Perspectives on Safety
Narrow Results Clear All
- Communication Improvement 50
- Culture of Safety 54
Education and Training
- Simulators 10
- Students 5
Error Reporting and Analysis
- Error Analysis 33
- Human Factors Engineering 33
Legal and Policy Approaches
- Regulation 15
- Logistical Approaches 25
- Policies and Operations 2
- Quality Improvement Strategies 97
- Research Directions 4
- Specialization of Care 8
- Teamwork 17
- Clinical Information Systems 32
- Transparency and Accountability 3
- Alert fatigue 3
- Device-related Complications 7
- Diagnostic Errors 26
- Discontinuities, Gaps, and Hand-Off Problems 19
- Fatigue and Sleep Deprivation 12
- Identification Errors 2
- Delirium 3
- Medication Errors/Preventable Adverse Drug Events 15
- Nonsurgical Procedural Complications 7
- Psychological and Social Complications 24
- Second victims 1
- Surgical Complications 20
- Dentistry 2
- Gynecology 54
- Surgery 15
- Nursing 12
- Pharmacy 12
- Family Members and Caregivers 6
- Health Care Executives and Administrators 210
Health Care Providers
- Nurses 7
- Physicians 40
Non-Health Care Professionals
- Educators 34
- Media 1
- Patients 7
with commentary by Alison H. Page, MS, MHA, Just Culture, October 2007
We've all been there...something goes wrong, a patient is harmed, and we, as medical directors, managers, and administrators, are forced to judge the behavioral choices of another human being. Most of the time, we conduct this complex leadership function guided by little more than vague policies, personal beliefs, and intuition. Frequently, we are frustrated by the fact that many other providers have made the same mistake or behavioral choice, with no adverse outcome to the patient, and the behavior was overlooked. Quite understandably, the staff is frustrated by what appears to be inconsistent, irrational decision-making by leadership. The "just culture" concept teaches us to shift our attention from retrospective judgment of others, focused on the severity of the outcome, to real-time evaluation of behavioral choices in a rational and organized manner.
Surgical Errors, September 2007
Atul Gawande, MD, MA, MPH, Associate Professor of Surgery at Harvard Medical School and the Harvard School of Public Health, is an accomplished surgeon and writer and is the recipient of a 2006 MacArthur Fellowship. He is an active clinician at Brigham and Women's Hospital and the Dana Farber Cancer Institute. Dr. Gawande has written two acclaimed and best-selling books: Complications: A Surgeon's Notes on an Imperfect Science and Better: A Surgeon's Notes on Performance. A staff writer for the New Yorker, he also recently completed a stint as a guest columnist for the New York Times. Dr. Gawande is leading the World Health Organization's Second Global Patient Safety Challenge: "Safe Surgery Saves Lives." We asked him to speak with us about professionalism, training, patient safety, and the writing process.
with commentary by Leo A. Gordon, MD, Surgical Errors, September 2007
There is a slumbering giantone that carries the potential to transform surgical safetymerely waiting to be awakened and freshened up. I refer to the iconic gathering that so readily evokes the surgical "days of the giants"the traditional surgical morbidity and mortality (M&M) conference.
The Board's Role in Patient Safety, July-August 2007
James L. Reinertsen, MD, heads the Reinertsen Group, a prominent health care consulting firm based in Wyoming. Prior to that, he was CEO at Beth Israel Deaconess Medical Center, where he developed a reputation for his unwavering focus on safety and quality. He is also a senior faculty member at the Institute for Healthcare Improvement (IHI), where he has taken a role in teaching leadership skills and promoting the engagement of health care boards and "C-suites" in patient safety efforts. He was a prime driver behind the IHI's decision to include the "Boards on Board" initiative as part of its recent 5 Million Lives Campaign. We asked him to speak with us about the role of boards in improving patient safety.
with commentary by John L. Haughom, MD, The Board's Role in Patient Safety, July-August 2007
In recent years, the case for improving the quality and safety of care has become irrefutable. Over the next few years, failure to act will likely have far-reaching consequences for hospitals and health systems including loss of market share, increased liability, a demoralized workforce, and a sharp rise in fear and distrust among patients who lack confidence in the ability of their provider to deliver safe care...
State Error Reporting Systems, June 2007
Diane Rydrych, MA, is Assistant Director of the Division of Health Policy at the Minnesota Department of Health, where she oversees their successful and influential adverse health events reporting system. We asked her to speak with us about the Minnesota initiative and some of the broader lessons for state error reporting systems.
with commentary by Jill Rosenthal, MPH, State Error Reporting Systems, June 2007
Seven years ago, the Institute of Medicine (IOM) called on states to create mandatory reporting systems as part of a strategy to identify and learn about medical errors and ultimately to improve patient safety. Since then, many states have responded by creating or improving reporting systems to collect information about hospital-based adverse events. These systems can provide states with an opportunity to strengthen their facility oversight functions, safeguard the public, and partner with providers to improve health care quality.
State Error Reporting Systems, June 2007
Dr. Spath did an excellent job of using the error as a springboard to explain the importance of an open and sharing environment of error reporting and learning. Although limited details on the error itself were provided, the information that was contained in the case report does give readers an opportunity to more thoroughly review their own systems to discover if an error such as this can happen in their emergency department (ED).
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 Susan Burnett and Charles Vincent, PhD, International Perspectives on Safety, May 2007
The dangers of health care in Britain have been long understood. Systematic data collection of the hazards of health care can be traced back at least to the time of Florence Nightingale's publications in the 1860s. In this short paper, we outline the evolution of patient safety and trace its development and progress over the last 10 years in Britain, where a nationalized health service and sustained commitment from Chief Medical Officer Sir Liam Donaldson and other senior figures have brought patient safety to considerable prominence.
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.
The Patient's Role in Safety, March 2007
Sorrel King is the mother of Josie King, who died tragically in 2001 at age 18 months because of medical errors during a hospitalization at Johns Hopkins Hospital. She has subsequently become one of the nation’s foremost patient advocates for safety, forming an influential foundation (the Josie King Foundation) and partnering with Johns Hopkins to promote the field of patient safety around the world.
with commentary by Mark L. Graber, MD, Diagnostic Errors, February 2007
Strike 3—You're OUT! Many a baseball game hinges on the accuracy of calls made by the men in black behind home plate. Umpires make crucial split-second decisions under conditions of substantial pressure and uncertainty, a challenge familiar to front-line...
Diagnostic Errors, February 2007
Joseph Britto, MD, is CEO and Co-founder of Isabel Healthcare Inc. Isabel, a clinical decision support system, was founded in 1999 by Britto and Jason and Charlotte Maude, whose daughter Isabel was harmed by a medical error. The company has been profiled in the Wall Street Journal, and the system has undergone several validation studies. We asked Dr. Britto to talk with us about eradicating diagnosis errors through diagnosis decision support systems.
Safety Culture, December 2006
J. Bryan Sexton, PhD, MA, is Assistant Professor, Department of Anesthesiology and Critical Care Medicine, at the Johns Hopkins University School of Medicine. Trained as a social psychologist, he has become one of the world's foremost authorities on the role of culture in patient safety. He developed the widely used Safety Attitudes Questionnaire and is one of the lead investigators of the Michigan Keystone ICU project, which aims to change practice and culture in intensive care units (ICUs) throughout the state. His research examines the connections between attitudes, behaviors, and outcomes in high-risk team environments, particularly aviation and medicine. We asked him to speak with us about safety climate surveys and efforts to change safety culture.
with commentary by Timothy J. Hoff, PhD, Safety Culture, December 2006
Safety cultures are the holy grail in any risky industry. Like all holy grails, they can never be fully realized. This is particularly the case in health care. Why? Health care organizations struggle with too many competing demands to make safety the only...
with commentary by John Gosbee, MD, MS, Human Factors, November 2006
Certain phrases are famously oxymoronic: "jumbo shrimp," "military intelligence." We chuckle at such terms, but they do little harm. In the patient safety field, the term "expected complication" is both defeatist and ultimately self-fulfilling. For that...
Human Factors, November 2006
Don Norman, PhD, is well known for his books "The Design of Everyday Things" and "Emotional Design." Although not focused on health care, his work introduced many in health care to the concepts of human factors engineering and to the importance of thoughtful design in ensuring that technology is used for its intended purposes. He is cofounder of the Nielsen Norman Group, professor at Northwestern University, and former vice president of Apple Computer. Dr. Norman is now writing "The Design of Future Things," discussing the role that automation will play in our everyday lives. We asked Dr. Norman to speak with us about human-centered design.
The Transformation of Patient Safety at the VA, September 2006
James P. Bagian, MD, is the Director of the Department of Veterans Affairs National Center for Patient Safety. Dr. Bagian began his career as a mechanical engineer, then became a physician, trained in surgery and anesthesia. A NASA Astronaut for 15 years, he flew on two space shuttle flights. In 2001, the American Medical Association awarded him the Nathan S. Davis Award for outstanding public service in the advancement of public health. We asked Dr. Bagian to speak with us about his experience transforming safety at in Veterans Affairs hospitals nationwide.
with commentary by Ashish K. Jha, MD, MPH, The Transformation of Patient Safety at the VA, September 2006
Five years after the landmark Crossing the Quality Chasm report by the Institute of Medicine (IOM), the quality and safety of health care in the United States remains far from ideal.(1) It is easy to feel pessimistic. Can health care organizations really...