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- Communication Improvement
- Culture of Safety
- Error Reporting and Analysis 2
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Perspectives on Safety > Interview
The Transformation of Patient Safety at the VA, September 2006
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.
Journal Article > Study
Practice and quality improvement: successful implementation of TeamSTEPPS tools into an academic interventional ultrasound practice.
Gupta RT, Sexton JB, Milne J, Frush DP. AJR Am J Roentgenol. 2015;204:105-110.
Journal Article > Commentary
Kadar N. Am J Obst Gynecol. 2014;211:596-601.
Peer review can provide clinicians with the opportunity to learn from failure. However, insufficient understanding of medical error, process complexity, and a penchant for blame can limit its effectiveness. This commentary suggests that standards for peer assessment specific to error must be developed to achieve learning from mistakes.