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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

Improving Diagnostic Safety and Quality
Jawad Al-Khafaji, MD, MHSA, Merton Lee, PhD, PharmD, Sarah Mossburg, RN, PhD |

Throughout 2022, AHRQ PSNet has shared research that elucidates the complex nature of misdiagnosis and diagnostic safety. This Year in Review explores recent work in diagnostic safety and ways that greater safety may be promoted using tools developed to... Read More

Technology as a Tool for Improving Patient Safety
Bryan Gale, Sarah Mossburg, A Jay Holmgren, and Susan McBride |

In the past several decades, technological advances have opened new possibilities for improving patient safety. Using technology to digitize healthcare processes has the potential to increase standardization and efficiency of clinical workflows and... Read More

Maternal Safety and Perinatal Mental Health
Christie Allen, MSN, RNC-NIC, CPHQ, C-ONQS, Cindy Manaoat Van, MHSA, Sarah E. Mossburg, RN, PhD |

This piece focuses on perinatal mental health and efforts to improve maternal safety.   

All Perspectives (25)
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Displaying 1 - 20 of 25 Results
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    • Special Edition Perspective: Technology Responses to COVID-19
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    • This Perspective differs from the typical Perspective in that it compiles findings and insights into a series of case studies from interviews and written responses from leaders at three different health systems who had to increase their telehealth capacities in response to the COVID-19 pandemic.

    Telehealth and Patient Safety During the COVID-19 Response
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    • This PSNet Perspective discusses how telehealth, regardless of payer (Medicare, private insurance, etc.), is supporting both patient and provider safety during the COVID-19 crisis. Precautions that institutions can take to alleviate safety risks resulting from a rapid expansion of capabilities and use are also discussed.
    In Conversation With... Joel Willis, DO, PA, MA, MPhiL and Neal Sikka, MD
    Joel Willis, DO, PA, MA, MPhiL is a Health Policy Fellow affiliated with the American Board of Family Medicine and the George Washington Medical Faculty Associates. Neal Sikka, MD is an Associate Professor and Attending Physician at George Washington Medical Faculty Associates and the Chief of the Innovative Practice and Telehealth Section of the Department of Emergency Medicine. We discussed with them how telehealth at GW is helping to protect patients and providers during the COVID-19 crisis.
    Artificial Intelligence and Diagnostic Errors
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    • This piece discusses the current use of artificial intelligence in diagnostic imaging and key patient safety considerations.

    David Gruen
    In Conversation With... David Gruen, MD

    David R. Gruen, MD, MBA, FACR is the Chief Medical Officer, Imaging at IBM Watson Health and is a thought leader and content expert for artificial intelligence in medical imaging. We spoke with him about the role artificial intelligence can play in healthcare diagnostics and the potential for reducing diagnostic errors.

    Medical Scribes and Patient Safety
    Deborah Woodcock, MS, MBA; Robby Bergstrom |
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    • 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.
    In Conversation With… Susan Smith, MD
    Dr. Smith is Chief Faculty Practices Officer for UCSF Health and a family medicine physician. Over the past 3–4 years, the health system has implemented a robust program using medical scribes in the outpatient setting. We spoke with her about her experience implementing this program, including the benefits and some of the potential patient safety ramifications.
    Update: Patient Engagement in Safety
    Rachel J. Stern, MD, and Urmimala Sarkar, MD |
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    • 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.
    EHR Copy and Paste and Patient Safety
    Shannon M. Dean, MD |
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    • This piece explores concerns regarding the use of copy and paste in electronic health records and offers potential strategies to improve clinical documentation accuracy.
    In Conversation With… Robert Hirschtick, MD
    Dr. Hirschtick is Associate Professor of Medicine at Northwestern Medicine, and the author of a number of prominent articles—many quite amusing—about the changes in medical practice wrought by information technology. We spoke with him about what it means to be a clinician in the modern era, particularly how digitization of health records has affected clinicians' notes.
    The Role of Patient-facing Technologies to Empower Patients and Improve Safety
    Ronen Rozenblum, MD, MPH, and David Bates, MD, MS |
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    • This piece explores how patient-facing technologies can enable patients to be more responsible for their care and improve the way clinicians practice.
    In Conversation With… Wanda Pratt, PhD
    Wanda Pratt is a professor in the Information School and an adjunct in Biomedical and Health Informatics in the School of Medicine at the University of Washington. We spoke with her about patient-facing technologies, including the opportunities and challenges for patient safety.
    Assessing the Safety of Electronic Health Records: What Have We Learned?
    Dean F. Sittig, PhD, and Hardeep Singh, MD, MPH |
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    • This piece highlights four key lessons that the authors believe are useful for clinicians and health care organizations that seek to identify, prevent, and mitigate electronic health record–related safety issues.
    In Conversation With… Andrew Gettinger, MD
    Dr. Gettinger is the Chief Medical Information Officer and the Executive Director of the Office of Clinical Quality and Safety for the Office of the National Coordinator (ONC). He led the development of an electronic health record (EHR) system at Dartmouth and was the senior physician leader during their transition to a vendor-based EHR. We spoke with him about safety and health information technology.
    Patient Engagement in Safety
    Rachel J. Stern, MD, and Urmimala Sarkar, MD |
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    • 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 |
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    • 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.
    Diagnostic Errors: A New Chapter in Patient Safety Science, Policy, and Practice
    Hardeep Singh, MD, MPH |
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    • This piece discusses momentum in the field of diagnostic error over the past several years (culminating in the recent Improving Diagnosis in Health Care report) and outlines future avenues to ensure progress in diagnostic safety.
    In Conversation With… Mark L. Graber, MD
    Dr. Graber founded the Society to Improve Diagnosis in Medicine and the journal, Diagnosis. We spoke with him about the recent National Academy of Medicine (formerly Institute of Medicine) Improving Diagnosis in Health Care report, and about diagnostic errors more generally.
    New Insights on Safety and Health IT
    A. Zach Hettinger, MD, MS; Raj Ratwani, PhD; Rollin J. (Terry) Fairbanks, MD, MS |
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    • This piece provides an overview of health IT usability design, including persisting challenges and progress in the field.
    In Conversation With… Robert M. Wachter, MD
    Dr. Wachter is Professor and the Interim Chairman of the Department of Medicine at UCSF. We talked with him about his new book, The Digital Doctor: Hope, Hype, and Harm at the Dawn of Medicine's Computer Age.
    Patient Safety and Health Information Technology: Learning from Our Mistakes
    Ross Koppel, PhD |
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    • This piece examines the promised benefits of health information technology alongside the challenges of implementation and idiosyncrasies of available systems.
    In Conversation With… David Blumenthal, MD, MPP
    Dr. Blumenthal recently returned to Harvard after a 2-year stint as the National Coordinator for Health Information Technology, where he was responsible for implementing the “Meaningful Use” health care IT incentive system in American hospitals and clinics.
    The Emergence of the Trigger Tool as the Premier Measurement Strategy for Patient Safety
    Paul J. Sharek, MD, MPH |
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    • This piece explains how the trigger tool approach identifies adverse events more efficiently than other detection methods such as voluntary incident reporting and patient safety indicators drawn from administrative data.
    In Conversation With…David C. Classen, MD, MS
    One of the pioneers of the trigger tool methodology for detecting adverse events, Dr. Classen is Chief Medical information Officer at Pascal Metrics and Associate Professor of Medicine at the University of Utah.
    Patient Safety: A Perspective from Office Practice
    Richard J. Baron, MD |
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    • Most patient interactions with the health care system occur in the outpatient setting. Many potential and actual safety problems occur there as well.(1) Yet patient safety literature and practice do not seem to have reached deeply into ambulatory care. This is likely due to a combination of factors: in most practices, there is no layer of administration providing a second look at routine policies and procedures; there is no accrediting agency, like The Joint Commission, to mandate safe practices (2); and those of us in office practice are so consumed with simply getting through the day that it is difficult to recognize the problems, large and small, that can lead to major safety hazards. The business case for safety, such as it is, relies almost entirely on the malpractice rate-setting process: errors that result in litigation lead to higher premiums and personal and professional misery. However, as Studdert (3) has argued, relying on the malpractice system to identify and "correct" errors is unlikely to be timely or productive.
    In Conversation with…William B. Weeks, MD, MBA
    The Business Case for Improving Safety
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