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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
Jawad Al-Khafaji, MD, MHSA, Merton Lee, PhD, PharmD, Sarah Mossburg, RN, PhD
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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.
Susan McGrath, PhD,George Blike, MD, MHCDS,Bryan M. Gale, MA,Sarah E. Mossburg, RN, PhD
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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
Bryan Gale, Sarah Mossburg, A Jay Holmgren, and Susan McBride
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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
Christie Allen, MSN, RNC-NIC, CPHQ, C-ONQS, Cindy Manaoat Van, MHSA, Sarah E. Mossburg, RN, PhD
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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
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Displaying 61 - 80 of 184 Results
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Rachel J. Stern, MD, and Urmimala Sarkar, MD |
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Patient engagement is widely acknowledged as a cornerstone of patient safety. Research in 2018 demonstrates that patient engagement, when done correctly, can help health care systems identify safety hazards, regain trust after they occur, and codesign sustainable solutions.
Shannon M. Dean, MD |
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This piece explores concerns regarding the use of copy and paste in electronic health records and offers potential strategies to improve clinical documentation accuracy.
Dr. Hirschtick is Associate Professor of Medicine at Northwestern Medicine, and the author of a number of prominent articles—many quite amusing—about the changes in medical practice wrought by information technology. We spoke with him about what it means to be a clinician in the modern era, particularly how digitization of health records has affected clinicians' notes.
Robert M. Wachter, MD |
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This piece explores progress of patient safety in the surgical field and where further improvement can be made, such as ongoing assessment of procedural skills along with video recording and review of surgical procedures.
Dr. Bilimoria is the Director of the Surgical Outcomes and Quality Improvement Center of Northwestern University, which focuses on national, regional, and local quality improvement research and practical initiatives. He is also the Director of the Illinois Surgical Quality Improvement Collaborative and a Faculty Scholar at the American College of Surgeons. In the second part of a two-part interview (the earlier one concerned residency duty hours), we spoke with him about quality and safety in surgery.
Ronen Rozenblum, MD, MPH, and David Bates, MD, MS |
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This piece explores how patient-facing technologies can enable patients to be more responsible for their care and improve the way clinicians practice.
Wanda Pratt is a professor in the Information School and an adjunct in Biomedical and Health Informatics in the School of Medicine at the University of Washington. We spoke with her about patient-facing technologies, including the opportunities and challenges for patient safety.
Julia E. Szymczak, PhD |
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This piece explores the risks of presenteeism among health care workers and factors, such as cultural expectations, that contribute to its occurrence.
Dean F. Sittig, PhD, and Hardeep Singh, MD, MPH |
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This piece highlights four key lessons that the authors believe are useful for clinicians and health care organizations that seek to identify, prevent, and mitigate electronic health record–related safety issues.
Dr. Gettinger is the Chief Medical Information Officer and the Executive Director of the Office of Clinical Quality and Safety for the Office of the National Coordinator (ONC). He led the development of an electronic health record (EHR) system at Dartmouth and was the senior physician leader during their transition to a vendor-based EHR. We spoke with him about safety and health information technology.
Kathy Malloy; Timothy P. Brigham, PhD; Thomas J. Nasca, MD |
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This piece reviews how changes to the ACGME requirements emphasize patient safety and quality improvement, address physician well-being, strengthen expectations around team-based care, and create flexibility for work hours within the maximum 80-hour workweek.
David Studdert, LLB, ScD |
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This piece explores the risk of recurring medicolegal events among providers who have received unsolicited patient complaints, faced disciplinary actions by medical boards, or accumulated malpractice claims.
Michelle Mello is Professor of Law at Stanford Law School and Professor of Health Research and Policy at Stanford University School of Medicine. She conducts empirical research into issues at the intersection of law, ethics, and health policy. We spoke with her about legal issues in patient safety.
Vanessa K. Martin, DO, MS; Nasim Mirnateghi, PhD; and Mahdi Khoshchehreh, MD, MS |
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This piece explores the weekend effect in cardiology and recommends allowing invasive management for patients with non ST-elevation myocardial infarction to improve outcomes in this group.
Professor Aylin is Professor of Epidemiology and Public Health at Imperial College London. We spoke with him about the weekend effect in health care—the observation that patients admitted to the hospital over the weekend often have worse outcomes than those admitted during the week.
Irene Berita Murimi, PhD, MA, and G. Caleb Alexander, MD, MS |
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This piece explores the opioid epidemic in the United States, including factors that led to increased opioid prescribing, its adverse effects, and tactics to reduce opioid-related harm.
Dr. Juurlink is professor of medicine, pediatrics, and health policy at the University of Toronto, where he is also director of the Division of Clinical Pharmacology and Toxicology. We spoke with him about the opioid epidemic and strategies to address this growing patient safety concern.
Sara J. Singer, MBA, PhD |
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This piece discusses the importance of strengthening safety culture in health care and offers insights for organizations seeking to achieve culture change.
Dr. Dixon-Woods is RAND Professor of Health Services Research at Cambridge University, Deputy Editor-in-Chief of BMJ Quality and Safety, and one of the world's leading experts on the sociology of health care. We spoke with her about new ways to approach safety culture.
David P. Baker, PhD; James B. Battles, PhD; Heidi B. King, MS |
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This piece outlines 10 insights about team training in health care learned from experience with the AHRQ-supported teamwork training program, TeamSTEPPS.
Dr. Edmondson is the Novartis Professor of Leadership and Management at Harvard Business School. She is an expert on leadership, teams, and organizational learning. We spoke with her about the role of teamwork in health care and why it is becoming increasingly important.
Rachel J. Stern, MD, and Urmimala Sarkar, MD |
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Patient engagement in safety has evolved from obscurity to maturity over the past two decades. This Annual Perspective highlights emerging approaches to engaging patients and caregivers in safety efforts, including novel technological innovations, and summarizes the existing evidence on the efficacy of such approaches.
Sumant Ranji, MD |
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A considerable body of evidence demonstrates worsened clinical outcomes for patients admitted to the hospital on weekends compared to those admitted on weekdays. This Annual Perspective summarizes innovative studies published in 2017 that helped clarify the magnitude of this effect and identify possible mechanisms by which it occurs.
Ross W. Simon and Elena G. Canacari, RN |
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This piece explores how a team at Beth Israel Deaconess Medical Center combined tools and techniques used in manufacturing along with continuous improvement to develop a process to identify, prioritize, and mitigate hazards in health care settings.
Mr. O'Neill served as the United States Secretary of the Treasury under President George W. Bush and, prior to that, chairman and CEO of Alcoa. We spoke with him about workplace safety and its relationship to patient safety and organizational excellence.
Carl Macrae, PhD |
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This piece explores how strategies from aviation, such as just culture and monitoring technologies, can be applied in health care to improve patient safety.
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.
Alvin Rajkomar, MD |
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This piece explores the role for a clinician data scientist in utilizing clinical datasets to improve health care quality and safety.
Dr. Platt is Professor and Chair of the Harvard Medical School Department of Population Medicine. We spoke with him about big data and patient safety.
Stephen Agboola, MD, MPH, and Joseph Kvedar, MD |
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This piece explores benefits and safety concerns associated with the increased adoption of telemedicine services.
Dr. Tuckson is President of the American Telemedicine Association. We spoke with him about telemedicine and patient safety.
Rachel Badovinac Ramoni, DMD, ScD; Muhammad Walji, PhD; and Elsbeth Kalenderian, DDS, MPH, PhD |
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This piece examines patient safety issues unique to dental care along with strategies to reduce risks.
Dr. Perea-Pérez is Director of the Spanish Observatory for Dental Patient Safety. We spoke with him about patient safety in dentistry.
Zahra Khudeira, PharmD |
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In this piece, a pharmacist highlights the importance of earning patient safety certification.
Dr. Meyer is Chief Clinical Officer of Partners Healthcare System, the large Boston-based system that includes Massachusetts General and Brigham and Women's Hospitals. We spoke with him about training and certification in patient safety.
