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Perspectives

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.

Latest Perspectives

Improving Diagnostic Safety and Quality
Jawad Al-Khafaji, MD, MHSA, Merton Lee, PhD, PharmD, Sarah Mossburg, RN, PhD |

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

Technology as a Tool for Improving Patient Safety
Bryan Gale, Sarah Mossburg, A Jay Holmgren, and Susan McBride |

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

Maternal Safety and Perinatal Mental Health
Christie Allen, MSN, RNC-NIC, CPHQ, C-ONQS, Cindy Manaoat Van, MHSA, Sarah E. Mossburg, RN, PhD |

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

All Perspectives (184)
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Displaying 41 - 60 of 184 Results
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    • Artificial Intelligence and Diagnostic Errors
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    • This piece discusses the current use of artificial intelligence in diagnostic imaging and key patient safety considerations.

    David Gruen
    In Conversation With... David Gruen, MD

    David R. Gruen, MD, MBA, FACR is the Chief Medical Officer, Imaging at IBM Watson Health and is a thought leader and content expert for artificial intelligence in medical imaging. We spoke with him about the role artificial intelligence can play in healthcare diagnostics and the potential for reducing diagnostic errors.

    Cultural Competence and Patient Safety
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    • This piece describes cultural competence in the context of patient safety and highlights several approaches and projects that may help to improve cultural competence.
    Cindy Brach
    In Conversation With... Cindy Brach

    Cindy Brach, MPP is a Senior Healthcare Researcher at the Agency for Healthcare Research and Quality and is the Co-Chair of the HHS Health Literacy Workgroup. We spoke with her about the role of cultural competence in patient safety.

     

    Patient Safety in Frail Older Patients
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    • This piece describes patient safety risks when caring for frail older patients and summarizes potential approaches for clinicians to minimize this risk.
    Heidi Wald
    In Conversation With... Heidi Wald, MD
    Dr. Wald, MD, MSPH, is the Chief Quality and Safety Officer at SCL Health in Denver, CO. She has previously served as a physician advisor for the Colorado Hospital Association and as a Quality Committee Chair for the American Geriatrics Society. We spoke with her about patient safety concerns when caring for frail older patients.
    First, Do No Harm: Value-driven Patient Safety in the Neonatal Intensive Care Unit
    Jochen Profit, MD, MPH; Annette Scheid, MD; and Erick Ridout, MD |
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    • This piece describes a collaborative, interdisciplinary team approach with a flat hierarchy used at Intermountain Healthcare's Dixie Regional Medical Center that led to substantial reduction of key neonatal morbidities and costs of care.
    Neal_Shah
    In Conversation With… Neel Shah, MD, MPP
    Dr. Shah is an Assistant Professor of Obstetrics, Gynecology and Reproductive Biology at Harvard Medical School and Director of the Delivery Decisions Initiative at Harvard's Ariadne Labs. He is also the founder of the organization Costs of Care. We spoke with him about patient safety in obstetrics, maternal mortality, the importance of dignity, and the overuse of cesarean deliveries.
    Medical Scribes and Patient Safety
    Deborah Woodcock, MS, MBA; Robby Bergstrom |
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    • This piece explores the role medical scribes play in health care, how to implement and evaluate a scribe program, and recommendations to reduce variations in scribe practice.
    In Conversation With… Susan Smith, MD
    Dr. Smith is Chief Faculty Practices Officer for UCSF Health and a family medicine physician. Over the past 3–4 years, the health system has implemented a robust program using medical scribes in the outpatient setting. We spoke with her about her experience implementing this program, including the benefits and some of the potential patient safety ramifications.
    Safety in the Prehospital Emergency Medical Services Setting
    P. Daniel Patterson, PhD, NRP, and Donald M. Yealy, MD |
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    • This piece explores the key role of emergency medical services in providing care to patients at their moment of greatest need, safety hazards in this field, and opportunities for improvement.
    In Conversation With… Jane Brice, MD, MPH
    Dr. Brice is Professor and Chair of the Department of Emergency Medicine at the University of North Carolina. She also serves as the Program Director for the Emergency Medical Services (EMS) Fellowship and was past-president of the National Association of EMS Physicians. We spoke with her about her experience working in emergency medical systems and safety concerns particular to this field.
    Building a Safety Program in a Vast Health Care Network
    Paul E. Phrampus, MD |
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    • This piece outlines how large integrated health care systems can implement effective patient safety programs and spotlights the importance of leadership engagement and a just culture.
    In Conversation With… Susan Haas, MD, MSc
    Dr. Haas is an obstetrician–gynecologist and co-Principal Investigator for Ariadne Labs' work focused on health care system expansion. We spoke with her about the trend of health systems getting larger and more integrated, the risks to patient safety, and ways to mitigate these risks.
    Building Systems Citizenship in Health Professions Education: The Continued Call for Health Systems Science Curricula
    Jed D. Gonzalo, MD, MSc, and Mamta K. Singh, MD, MSc |
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    • This piece spotlights the need for educational and cultural transformation to achieve sustainable progress in patient outcomes and health.
    In Conversation With… Susan E. Skochelak, MD, PhD
    Dr. Skochelak is the Group Vice President for Medical Education at the American Medical Association (AMA). She leads the AMA's Accelerating Change in Medical Education initiative, which aims to align physician training with the changing needs of our health care system. We spoke with her about her experience in medical education.
    Maternal Safety
    Audrey Lyndon, RN, PhD |
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    • This perspective examines the troubling decline in maternal health outcomes in the United States and summarizes recent national initiatives to improve safety in maternity care.
    The Comprehensivist Model of Care: A Hospitalist's View
    Robert Wachter, MD |
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    • This piece, written by the physician who coined the term "hospitalist," provides an overview of the hospitalist model and reflects on key advantages of and challenges faced by the Comprehensive Care Physician Model.
    In Conversation With… David Meltzer, MD, PhD
    Dr. Meltzer is the Fanny L. Pritzker Professor of Medicine, Chief of the Section of Hospital Medicine, and Director of the Center for Health and the Social Sciences at the University of Chicago. His research aims to improve the quality and lower the cost of hospital care. We spoke with him about the Comprehensive Care Physician Model, which he pioneered and was recently featured in an article in The New York Times Magazine.
    Safety in the Retail Pharmacy
    Michelle A. Chui, PharmD, PhD |
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    • This piece reviews unique characteristics of community pharmacies that can affect medication safety and spotlights the need for further research examining medication errors in community settings.
    How Does Health Care Simulation Affect Patient Care?
    Joseph O. Lopreiato, MD, MPH |
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    • This piece explores health care simulation including the four main methods used and the evidence base for its impact on learning and patient care.
    In Conversation With… Matthew Weinger, MD
    Dr. Weinger is Director of the Center for Research and Innovation in Systems Safety and Professor of Anesthesiology, Biomedical Informatics, and Medical Education at Vanderbilt University. He holds the Norman Ty Smith Chair in Patient Safety and Medical Simulation. We spoke with him about the current state of simulation training in health care, barriers to progress, and potential innovations.
    Safety Considerations in Building a Point-of-Care Ultrasound Program
    Chris Moore, MD |
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    • This piece highlights how point-of-care ultrasound can improve and expedite diagnosis and advocates for having an individual responsible for overseeing point-of-care ultrasound use within a health care delivery organization.
    In Conversation With… Richard Hoppmann, MD
    Dr. Hoppmann is the Dorothea H. Krebs Endowed Chair of Ultrasound Education, Professor of Medicine, and Director of the Ultrasound Institute of the University of South Carolina School of Medicine. He founded and served as the first President of the Society of Ultrasound in Medical Education. We talked to him about safety and usability of point-of-care ultrasound.
    Patient Safety During Hospital Discharge
    Katherine Liang and Eric Alper, MD |
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    • This piece explores the risks patients face after hospital discharge and strategies to address them, such as patient education, Project RED, and the Care Transitions Intervention.
    In Conversation With… Harlan Krumholz, MD, SM
    Dr. Krumholz is Professor of Medicine at the University of Yale School of Medicine and Director of the Yale-New Haven Hospital Center for Outcomes Research and Evaluation. We spoke with him about readmissions and post-hospital syndrome, a term he coined in an article in the New England Journal of Medicine to describe the risk of adverse health events in recently hospitalized patients.
    Missed Nursing Care: A Key Measure for Patient Safety
    Jane Ball, PhD, and Peter Griffiths, PhD |
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    • This piece explores how missed nursing care may explain the association between low nurse staffing levels and increased mortality in hospital patients.
    In Conversation With… Linda Aiken, PhD, RN
    Dr. Aiken is Claire M. Fagin Leadership Professor of Nursing, Professor of Sociology, and Director of the Center for Health Outcomes and Policy Research at University of Pennsylvania. She is generally considered the nation's foremost expert on health policy as it relates to the nursing workforce. We spoke with her about how nurse staffing and the work environment can affect patient safety and outcomes.
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