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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
Elizabeth Seidel, MSW, Tara Cortes, PhD, RN, FAAN, and Cynthia Chong, MPA |
Many people have trouble understanding health information. As more people search for health information online, it is critical that people are able to obtain accurate health information and access healthcare services. Digital... Read More
Deb Bakerjian, PhD, APRN, FAANP, FGSA, FAAN |
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
Elizabeth Seidel, MSW, Tara Cortes, PhD, RN, FAAN, and Cynthia Chong, MPA |
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
Irina Tokareva, RN, BSN, MAS, CPHQ and Patrick Romano, MD, MPH. |
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
All Primers (65)
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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.
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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.
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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.
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Pharmacists in all settings play a crucial role in medication safety.
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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.
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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.
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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.
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This Primer provides an overview of the history and current status of the patient safety field and key definitions and concepts. It links to other Patient Safety Primers that discuss the concepts in more detail.
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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.
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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.
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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.
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Sleep deprivation is known to impair various cognitive functions, and its effect on clinician performance may have significant implications for patient safety.
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Measuring patient safety is a complex and evolving field, and achieving accurate and reliable measurement strategies remains a challenge for the safety field.
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The terms adverse events, near misses, and medical errors are used in patient safety to refer to events where patients were harmed (or easily could have been).
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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.
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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.
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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.
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The first priority following a medical error or adverse event is to attend to the patient and family. However clinicians can also be deeply affected by errors and adverse events and may need structured follow-up to ensure adaptive coping and organization learning.
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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.
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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.
