Dr. Brice is Professor and Chair of the Department of Emergency Medicine at the University of North Carolina. She also serves as the Program Director for the Emergency Medical Services (EMS) Fellowship and was past-president of the National Association of EMS Physicians. We spoke with her about her experience working in emergency medical systems and safety concerns particular to this field.
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.
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.
Peter J. Pronovost, MD, PhD, is a Professor of Anesthesia, Critical Care, and Health Policy at Johns Hopkins University and Director of the Johns Hopkins Quality and Safety Research Group. He may be best known for having led the Michigan Keystone project, which used checklists and other interventions to markedly reduce catheter-associated bloodstream infections in ICUs throughout the state. For this work and more, he received a MacArthur Foundation Fellowship, and Time Magazine named him as one of the 100 most influential people in the world.
Dean Schillinger, MD, is a Professor of Medicine at University of California, San Francisco, Director of the UCSF Center for Vulnerable Populations, and Chief of the California Diabetes Prevention and Control Program. His role as a practicing clinician at a safety net hospital (San Francisco General Hospital) has put him in a unique position to pursue influential and relevant research related to health literacy and improving care for vulnerable populations.
Clear health communication is increasingly recognized as essential for promoting patient safety. Yet according to a recent Joint Commission report, What Did the Doctor Say? Improving Health Literacy to Protect Patient Safety, communication problems among health care providers, patients, and families are common and a leading root cause of adverse outcomes.
Disclosure of medical error is inextricably linked to today's patient safety efforts. Health care experts advocate that greater disclosure is necessary to achieve complete transparency and ameliorate barriers to error reporting.(1,2) Of course, the ethical obligations triggered by the occurrence of a medical error are not to be overlooked.
Thomas H. Gallagher, MD, is Associate Professor in the Department of Medicine and the Department of Medical History and Ethics at the University of Washington in Seattle. Dr. Gallagher's current research covers the disclosure of medical errors, examining patients' and doctors' attitudes about disclosure, how best to train providers to disclose and apologize for errors, and how to create a system that promotes appropriate disclosure. We asked him to speak with us about new developments in the field of patient disclosure and apologies.
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.
Michael Cohen, RPh, MS, ScD, is president of the Institute for Safe Medication Practices (ISMP) and co-editor of ISMP Medication Safety Alert!, a biweekly newsletter. A pharmacist by training, his ground-breaking work and commitment to patient safety and preventing medication errors has spanned three decades. He received one of the prestigious MacArthur Fellowships (informally known as the "genius awards") in 2005.
Let’s take as a given that improving the ability of individuals and teams to function “as a team” is important in health care, especially in highly dynamic clinical environments.(1) How can this best be accomplished? In a comprehensive approach to teamwork...
In recent years, the medical community has reached a near-consensus that team training and Crew Resource Management (CRM) techniques can improve patient safety. However, the most effective way to teach and implement these concepts is much less clear...
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