Patient safety indicators are tools used to assess the frequency, severity, and impact of potential harms in health care, both within health care organizations and at the health care system, regional, and national levels. This primer describes how patient safety indicators are applied in acute, ambulatory, and post-acute care settings and how these indicators are being incorporated into new federal healthcare quality measurement initiatives.  

This primer provides a broad overview of three widely used tools for investigating and responding to patient safety events and near misses. Tools covered in this primer are incident reporting systems, Root Cause Analysis (RCA), and Failure Modes and Effects Analysis (FMEA). These tools have been used in high-risk industries and occupations such as aviation, manufacturing, nuclear power, and the military and have been adapted for use in enhancing patient safety in healthcare settings over the past two decades.

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.

An essential aspect of preventing medical errors and improving patient safety is using data effectively to understand, track and communicate performance on patient safety metrics. This primer provides an overview of visual tools – histograms, scatter plots, run charts and control charts – hospitals and health systems can leverage to track patient safety data.

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.

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.

Falls are a common source of patient harm in hospitals, and are considered a never event when they result in serious injury. Fall prevention requires a coordinated, multidisciplinary approach that entails individualized risk assessment and preventive interventions.

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.

Measuring patient safety is a complex and evolving field, and achieving accurate and reliable measurement strategies remains a challenge for the safety field.

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).

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.

Initially developed to analyze industrial accidents, root cause analysis is now widely deployed as an error analysis tool in health care. A central tenet of RCA is to identify underlying problems that increase the likelihood of errors while avoiding the trap of focusing on mistakes by individuals.

The list of never events has expanded over time to include adverse events that are unambiguous, serious, and usually preventable. While most are rare, when never events occur, they are devastating to patients and indicate serious underlying organizational safety problems.

Many victims of medical errors never learn of the mistake, because the error is simply not disclosed. Physicians have traditionally shied away from discussing errors with patients, due to fear of precipitating a malpractice lawsuit and embarrassment and discomfort with the disclosure process.