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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
Jawad Al-Khafaji, MD, MHSA, Merton Lee, PhD, PharmD, Sarah Mossburg, RN, PhD
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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
Drs. Susan McGrath and George Blike discuss surveillance monitoring and its challenges and opportunities.
Susan McGrath, PhD,George Blike, MD, MHCDS,Bryan M. Gale, MA,Sarah E. Mossburg, RN, PhD
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This piece discusses surveillance monitoring of patients in low-acuity units of the hospital to prevent failure to rescue events, its difference from high-acuity continuous monitoring, and its potential applications in... Read More
Bryan Gale, Sarah Mossburg, A Jay Holmgren, and Susan McBride
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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
Christie Allen, MSN, RNC-NIC, CPHQ, C-ONQS, Cindy Manaoat Van, MHSA, Sarah E. Mossburg, RN, PhD
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This piece focuses on perinatal mental health and efforts to improve maternal safety.
Christie Allen is the Senior Director of Quality Improvement at the American College of Obstetrics and Gynecology (ACOG). We spoke to her about her experience in maternal safety and improving perinatal mental... Read More
All Perspectives (16)
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Displaying 1 - 16 of 16 Results
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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.
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.
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.
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.
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.
Alvin Rajkomar, MD |
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This piece explores the role for a clinician data scientist in utilizing clinical datasets to improve health care quality and safety.
Dr. Platt is Professor and Chair of the Harvard Medical School Department of Population Medicine. We spoke with him about big data and patient safety.
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.
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.
Robert M. Wachter, MD |
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This editorial provides an overview of how PSNet and WebM&M have evolved in the past decade.
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.
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.
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.
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.
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.
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.
Christopher Nemeth, PhD |
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This piece discusses how adopting new technology can have unintended effects.
His seminal work in patient safety is generally credited with introducing the concept of unintended consequences.
Sunil Kripalani, MD, MSc |
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This piece discusses how medical centers can improve handover quality and patient safety.
An Associate Professor at the University of Chicago, her research focuses on resident duty hours, handoffs, and professionalism.
Jeffrey M. Rothschild, MD, MPH; Carol Keohane, RN, BSN |
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Medication safety in hospitals depends on the successful execution of a complex system of scores of individual tasks that can be categorized into five stages: ordering or prescribing, preparing, dispensing, transcribing, and monitoring the patient's response. Many of these tasks lend themselves to technologic tools. Over the past 20 years, technology has played an increasingly larger role toward achieving the five rights of medication safety: getting the right dose of the right drug to the right patient using the right route and at the right time. While several of these technologies may incur significant upfront and maintenance costs, the net impact over time may be reduced overall institutional costs and improvements in work efficiency. Examples of technologic tools commonly seen in many hospitals today include computerized provider order entry (CPOE) with decision support and automatic dispensing carts, also known as medication dispensing robots. While outside the scope of this Perspective, it is important to emphasize that many nontechnologic interventions, such as clinical pharmacists on physician rounds, can be equally effective in improving medication safety.
Eric G. Poon, MD, MPH, is Director of Clinical Informatics at Brigham and Women’s Hospital and Assistant Professor of Medicine at Harvard Medical School. Dr. Poon’s research has focused on using health information technology to improve patient safety. He oversees the development and implementation of clinical applications including computerized physician order entry (CPOE) and barcode-assisted electronic medication administration record, and was lead author on the first rigorous study demonstrating the impact of a bar coding system in a hospital pharmacy. We asked him to speak with us about how such technology can augment medication safety.
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.
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.
Nancy C. Elder, MD, MSPH |
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Dr. Jones was sure he had increased Mr. H's cholesterol-lowering medication to 80 mg 6 months ago, but, at his visit today, his pill bottle still says 40 mg. In reviewing Ms. B's chart in preparation for performing a well-woman examination, Dr. Smith find...
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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...
