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.

This piece explores how missed nursing care may explain the association between low nurse staffing levels and increased mortality in hospital patients.

This piece explores how strategies from aviation, such as just culture and monitoring technologies, can be applied in health care to improve patient safety.

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.

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.

This piece describes the evolution of the World Health Organization's African Partnerships for Patient Safety program and its implications for global patient safety improvement.

This piece describes the emergence of medical care overuse as a patient safety issue and relates efforts to change clinician behaviors to prevent overtreatment.

This piece explores how to mitigate risks associated with radiology procedures.

This piece details the benefits of an evidenced-based approach to physical examination and diagnosis.

This piece describes how evidence-based improvements to the medical liability system could influence both accountability and compensation for errors.

This piece discusses how increased supervision influences the educational experience for trainees.

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.

Patients have three roles in improving patient safety: helping to ensure their own safety, working with health care organizations to improve safety at the organization and unit level, and advocating as citizens for public reporting and accountability of hospital and health system performance. The following case illustrates how patients can help ensure their own safety.

Strike 3—You're OUT! Many a baseball game hinges on the accuracy of calls made by the men in black behind home plate. Umpires make crucial split-second decisions under conditions of substantial pressure and uncertainty, a challenge familiar to front-line...