Perspectives

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 medication safety are also discussed.

A psychologically safe environment for healthcare teams is desirable for optimal team performance, team member well-being, and favorable patient safety outcomes. This piece explores facilitators of and barriers to psychological safety across healthcare settings. Future research directions examining psychological safety in healthcare are discussed.

In this PSNet Annual Perspective, we worked with co-authors Dr. Jacqueline C. Stocking, a quality improvement and critical care specialist, and Dr. Christian Sandrock, a patient safety professional and emerging infectious diseases specialist, to provide a look at news and research related to the impact of the COVID-19 pandemic on patient safety.

In this PSNet Annual Perspective, we review key findings related to improvement strategies when communicating with patients and different structured communication techniques to improve communication across providers. Lessons learned from innovative approaches explored under COVID-19 that could be considered as usual care resumes are also discussed.

This piece describes key themes reflected in AHRQ PSNet resources released in 2019 related to how medical, nursing, and other clinical education can better incorporate patient safety concepts.

This perspective describes key themes reflected in AHRQ PSNet resources released in 2019 related to the role of the pharmacist in enhancing patient safety.

This perspective describes key themes reflected in AHRQ PSNet resources released in 2019 related to how the use of HIT can improve patient safety.

This perspective describes key themes reflected in AHRQ PSNet resources released in 2019 related to patient safety in primary care.

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.

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.

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.

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.

The toll of medical errors is often expressed in terms of mortality attributable to patient safety problems. In 2016, there was considerable debate regarding the number of patients who die due to medical errors. This Annual Perspective explores the methodological approaches to estimating mortality attributable to preventable adverse events and discusses the benefits and limitations of existing approaches.

Root cause analysis is widely accepted as a key component of patient safety programs. In 2016, the literature outlined ongoing problems with the root cause analysis process and shed light on opportunities to improve its application in health care. This Annual Perspective reviews concerns about the root cause analysis process and highlights recommendations for improvement put forth by the National Patient Safety Foundation.

Opioids are known to be high risk medications, and concerns about patient harm from prescription opioid misuse have been increasing in the United States. This Annual Perspective summarizes research published in 2016 that explored the extent of harm from their use, described problematic prescribing practices that likely contribute to adverse events, and demonstrated some promising practices to foster safer opioid use.

Computerized provider order entry is a cornerstone of patient safety efforts, and the increasingly widespread implementation of electronic health records has made it a standard practice in health care. This Annual Perspective summarizes novel findings and research directions in computerized provider order entry in 2015.

Clinician burnout is prevalent across health care settings and may impair clinicians' ability to maintain safe practices and detect emerging safety threats. This Annual Perspective summarizes studies published in 2015, with a particular focus on the relationship between burnout and patient safety, and interventions to address burnout among clinicians.

While the patient safety world has largely embraced the concept of a just culture for many years, in 2015 the discussion moved toward tackling some of the specifics and many gray areas that must be addressed to realize this ideal. This Annual Perspective reviews the context of the "no blame" movement and the recent shift toward a framework of a just culture, which incorporates appropriate accountability in health care.