Patient Safety Primers

Guides for key topics in patient safety through context, epidemiology, and relevant AHRQ PSNet content.

Adverse Events after Hospital Discharge

Being discharged from the hospital can be dangerous for patients. Nearly 20% of patients experience an adverse event in the first 3 weeks after discharge, including medication errors, health care–associated infections, and procedural complications.

Alert Fatigue

Computerized warnings and alarms are used to improve safety by alerting clinicians of potentially unsafe situations. However, this proliferation of alerts may have negative implications for patient safety as well.


Though a seemingly simple intervention, checklists have played a leading role in the most significant successes of the patient safety movement, including the near-elimination of central line–associated bloodstream infections in many intensive care units.

Computerized Provider Order Entry

Computerized provider order entry systems ensure standardized, legible, and complete orders, and—especially when paired with decision support systems—have the potential to sharply reduce medication prescribing errors.

Detection of Safety Hazards

Health care organizations use a variety of established and emerging methods to prospectively identify safety hazards before errors have occurred and to retrospectively analyze errors to prevent future harm.

Diagnostic Errors

Thousands of patients die every year due to diagnostic errors. While clinicians’ cognitive biases play a role in many diagnostic errors, underlying health care system problems also contribute to missed and delayed diagnoses.

Disruptive and Unprofessional Behavior

Popular media often depicts physicians as brilliant, intimidating, and condescending in equal measures. This stereotype, though undoubtedly dramatic and even amusing, obscures the fact that disruptive and unprofessional behavior by clinicians poses a definite threat to patient safety.

Error Disclosure

Many victims of medical errors never learn of the mistake, because the error is simply not disclosed. Physicians have traditionally shied away from discussing errors with patients, due to fear of precipitating a malpractice lawsuit and embarrassment and discomfort with the disclosure process.

Handoffs and Signouts

Discontinuity is an unfortunate but necessary reality of hospital care. No provider can stay in the hospital around the clock, creating the potential for errors when clinical information is transmitted incompletely or incorrectly between clinicians.

Health Care–Associated Infections

Although long accepted by clinicians as an inevitable hazard of hospitalization, recent efforts demonstrate that relatively simple measures can prevent the majority of health care–associated infections. As a result, hospitals are under intense pressure to reduce the burden of these infections.

High Reliability

High reliability organizations are organizations that operate in complex, high-hazard domains for extended periods without serious accidents or catastrophic failures. High reliability is an ongoing process of cultivating organizational mindfulness; standardization is necessary but not sufficient for achieving resilient and reliable health care systems.

Human Factors Engineering

Human factors engineering is the discipline that attempts to identify and address safety problems that arise due to the interaction between people, technology, and work environments.

Improving Communication Between Clinicians

Clear and high-quality communication between all staff involved in caring for a patient is essential in order to achieve situational awareness. Breakdowns in communication are closely tied to preventable adverse events in hospitalized and ambulatory patients.

Medication Errors

Adverse drug events are likely the most common source of preventable harm in both hospitalized and ambulatory patients, and preventing ADEs is a major priority for accrediting bodies and regulatory agencies. Medication errors can occur at any stage of the medication use pathway, and a growing evidence base supports specific strategies to prevent ADEs.

Medication Reconciliation

Unintended inconsistencies in medication regimens occur with any transition in care. Medication reconciliation refers to the process of avoiding such inadvertent inconsistencies by reviewing the patient's current medication regimen and comparing it with the regimen being considered for the new setting of care.

Missed Nursing Care

Missed nursing care is linked to patient harm including falls and infections. Organizations can prevent missed nursing care by ensuring appropriate nurse staffing, promoting a positive safety culture, and making sure needed supplies and equipment are readily available.

Never Events

The list of never events has expanded over time to include adverse events that are unambiguous, serious, and usually preventable. While most are rare, when never events occur, they are devastating to patients and indicate serious underlying organizational safety problems.

Nursing and Patient Safety

Nurses play a critical role in patient safety through their constant presence at patient's bedside. However, staffing issues and suboptimal working conditions can impede nurses' ability to detect and prevent adverse events.

Patient Safety in Ambulatory Care

The vast majority of health care takes place in the outpatient, or ambulatory, setting, and a growing body of research has identified and characterized factors that influence safety in office practice, the types of errors commonly encountered in ambulatory care, and potential strategies for improving ambulatory safety.

Physician Work Hours and Patient Safety

Long and unpredictable work hours have been a staple of medical training for centuries. However, little attention was paid to the patient safety effects of fatigue among residents until March 1984, when Libby Zion died due to a medication-prescribing error while under the care of residents in the midst of a 36-hour shift.

Radiation Safety

Greater availability of advanced diagnostic imaging techniques has resulted in tremendous benefits to patients. However, the increased use of diagnostic imaging poses significant harm to patients through excessive exposure to ionizing radiation.

Rapid Response Systems

Rapid response teams represent an intuitively simple concept: when a patient demonstrates signs of imminent clinical deterioration, a team of providers is summoned to the bedside to immediately assess and treat the patient with the goal of preventing adverse clinical outcomes.

Root Cause Analysis

Initially developed to analyze industrial accidents, root cause analysis is now widely deployed as an error analysis tool in health care. A central tenet of RCA is to identify underlying problems that increase the likelihood of errors while avoiding the trap of focusing on mistakes by individuals.

Safety Culture

High-reliability organizations consistently minimize adverse events despite carrying out intrinsically hazardous work. Such organizations establish a culture of safety by maintaining a commitment to safety at all levels, from frontline providers to managers and executives.

Simulation Training

Simulation-based training has been successful in other industries, such as aviation, and is emerging as a key component of the patient safety movement. Simulation is increasingly being used to improve clinical and teamwork skills in a variety of health care environments.

Support for Clinicians Involved in Errors and Adverse Events (Second Victims)

The first priority following a medical error or adverse event is to attend to the patient and family. However clinicians can also be deeply affected by errors and adverse events and may need structured follow-up to ensure adaptive coping and organization learning.

Systems Approach

Medicine has traditionally treated errors as failings on the part of individual providers, reflecting inadequate knowledge or skill. The systems approach, by contrast, takes the view that most errors reflect predictable human failings in the context of poorly designed systems.

Teamwork Training

Providing safe health care depends on highly trained individuals with disparate roles and responsibilities acting together in the best interests of the patient. The need for improved teamwork has led to the application of teamwork training principles, originally developed in aviation, to a variety of health care settings.

The Role of the Patient in Safety

Efforts to engage patients in safety efforts have focused on three areas: enlisting patients in detecting adverse events, empowering patients to ensure safe care, and emphasizing patient involvement as a means of improving the culture of safety.

Voluntary Patient Safety Event Reporting (Incident Reporting)

Patient safety event reporting systems are ubiquitous in hospitals and are a mainstay of efforts to detect safety and quality problems. However, while event reports may highlight specific safety concerns, they do not provide insights into the epidemiology of safety problems.

Wrong-Site, Wrong-Procedure, and Wrong-Patient Surgery

Few medical errors are as terrifying as those that involve patients who have undergone surgery on the wrong body part, undergone the incorrect procedure, or had a procedure intended for another patient. These "wrong-site, wrong-procedure, wrong-patient errors" (WSPEs) are rightly termed never events.

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