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Perspectives on Safety > Annual Perspective
with commentary by Rachel J. Stern, MD, and Urmimala Sarkar, MD, 2018
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.
Office of the Inspector General. Washington, DC: US Department of Health and Human Services; July 2006. Report No. OEI-01-04-00340.
This report shares findings from an assessment of Centers for Medicaid and Medicare Services response to nursing home complaints. The report identifies weaknesses in the current investigation process and provides recommendations for improvement.
Journal Article > Commentary
Sangarlangkarn A. Healthc (Amst). 2019;7:31-32.
Rigid adherence to protocols may detract from safety when unexpected critical events occur that require deviation from the standard process. This commentary explores insights from a physician, both as a clinician and as a new mother, when health care staff failed to effectively consider patient concerns and knowledge in understanding and treating the cause of postlabor pain. The patient identified the cause and requested appropriate treatment, but nurses consulted protocols for pain after labor and only offered pain medications, which might have exacerbated the problem. The author calls for clinician autonomy to recognize when standardization is not appropriate and how to address individual patient needs.