety Foundation and Associate Professor of Medicine at Harvard Medical School. We spoke with her about NPSF's evolving role in enhancing health care at a national level.
with commentary by Christopher Nemeth, PhD, Unintended Consequences, June 2011
This piece discusses how adopting new technology can have unintended effects.
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.
The Business Case for Improving Safety, May 2009
The Business Case for Improving Safety
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.
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.