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Primers

Guides for key topics in patient safety through context, epidemiology, and relevant AHRQ PSNet content. The Patient Safety 101 Primer provides an overview of the patient safety field and covers key definitions and concepts.

Latest Primers

Vanessa McElroy, MSN, PHN, ACM-RN, IQCI, Ron Billano Ordona, DNP, FNP-BC, GS-C, and Deb Bakerjian, PhD, APRN, FAAN, FAANP, FGSA |

Post-acute transitions – which involve patients being discharged from the hospital to home-based or community care environments – are associated with patient safety risks, often due to poor communication and fragmented care. This primer outlines the... Read More

Ulfat Shaikh, MD, MPH, MS |

This primer provides a broad overview of three widely used tools for investigating and responding to patient safety events and near misses. Tools covered in this primer are incident reporting systems, Root Cause Analysis (RCA), and Failure Modes and... Read More

Elsbeth Kalenderian, DDS, MPH, PhD; Yan Xiao, PhD, MS; Heiko Spallek, DMD, PhD, MSBA (CIS); Amy Franklin, PhD; Gregory Olsen, DDS, MSc; Muhammad F. Walji, PhD |

This publication serves as an update to the PSNet Primer released in August 2020. This content describes the outbreak of coronavirus disease 2019 (COVID-19), which effectively shut down the practices of approximately 198,000 active dental... Read More

All Primers (61)

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The widespread implementation of electronic health records has caused a sea change in health care and in medical practice. The digitization of health care data has had some positive effects on patient safety, but it has also created new patient safety concerns.
Most safety improvement efforts justifiably emphasize system performance. A clinician's individual skill level is an important component of the care delivery system that can influence patient safety—both independently and in conjunction with other system components. Emerging evidence examines assessment, monitoring, and improvement of clinicians' competence as a means of addressing this unique component and ensuring patient safety.
Failure to rescue is both a concept and a measure of hospital quality and safety. The concept captures the idea that systems should be able to rapidly identify and treat complications when they occur, while the measure has been defined as the inability to prevent death after a complication develops.
A large and growing number of Americans require care in skilled nursing facilities, inpatient rehabilitation facilities, or long-term acute care hospitals, often after an acute hospitalization. Data indicates that more than 20% of patients in these settings experience an adverse event during their stay.
Falls are a common source of patient harm in hospitals, and are considered a never event when they result in serious injury. Fall prevention requires a coordinated, multidisciplinary approach that entails individualized risk assessment and preventive interventions.
Anyone can find it challenging to understand medical terms, and millions of Americans have trouble understanding and acting upon health information. The mismatch between individuals' health literacy skills and the complexity of health information and health care tasks involved in managing health has implications on patient safety.
Measuring patient safety is a complex and evolving field, and achieving accurate and reliable measurement strategies remains a challenge for the safety field.
Though hospital boards have traditionally had relatively little oversight over quality and safety performance, emerging data indicates that board engagement is correlated with improved safety, and specific management strategies can be used to enhance an organization's quality and safety performance.
Triggers have become a widely used method of retrospectively analyzing medical records in order to identify errors and adverse events, measure the frequency with which such events occur, and track the progress of safety initiatives over time.
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.
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.
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.
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.
Medication errors can occur at any step along the pathway that begins when a clinician prescribes a medication and ends when the patient receives the medication. Adverse drug events—harm experienced by a patient as a result of exposure to a medication—are often the result of medication errors and are likely the most common source of preventable harm in both hospitalized and ambulatory patients. Preventing adverse drug events is a major priority for accrediting bodies and regulatory agencies.
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.
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.
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.