Our Perspectives on Safety section features expert viewpoints on current themes in patient safety, including interviews and written essays published monthly. Annual Perspectives highlight vital and emerging patient safety topics.
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... Read More
Drs. Susan McGrath and George Blike discuss surveillance monitoring and its challenges and opportunities.
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... Read More
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... Read More
This piece focuses on perinatal mental health and efforts to improve maternal safety.
Christie Allen is the Senior Director of Quality Improvement at the American College of Obstetrics and Gynecology (ACOG). We spoke to her about her experience in maternal safety and improving perinatal mental... Read More
All Perspectives (184)
- Quality Improvement Strategies(61)
- Error Reporting and Analysis(54)
- Education and Training(47)
- Culture of Safety(43)
- Technologic Approaches(42)
- Communication Improvement(41)
- Legal and Policy Approaches(35)
- Human Factors Engineering(21)
- Logistical Approaches(16)
- Computerized Decision Support(8)
- Policies and Operations(6)
- Research Directions(6)
- Care Coordination(5)
- Computerized Provider Order Entry (CPOE)(5)
- Specialization of Care(5)
- Transparency and Accountability(5)
- Behavioral change(1)
- Medication Safety(34)
- Diagnostic Errors(24)
- Discontinuities, Gaps, and Hand-Off Problems(21)
- Medical Complications(20)
- Psychological and Social Complications(20)
- Surgical Complications(11)
- Device-Related Complications(7)
- Alert fatigue(6)
- Fatigue and Sleep Deprivation(6)
- Nonsurgical Procedural Complications(5)
- Transitions of Care(5)
- Failure to rescue(3)
- Identification Errors(3)
- Drug shortages(1)
- Interruptions and distractions(1)
- Second victims(1)
- Transfusion Complications(1)
- Health Care Executives and Administrators(124)
- Health Care Providers(103)
- Non-Health Care Professionals(85)
- General Public(6)
- Family Members and Caregivers(5)
- Public Health Professionals(2)
- Health Professional Students(1)
- Hospital Pharmacists(1)
This piece discusses an expanded view of maternal and infant safety that includes the concept of whole-person care, which addresses the structural and social determinants of maternal health.
Alison Stuebe, MD, MSc, is a professor and Division Director for Maternal-Fetal Medicine in the Department of Obstetrics and Gynecology at the University of North Carolina (UNC) at Chapel Hill and the co-director of the Collaborative for Maternal and Infant Health. Kristin Tully, PhD, is a research assistant professor in the Department of Obstetrics and Gynecology at UNC Chapel Hill and a member of the Collaborative for Maternal and Infant Health. We spoke with them about their work in maternal and infant care and what they are discovering about equitable care and its impact on patient safety.
This piece discusses EMS patient safety concerns in the field and discusses operational concerns, clinical concerns, and safety of personnel.
James Augustine, MD, is the National Director of Prehospital Strategy at US Acute Care Solutions where he provides service as a Fire EMS Medical Director. We spoke with him about threats and concerns for patient safety for EMS when responding to a 911 call.
This piece discusses areas where the healthcare built environment may contribute to the risk of COVID-19 transmission, mitigating strategies, and how the pandemic may impact the built environment moving forward.
Anjali Joseph, PhD, EDAC, is a Spartanburg Regional Healthcare System Endowed Chair in Architecture and Health Design. Molly M. Scanlon, PhD, FAIA, FACHA, is the Director at Phigenics, LLC. We spoke with them about how healthcare built environments have been temporarily modified during the COVID-19 pandemic and what learnings may be used moving forward.
This piece discusses Just Culture in EMS, where variation exists across systems, and challenges and opportunities to enhancing safety event reporting.
Chris Cebollero, BS, CCEMT-P, is the President and CEO of Cebollero & Associates Consulting Group. He has served as a paramedic for over 20 years, and in his last operational role he was the Chief of EMS at Christian Hospital in North St. Louis. We spoke with him about the status of safety culture in EMS and challenge associated with safety event reporting.
This piece discusses how the program mitigates safety risks for in-home dialysis and the potential for in-home programs to greatly expand.
José A, Morfín, MD, FASN, is a health sciences clinical professor at the University of California Davis School of Medicine. In his professional role, he serves as the Medical Director for Satellite Health Care and as a member of the Medical Advisory Board for Nx Stage Medical. We discussed with him home dialysis and patient safety considerations.
In this PSNet Annual Perspective, we worked with co-authors Dr. Jacqueline C. Stocking, a quality improvement and critical care specialist, and Dr. Christian Sandrock, a patient safety professional and emerging infectious diseases specialist, to provide a look at news and research related to the impact of the COVID-19 pandemic on patient safety.
This piece discusses current practices and future directions in the measurement of patient and family engagement.
Libby Hoy, Patient Family Advisor (PFA), is the Founder and CEO of Patient Family Centered Care Partners (PFCCpartners). Stephen Hoy is the COO of PFCCpartners. We spoke to them about the current state of measurement of patient and family engagement and potential future directions.
In this PSNet Annual Perspective, we review key findings related to improvement strategies when communicating with patients and different structured communication techniques to improve communication across providers. Lessons learned from innovative approaches explored under COVID-19 that could be considered as usual care resumes are also discussed.
This piece discusses prevalent adverse events in dental care and the challenges in identifying these patient safety events.
Elsabeth Kalenderian, DDS, MPH, PhD is a professor at UCSF. Muhammad F. Walji, PhD is the Associate Dean for Technology Services and Informatics and professor for Diagnostic and Biomedical Sciences at the UT Health Science Center at Houston, School of Dentistry. We spoke to them about the identification and prevention of adverse events in dentistry.
This piece discusses overprescribing of antibiotics and opioids in dental care and challenges in implementing stewardship programs.
Katie J. Suda, PharmD, MS is a professor at the University of Pittsburgh School of Medicine in the Division of General Internal Medicine. She is a pharmacist by training with a specialty in infectious diseases and a research concentration in the area of dental antibiotic and opioid stewardship. We discussed antibiotic and opioid prescribing in dental care and challenges for implementing stewardship programs.
This piece discusses the challenges faced by long-term care facilities in responding to the COVID-19 pandemic, with a particular focus on visitor restrictions, staffing turnover, and infection prevention and control.
Charles A Crecelius, MD, PhD CMD, is the Medical Director for post-acute care at BJC Medical Group and the Project Medical Director for the Missouri Quality Initiative (MOQI). Lori L Popejoy, PhD, RN, FAAN is an Associate Dean for Innovation and Partnerships and an Associate Professor at the University of Missouri Sinclair School of Nursing. We discussed with them the response to the COVID-19 pandemic in long-term care facilities.
This piece discusses the concept of Safety Across the Board and reviews the three key components necessary for successful implementation in a healthcare organization: culture, strong safety processes, and engagement.
Edwin Loftin, DNP, MBA, RN, NEA-BC-FACHE is the Senior Vice President of Integrated and Acute Care Services and the Chief Nursing Officer (CNO) at Parrish Medical Center in Titusville, Florida. We spoke with him about his experiences with the concept of safety across the board at his medical center.
This Perspective differs from the typical Perspective in that it compiles findings and insights into a series of case studies from interviews and written responses from leaders at three different health systems who had to increase their telehealth capacities in response to the COVID-19 pandemic.