Debriefing is an important strategy for learning about and making improvements in individual, team, and system performance. It is one of the central learning tools in simulation training and is also recommended after significant clinical 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.
Burnout among health care professionals is highly prevalent. Current work focuses on understanding burnout and clinician well-being as system-level concerns that can influence safety, quality, and organizational performance.
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.
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.
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.
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.
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 of health information and health care tasks involved in managing health has implications on patient safety.
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.
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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