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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 (7)
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Displaying 1 - 7 of 7 Results
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    • EMS Patient Safety in the Field
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    • This piece discusses EMS patient safety concerns in the field and discusses operational concerns, clinical concerns, and safety of personnel.

    James_Augustine
    In Conversation With... James Augustine, MD

    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.

    The Role of the FDA in Ensuring Device Safety
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    • This piece discusses the role of the Food and Drug Administration in ensuring the safety of medical devices.
    Jeffrey Shuren
    In Conversation With... Jeffrey Shuren, MD, JD
    Jeffrey Shuren, MD, JD is the Director of the Center for Devices and Radiological Health at the Food and Drug Administration. We spoke with him about the role of the Food and Drug Administration in ensuring the safety of medical devices.
    Making Healthcare Safer III Report
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    • This perspective discusses the Making Healthcare Safer Report, what is new in the recently released third edition, and how the report can be used.
    An Gaffey
    In Conversation With... Ann Gaffey, RN, MSN, CPHRM and Bruce Spurlock, MD
    Ann D. Gaffey, RN, MSN, CPHRM, DFASHRM is the President of Healthcare Risk and Safety Strategies, LLC. Bruce Spurlock, MD is the President and CEO of Cynosure Health. We spoke with them about their role in the development of the Making Healthcare Safer III Report and what new information they think audiences will find particularly useful and interesting.
    Reducing the Safety Hazards of Monitor Alert and Alarm Fatigue
    Samantha Jacques, PhD, and Eric Williams, MD, MS, MMM |
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    • This piece describes strategies to reduce alarm fatigue in hospitals, including educating staff and patients, customizing alarm settings, and performing maintenance of lead wires.
    In Conversation With... Barbara Drew, RN, PhD
    Dr. Drew is the David Mortara Distinguished Professor of Physiological Nursing and Clinical Professor of Medicine in Cardiology at the University of California, San Francisco. We spoke with her about the perils and prevalence of alert fatigue.
    Health Care–Acquired Urinary Tract Infection: The Problem and Solutions
    Lindsay E. Nicolle, MD |
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    • Urinary tract infection (UTI) is the most common hospital-acquired infection, accounting for 40% of all hospital-acquired infections. More than 80% of these infections are attributable to use of an indwelling urethral catheter.(1) Catheter-acquired urinary infections (cUTIs) have received significantly less attention than other health care–acquired infections, such as surgical site infections, ventilator-associated pneumonia, and bacteremia.
    In Conversation with…Sanjay Saint, MD, MPH
    Sanjay Saint, MD, MPH, is Professor of Medicine at the University of Michigan and the Ann Arbor VA Medical Center in Ann Arbor, Michigan. Dr. Saint's research has focused on reducing health care–associated infections, with a particular focus on preventing catheter-related urinary tract infections (UTIs). We asked him to speak with us about how research on UTI prevention provides broader lessons for patient safety.
    The Role of Bar Coding and Smart Pumps in Safety
    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.
    In Conversation with…Eric G. Poon, MD, MPH
    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.
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