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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

Remle Crowe, PhD, NREMT, is the Director of Clinical and Operational Research at ESO. In her professional role, she provides strategic direction for the research mission of the organization, including oversight of a warehouse research data set of de... Read More

Michael L. Millenson is the President of Health Quality Advisors LLC, author of the critically acclaimed book Demanding Medical Excellence: Doctors and Accountability in the Information Age, and an adjunct associate professor of medicine at... Read More

Errors in medication management and administration are major threats to patient safety. This piece explores issues with opioid and nursing-sensitive medication safety as well as medication safety in older adults. Future research directions in... Read More

All Perspectives (333)

1 - 20 of 52 Results

Patient Safety Organizations (PSOs) are organizations dedicated to improving patient safety and healthcare quality that serve to collect and analyze data voluntarily reported by healthcare providers to promote learning. Federal confidentiality and privilege protections apply to certain information (defined as “patient safety work product”) developed when a healthcare provider works with a federally listed PSO under the Patient Safety and Quality Improvement Act of 2005 and its implementing regulation. AHRQ is responsible for the administration and enforcement of the PSO listing process. Based on their presentations at an AHRQ annual meeting, we spoke with representatives from two PSOs, Poonam Sharma, MD, MPH, the Senior Clinical Data Analyst at Atrium Health, and Rhonda Dickman, MSN, RN, CPHQ, the Director of the Tennessee Hospital Association PSO about how the unique circumstances surrounding care during the COVID-19 pandemic impacted patient safety risks in both COVID-19 and non-COVID-19 patients.

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.

Deborah Woodcock, MS, MBA; Robby Bergstrom |
This piece explores the role medical scribes play in health care, how to implement and evaluate a scribe program, and recommendations to reduce variations in scribe practice.
Dr. Schulz Moore is the Director of Learning and Teaching at the University of New South Wales Faculty of Law and an Associate with the University of New South Wales School of Public Health and Community Medicine. Her research in health law draws from her unique training in public health, law, and health social sciences. We spoke with her about disclosure and apology in health care as well as the intersection between health and legal systems in Australia, New Zealand, and the United States.
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.
Dr. Schiff is Associate Director of Brigham and Women's Center for Patient Safety Research and Practice, Associate Professor of Medicine at Harvard Medical School, and Quality and Safety Director for the Harvard Medical School Center for Primary Care. He was an invited expert and reviewer for the Improving Diagnosis in Health Care report of the National Academy of Medicine. We spoke with him about understanding and preventing diagnostic errors.
Dr. Hoppmann is the Dorothea H. Krebs Endowed Chair of Ultrasound Education, Professor of Medicine, and Director of the Ultrasound Institute of the University of South Carolina School of Medicine. He founded and served as the first President of the Society of Ultrasound in Medical Education. We talked to him about safety and usability of point-of-care ultrasound.
Rachel J. Stern, MD, and Urmimala Sarkar, MD |
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.
Professor Aylin is Professor of Epidemiology and Public Health at Imperial College London. We spoke with him about the weekend effect in health care—the observation that patients admitted to the hospital over the weekend often have worse outcomes than those admitted during the week.
Irene Berita Murimi, PhD, MA, and G. Caleb Alexander, MD, MS |
This piece explores the opioid epidemic in the United States, including factors that led to increased opioid prescribing, its adverse effects, and tactics to reduce opioid-related harm.
Dr. Juurlink is professor of medicine, pediatrics, and health policy at the University of Toronto, where he is also director of the Division of Clinical Pharmacology and Toxicology. We spoke with him about the opioid epidemic and strategies to address this growing patient safety concern.
Rachel J. Stern, MD, and Urmimala Sarkar, MD |
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.
Sumant Ranji, MD |
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.
Dr. Bagian is Director of the Center for Healthcare Engineering and Patient Safety at the University of Michigan, and a former astronaut. He co-chaired the team that produced the influential NPSF report entitled, RCA2: Improving Root Cause Analyses and Actions to Prevent Harm.