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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

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Digital Health Literacy
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

Personal Health Literacy
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

Strategies to Improve Organizational Health Literacy.
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

Patient Safety Indicators.
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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Displaying 61 - 65 of 65 Results
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    • Culture of Safety
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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.
    Rapid Response Systems
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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.
    Never Events
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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.
    Disclosure of 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.
    Medication Reconciliation
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    • 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.
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