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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 |

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

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

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 (165)

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This piece discusses the critical role community pharmacists play in ensuring medication safety.

Gina Luchen

Georgia Galanou Luchen, Pharm. D., is the Director of Member Relations at the American Society of Health-System Pharmacists (ASHP). In this role, she leads initiatives related to community pharmacy practitioners and their impact throughout the care continuum. We spoke with her about different types of community pharmacists and the role they play in ensuring patient safety. 

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 photo

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

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

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

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.

Jose Morfin Headshot

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

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.

Muhammad Walji

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 Suda

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. 

Lori Popejoy

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.

George Edwin

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.

This piece discusses the impact that COVID-19 has had on the services provided by pharmacists and highlights available resources to support them in ensuring medication safety.
Anna Dopp
Anna Legreid Dopp, Pharm. D is the Senior Director of Clinical Guidelines and Quality Improvement at the American Society of Health-System Pharmacists (ASHP). We spoke with her about how pharmacist care delivery services have been impacted by COVID-19.
This piece discusses the role of the Food and Drug Administration in ensuring the safety of medical devices.
Jeffrey Shuren
Jeffrey Shuren, MD, JD is the Director of the Center for Devices and Radiological Health at the Food and Drug Administration. We spoke with him about the role of the Food and Drug Administration in ensuring the safety of medical devices.
This PSNet Perspective discusses how telehealth, regardless of payer (Medicare, private insurance, etc.), is supporting both patient and provider safety during the COVID-19 crisis. Precautions that institutions can take to alleviate safety risks resulting from a rapid expansion of capabilities and use are also discussed.
Joel Willis, DO, PA, MA, MPhiL is a Health Policy Fellow affiliated with the American Board of Family Medicine and the George Washington Medical Faculty Associates. Neal Sikka, MD is an Associate Professor and Attending Physician at George Washington Medical Faculty Associates and the Chief of the Innovative Practice and Telehealth Section of the Department of Emergency Medicine. We discussed with them how telehealth at GW is helping to protect patients and providers during the COVID-19 crisis.
This perspective discusses the Making Healthcare Safer Report, what is new in the recently released third edition, and how the report can be used.
An Gaffey
Ann D. Gaffey, RN, MSN, CPHRM, DFASHRM is the President of Healthcare Risk and Safety Strategies, LLC. Bruce Spurlock, MD is the President and CEO of Cynosure Health. We spoke with them about their role in the development of the Making Healthcare Safer III Report and what new information they think audiences will find particularly useful and interesting.