Perspectives on Safety
Narrow Results Clear All
- Communication Improvement 48
- Culture of Safety 51
Education and Training
- Simulators 10
- Students 4
Error Reporting and Analysis
- Error Analysis 33
- Human Factors Engineering 31
Legal and Policy Approaches
- Regulation 15
- Logistical Approaches 25
- Policies and Operations 1
- Quality Improvement Strategies 97
- Research Directions 2
- Specialization of Care 8
- Teamwork 17
- Clinical Information Systems 32
- Transparency and Accountability 1
- 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 6
- Psychological and Social Complications 18
- Surgical Complications 20
- Dentistry 2
- Gynecology 53
- Surgery 15
- Nursing 12
- Pharmacy 12
- Family Members and Caregivers 6
- Health Care Executives and Administrators 206
Health Care Providers
- Nurses 7
- Physicians 36
Non-Health Care Professionals
- Educators 32
- Media 1
- Patients 7
Pharmacy and Safety, April 2006
Michael Cohen, RPh, MS, ScD, is president of the Institute for Safe Medication Practices (ISMP) and co-editor of ISMP Medication Safety Alert!, a biweekly newsletter. A pharmacist by training, his ground-breaking work and commitment to patient safety and preventing medication errors has spanned three decades. He received one of the prestigious MacArthur Fellowships (informally known as the "genius awards") in 2005.
with commentary by Brian K. Alldredge, PharmD; Mary Anne Koda-Kimble, PharmD, Pharmacy and Safety, April 2006
Pharmacists are comfortable participants in the patient safety movement in matters pertaining to prescriptions, medication systems, institutions, and national policy development. The very existence of the profession of pharmacy is rooted in the fundamental...
with commentary by David M. Gaba, MD, Point–Counterpoint: Simulation vs. Team Training, March 2006
Let’s take as a given that improving the ability of individuals and teams to function “as a team” is important in health care, especially in highly dynamic clinical environments.(1) How can this best be accomplished? In a comprehensive approach to teamwork...
with commentary by Stephen D. Pratt, MD and Benjamin P. Sachs, MB, Point–Counterpoint: Simulation vs. Team Training, March 2006
In recent years, the medical community has reached a near-consensus that team training and Crew Resource Management (CRM) techniques can improve patient safety. However, the most effective way to teach and implement these concepts is much less clear...
with commentary by Albert W. Wu, MD, MPH, Disclosing Mistakes, February 2006
You pull into a parking space, swing open the car door, and are dismayed to hear it hit the car next to you. What is the first thing that you do? Here are two possible answers—look around to see if anyone else saw what happened, then rub the scrape with...
Disclosing Mistakes, February 2006
John Banja, PhD, is Assistant Director for Health Sciences and Clinical Ethics and Associate Professor of Clinical Ethics at Emory University School of Medicine. Dr. Banja, whose doctorate is in philosophy, is currently participating in AHRQ-funded studies designed to help clinicians communicate more effectively in emotionally charged situations after errors or unforeseen outcomes. His book, Medical Errors and Medical Narcissism, covers issues around the appropriate, ethical disclosure of medical errors by health care professionals.
with commentary by Eric J. Thomas, MD, MPH, Aviation and Patient Safety, January 2006
On August 2, 2005, Air France flight 358 crashed while landing in Toronto. In less than 2 minutes, the crew evacuated 309 passengers. Several minutes later, the plane burst into flames.(1) Crashes like this are remarkably rare, yet the crew was prepared to...
Aviation and Patient Safety, January 2006
Jack Barker, PhD, is Vice President of Research and Development for Mach One Leadership and a commercial pilot for a major airline. Dr. Barker began his career in the Air Force and proceeded to get his doctorate in cognitive psychology. His research has centered on high-performance teams, crew resource management (CRM), and training. He has trained hundreds of commercial airline pilots, as well as pilots and others working for NASA in the Space Shuttle program and Mars mission. His company, like several others, works with health care providers and organizations in an effort to translate aviation safety principles to health care.
The Law and Patient Safety, December 2005
Dr. Brennan is a Professor of Medicine at Harvard Medical School and Professor of Law and Public Health at the Harvard School of Public Health. As the lead investigator of the groundbreaking study that assessed the prevalence of adverse events in hospitalized patients, Dr. Brennan has contributed dramatically to our understanding of the epidemiology of medical errors. More recently, he has emerged as one of the world's most thoughtful and influential analysts of the complex interplay among medicine, ethics, law, and public health.
with commentary by Paul Barach, MD, MPH , The Law and Patient Safety, December 2005
Quality health care and patient safety have emerged as major concerns in society. The Institute of Medicine’s report entitled To Err is Human: Building a Safer Health System led to considerable discussion in both the public and private sectors on the need...
100,000 Lives Campaign: Concept and Implementation, November 2005
Dr. Berwick is President and Chief Executive Officer of the Institute for Healthcare Improvement (IHI). A pediatrician and professor at both Harvard Medical School and the Harvard School of Public Health, he is generally acknowledged as one of the foremost experts and leaders in health care quality and patient safety. He has published more than 100 articles and several books, has been the recipient of several major honors and awards, and was recently named an honorary Knight Commander of the British Empire by Queen Elizabeth II. In December 2004, he announced an IHI-led "Campaign to Save 100,000 Lives"promoting the implementation of evidence-based interventions to improve patient safety and decrease mortality in six clinical areas. In less than a year, the campaign has already signed up nearly half the hospitals in the United States.
with commentary by William S. Krimsky, MD, 100,000 Lives Campaign: Concept and Implementation, November 2005
Health care organizations throughout the world have identified Rapid Response Teams (RRTs) as a powerful intervention aimed at saving lives by identifying and intervening in patient care at the first sign of clinical deterioration or concern expressed by...
Patient Safety Initiatives, September 2005
Dr. Carolyn Clancy has been the Director of the Agency for Healthcare Research and Quality (AHRQ) since 2003. Prior to becoming AHRQ Director, she led the Agency's Center for Outcomes and Effectiveness Research. A general internist and health services researcher, she has published widely in the peer reviewed literature on a variety of topics, ranging from quality improvement to primary care. She is a member of the Institute of Medicine and a Master of the American College of Physicians.
with commentary by Robert M. Wachter, MD, Patient Safety Initiatives, September 2005
Translational research is all the rage in biomedicine. In its purest form, the concept refers to the translation of basic research discoveries into clinical applications, followed by patient-oriented studies to demonstrate benefit.(1) Increasingly, it also...
Patient Safety Initiatives, September 2005
In Drs. Flanders and Saint’s otherwise superb summary and review of the use of root cause analysis to identify systems’ vulnerabilities and improve overall patient care delivery, I was surprised by their statement that RCAs are “performed by a team with...
with commentary by Linda H. Aiken, PhD, RN , Nursing and Patient Safety , July-August 2005
The goal set by the Institute of Medicine (IOM) in 1999 to reduce medical errors by half within 5 years has not been achieved. Opinion polls of consumers and health professionals show that concerns about patient safety remain high. Yet only 16% of hospital...
Nursing and Patient Safety , July-August 2005
Barbara A. Blakeney, MS, RN, is President of the 150,000-member American Nurses Association (ANA). A nurse practitioner and expert in public health practice, policy, and primary care, Ms. Blakeney is on leave from the Boston Public Health Commission, where she has been director of health care services for the homeless. She is the recipient of numerous awards and has been named to Modern Healthcare Magazine's list of the 100 most influential people in health care for the past 3 years.
with commentary by Kaveh G. Shojania, MD, Research in Patient Safety , June 2005
Five years ago, a widely publicized randomized trial reported a 90% reduction in the incidence of contrast dye-induced renal failure when patients were pretreated with acetylcysteine, an agent previously used to treat acetaminophen overdoses and bronchitis...
Research in Patient Safety , June 2005
Peter J. Pronovost, MD, PhD, is Medical Director of the Johns Hopkins Center for Innovation in Quality Patient Care. A practicing anesthesiologist and critical care physician, he has appointments in both The Johns Hopkins University School of Medicine and its Bloomberg School of Public Health. Dr. Pronovost's research, which has focused on how to improve patient safety and quality in the ICU setting, has been characterized by a blend of methodologic sophistication and practical attention to the details of making change happen and making it stick. His many contributions include studies of the value of intensivists, of the use of daily goal cards on safety and communication, of an executive adopt-a-unit strategy, and of a comprehensive unit-based safety program. For this work, much of which has been supported by AHRQ, he was awarded the John M. Eisenberg Award in Research Achievement in 2004.
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...