Perspectives

This piece focuses on workplace violence trends in healthcare settings and strategies for creating a safer healthcare environment.

This piece focuses on the importance of patient safety following the end of the public health emergency and how organizations can move beyond the pandemic.

This piece discusses virtual nursing, an approach to care that incorporates an advanced practice nurse into hospital-based patient care through telehealth. Virtual nursing increases patient safety and may enable expert nurses to continue to meet patient needs in future staffing shortages.

This piece focuses on the importance of building the capacity of the workforce and organizations for patient safety using patient safety education.

This piece discusses how family presence and participation in healthcare at all levels can improve patient safety as well as how the COVID-19 pandemic affected partnership with patients and families, ultimately highlighting the critical importance of family presence and participation.

Throughout 2022, AHRQ PSNet has shared research that elucidates the complex nature of misdiagnosis and diagnostic safety. This Year in Review explores recent work in diagnostic safety and ways that greater safety may be promoted using tools developed to improve diagnostic practices.

This piece discusses surveillance monitoring of patients in low-acuity units of the hospital to prevent failure to rescue events, its difference from high-acuity continuous monitoring, and its potential applications in other settings.

In the past several decades, technological advances have opened new possibilities for improving patient safety. Using technology to digitize healthcare processes has the potential to increase standardization and efficiency of clinical workflows and to reduce errors and cost across all healthcare settings.¹ However, if technological approaches are designed or implemented poorly, the burden on clinicians can increase. For example, overburdened clinicians can experience alert fatigue and fail to respond to notifications. This can lead to more medical errors. As a testament to the significance of this topic in recent years, several government agencies [(e.g. the Agency for Healthcare Research and Quality (AHRQ) and the Centers for Medicare and Medicaid services (CMS)] have developed resources to help healthcare organizations integrate technology, such as the Safety Assurance Factors for EHR Resilience (SAFER) guides developed by the Office of the National Coordinator for Health Information Technology (ONC).^2,3,4 However, there is some evidence that these resources have not been widely used.5 Recently, the Centers for Medicare & Medicaid Services (CMS) started requiring hospitals to use the SAFER guides as part of the FY 2022 Hospital Inpatient Prospective Payment Systems (IPPS), which should raise awareness and uptake of the guides.⁶

This piece focuses on perinatal mental health and efforts to improve maternal safety.   

Throughout 2022, the impact of system failures on healthcare workers was a recurrent theme of articles on AHRQ PSNet. This Year in Review explores these impacts and ways to support healthcare workers involved in a system failure.  

This piece discusses the evolution of remote patient monitoring, emergence into use with acute conditions, patient safety considerations, and the continued challenges of telehealth implementation.

This piece discusses patient safety concerns among members of the LGBTQ+ community which may inhibit access to needed healthcare and potential ways to provide patient-centered care and mitigate the risk of adverse events.

This piece discusses resilient healthcare and the Safety-I and Safety-II approaches to patient safety.

This collaborative piece with the Centers for Medicare & Medicaid Services discusses the current state of patient safety measurement, advancements in measuring patient safety, and explores future directions.

Human factors engineering or ergonomics (HFE) is a scientific discipline broadly focused on interactions among humans and other elements of a system. The International Ergonomics Association defines HFE as “the scientific discipline concerned with the understanding of interactions among humans and other elements of a system, and the profession that applies theory, principles, data, and methods to design in order to optimize human well-being and overall system performance.” ¹ The goal in HFE is to improve interactions between people and other elements of the work system, such as technologies, tasks, and the physical environment. This work is done by conducting a thorough analysis of the entire system in which these interactions occur; then based on this understanding, the systems can be designed to support performance and enhance safety and well-being. HFE interventions commonly focus on people, tools, technology, procedures, and processes. As a field of study, HFE originated in the 1940s in the field of aviation. Since then, it has been used to improve systems in electric power plants, manufacturing plants, and healthcare, among other fields.² In healthcare, HFE focuses on designing systems around the end-user to improve performance, safety, and efficiency, using psychology, sociology, and other behavioral sciences to improve the experience for all who interact with other elements of the system. The data required to create improvements is collected through multiple methods, including observation, interview, focus group, survey, and review of archival data. These data provide a thorough understanding of the work system—that is, people, tasks, tools and technologies, the physical environment, and organizational conditions—of the setting in question. With an understanding of how interactions among all work system elements (including people) can go right or wrong, HFE uses human-centered design processes and methods to address problems and improve the overall work system design.

Special thanks to Freya Spielberg, MD, MPH, Founder and CEO of Urgent Wellness LLC in Washington, DC; and Jack Westfall, MD, MPH, Director of the Robert Graham Center for Policy Studies in Family Medicine and Primary Care, for their thoughtful interviews on the topic of Primary Care and Patient Safety, which helped lay the groundwork for this Perspective.

This piece focuses on the emergence and use of digital applications (apps), app-based products and devices for healthcare, and the implications for patient safety.

The focus on patient safety in the ambulatory setting was impacted by the COVID-19 pandemic and appropriately shifting priorities to responding to the pandemic. This piece explores some of the core themes of patient safety in the ambulatory setting, including diagnostic safety and diagnostic errors. Ways to enhance patient safety in the ambulatory care setting and next steps in ambulatory care safety are addressed. 

This piece focuses on measuring and monitoring patient safety in the prehospital setting.