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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

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... Read More

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. Read More

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This piece discusses Just Culture in EMS, where variation exists across systems, and challenges and opportunities to enhancing safety event reporting. 

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 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.

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.
Dr. Hollnagel is Senior Professor of Patient Safety at the University of Jönköping (Sweden) as well as Visiting Professorial Fellow at Macquarie University in Sydney (Australia). We spoke with him about his work studying safety in health care and the differences between designing safety improvements in health care versus other industries.
Dr. McDonald is President of the Center for Open and Honest Communication at the MedStar Institute for Quality and Safety, and Adjunct Professor of Law at Loyola University-Chicago School of Law and the Beazley Institute for Health Law and Policy. An internationally recognized patient safety expert, he served as a lead architect for the Communication and Optimal Resolution (CANDOR) toolkit, supported by AHRQ. We spoke with him about lessons learned over the years regarding event reporting and his insights about building and disseminating communication-and-resolution programs.
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.
Professor Sutcliffe is a Bloomberg Distinguished Professor of Business and Medicine at Johns Hopkins University. She studies organizational adaptability, reliability, resilience, and safety in health care. We spoke with her about high reliability in health care organizations.
Dr. Chassin is president and chief executive officer of The Joint Commission. He is also president of the Joint Commission Center for Transforming Healthcare, a center he began to promote high reliability and transformative practice. We spoke with him about new thinking in high reliability.
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.
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.
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.