Email Updates
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
Clinical decision support systems provide information or recommendations to help clinicians make safe and evidence-based decisions. The use and sophistication of these systems have grown markedly over the past decade,... Read More
A clinician's individual skill level is an important component of the care delivery system that can influence patient safety—both independently and in conjunction with other system components. Emerging evidence... Read More
Triggers have become a widely used method of retrospectively analyzing medical records in order to identify errors and adverse events, measure the frequency with which such events occur, and track the progress of safety... Read More
Greater availability of advanced diagnostic imaging techniques has resulted in tremendous benefits to patients. However, the increased use of diagnostic imaging poses significant harm to patients through excessive exposure to ionizing... Read More
All Primers (71)
Back to all filtersPatient 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.
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.
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.
