Primers

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.

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.

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

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.

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.

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. 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.

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.