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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.

GMS J Med Educ. 2019;36:Doc11-Doc22.

Patient safety has been described as an unmet need in physician training. This special issue covers areas of focus for a patient safety curriculum drawn from experience in the German medical education system. Topics covered include human error, blame, and responsibility. Articles also review the epidemiology of common problems such as medication safety, organizational contributors to failure, and diagnostic error.

J Health Serv Res Policy. 2015;20(suppl 1):S1-S60.

Articles in this special supplement explore research commissioned by National Institute for Health Research in the United Kingdom to address four patient safety research gaps: how organizational culture and context influence evaluations of interventions, organizational boundaries that affect handovers and other aspects of care, the role of the patient in safety improvement, and the economic costs and benefits of safety interventions.
Reynard J, Reynolds J, Stevenson P. Oxford, UK: Oxford University Press; 2009. ISBN: 9780199239931.
This book provides an introduction to key patient safety topics and includes a set of 20 case studies to demonstrate opportunities for error prevention.
Oakbrook Terrace, IL: The Joint Commission; November 2008.
The quality of care delivered at US hospitals continues to improve, according to data gathered by the Joint Commission from nearly 1,500 institutions. Hospitals improved their provision of evidence-based care for patients with heart attacks, congestive heart failure, and pneumonia, and also improved at prevention of health care–associated infections in surgical patients. As in the 2007 report, adherence to the National Patient Safety Goals was more mixed. Although performance improved in some areas (including medication reconciliation and eliminating "do not use" abbreviations), many hospitals do not systematically perform time outs prior to procedures, or have reliable mechanisms for communicating critical test results.
Prior to surgery, an anesthesiologist and surgical physician assistant noted a patient's allergy to IV contrast dye, but no order was written. During a time out before the procedure, an operative nurse raised concern about the allergy, but the attending anesthesiologist was not present and the resident did not speak up.
Intern J Health Care Qual Assur. 2007;20(7):555-632.
This special issue includes articles by authors from Australia, Israel, France, Iran, and Belgium that explore ideas such as building a culture of safety, replacing medical equipment, and measuring safety improvements.
Bagnara S; Tartaglia R; Wears RL; Perry SJ; Salas E; Rosen MA; King H; Carayon P; Alvarado CJ; Hundt AS; Healey AN; Vincent CA; Falzon P; Mollo V; Friesdorf W; Buss B; Marsolek I; Barach P; Bellandi T; Albolino S; Tomassini CR.
This special issue contains articles focusing on ergonomic research areas that intersect with patient safety, such as team management, work design, and safety culture.
On the day of a patient's scheduled electroconvulsive therapy, the clinic anesthesiologist called in sick. Unprepared for such an absence, the staff asked the very busy OR anesthesiologist to fill in on the case. Because the wrong drug was administered, the patient did not wake up as quickly as expected.
Matlow A; Laxer RM; Morath JM; Sharek PJ; Classen D; Keatings M; Martin M; McCallum A; Lewis J; Stevens P; Harrison C; Scanlon MC; Karsh BT; Densmore EM; Luria JW; Muething SE; Schoettker PJ; Kotagal UR; Parshuram CS; Kozer E; Berkovitch M; Koren G; Lehmann C; Kim GR; Streitenberger K; Breen-Reid K; Harris C; Flores G; Ngui E; Dunn KL; Moulden A; McDougall P; Bowes G; Curley MAQ; Schwalenstocker E; Deshpande JK; Ganser CC; Bertoch D; Brandon J; Kurtin P; Stevens P.
This special issue examines patient safety through the perspectives of parents, hospital leadership, human factors experts, and clinicians.
Feldman R
In this article, a nurse shares her firsthand account of what it was like to be a surgical patient and the surprising safety and quality shortcomings she encountered during her hospital stay.
Barbara A. Blakeney, MS, RN, is President of the 150,000-member American Nurses Association (ANA). A nurse practitioner and expert in public health practice, policy, and primary care, Ms. Blakeney is on leave from the Boston Public Health Commission, where she has been director of health care services for the homeless. She is the recipient of numerous awards and has been named to Modern Healthcare Magazine's list of the 100 most influential people in health care for the past 3 years.
Due to a series of incomplete signouts, information about a patient's post-operative leg pain and chest discomfort is not conveyed to the primary team. A PE is discovered post-mortem.