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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

This piece focuses on the emergence and use of digital applications (apps), app-based products and devices for healthcare, and the implications for patient safety.

Francoise A. Marvel, MD, is an assistant professor of medicine within the Division of Cardiology at Johns Hopkins Hospital, codirector of the Johns Hopkins Digital Health Innovation Lab, and the chief executive officer (CEO) and cofounder of Corrie... Read More

The focus on patient safety in the ambulatory setting was impacted by the COVID-19 pandemic and appropriately shifting priorities to responding to the pandemic. This piece explores some of the core themes of patient safety in the ambulatory setting,... Read More

Remle Crowe, PhD, NREMT, is the Director of Clinical and Operational Research at ESO. In her professional role, she provides strategic direction for the research mission of the organization, including oversight of a warehouse research data set of de... Read More

Michael L. Millenson is the President of Health Quality Advisors LLC, author of the critically acclaimed book Demanding Medical Excellence: Doctors and Accountability in the Information Age, and an adjunct associate professor of medicine at... Read More

All Perspectives (336)

1 - 19 of 19 Results

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.

Dr. Schulz Moore is the Director of Learning and Teaching at the University of New South Wales Faculty of Law and an Associate with the University of New South Wales School of Public Health and Community Medicine. Her research in health law draws from her unique training in public health, law, and health social sciences. We spoke with her about disclosure and apology in health care as well as the intersection between health and legal systems in Australia, New Zealand, and the United States.
Dr. McDonald is President of the Center for Open and Honest Communication at the MedStar Institute for Quality and Safety, and Adjunct Professor of Law at Loyola University-Chicago School of Law and the Beazley Institute for Health Law and Policy. An internationally recognized patient safety expert, he served as a lead architect for the Communication and Optimal Resolution (CANDOR) toolkit, supported by AHRQ. We spoke with him about lessons learned over the years regarding event reporting and his insights about building and disseminating communication-and-resolution programs.
Christopher Moriates, MD |
This piece describes the emergence of medical care overuse as a patient safety issue and relates efforts to change clinician behaviors to prevent overtreatment.
Dr. Coiera, a professor at the University of New South Wales, has extensively researched and written about clinical communication processes and information systems. We spoke with him about how interruptions and distractions in the clinical environment influence patient safety.
Dr. Singh has conducted extensive multidisciplinary research supported by the VA, AHRQ, and NIH and is now a nationally recognized expert in electronic health record–related patient safety issues and diagnostic errors. We spoke with him about becoming a patient safety researcher.
Alison H. Page, MS, MHA |
We've all been there...something goes wrong, a patient is harmed, and we, as medical directors, managers, and administrators, are forced to judge the behavioral choices of another human being. Most of the time, we conduct this complex leadership function guided by little more than vague policies, personal beliefs, and intuition. Frequently, we are frustrated by the fact that many other providers have made the same mistake or behavioral choice, with no adverse outcome to the patient, and the behavior was overlooked. Quite understandably, the staff is frustrated by what appears to be inconsistent, irrational decision-making by leadership. The "just culture" concept teaches us to shift our attention from retrospective judgment of others, focused on the severity of the outcome, to real-time evaluation of behavioral choices in a rational and organized manner.
An engineer and an attorney by training, David Marx, JD, is president of Outcome Engineering, a risk management firm. After a career focused on safety assessment and improvement in aviation, he has spent the last decade focusing on the interface between systems engineering, human factors, and the law. In 2001, he wrote a seminal paper describing the concept of just culture, which became a focal point for efforts to reconcile notions of "no blame" and "accountability." He has gone on to form the "Just Culture Community" to address these issues at health care institutions around the country.
Lucian Leape, MD, is generally known as the father of the modern patient safety movement in the United States. A Harvard professor, Leape shifted his career two decades ago from his clinical practice as a pediatric surgeon to a focus on understanding how medical errors occur and how patient safety can be improved. The result was several groundbreaking studies and commentaries that helped shift the paradigm from "bad people" to "bad systems," and which paved the way for the Institute of Medicine report, "To Err is Human," which he helped write. He has received dozens of honors, including the John M. Eisenberg patient safety award, the duPont Award for Excellence in Children's Health Care, and the Robert Wood Johnson Foundation Investigator's Award in Health Policy Research. He spoke to us about his remarkable career and his thoughts about the patient safety movement.
P. Jeffrey Brady, MD, MPH; William B. Munier, MD, MBA; Irim Azam, MPH |
This piece, written by three leaders in AHRQ's research portfolio, covers future avenues for patient safety research and reviews current AHRQ projects.