Patient safety events that occur in health care facilities require prompt action to ensure that further harm is mitigated, and future errors are prevented. Using a standardized and robust organizational approach to respond to such events promotes a culture of patient safety. Steps in responding to patient safety events include reporting, investigation, communication, remediation, data tracking, and system improvement. This Patient Safety Primer will focus on communication, remediation, and system improvement.

Safety I and Safety II are perspectives on how to think about systems and safety. Safety I defines safety as having as few things go wrong as possible whereas the Safety II perspective defines safety by as many things going right as possible. This primer describes the historical foundations of Safety I/II, compares the principles of each perspective, and provides examples of how they can be applied by healthcare organizations.  

A retained surgical item (RSI) is a surgical patient safety problem stemming from ineffective practices and communication strategies among healthcare professionals working in a complex, stressful environment. RSI prevention efforts should focus on improving surgical item management and enhancing effective communication among members of the healthcare team.

The National Patient Safety Goals (NPSG) were developed in response to the high prevalence of preventable medical errors in the United States. This primer describes the NPSGs, how they relate to other goals and priorities established by national organizations, and how health care systems can use these goals to drive patient safety improvement efforts.