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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
Cheryl B. Jones, PhD, RN, FAAN |
Editor’s note: Cheryl B. Jones is a professor, director of the Hillman Scholars Program, and interim associate dean of the School of Nursing’s PhD program at the University of North Carolina at... Read More
Cheryl B. Jones, PhD, RN, FAAN; Zoe Sousane, BS; Sarah E. Mossburg, RN, PhD
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This piece focuses on workplace violence trends in healthcare settings and strategies for creating a safer healthcare environment.
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
All Perspectives (19)
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Audrey Lyndon, RN, PhD |
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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.
David Studdert, LLB, ScD |
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This piece explores the risk of recurring medicolegal events among providers who have received unsolicited patient complaints, faced disciplinary actions by medical boards, or accumulated malpractice claims.
Michelle Mello is Professor of Law at Stanford Law School and Professor of Health Research and Policy at Stanford University School of Medicine. She conducts empirical research into issues at the intersection of law, ethics, and health policy. We spoke with her about legal issues in patient safety.
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.
Susan S. Huang, MD, MPH |
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This piece describes the history around efforts to address preventable health care–associated infections, including federal initiatives and further research avenues to consider.
Dr. Holmes is Director of Infection Prevention and Control and a professor at Imperial College London. We spoke with her about infection prevention and patient safety.
Peter K. Lindenauer, MD, MSc |
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This piece discusses efforts to promote the business case for safety and quality in health care.
Harvard internist Dr. Jha is a national leader in policy issues related to safety and quality.
Robert M. Wachter, MD |
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This piece examines differences in the patient safety movements in the UK and US, as seen through the eyes of an American safety expert who spent 6 months in England last year.
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.
James M. Naessens, ScD |
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Interest is growing in the use of existing data sources to identify opportunities to improve the delivery and safety of medical care, to measure and compare quality and patient safety, and even to change provider incentives through pay for performance initiatives.
At the University of California, San Francisco, Robert M. Wachter, MD, is Professor and Chief of the Division of Hospital Medicine; Associate Chairman of the Department of Medicine; Lynne and Marc Benioff Endowed Chair in Hospital Medicine; and Chief of the Medical Service at UCSF Medical Center. He is also Editor of AHRQ WebM&M and AHRQ Patient Safety Network.
Loran Hauck, MD, and Jan Jacob, MBA, RN |
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Hospitals and health systems across the United States are struggling to put strategies and structures in place to improve patient safety at their institutions. This article will share the safety and quality journey of Adventist Heath System (AHS), the largest Protestant not-for-profit health care system in the United States.
Jennifer Daley, MD, is the Chief Medical Officer of Partners Community Healthcare Inc., the organization for the 6000 physicians employed/affiliated with Partners HealthCare System (which includes Massachusetts General and Brigham & Women's Hospitals). From 2002 to 2007, she was the Chief Medical Officer for Tenet Healthcare, one of the nation's largest hospital systems, where she was responsible for the development and implementation of Tenet's Commitment to Quality (C2Q). Her academic background (including her previous directorship of the Center for Health Systems Design and Evaluation in the Institute for Health Policy at Massachusetts General Hospital and Partners HealthCare) and her years of leadership at a huge multistate private sector system provide her with a unique perch from which to view patient safety implementation in complex systems.
Sunil Kripalani, MD, MSc |
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Hospital discharge is often viewed as the end of an acute medical event. Goodbyes are said as patients pack their belongings and return home. Physicians scratch the patient's name off their rounding list, and hospital staff remove the patient from the census as they clean out the room...
Eric A. Coleman, MD, MPH, is Associate Professor of Medicine at the University of Colorado. Trained in both geriatrics and health services research, Dr. Coleman has emerged as one of the world's leading authorities on issues surrounding transitions of care, particularly between acute and postacute settings. His care model, the Care Transitions Intervention, is being adopted by leading health care organizations around the country. The Intervention has been associated with significant decreases in rehospitalization rates.
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.
John L. Haughom,
MD |
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In recent years, the case for improving the quality and safety of care has become irrefutable. Over the next few years, failure to act will likely have far-reaching consequences for hospitals and health systems including loss of market share, increased liability, a demoralized workforce, and a sharp rise in fear and distrust among patients who lack confidence in the ability of their provider to deliver safe care...
James L. Reinertsen, MD, heads the Reinertsen Group, a prominent health care consulting firm based in Wyoming. Prior to that, he was CEO at Beth Israel Deaconess Medical Center, where he developed a reputation for his unwavering focus on safety and quality. He is also a senior faculty member at the Institute for Healthcare Improvement (IHI), where he has taken a role in teaching leadership skills and promoting the engagement of health care boards and "C-suites" in patient safety efforts. He was a prime driver behind the IHI's decision to include the "Boards on Board" initiative as part of its recent 5 Million Lives Campaign. We asked him to speak with us about the role of boards in improving patient safety.
Jill Rosenthal, MPH |
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Seven years ago, the Institute of Medicine (IOM) called on states to create mandatory reporting systems as part of a strategy to identify and learn about medical errors and ultimately to improve patient safety. Since then, many states have responded by creating or improving reporting systems to collect information about hospital-based adverse events. These systems can provide states with an opportunity to strengthen their facility oversight functions, safeguard the public, and partner with providers to improve health care quality.
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.
Ashish K. Jha, MD, MPH |
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Five years after the landmark Crossing the Quality Chasm report by the Institute of Medicine (IOM), the quality and safety of health care in the United States remains far from ideal.(1) It is easy to feel pessimistic. Can health care organizations really...
James P. Bagian, MD, is the Director of the Department of Veterans Affairs National Center for Patient Safety. Dr. Bagian began his career as a mechanical engineer, then became a physician, trained in surgery and anesthesia. A NASA Astronaut for 15 years, he flew on two space shuttle flights. In 2001, the American Medical Association awarded him the Nathan S. Davis Award for outstanding public service in the advancement of public health. We asked Dr. Bagian to speak with us about his experience transforming safety at in Veterans Affairs hospitals nationwide.
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.
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In February 2003, 17-year-old Jessica Santillan died at Duke University Medical Center due to a mismatched heart-lung transplantation. As with the Dana-Farber experience, the death made headlines around the world and devastated the leaders and providers at...
James B. Conway; Saul N. Weingart, MD, PhD |
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A decade ago, two tragic medical errors rocked one of the world’s great cancer hospitals, Dana-Farber Cancer Institute (DFCI) in Boston, to its core. The errors led to considerable soul searching and, ultimately, a major change in institutional practices a...
