The AHRQ PSNet Collection comprises an extensive selection of resources relevant to the patient safety community. These resources come in a variety of formats, including literature, research, tools, and Web sites. Resources are identified using the National Library of Medicine’s Medline database, various news and content aggregators, and the expertise of the AHRQ PSNet editorial and technical teams.
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.
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.
Health care organizations use a variety of established and emerging methods to prospectively identify safety hazards before errors have occurred and to retrospectively analyze errors to prevent future harm.
Medicine has traditionally treated errors as failings on the part of individual providers, reflecting inadequate knowledge or skill. The systems approach, by contrast, takes the view that most errors reflect predictable human failings in the context of poorly designed systems.
Patient safety event reporting systems are ubiquitous in hospitals and are a mainstay of efforts to detect safety and quality problems. However, while event reports may highlight specific safety concerns, they do not provide insights into the epidemiology of safety problems.
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.
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