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

In conversation with Ellen Deutsch, MD, MS, FACS, FAAP, FSSH, CPPS

December 14, 2022

Ellen Deutsch, MD, MS, FACS, FAAP, FSSH, CPPS is a Medical Officer in the Center for Quality Improvement and Patient Safety at the Agency for Healthcare Research and Quality. Dr. Deutsch is a pediatric otolaryngologist and has vast experience in... Read More

Resilient Healthcare and the Safety-I and Safety-II Frameworks

December 14, 2022

This piece discusses resilient healthcare and the Safety-I and Safety-II approaches to patient safety.

In Conversation with Dr. Michelle Schreiber on Measuring Patient Safety

December 14, 2022

We spoke to Dr. Michelle Schreiber about measuring patient safety, the CMS National Quality Strategy, and the future of measurement. Michelle Schreiber, MD, is the Deputy Director of the Center for Clinical Standards and Quality and the Director of... Read More

Measuring Patient Safety

December 14, 2022

This collaborative piece with the Centers for Medicare & Medicaid Services discusses the current state of patient safety measurement, advancements in measuring patient safety, and explores future directions.

Using Human Factors Engineering and the SEIPS Model to Advance Patient Safety in Care Transitions

November 16, 2022

Human factors engineering or ergonomics (HFE) is a scientific discipline broadly focused on interactions among humans and other elements of a system. The International Ergonomics Association defines HFE as “the scientific discipline concerned with... Read More

In Conversation With... Pascale Carayon, PhD and Nicole Werner, PhD

November 16, 2022

Dr. Pascale Carayon, PhD, is a professor emerita in the Department of Industrial and Systems Engineering and the founding director of the Wisconsin Institute for Healthcare Systems Engineering (WIHSE). Dr. Nicole Werner, PhD, is an associate... Read More

All Perspectives (345)

Perspective Type

Additional Filters

Approach to Improving Safety

Safety Target

Setting of Care

Clinical Area

Target Audience

Error Types

Clear all

Clear all filter(s)

Displaying 1 - 19 of 19 Results

AHRQ PSNet Annual Perspective: Impact of the COVID-19 Pandemic on Patient Safety

March 30, 2021

Save to Library

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.

Approach to Improving Patient Safety: Communication

March 10, 2021

Save to Library

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.

Patient Safety in Medical, Nursing, and Other Clinical Education

March 16, 2020

Save to Library

This piece describes key themes reflected in AHRQ PSNet resources released in 2019 related to how medical, nursing, and other clinical education can better incorporate patient safety concepts.

Pharmacist Role in Patient Safety

February 21, 2020

Save to Library

This perspective describes key themes reflected in AHRQ PSNet resources released in 2019 related to the role of the pharmacist in enhancing patient safety.

Updates in the Role of Health IT in Patient Safety

February 21, 2020

Save to Library

This perspective describes key themes reflected in AHRQ PSNet resources released in 2019 related to how the use of HIT can improve patient safety.

Patient Safety in Primary Care

February 21, 2020

Save to Library

This perspective describes key themes reflected in AHRQ PSNet resources released in 2019 related to patient safety in primary care.

Maternal Safety

Audrey Lyndon, RN, PhD |

December 22, 2018

Save to Library

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.

Update: Patient Engagement in Safety

Rachel J. Stern, MD, and Urmimala Sarkar, MD |

January 1, 2018

Save to Library

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.

Patient Engagement in Safety

Rachel J. Stern, MD, and Urmimala Sarkar, MD |

January 1, 2017

Save to Library

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.

The Weekend Effect

Sumant Ranji, MD |

January 1, 2017

Save to Library

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.

Measuring and Responding to Deaths From Medical Errors

Sumant Ranji, MD |

March 22, 2016

Save to Library

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.

Rethinking Root Cause Analysis

Kiran Gupta, MD, MPH, and Audrey Lyndon, PhD |

January 1, 2016

Save to Library

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.

Patient Safety and Opioid Medications

Urmimala Sarkar, MD, and Kaveh Shojania, MD |

January 1, 2016

Save to Library

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.

Computerized Provider Order Entry and Patient Safety

Urmimala Sarkar, MD, and Kaveh Shojania, MD |

January 1, 2015

Save to Library

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.

Burnout Among Health Professionals and Its Effect on Patient Safety

Audrey Lyndon, PhD |

January 1, 2015

Save to Library

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.

Accountability in Patient Safety

Christopher Moriates, MD, and Robert M. Wachter, MD |

January 1, 2015

Save to Library

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.

Handoffs and Transitions

Niraj Sehgal, MD, MPH |

January 22, 2014

Save to Library

Safety and Medical Education

Sumant Ranji, MD |

January 1, 2014

Save to Library

Diagnostic Errors

Urmimala Sarkar, MD; Kaveh Shojania, MD |

January 1, 2014

Save to Library

Perspectives

Latest Perspectives

All Perspectives (345)

Connect With Us

Sign up for Email Updates

Agency for Healthcare Research and Quality

Perspectives

Latest Perspectives

All Perspectives (345)

Connect With Us

Sign up for Email Updates

Agency for Healthcare Research and Quality

PSNet Log in

Submit Your Case

Continue as a Guest

Continue Logged In

Submit Your Case

Continue as a Guest

Already have a PSNet

Account?

New Users