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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.
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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.
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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.
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Discharge planning is an essential part of transitions of care, during which patients are often at a higher risk for adverse events and harm. It is important for all healthcare providers to identify risk factors prior to transitioning patients and put plans in place as part of the discharge plan to mitigate harm. Effective discharge planning between the discharging and accepting healthcare teams can help reduce adverse events.
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Communication failures among healthcare personnel are significant contributors to medical errors and patient harm.
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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.
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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.
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Clear and high-quality communication between all staff involved in caring for a patient is essential in order to achieve situational awareness. Breakdowns in communication are closely tied to preventable adverse events in hospitalized and ambulatory patients.
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Efforts to engage patients in safety efforts have focused on three areas: enlisting patients in detecting adverse events, empowering patients to ensure safe care, and emphasizing patient involvement as a means of improving the culture of safety.
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Discontinuity is an unfortunate but necessary reality of hospital care. No provider can stay in the hospital around the clock, creating the potential for errors when clinical information is transmitted incompletely or incorrectly between clinicians.
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Unintended inconsistencies in medication regimens occur with any transition in care. Medication reconciliation refers to the process of avoiding such inadvertent inconsistencies by reviewing the patient's current medication regimen and comparing it with the regimen being considered for the new setting of care.
