Primers

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 main types of home-based care services and formal home-based care programs and how these services can increase patient safety and improve health outcomes.

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 Effects Analysis (FMEA). These tools have been used in high-risk industries and occupations such as aviation, manufacturing, nuclear power, and the military and have been adapted for use in enhancing patient safety in healthcare settings over the past two decades.

Residents living in nursing homes or residential care facilities use common dining and activity spaces and may share rooms, which increases the risk for transmission of COVID-19 infection. This document describes key patient safety challenges facing older adults living in these settings, who are particularly vulnerable to the effects of the virus, and identifies federal guidelines and resources related to COVID-19 prevention and mitigation in long-term care. As of April 13, 2020, the Associated

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 practitioners in the USA. This primer summarizes best practices for infection control and prevention in the dental office setting, reviews HHS guidance on treating dental patients with suspected or confirmed COVID-19, discusses access issues for patients needing oral healthcare, and offers various Federal and professional resources to support the reconfiguration of dental practice, the implementation of tele-dentistry, and the prioritization of dental care needs after practices reopen. This primer concludes with key research priorities to support safe and effective dental care during and after the COVID-19 pandemic.

Diagnostic error has been increasingly recognized as an important and evolving patient safety issue. This Primer applies well-established principles of diagnostic error and improvement of diagnostic accuracy to the topic of COVID-19.

Debriefing is an important strategy for learning about and making improvements in individual, team, and system performance. It is one of the central learning tools in simulation training and is also recommended after significant clinical events.

Deprescribing is an intervention used to reduce the risk of adverse drug events (ADEs) that can result from polypharmacy. It is the process of supervised medication discontinuation or dose reduction to reduce potentially inappropriate medication (PIM) use.

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

An essential aspect of preventing medical errors and improving patient safety is using data effectively to understand, track and communicate performance on patient safety metrics. This primer provides an overview of visual tools – histograms, scatter plots, run charts and control charts – hospitals and health systems can leverage to track patient safety data.

Medication administration errors are a persistent patient safety problem. Increasing the safety of medication administration requires a multifaceted, system-level approach that spans all areas of health care delivery, such as primary, specialty, inpatient, and community-based care.

This primer describes stressors relevant to the healthcare response to the COVID-19 pandemic from the perspective of care deliverers and the significant personal toll the pandemic is taking on individuals who work in the healthcare system. This primer highlights foundational patient safety strategies – signage, workflow review and redesign, checklists and simulations – whose implementation is more important than ever for keeping patients and healthcare providers safe in the age of COVID-19.

Discharge planning is an essential part of transitions of care, during which patients are often at a higher risk for adverse events and harm. It is important for all healthcare providers to identify risk factors prior to transitioning patients and put plans in place as part of the discharge plan to mitigate harm. Effective discharge planning between the discharging and accepting healthcare teams can help reduce adverse events.

Communication failures among healthcare personnel are significant contributors to medical errors and patient harm.  This new primer provides an overview of “huddles”, a technique to enhance team communication that has been shown to reduce the risk for harm. The “Huddles” primer provides a definition along with when and how huddles might be used to improve patient safety.

Clinical decision support systems provide information or recommendations to help clinicians make safe and evidence-based decisions. The use and sophistication of these systems have grown markedly over the past decade, due to widespread implementation of electronic health records and advances in clinical informatics.

Pregnancy, childbirth, and the postpartum year present a complex set of patient safety challenges. Numerous maternal safety initiatives aim to prevent errors and harm, while enhancing readiness to address maternal complications.

Over the past decade, the opioid epidemic has taken the lives of tens of thousands of patients. Much of the epidemic can be ascribed to inappropriate prescribing of opioids, despite knowledge of the safety risks they pose. Current efforts to improve opioid safety have primarily focused on reducing opioid prescribing.

Pharmacists in all settings play a crucial role in medication safety.

Infections after surgery are common and frequently lead to hospital readmission and other adverse consequences for patients. Recent programs, including several led by the Agency for Healthcare Research and Quality, have demonstrated how hospitals can successfully prevent these infections.

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.

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.