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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
Patricia McGaffigan, MS, RN, CPPS; Cindy Manaoat Van, MHSA, CPPS; Sarah E. Mossburg, RN, PhD
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This piece focuses on the importance of patient safety following the end of the public health emergency and how organizations can move beyond the pandemic.
Patricia McGaffigan, MS, RN, CPPS; Cindy Manaoat Van, MHSA, CPPS; Sarah E. Mossburg, RN, PhD
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This piece focuses on the importance of patient safety following the end of the public health emergency and how organizations can move beyond the pandemic.
Kathleen Sanford DBA, RN, FAAN, FACHE; Sue Schuelke PhD, RN-BC, CNE, CCRN-K; Merton Lee, PharmD, PhD; Sarah E. Mossburg, RN, PhD
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Editor’s note: Kathleen Sanford is the chief nursing officer and an executive vice president at CommonSpirit. Sue Schuelke is an assistant professor at the College of Nursing–Lincoln Division, University of Nebraska... Read More
Kathleen Sanford DBA, RN, FAAN, FACHE; Sue Schuelke PhD, RN-BC, CNE, CCRN-K; Merton Lee, PharmD, PhD; Sarah E. Mossburg, RN, PhD
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This piece discusses virtual nursing, an approach to care that incorporates an advanced practice nurse into hospital-based patient care through telehealth. Virtual nursing increases patient safety and may enable expert nurses to... Read More
Regina M. Hoffman, MBA, RN, Cindy Manaoat Van, MHSA, CPPS,Sarah E. Mossburg, RN, PhD
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Regina M. Hoffman, MBA, RN, Cindy Manaoat Van, MHSA, CPPS, Sarah E. Mossburg, RN, PhD
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This piece focuses on the importance of building the capacity of the workforce and organizations for patient safety using patient safety education.
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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.
Arpana R. Vidyarthi, MD; Robert B. Baron, MD, MS |
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Clear health communication is increasingly recognized as essential for promoting patient safety. Yet according to a recent Joint Commission report, What Did the Doctor Say? Improving Health Literacy to Protect Patient Safety, communication problems among health care providers, patients, and families are common and a leading root cause of adverse outcomes.(1) Addressing health literacy—the capacity of individuals to obtain, process, and understand basic health information and services needed to make appropriate health decisions—has become a primary objective for many health systems in order to protect patients from harm.
Thomas J. Nasca, MD, is the executive director and chief executive officer of the Accreditation Council for Graduate Medical Education (ACGME). Prior to joining the ACGME in 2007, Dr. Nasca, a nephrologist, was dean of Jefferson Medical College and Senior Vice President for Academic Affairs of Thomas Jefferson University. We asked him to speak with us about the role of the ACGME in patient safety.
Alan H. Rosenstein, MD, MBA; Michelle O'Daniel, MSG, MHA |
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The 1999 Institute of Medicine report highlighted the need for health care providers to address the serious concerns raised about the quality and safety of patient care being provided in our health care organizations. Organizations responded by looking at new ways to fix the system, mostly through the introduction of new technologies and system/process redesign. Advances have been made, but there are still significant opportunities for improvement. Is the barrier poor system or process design, or is it related to addressing basic human behaviors?
Gerald B. Hickson, MD, is one of the world's leading experts on physician behavior and its connection to clinical outcomes and medical malpractice. He is a Professor at the Vanderbilt University School of Medicine, where he is also the Joseph C. Ross Chair in Medical Education and Administration, Associate Dean for Clinical Affairs, Director of the Vanderbilt Center for Patient and Professional Advocacy, and Director of Clinical Risk and Loss Prevention. We asked him to speak with us about high-risk physicians and malpractice.
Alison H. Page, MS, MHA |
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We've all been there...something goes wrong, a patient is harmed, and we, as medical directors, managers, and administrators, are forced to judge the behavioral choices of another human being. Most of the time, we conduct this complex leadership function guided by little more than vague policies, personal beliefs, and intuition. Frequently, we are frustrated by the fact that many other providers have made the same mistake or behavioral choice, with no adverse outcome to the patient, and the behavior was overlooked. Quite understandably, the staff is frustrated by what appears to be inconsistent, irrational decision-making by leadership. The "just culture" concept teaches us to shift our attention from retrospective judgment of others, focused on the severity of the outcome, to real-time evaluation of behavioral choices in a rational and organized manner.
An engineer and an attorney by training, David Marx, JD, is president of Outcome Engineering, a risk management firm. After a career focused on safety assessment and improvement in aviation, he has spent the last decade focusing on the interface between systems engineering, human factors, and the law. In 2001, he wrote a seminal paper describing the concept of just culture, which became a focal point for efforts to reconcile notions of "no blame" and "accountability." He has gone on to form the "Just Culture Community" to address these issues at health care institutions around the country.
Rosemary Gibson, MSc |
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Patients have three roles in improving patient safety: helping to ensure their own safety, working with health care organizations to improve safety at the organization and unit level, and advocating as citizens for public reporting and accountability of hospital and health system performance. The following case illustrates how patients can help ensure their own safety.
Sorrel King is the mother of Josie King, who died tragically in 2001 at age 18 months because of medical errors during a hospitalization at Johns Hopkins Hospital. She has subsequently become one of the nation’s foremost patient advocates for safety, forming an influential foundation (the Josie King Foundation) and partnering with Johns Hopkins to promote the field of patient safety around the world.
Linda H. Aiken, PhD, RN |
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The goal set by the Institute of Medicine (IOM) in 1999 to reduce medical errors by half within 5 years has not been achieved. Opinion polls of consumers and health professionals show that concerns about patient safety remain high. Yet only 16% of hospital...
Barbara A. Blakeney, MS, RN, is President of the 150,000-member American Nurses Association (ANA). A nurse practitioner and expert in public health practice, policy, and primary care, Ms. Blakeney is on leave from the Boston Public Health Commission, where she has been director of health care services for the homeless. She is the recipient of numerous awards and has been named to Modern Healthcare Magazine's list of the 100 most influential people in health care for the past 3 years.
