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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
Deb Bakerjian PhD, APRN, FAAN, FAANP, FGSA |
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... 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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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.
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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.
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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.
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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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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.
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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.
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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.
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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.
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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.
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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.
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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.
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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.
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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.
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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.
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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.
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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.
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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.
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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.
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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.
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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.
