Perspectives | AHRQ Patient Safety Network

Perspectives | AHRQ Patient Safety Network

Perspectives on Safety

ANNUAL PERSPECTIVE

Rethinking Root Cause Analysis

with commentary by Kiran Gupta, MD, MPH, and Audrey Lyndon, PhD, 2016

Root cause analysis is widely accepted as a key component of patient safety programs. In 2016, the literature outlined ongoing problems with the root cause analysis process and shed light on opportunities to improve its application in health care. This Annual Perspective reviews concerns about the root cause analysis process and highlights recommendations for improvement put forth by the National Patient Safety Foundation.

INTERVIEW

In Conversation With... James P. Bagian, MD, PE

Root Cause Analysis: What Have We Learned?, December 2016

Dr. Bagian is Director of the Center for Healthcare Engineering and Patient Safety at the University of Michigan, and a former astronaut. He co-chaired the team that produced the influential NPSF report entitled, RCA2: Improving Root Cause Analyses and Actions to Prevent Harm.

PERSPECTIVE

Errors and Near Misses: What Health Care Could Learn From Aviation

with commentary by Carl Macrae, PhD, Root Cause Analysis: What Have We Learned?, December 2016

This piece explores how strategies from aviation, such as just culture and monitoring technologies, can be applied in health care to improve patient safety.

INTERVIEW

In Conversation With… Andrew Bindman, MD

New Leaders in Safety and Quality, November 2016

Dr. Bindman, an expert in health policy in underserved populations, was appointed as director of the Agency for Healthcare Research and Quality (AHRQ) in May 2016. We spoke with him about his new role at AHRQ.

INTERVIEW

In Conversation With… Derek Feeley

New Leaders in Safety and Quality, November 2016

In January 2016, Mr. Feeley, a leading health care administrator from Scotland, became the third President and CEO of the Institute for Healthcare Improvement (IHI), probably the most influential organization of its kind. We spoke with him about his work at IHI to improve health care quality and safety.

INTERVIEW

In Conversation With… Richard Platt, MD, MSc

Big Data and Patient Safety, October 2016

Dr. Platt is Professor and Chair of the Harvard Medical School Department of Population Medicine. We spoke with him about big data and patient safety.

PERSPECTIVE

Health Care Data Science for Quality Improvement and Patient Safety

with commentary by Alvin Rajkomar, MD, Big Data and Patient Safety, October 2016

This piece explores the role for a clinician data scientist in utilizing clinical datasets to improve health care quality and safety.

INTERVIEW

In Conversation With… Reed V. Tuckson, MD

Telemedicine and Patient Safety, September 2016

Dr. Tuckson is President of the American Telemedicine Association. We spoke with him about telemedicine and patient safety.

PERSPECTIVE

Telemedicine and Patient Safety

with commentary by Stephen Agboola, MD, MPH, and Joseph Kvedar, MD, Telemedicine and Patient Safety, September 2016

This piece explores benefits and safety concerns associated with the increased adoption of telemedicine services.

INTERVIEW

In Conversation With… Bernardo Perea-Pérez, MD, DDS, PhD

Patient Safety in Dentistry, July/August 2016

Dr. Perea-Pérez is Director of the Spanish Observatory for Dental Patient Safety. We spoke with him about patient safety in dentistry.

PERSPECTIVE

Safety In Dentistry

with commentary by Rachel Badovinac Ramoni, DMD, ScD; Muhammad Walji, PhD; and Elsbeth Kalenderian, DDS, MPH, PhD, Patient Safety in Dentistry, July/August 2016

This piece examines patient safety issues unique to dental care along with strategies to reduce risks.

INTERVIEW

In Conversation With… Gregg S. Meyer, MD, MSc

Certification in Patient Safety, June 2016

Dr. Meyer is Chief Clinical Officer of Partners Healthcare System, the large Boston-based system that includes Massachusetts General and Brigham and Women's Hospitals. We spoke with him about training and certification in patient safety.

PERSPECTIVE

Becoming a Certified Professional in Patient Safety—A Registered Nurse's Perspective

with commentary by Karen Frank, DNP, RN, MSHA, Certification in Patient Safety, June 2016

This piece offers a nurse's viewpoint on the benefits of acquiring certification in patient safety.

PERSPECTIVE

Becoming a Certified Professional in Patient Safety—A Pharmacist's Perspective

with commentary by Zahra Khudeira, PharmD, Certification in Patient Safety, June 2016

In this piece, a pharmacist highlights the importance of earning patient safety certification.

PERSPECTIVE

Reducing the Safety Hazards of Monitor Alert and Alarm Fatigue

with commentary by Samantha Jacques, PhD, and Eric Williams, MD, MS, MMM, Alert and Alarm Fatigue, May 2016

This piece describes strategies to reduce alarm fatigue in hospitals, including educating staff and patients, customizing alarm settings, and performing maintenance of lead wires.

INTERVIEW

In Conversation With... Barbara Drew, RN, PhD

Alert and Alarm Fatigue, May 2016

Dr. Drew is the David Mortara Distinguished Professor of Physiological Nursing and Clinical Professor of Medicine in Cardiology at the University of California, San Francisco. We spoke with her about the perils and prevalence of alert fatigue.

INTERVIEW

In Conversation With… Thomas J. Nasca, MD, MACP

CLER and I-PASS, April 2016

Dr. Nasca is CEO of the Accreditation Council for Graduate Medical Education, the major accreditor of residency and fellowship training programs, and CEO of ACGME International. We spoke with him about ACGME's Clinical Learning Environment Review (CLER) program and its impact on medical education.

INTERVIEW

In Conversation With… Amy J. Starmer, MD, MPH

CLER and I-PASS, April 2016

Dr. Starmer is Director of Primary Care Quality Improvement and Assistant Professor of Pediatrics at Boston Children's Hospital and Harvard Medical School. We spoke with her about handoffs and the implementation and findings of the landmark I-PASS study.

INTERVIEW

In Conversation With… Richard Kronick, PhD

Federal Organizations in Patient Safety, March 2016

Dr. Kronick has served as director of the Agency for Healthcare Research and Quality since August 2013, and will be stepping down from the role this month. We spoke with him about AHRQ's efforts to develop measurements and implement improvements in patient safety.

INTERVIEW

In Conversation With… Paul McGann, MD

Federal Organizations in Patient Safety, March 2016

Dr. McGann is the Chief Medical Officer for Quality Improvement at the Centers for Medicare & Medicaid Services (CMS) and the Co-Director of the CMS Partnership for Patients. We spoke with him about his work at CMS and with the Partnership for Patients initiative.