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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

Grace O'Malley, PhD, Ulfat Shaikh, MD, MPH, MS and James Marcin, MD, MPH |

The rapid expansion of telehealth and the variation in implementation of new models of care into medical practice has resulted in emerging concerns regarding patient safety. This primer summarizes these concerns – including diagnostic errors,... Read More

Peter Yellowlees, MBBS, MD and Margaret Rea, PhD |

Burnout is an occupational phenomenon that is highly prevalent among health care professionals. Current work focuses on understanding burnout and clinician well-being as system-level concerns that can adversely influence safety, quality, and... Read More

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

All Primers (62)

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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.
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.