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This primer describes stressors relevant to the healthcare response to the COVID-19 pandemic from the perspective of care deliverers and the significant personal toll the pandemic is taking on individuals who work in the healthcare system. This primer highlights foundational patient safety strategies – signage, workflow review and redesign, checklists and simulations – whose implementation is more important than ever for keeping patients and healthcare providers safe in the age of COVID-19.
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.
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.
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.
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.
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.
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.
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.
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.