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- Communication Improvement(14)
- Computerized Decision Support(2)
- Computerized Provider Order Entry (CPOE)(3)
- Culture of Safety(12)
- Education and Training(13)
- Error Reporting and Analysis(19)
- Human Factors Engineering(10)
- Legal and Policy Approaches(4)
- Logistical Approaches(9)
- Policies and Operations(5)
- Quality Improvement Strategies(14)
- Research Directions(1)
- Specialization of Care(6)
- Technologic Approaches(8)
- Alert fatigue(2)
- Device-Related Complications(2)
- Diagnostic Errors(5)
- Discontinuities, Gaps, and Hand-Off Problems(6)
- Failure to rescue(2)
- Fatigue and Sleep Deprivation(1)
- Identification Errors(2)
- Inpatient suicide(1)
- Interruptions and distractions(2)
- Medical Complications(9)
- Medication Safety(11)
- MRI safety(1)
- Nonsurgical Procedural Complications(3)
- Psychological and Social Complications(5)
- Second victims(3)
- Surgical Complications(5)
- Transitions of Care(2)
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.
The rapid expansion of telehealth and the variation in implementation of new models of care into medical practice has resulted in emerging concerns regarding patient safety. This primer summarizes these concerns – including diagnostic errors, medication errors, and health equity considerations – as well as telehealth implementation strategies to enhance patient safety.
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.
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.
This publication serves as an update to the PSNet Primer released in August 2020. This content describes the outbreak of coronavirus disease 2019 (COVID-19), which effectively shut down the practices of approximately 198,000 active dental practitioners in the USA.
Diagnostic error has been increasingly recognized as an important and evolving patient safety issue. This Primer applies well-established principles of diagnostic error and improvement of diagnostic accuracy to the topic of COVID-19.
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.
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.
Communication failures among healthcare personnel are significant contributors to medical errors and patient harm.