Patient Safety Primers
Adverse Events, Near Misses, and Errors
The terms adverse events, near misses, and medical errors are used in patient safety to refer to events where patients were harmed (or easily could have been).
Computerized warnings and alarms are used to improve safety by alerting clinicians of potentially unsafe situations. However, this proliferation of alerts may have negative implications for patient safety as well.
Ambulatory Care Safety
The vast majority of health care takes place in the outpatient, or ambulatory, setting, and a growing body of research has identified and characterized factors that influence safety in office practice, the types of errors commonly encountered in ambulatory care, and potential strategies for improving ambulatory safety.
Though a seemingly simple intervention, checklists have played a leading role in the most significant successes of the patient safety movement, including the near-elimination of central line–associated bloodstream infections in many intensive care units.
Communication Between Clinicians
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.
Computerized Provider Order Entry
Computerized provider order entry systems ensure standardized, legible, and complete orders, and—especially when paired with decision support systems—have the potential to sharply reduce medication prescribing errors.
Culture of Safety
High-reliability organizations consistently minimize adverse events despite carrying out intrinsically hazardous work. Such organizations establish a culture of safety by maintaining a commitment to safety at all levels, from frontline providers to managers and executives.
Debriefing for Clinical Learning
Debriefing is an important strategy for learning from defects and for improving performance. It is one of the central learning tools in simulation and is also recommended after a real-life emergency response.
Detection of Safety Hazards
Health care organizations use a variety of established and emerging methods to prospectively identify safety hazards before errors have occurred and to retrospectively analyze errors to prevent future harm.
Thousands of patients die every year due to diagnostic errors. While clinicians’ cognitive biases play a role in many diagnostic errors, underlying health care system problems also contribute to missed and delayed diagnoses.
Disclosure of Errors
Many victims of medical errors never learn of the mistake, because the error is simply not disclosed. Physicians have traditionally shied away from discussing errors with patients, due to fear of precipitating a malpractice lawsuit and embarrassment and discomfort with the disclosure process.
Disruptive and Unprofessional Behavior
Popular media often depicts physicians as brilliant, intimidating, and condescending in equal measures. This stereotype, though undoubtedly dramatic and even amusing, obscures the fact that disruptive and unprofessional behavior by clinicians poses a definite threat to patient safety.
Duty Hours and Patient Safety
Long and unpredictable work hours have been a staple of medical training for centuries. However, little attention was paid to the patient safety effects of fatigue among residents until March 1984, when Libby Zion died due to a medication-prescribing error while under the care of residents in the midst of a 36-hour shift.
Electronic Health Records NEW
The widespread implementation of electronic health records has caused a sea change in health care and in medical practice. The digitization of health care data has had some positive effects on patient safety, but it has also created new patient safety concerns.
Failure to Rescue
Failure to rescue is both a concept and a measure of hospital quality and safety. The concept captures the idea that systems should be able to rapidly identify and treat complications when they occur, while the measure has been defined as the inability to prevent death after a complication develops.
Falls are a common source of patient harm in hospitals, and are considered a never event when they result in serious injury. Fall prevention requires a coordinated, multidisciplinary approach that entails individualized risk assessment and preventive interventions.
Fatigue, Sleep Deprivation, and Patient Safety
Sleep deprivation is known to impair various cognitive functions, and its effect on clinician performance may have significant implications for patient safety.
Handoffs and Signouts
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.
Health Care–Associated Infections
Although long accepted by clinicians as an inevitable hazard of hospitalization, recent efforts demonstrate that relatively simple measures can prevent the majority of health care–associated infections. As a result, hospitals are under intense pressure to reduce the burden of these infections.
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.
High reliability organizations are organizations that operate in complex, high-hazard domains for extended periods without serious accidents or catastrophic failures. High reliability is an ongoing process of cultivating organizational mindfulness; standardization is necessary but not sufficient for achieving resilient and reliable health care systems.
Human Factors Engineering
Human factors engineering is the discipline that attempts to identify and address safety problems that arise due to the interaction between people, technology, and work environments.
Individual Clinician Performance Issues NEW
Most safety improvement efforts justifiably emphasize system performance. 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 examines assessment, monitoring, and improvement of clinicians' competence as a means of addressing this unique component and ensuring patient safety.
Leadership Role in Improving Safety
Though hospital boards have traditionally had relatively little oversight over quality and safety performance, emerging data indicates that board engagement is correlated with improved safety, and specific management strategies can be used to enhance an organization's quality and safety performance.
Long-term Care and Patient Safety
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.
Measurement of Patient Safety
Measuring patient safety is a complex and evolving field, and achieving accurate and reliable measurement strategies remains a challenge for the safety field.
Adverse drug events are likely the most common source of preventable harm in both hospitalized and ambulatory patients, and preventing ADEs is a major priority for accrediting bodies and regulatory agencies. Medication errors can occur at any stage of the medication use pathway, and a growing evidence base supports specific strategies to prevent ADEs.
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.
Missed Nursing Care
Missed nursing care is linked to patient harm including falls and infections. Organizations can prevent missed nursing care by ensuring appropriate nurse staffing, promoting a positive safety culture, and making sure needed supplies and equipment are readily available.
The list of never events has expanded over time to include adverse events that are unambiguous, serious, and usually preventable. While most are rare, when never events occur, they are devastating to patients and indicate serious underlying organizational safety problems.
Nursing and Patient Safety
Nurses play a critical role in patient safety through their constant presence at patient's bedside. However, staffing issues and suboptimal working conditions can impede nurses' ability to detect and prevent adverse events.
Patient Engagement and Safety
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.
Patient Safety 101
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.
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 radiation.
Rapid Response Systems
Rapid response teams represent an intuitively simple concept: when a patient demonstrates signs of imminent clinical deterioration, a team of providers is summoned to the bedside to immediately assess and treat the patient with the goal of preventing adverse clinical outcomes.
Readmissions and Adverse Events After Discharge
Being discharged from the hospital can be dangerous for patients. Nearly 20% of patients experience an adverse event in the first 3 weeks after discharge, including medication errors, health care–associated infections, and procedural complications.
Reporting Patient Safety Events
Patient safety event reporting systems are ubiquitous in hospitals and are a mainstay of efforts to detect safety and quality problems. However, while event reports may highlight specific safety concerns, they do not provide insights into the epidemiology of safety problems.
Root Cause Analysis
Initially developed to analyze industrial accidents, root cause analysis is now widely deployed as an error analysis tool in health care. A central tenet of RCA is to identify underlying problems that increase the likelihood of errors while avoiding the trap of focusing on mistakes by individuals.
Second Victims: Support for Clinicians Involved in Errors and Adverse Events
The first priority following a medical error or adverse event is to attend to the patient and family. However clinicians can also be deeply affected by errors and adverse events and may need structured follow-up to ensure adaptive coping and organization learning.
Simulation-based training has been successful in other industries, such as aviation, and is emerging as a key component of the patient safety movement. Simulation is increasingly being used to improve clinical and teamwork skills in a variety of health care environments.
Medicine has traditionally treated errors as failings on the part of individual providers, reflecting inadequate knowledge or skill. The systems approach, by contrast, takes the view that most errors reflect predictable human failings in the context of poorly designed systems.
Providing safe health care depends on highly trained individuals with disparate roles and responsibilities acting together in the best interests of the patient. The need for improved teamwork has led to the application of teamwork training principles, originally developed in aviation, to a variety of health care settings.
Triggers and Trigger Tools
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 initiatives over time.
Wrong-Site, Wrong-Procedure, and Wrong-Patient Surgery
Few medical errors are as terrifying as those that involve patients who have undergone surgery on the wrong body part, undergone the incorrect procedure, or had a procedure intended for another patient. These "wrong-site, wrong-procedure, wrong-patient errors" (WSPEs) are rightly termed never events.
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