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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.

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.

Nurses play a critical role in patient safety through their constant presence at the patient's bedside. However, staffing issues and suboptimal working conditions can impede a nurse’s ability to detect and prevent adverse events.

Medication administration errors are a persistent patient safety problem. Increasing the safety of medication administration requires a multifaceted, system-level approach that spans all areas of health care delivery, such as primary, specialty, inpatient, and community-based care.

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.

Pharmacists in all settings play a crucial role in medication safety.

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.

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).

Medication errors can occur at any step along the pathway that begins when a clinician prescribes a medication and ends when the patient receives the medication. Adverse drug events—harm experienced by a patient as a result of exposure to a medication—are often the result of medication errors and are likely the most common source of preventable harm in both hospitalized and ambulatory patients. Preventing adverse drug events is a major priority for accrediting bodies and regulatory agencies.

Computerized provider order entry systems ensure standardized, legible, and complete orders, and—especially when paired with decision support systems—have the potential to sharply reduce medication prescribing errors.