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Perspectives

Our Perspectives on Safety section features expert viewpoints on current themes in patient safety, including interviews and written essays published monthly. Annual Perspectives highlight vital and emerging patient safety topics.

Latest Perspectives

Angela D. Thomas, DrPH, MPH, MBA; Merton Lee, PhD, PharmD; Sarah Mossburg, RN, PhD |

Certain groups of people disproportionately experience avoidable harm in our healthcare system. Over the course of 2023, research posted to AHRQ PSNet has focused on the issue of equity in patient safety. This Year in Review Perspective discusses this body of research,... Read More

Ayse P. Gurses; Sarah Mossburg; Zoe Sousane |

Throughout 2023, the importance of communication during transitions of care was a recurrent theme among articles on AHRQ PSNet. This Year in Review Perspective for 2023 discusses strategies for effective communication during transitions of care, spanning... Read More

Barbara Pelletreau, RN; John Riggi; Bryan M. Gale, MA; Sarah E. Mossburg, RN, PhD |

This piece discusses the threat that cybersecurity attacks pose to patient safety, as well as ways to prepare and respond to attacks.

John Murray, Joann Sorra, Bryan Gale, Sarah Mossburg |

Throughout 2023, the importance patient safety culture and workforce safety culture were recurrent themes among articles on AHRQ PSNet. This Year in Review Perspective for 2023 discusses concepts of psychological safety and employee voice,... Read More

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Displaying 1 - 20 of 197 Results
Angela D. Thomas, DrPH, MPH, MBA; Merton Lee, PhD, PharmD; Sarah Mossburg, RN, PhD |

Certain groups of people disproportionately experience avoidable harm in our healthcare system. Over the course of 2023, research posted to AHRQ PSNet has focused on the issue of equity in patient safety. This Year in Review Perspective discusses this body of research, through findings on clinician bias, technological tools, current initiatives directed at improving health equity, and in clinical areas such as obstetrics.

Ayse P. Gurses; Sarah Mossburg; Zoe Sousane |

Throughout 2023, the importance of communication during transitions of care was a recurrent theme among articles on AHRQ PSNet. This Year in Review Perspective for 2023 discusses strategies for effective communication during transitions of care, spanning interactions among healthcare professionals, across organizations, and with patients, families, and caregivers.

Barbara Pelletreau, RN; John Riggi; Bryan M. Gale, MA; Sarah E. Mossburg, RN, PhD |

This piece discusses the threat that cybersecurity attacks pose to patient safety, as well as ways to prepare and respond to attacks.

Barbara Pelletreau photograph

John Riggi is the national advisor for cybersecurity and risk at the American Hospital Association. Barbara Pelletreau is a former senior vice president of patient safety for a large healthcare organization. We spoke to them about the risks of cybersecurity to patient safety and how organizations can prepare and respond to cyberattacks.

Patrick Tighe, MD, MS; Bryan M. Gale, MA; Sarah E. Mossburg, RN, PhD |

This piece discusses the current and potential impacts of artificial intelligence on patient safety, as well as challenges to successful implementation.

Patrick Tighe photograph

Patrick Tighe, MD, MS, is a practicing anesthesiologist at University of Florida Health (UF Health) and the executive director of UF Health’s Quality and Patient Safety Initiative. We spoke to him about the current and potential impacts of artificial intelligence (AI) on patient safety as well as challenges to successful implementation.

John Murray, Joann Sorra, Bryan Gale, Sarah Mossburg |

Throughout 2023, the importance patient safety culture and workforce safety culture were recurrent themes among articles on AHRQ PSNet. This Year in Review Perspective for 2023 discusses concepts of psychological safety and employee voice, individual and team factors, and leadership and organizational factors related to safety culture.

Monika Haugstetter, MHA, MSN, RN, CPHQ; Stephen Hines, PhD; Zoe Sousane, BS; Sarah Mossburg, RN, PhD |

This piece discusses the impact of AHRQ’s TeamSTEPPS training curriculum on patient safety and highlights updates made to the curriculum in 2023 with the launch of TeamSTEPPS 3.0.

Stephen Hines headshot

Monika Haugstetter, MHA, MSN, RN, CPHQ, is a Health Science Administrator with AHRQ, leading AHRQ’s TeamSTEPPS® initiative. Stephen Hines, PhD, is a Senior Research Scientist at the Arbor Research Collaborative for Health. While at Abt Associates, he co-led the TeamSTEPPS 3.0 revisions in collaboration with AHRQ. We spoke with Monika and Stephen about the newly released TeamSTEPPS 3.0 curriculum.

Richard Ricciardi, Ph.D., CRNP, FAANP, FAAN; Merton Lee, PharmD, PhD; Sarah E. Mossburg, RN, PhD |

This perspective discusses patient safety in office-based care settings, where most patients get their healthcare. We discuss patient safety events that arise in routine office-based settings and those more particular to procedures performed in office-based ambulatory surgery centers. Communication strategies can mitigate safety risks and can be applied in many healthcare settings.

Richard Ricciardi

Richard Ricciardi is the associate dean for clinical practice and community engagement and the executive director of the Center for Health Policy and Media Engagement at the George Washington University. He has served as the director of the Division of Practice Improvement and senior advisor for nursing at AHRQ, and he maintains a part-time clinical practice at Mercy Health Clinic. We spoke to him on patient safety in office-based settings.

Jodi Sherman, MD, Merton Lee, PharmD, PhD, Sarah Mossburg, RN, PhD |

This perspective discusses the impact of climate change on human health and healthcare delivery, and how the healthcare system has contributed to pollution and climate change. Initiatives to decrease waste and emissions from healthcare can reduce the harm that healthcare pollution inflicts on population health while achieving safer, more resilient care.  

Jodi Sherman headshot

Jodi Sherman is an associate professor of anesthesiology at Yale School of Medicine and is the director of the Yale Program on Healthcare Environmental Sustainability. She also serves as the medical director for the Yale New Haven Health System Center for Sustainable Healthcare. We spoke to her on patient safety and sustainable healthcare.

Joan Stanley, PhD, NP, FAAN, FAANP; Bryan M. Gale, MA; Sarah E. Mossburg, RN, PhD |

This piece discusses how undergraduate professional nursing education integrates the topic of patient safety into classroom and clinical instruction, and how this affects patient safety as a whole.

Joan Stanley

Joan Stanley is the chief academic officer at the American Association of Colleges of Nursing (AACN).  We spoke to her about how undergraduate professional nursing education integrates the topic of patient safety into classroom and clinical instruction, and how this affects patient safety as a whole.

Cheryl B. Jones, PhD, RN, FAAN; Zoe Sousane, BS; Sarah E. Mossburg, RN, PhD |

This piece focuses on workplace violence trends in healthcare settings and strategies for creating a safer healthcare environment.

Cheryl B. Jones

Cheryl B. Jones is a professor, director of the Hillman Scholars Program, and interim associate dean of the School of Nursing’s PhD program at the University of North Carolina at Chapel Hill. We spoke to her about workplace violence trends in healthcare settings and how we can create a safer work environment for healthcare staff.

Patricia McGaffigan, MS, RN, CPPS; Cindy Manaoat Van, MHSA, CPPS; Sarah E. Mossburg, RN, PhD |

This piece focuses on the importance of patient safety following the end of the public health emergency and how organizations can move beyond the pandemic.

Patricia McGaffigan

Patricia McGaffigan is the Vice President for Safety Programs at the Institute for Healthcare Improvement and President of the Certification Board for Professionals in Patient Safety. We spoke to Patricia about patient safety trends and how patient safety will move beyond the pandemic.

Kathleen Sanford DBA, RN, FAAN, FACHE; Sue Schuelke PhD, RN-BC, CNE, CCRN-K; Merton Lee, PharmD, PhD; Sarah E. Mossburg, RN, PhD |

This piece discusses virtual nursing, an approach to care that incorporates an advanced practice nurse into hospital-based patient care through telehealth. Virtual nursing increases patient safety and may enable expert nurses to continue to meet patient needs in future staffing shortages.

Kathleen Sanford

Kathleen Sanford is the chief nursing officer and an executive vice president at CommonSpirit. Sue Schuelke is an assistant professor at the College of Nursing–Lincoln Division, University of Nebraska Medical Center. They have pioneered and tested a new model of nursing care that utilizes technology to add experienced expert nurses to care teams, called Virtual Nursing.

Regina M. Hoffman, MBA, RN, Cindy Manaoat Van, MHSA, CPPS, Sarah E. Mossburg, RN, PhD |

This piece focuses on the importance of building the capacity of the workforce and organizations for patient safety using patient safety education.

Regina Hoffman

Regina Hoffman is the executive director of the Pennsylvania Patient Safety Authority. We spoke to her about her experience in collaborative learning, sharing information across healthcare facilities, and patient safety education.

Beverley H. Johnson, FAAN, Merton Lee, PharmD, PhD, Sarah E. Mossburg, RN, PhD |

This piece discusses how family presence and participation in healthcare at all levels can improve patient safety as well as how the COVID-19 pandemic affected partnership with patients and families, ultimately highlighting the critical importance of family presence and participation.

Beverley H. Johnson

Beverley H. Johnson is the president and CEO of the Institute for Patient- and Family-Centered Care (IPFCC). We spoke to her about her experience in patient and family engagement and improving patient safety, including how to continue to partner with families during pandemics and through technology.

Jawad Al-Khafaji, MD, MHSA, Merton Lee, PhD, PharmD, Sarah Mossburg, RN, PhD |

Throughout 2022, AHRQ PSNet has shared research that elucidates the complex nature of misdiagnosis and diagnostic safety. This Year in Review explores recent work in diagnostic safety and ways that greater safety may be promoted using tools developed to improve diagnostic practices.

Susan McGrath, PhD,George Blike, MD, MHCDS,Bryan M. Gale, MA,Sarah E. Mossburg, RN, PhD |

This piece discusses surveillance monitoring of patients in low-acuity units of the hospital to prevent failure to rescue events, its difference from high-acuity continuous monitoring, and its potential applications in other settings.

Drs. Susan McGrath and George Blike discuss surveillance monitoring and its challenges and opportunities.

A Jay Holmgren, Susan McBride,Bryan Gale, Sarah Mossburg |

In the past several decades, technological advances have opened new possibilities for improving patient safety. Using technology to digitize healthcare processes has the potential to increase standardization and efficiency of clinical workflows and to reduce errors and cost across all healthcare settings.1 However, if technological approaches are designed or implemented poorly, the burden on clinicians can increase. For example, overburdened clinicians can experience alert fatigue and fail to respond to notifications. This can lead to more medical errors. As a testament to the significance of this topic in recent years, several government agencies [(e.g. the Agency for Healthcare Research and Quality (AHRQ) and the Centers for Medicare and Medicaid services (CMS)] have developed resources to help healthcare organizations integrate technology, such as the Safety Assurance Factors for EHR Resilience (SAFER) guides developed by the Office of the National Coordinator for Health Information Technology (ONC).2,3,4 However, there is some evidence that these resources have not been widely used.5 Recently, the Centers for Medicare & Medicaid Services (CMS) started requiring hospitals to use the SAFER guides as part of the FY 2022 Hospital Inpatient Prospective Payment Systems (IPPS), which should raise awareness and uptake of the guides.6

Christie Allen, MSN, RNC-NIC, CPHQ, C-ONQS, Cindy Manaoat Van, MHSA, Sarah E. Mossburg, RN, PhD |

This piece focuses on perinatal mental health and efforts to improve maternal safety.   

Christie Allen

Christie Allen is the Senior Director of Quality Improvement at the American College of Obstetrics and Gynecology (ACOG). We spoke to her about her experience in maternal safety and improving perinatal mental healthcare, which is care for mental health conditions during pregnancy and the twelve months following delivery

George Zangaro, PhD, RN, FAAN, Cindy Manaoat Van, MHSA, Sarah Mossburg, RN, PhD |

Throughout 2022, the impact of system failures on healthcare workers was a recurrent theme of articles on AHRQ PSNet. This Year in Review explores these impacts and ways to support healthcare workers involved in a system failure.  

Colton Hood, MD, MBI,Neal Sikka, MD,Cindy Manaoat Van, MHSA,Sarah E. Mossburg, RN, PhD |

This piece discusses the evolution of remote patient monitoring, emergence into use with acute conditions, patient safety considerations, and the continued challenges of telehealth implementation.

Dr. Neal Sikka and Dr. Colton Hood are emergency medicine physicians who work in the Innovative Practice & Telemedicine section at George Washington University Hospital (GW). We spoke with them about their experience implementing remote patient monitoring (RPM) programs, GW’s Maritime Medical Access program, and patient safety considerations in the remote environment.