Perspectives | AHRQ Patient Safety Network

Perspectives | AHRQ Patient Safety Network

Perspectives on Safety

INTERVIEW

In Conversation With… Andrew Gettinger, MD

Health Information Technology and Safety, September 2017

Dr. Gettinger is the Chief Medical Information Officer and the Executive Director of the Office of Clinical Quality and Safety for the Office of the National Coordinator (ONC). He led the development of an electronic health record (EHR) system at Dartmouth and was the senior physician leader during their transition to a vendor-based EHR. We spoke with him about safety and health information technology.

PERSPECTIVE

Assessing the Safety of Electronic Health Records: What Have We Learned?

with commentary by Dean F. Sittig, PhD, and Hardeep Singh, MD, MPH, Health Information Technology and Safety, September 2017

This piece highlights four key lessons that the authors believe are useful for clinicians and health care organizations that seek to identify, prevent, and mitigate electronic health record–related safety issues.

INTERVIEW

In Conversation With… Karl Bilimoria, MD, MS

Resident Duty Hours Policy Changes, August 2017

Dr. Bilimoria is the Director of the Surgical Outcomes and Quality Improvement Center of Northwestern University. He is the principal investigator of the Flexibility in Duty Hour Requirements for Surgical Trainees (FIRST) trial and a Faculty Scholar at the American College of Surgeons. We spoke with him about the FIRST trial, which examined how less restrictive duty hours affected patient outcomes and resident satisfaction. Its results informed recent changes to duty hour policies.

PERSPECTIVE

ACGME's 2017 Revision of Common Program Requirements

with commentary by Kathy Malloy; Timothy P. Brigham, PhD; Thomas J. Nasca, MD, Resident Duty Hours Policy Changes, August 2017

This piece reviews how changes to the ACGME requirements emphasize patient safety and quality improvement, address physician well-being, strengthen expectations around team-based care, and create flexibility for work hours within the maximum 80-hour workweek.

INTERVIEW

In Conversation With… Michelle Mello, MPhil, JD, PhD

Legal Issues and Patient Safety, July 2017

Michelle Mello is Professor of Law at Stanford Law School and Professor of Health Research and Policy at Stanford University School of Medicine. She conducts empirical research into issues at the intersection of law, ethics, and health policy. We spoke with her about legal issues in patient safety.

PERSPECTIVE

Doctors With Multiple Malpractice Claims, Disciplinary Actions, and Complaints: What Do We Know?

with commentary by David Studdert, LLB, ScD, Legal Issues and Patient Safety, July 2017

This piece explores the risk of recurring medicolegal events among providers who have received unsolicited patient complaints, faced disciplinary actions by medical boards, or accumulated malpractice claims.

INTERVIEW

In Conversation With… Paul Aylin, MBChB

The Weekend Effect, June 2017

Professor Aylin is Professor of Epidemiology and Public Health at Imperial College London. We spoke with him about the weekend effect in health care—the observation that patients admitted to the hospital over the weekend often have worse outcomes than those admitted during the week.

PERSPECTIVE

The Weekend Effect in Cardiology: Is It Real? If So, Can It Be Fixed?

with commentary by Vanessa K. Martin, DO, MS; Nasim Mirnateghi, PhD; and Mahdi Khoshchehreh, MD, MS, The Weekend Effect, June 2017

This piece explores the weekend effect in cardiology and recommends allowing invasive management for patients with non ST-elevation myocardial infarction to improve outcomes in this group.

INTERVIEW

In Conversation With… David Juurlink, MD, PhD

Opioids and Patient Safety, May 2017

Dr. Juurlink is professor of medicine, pediatrics, and health policy at the University of Toronto, where he is also director of the Division of Clinical Pharmacology and Toxicology. We spoke with him about the opioid epidemic and strategies to address this growing patient safety concern.

PERSPECTIVE

Opioid Overdose as a Patient Safety Problem

with commentary by Irene Berita Murimi, PhD, MA, and G. Caleb Alexander, MD, MS, Opioids and Patient Safety, May 2017

This piece explores the opioid epidemic in the United States, including factors that led to increased opioid prescribing, its adverse effects, and tactics to reduce opioid-related harm.

INTERVIEW

In Conversation With… Mark Chassin, MD, MPP, MPH

New Thinking About High Reliability, April 2017

Dr. Chassin is president and chief executive officer of The Joint Commission. He is also president of the Joint Commission Center for Transforming Healthcare, a center he began to promote high reliability and transformative practice. We spoke with him about new thinking in high reliability.

INTERVIEW

In Conversation With… Kathleen Sutcliffe, MN, PhD

New Thinking About High Reliability, April 2017

Professor Sutcliffe is a Bloomberg Distinguished Professor of Business and Medicine at Johns Hopkins University. She studies organizational adaptability, reliability, resilience, and safety in health care. We spoke with her about high reliability in health care organizations.

INTERVIEW

In Conversation With… Mary Dixon-Woods, DPhil

Approaching Safety Culture in New Ways, March 2017

Dr. Dixon-Woods is RAND Professor of Health Services Research at Cambridge University, Deputy Editor-in-Chief of BMJ Quality and Safety, and one of the world's leading experts on the sociology of health care. We spoke with her about new ways to approach safety culture.

PERSPECTIVE

Our Maturing Understanding of Safety Culture: How to Change It and How It Changes Safety

with commentary by Sara J. Singer, MBA, PhD, Approaching Safety Culture in New Ways, March 2017

This piece discusses the importance of strengthening safety culture in health care and offers insights for organizations seeking to achieve culture change.

ANNUAL PERSPECTIVE

Measuring and Responding to Deaths From Medical Errors

with commentary by Sumant Ranji, MD, 2016

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.

INTERVIEW

In Conversation With… Amy C. Edmondson, PhD, AM

Update on Teamwork, February 2017

Dr. Edmondson is the Novartis Professor of Leadership and Management at Harvard Business School. She is an expert on leadership, teams, and organizational learning. We spoke with her about the role of teamwork in health care and why it is becoming increasingly important.

PERSPECTIVE

New Insights About Team Training From a Decade of TeamSTEPPS

with commentary by David P. Baker, PhD; James B. Battles, PhD; Heidi B. King, MS, Update on Teamwork, February 2017

This piece outlines 10 insights about team training in health care learned from experience with the AHRQ-supported teamwork training program, TeamSTEPPS.

INTERVIEW

In Conversation With… Paul H. O'Neill, MPA

Workplace Safety, January 2017

Mr. O'Neill served as the United States Secretary of the Treasury under President George W. Bush and, prior to that, chairman and CEO of Alcoa. We spoke with him about workplace safety and its relationship to patient safety and organizational excellence.

PERSPECTIVE

Workplace Safety in Health Care

with commentary by Ross W. Simon and Elena G. Canacari, RN, Workplace Safety, January 2017

This piece explores how a team at Beth Israel Deaconess Medical Center combined tools and techniques used in manufacturing along with continuous improvement to develop a process to identify, prioritize, and mitigate hazards in health care settings.

ANNUAL PERSPECTIVE

Patient Safety and Opioid Medications

with commentary by Urmimala Sarkar, MD, and Kaveh Shojania, MD, 2016

Opioids are known to be high risk medications, and concerns about patient harm from prescription opioid misuse have been increasing in the United States. This Annual Perspective summarizes research published in 2016 that explored the extent of harm from their use, described problematic prescribing practices that likely contribute to adverse events, and demonstrated some promising practices to foster safer opioid use.