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.
Anyone can find it challenging to understand medical terms, and millions of Americans have trouble understanding and acting upon health information. Health literate organizations make health... Read More
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... Read More
Patient safety indicators are tools used to assess the frequency, severity, and impact of potential harms in health care, both within health care organizations and at the health care system, regional, and national levels.... Read More
Simulation training has become a key component of the patient safety movement and healthcare professional education. Simulation is increasingly being used to improve clinical and teamwork skills in a variety of health care... Read More
All Primers (64)
- Error Reporting and Analysis(16)
- Communication Improvement(12)
- Quality Improvement Strategies(11)
- Culture of Safety(10)
- Education and Training(10)
- Human Factors Engineering(7)
- Logistical Approaches(6)
- Technologic Approaches(5)
- Policies and Operations(4)
- Specialization of Care(3)
- Computerized Provider Order Entry (CPOE)(2)
- Legal and Policy Approaches(2)
- Computerized Decision Support(1)
- Medication Safety(10)
- Medical Complications(8)
- Discontinuities, Gaps, and Hand-Off Problems(5)
- Surgical Complications(4)
- Diagnostic Errors(3)
- Psychological and Social Complications(3)
- Identification Errors(2)
- Interruptions and distractions(2)
- Nonsurgical Procedural Complications(2)
- Second victims(2)
- Transitions of Care(2)
- Alert fatigue(1)
- Device-Related Complications(1)
- Failure to rescue(1)
- Fatigue and Sleep Deprivation(1)
- Inpatient suicide(1)
- MRI safety(1)
Anyone can find it challenging to understand medical terms, and millions of Americans have trouble understanding and acting upon health information. Health literate organizations make health systems easier to navigate and health information easier to understand, improving healthcare delivery and outcomes.
Patient safety indicators are tools used to assess the frequency, severity, and impact of potential harms in health care, both within health care organizations and at the health care system, regional, and national levels. This primer describes how patient safety indicators are applied in acute, ambulatory, and post-acute care settings and how these indicators are being incorporated into new federal healthcare quality measurement initiatives.
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, medication errors, and health equity considerations – as well as telehealth implementation strategies to enhance patient safety.
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.
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.
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.
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.
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.