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Primers

Guides for key topics in patient safety through context, epidemiology, and relevant AHRQ PSNet content. The Patient Safety 101 Primer provides an overview of the patient safety field and covers key definitions and concepts.

Latest Primers

Deb Bakerjian PhD, APRN, FAAN, FAANP, FGSA |

A large and growing number of Americans require care in skilled nursing facilities, inpatient rehabilitation facilities, or long-term acute care hospitals, often after an acute hospitalization. Data indicates that... Read More

Anna Satake PhD, MSN, GCNS, RN and Vanessa McElroy, MSN, PHN, ACM-RN, IQCI |

Transitions of care occur frequently during hospitalizations and present notable risks associated with communication, medication management, and caregiver preparedness. To address these... Read More

Ulfat Shaikh, MD, MPH, FAAP |

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... Read More

Marla Shauer, PhD(c), MSN, CNM; Amy Nichols, EdD, RN, CNS, CHSE, ANEF; Audrey Lyndon, RN, PhD, FAAN |

Pregnancy, childbirth, and the postpartum year present a complex set of patient safety challenges. Numerous maternal safety initiatives aim to prevent errors and harm, while enhancing readiness to address maternal complications.

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Displaying 1 - 20 of 68 Results
Displaying 1 - 20 of 68 Results
Deb Bakerjian PhD, APRN, FAAN, FAANP, FGSA |
A large and growing number of Americans require care in skilled nursing facilities, inpatient rehabilitation facilities, or long-term acute care hospitals, often after an acute hospitalization. Data indicates that more than 20% of patients in these settings experience an adverse event during their stay.
Anna Satake PhD, MSN, GCNS, RN and Vanessa McElroy, MSN, PHN, ACM-RN, IQCI |

Transitions of care occur frequently during hospitalizations and present notable risks associated with communication, medication management, and caregiver preparedness. To address these risks, healthcare systems must create safety nets to ensure seamless transitions and patient-centered experience while decreasing the risk of medical errors, elevating the overall quality of care and bettering patient outcomes.

Ulfat Shaikh, MD, MPH, FAAP |

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.

Marla Shauer, PhD(c), MSN, CNM; Amy Nichols, EdD, RN, CNS, CHSE, ANEF; Audrey Lyndon, RN, PhD, FAAN |
Pregnancy, childbirth, and the postpartum year present a complex set of patient safety challenges. Numerous maternal safety initiatives aim to prevent errors and harm, while enhancing readiness to address maternal complications.
Verna Gibbs, MD and Patrick Romano, MD, MPH |

Surgical items are supplies and devices used in or around a surgical or procedural site, wound, or incision that are used to aid in the performance of an operation or procedure, to provide exposure or coverage, or to absorb blood and other body fluids. When a surgical item is not removed, it is referred to as a retained surgical item (RSI) and differs from retained foreign objects (RFO) or retained foreign bodies (RFB) (e.g., bullets, ingested batteries or safety pins, aspirated nuts), which may require surgical intervention for removal. This primer describes the types of RSIs, RSI event reporting, and summarizes the evidence on the incidence of, and risk factors for, RSIs

Elizabeth Seidel, MSW, Tara Cortes, PhD, RN, FAAN, and Cynthia Chong, MPA |

Many people have trouble understanding health information. As more people search for health information online, it is critical that people are able to obtain accurate health information and access healthcare services. Digital health literacy (or eHealth literacy), is a person’s ability to seek, find, understand, and appraise health information from electronic sources and apply the knowledge gained to addressing or solving a health problem.

Deb Bakerjian, PhD, APRN, FAANP, FGSA, FAAN |
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.
Elizabeth Seidel, MSW, Tara Cortes, PhD, RN, FAAN, and Cynthia Chong, MPA |

Anyone can find it challenging to understand medical terms, and millions of Americans have trouble understanding and acting upon health information. Health literate organizations make health systems easier to navigate and health information easier to understand, improving healthcare delivery and outcomes.

Irina Tokareva, RN, BSN, MAS, CPHQ and Patrick Romano, MD, MPH. |

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.  

Jennifer J. Edwards, MS, RN, CHSE; Amy Nichols, EdD, RN, CNS, CHSE, ANEF; and Deb Bakerjian, PhD, APRN, FAANP, FGSA, FAAN |
Simulation training has become a key component of the patient safety movement and healthcare professional education. Simulation is increasingly being used to improve clinical and teamwork skills in a variety of health care environments. As its grown in use over the past decade, additional research and understanding has led to the development of standards, best practice guidelines and models.
Grace O'Malley, PhD, Ulfat Shaikh, MD, MPH, MS and James Marcin, MD, MPH |

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.

Peter Yellowlees, MBBS, MD and Margaret Rea, PhD |
Burnout is an occupational phenomenon that is highly prevalent among health care professionals. Current work focuses on understanding burnout and clinician well-being as system-level concerns that can adversely influence safety, quality, and organizational performance.
Vanessa McElroy, MSN, PHN, ACM-RN, IQCI, Ron Billano Ordona, DNP, FNP-BC, GS-C, and Deb Bakerjian, PhD, APRN, FAAN, FAANP, FGSA |

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.

Ulfat Shaikh, MD, MPH, MS |

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.

Deb Bakerjian PhD, APRN, FAAN, FAANP, FGSA |
Residents living in nursing homes or residential care facilities use common dining and activity spaces and may share rooms, which increases the risk for transmission of COVID-19 infection. This document describes key patient safety challenges facing older adults living in these settings, who are particularly vulnerable to the effects of the virus, and identifies federal guidelines and resources related to COVID-19 prevention and mitigation in long-term care. As of April 13, 2020, the Associated
Elsbeth Kalenderian, DDS, MPH, PhD; Yan Xiao, PhD, MS; Heiko Spallek, DMD, PhD, MSBA (CIS); Amy Franklin, PhD; Gregory Olsen, DDS, MSc; Muhammad F. Walji, PhD |

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. This primer summarizes best practices for infection control and prevention in the dental office setting, reviews HHS guidance on treating dental patients with suspected or confirmed COVID-19, discusses access issues for patients needing oral healthcare, and offers various Federal and professional resources to support the reconfiguration of dental practice, the implementation of tele-dentistry, and the prioritization of dental care needs after practices reopen. This primer concludes with key research priorities to support safe and effective dental care during and after the COVID-19 pandemic.

Angel N. Desai, MD, MPH and Patrick S. Romano, MD, MPH, on behalf of the AHRQ PSNet team |

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.

Jennifer J. Edwards, MS, RN, CHSE, Sage Wexner, MD, RN, and Amy Nichols, EdD, RN, CNS, CHSE |
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.
Shannan Takhar, PharmD, BCACP and Noelle Nelson, PharmD, MSPH |

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.

Jessamyn Phillips, DNP, FNP-C, Alex Peck Malliaris, MSN, MSHCA, FNP-C, and Debra Bakerjian PhD, APRN |
Nurses play a critical role in patient safety through their constant presence at the patient's bedside. However, staffing issues and suboptimal working conditions can impede a nurse’s ability to detect and prevent adverse events.