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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
All Perspectives (184)
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Displaying 81 - 100 of 184 Results
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Karen Frank, DNP, RN, MSHA |
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This piece offers a nurse's viewpoint on the benefits of acquiring certification in patient safety.
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.
Samantha Jacques, PhD, and Eric Williams, MD, MS, MMM |
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This piece describes strategies to reduce alarm fatigue in hospitals, including educating staff and patients, customizing alarm settings, and performing maintenance of lead wires.
Dr. Drew is the David Mortara Distinguished Professor of Physiological Nursing and Clinical Professor of Medicine in Cardiology at the University of California, San Francisco. We spoke with her about the perils and prevalence of alert fatigue.
Sumant Ranji, MD |
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The toll of medical errors is often expressed in terms of mortality attributable to patient safety problems. In 2016, there was considerable debate regarding the number of patients who die due to medical errors. This Annual Perspective explores the methodological approaches to estimating mortality attributable to preventable adverse events and discusses the benefits and limitations of existing approaches.
Mark Friedberg, MD, MPP |
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This piece highlights the importance of focusing on physician professional satisfaction as a way to determine potential patient safety hazards and improve health care quality.
Kiran Gupta, MD, MPH, and Audrey Lyndon, PhD |
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Root cause analysis is widely accepted as a key component of patient safety programs. In 2016, the literature outlined ongoing problems with the root cause analysis process and shed light on opportunities to improve its application in health care. This Annual Perspective reviews concerns about the root cause analysis process and highlights recommendations for improvement put forth by the National Patient Safety Foundation.
Urmimala Sarkar, MD, and Kaveh Shojania, MD |
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Opioids are known to be high risk medications, and concerns about patient harm from prescription opioid misuse have been increasing in the United States. This Annual Perspective summarizes research published in 2016 that explored the extent of harm from their use, described problematic prescribing practices that likely contribute to adverse events, and demonstrated some promising practices to foster safer opioid use.
Hardeep Singh, MD, MPH |
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This piece discusses momentum in the field of diagnostic error over the past several years (culminating in the recent Improving Diagnosis in Health Care report) and outlines future avenues to ensure progress in diagnostic safety.
Dr. Graber founded the Society to Improve Diagnosis in Medicine and the journal, Diagnosis. We spoke with him about the recent National Academy of Medicine (formerly Institute of Medicine) Improving Diagnosis in Health Care report, and about diagnostic errors more generally.
Robert M. Wachter, MD |
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This editorial provides an overview of how PSNet and WebM&M have evolved in the past decade.
A. Zach Hettinger, MD, MS; Raj Ratwani, PhD; Rollin J. (Terry) Fairbanks, MD, MS |
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This piece provides an overview of health IT usability design, including persisting challenges and progress in the field.
Dr. Wachter is Professor and the Interim Chairman of the Department of Medicine at UCSF. We talked with him about his new book, The Digital Doctor: Hope, Hype, and Harm at the Dawn of Medicine's Computer Age.
Yan Xiao, PhD; Colin F. Mackenzie, MB, ChB; and F. Jacob Seagull, PhD |
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This piece explores the advantages of using video in clinical practice and health care education to augment safety and quality.
Ian Scott, MBBS, MHA, MEd |
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This piece discusses risk-adjusted hospital mortality rates as a measure of hospital safety, including why they've become popular, major flaws such as low sensitivity, and alternative ways to use them.
Sir Brian Jarman designed the methodology for hospital standardized mortality ratios, a widely used method of measuring quality and safety, and was involved with the Bristol Royal Infirmary Inquiry. We spoke with him about the development of the HSMR and their role in monitoring performance.
Urmimala Sarkar, MD, and Kaveh Shojania, MD |
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Computerized provider order entry is a cornerstone of patient safety efforts, and the increasingly widespread implementation of electronic health records has made it a standard practice in health care. This Annual Perspective summarizes novel findings and research directions in computerized provider order entry in 2015.
Audrey Lyndon, PhD |
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Clinician burnout is prevalent across health care settings and may impair clinicians' ability to maintain safe practices and detect emerging safety threats. This Annual Perspective summarizes studies published in 2015, with a particular focus on the relationship between burnout and patient safety, and interventions to address burnout among clinicians.
Christopher Moriates, MD, and Robert M. Wachter, MD |
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While the patient safety world has largely embraced the concept of a just culture for many years, in 2015 the discussion moved toward tackling some of the specifics and many gray areas that must be addressed to realize this ideal. This Annual Perspective reviews the context of the "no blame" movement and the recent shift toward a framework of a just culture, which incorporates appropriate accountability in health care.
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This book excerpt describes how integrating innovation and Lean concepts at Virginia Mason enhances clinical performance and the patient experience.
Mr. Graban is an internationally recognized expert in Lean Healthcare. We spoke with him about applying Lean in hospitals to improve safety and decrease waste.
Shams B. Syed, MD, MPH |
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This piece describes the evolution of the World Health Organization's African Partnerships for Patient Safety program and its implications for global patient safety improvement.
Dr. Kelley, PhD, is Director of Service Delivery and Safety for the World Health Organization (WHO). We spoke with him about his work with WHO and the global impact of the organization on patient safety.
Christopher Moriates, MD |
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This piece describes the emergence of medical care overuse as a patient safety issue and relates efforts to change clinician behaviors to prevent overtreatment.
Ms. Gibson is Senior Advisor to The Hastings Center, an editor for JAMA Internal Medicine, and co-author of Wall of Silence and The Treatment Trap. We spoke with her about overuse of medical care and its effect on patient safety.
Margaret Plews-Ogan, MD, MS |
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This piece describes the new landscape of patient safety in outpatient care, including elements adapted from hospital settings and the growing evidence base for ambulatory-specific efforts.
Dr. Sarkar is an associate professor of medicine at UCSF whose research has focused on ambulatory patient safety, including missed and delayed diagnosis, adverse drug events, and monitoring failures for outpatients with chronic diseases. We spoke with her about patient safety in the ambulatory setting.
Helen Haskell, MA |
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This piece describes the evolution of the patient advocacy movement, including the events that spurred it, resulting reforms, and the impact of online access to medical information.
Dave deBronkart, known as e-Patient Dave, is a co-founder and co-chair of the Society for Participatory Medicine and coauthor of Let Patients Help: A Patient Engagement Handbook. We spoke with him about engaging patients in their care and allowing patients to access their medical records.
Alexandre R. Marra, MD and Michael B. Edmond, MD, MPH, MPA |
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This piece describes barriers to hand hygiene compliance in health care along with strategies to enhance and measure it.
Dr. Pittet is Director of the Infection Control Programme and WHO Collaborating Centre on Patient Safety at the University of Geneva Hospitals, Switzerland. We spoke with him about hand hygiene in health care, including how to implement culture change and improve safety.
