PATIENT SAFETY PRIMERS
COVID-19: Team and Human Factors to Improve Safety
This primer describes stressors relevant to the healthcare response to the COVID-19 pandemic from the perspective of care deliverers and the significant personal toll the pandemic is taking on individuals who work in the healthcare system. This primer highlights foundational patient safety strategies – signage, workflow review and redesign, checklists and simulations – whose implementation is more important than ever for keeping patients and healthcare providers safe in the age of COVID-19.
PATIENT SAFETY PRIMERS
Coronavirus Disease 2019 (COVID-19) and Safety of Older Adults
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
PATIENT SAFETY PRIMERS
Discharge Planning and Transitions of Care
Discharge planning is an essential part of transitions of care, during which patients are often at a higher risk for adverse events and harm. It is important for all healthcare providers to identify risk factors prior to transitioning patients and put plans in place as part of the discharge plan to mitigate harm. Effective discharge planning between the discharging and accepting healthcare teams can help reduce adverse events.
PATIENT SAFETY PRIMERS
Improving Patient Safety and Team Communication through Daily Huddles
Communication failures among healthcare personnel are significant contributors to medical errors and patient harm. This new primer provides an overview of “huddles”, a technique to enhance team communication that has been shown to reduce the risk for harm. The “Huddles” primer provides a definition along with when and how huddles might be used to improve patient safety.
PATIENT SAFETY PRIMERS
Clinical Decision Support Systems
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, due to widespread implementation of electronic health records and advances in clinical informatics.
PATIENT SAFETY PRIMERS
Opioid Safety
Over the past decade, the opioid epidemic has taken the lives of tens of thousands of patients. Much of the epidemic can be ascribed to inappropriate prescribing of opioids, despite knowledge of the safety risks they pose. Current efforts to improve opioid safety have primarily focused on reducing opioid prescribing.
PATIENT SAFETY PRIMERS
Maternal Safety
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.
PATIENT SAFETY PRIMERS
Burnout
Burnout among health care professionals is highly prevalent. Current work focuses on understanding burnout and clinician well-being as system-level concerns that can influence safety, quality, and organizational performance.
PATIENT SAFETY PRIMERS
Medication Administration Errors
Medication administration errors are a persistent safety problem. Increasing the safety of medication administration requires a multifaceted system-level approach that spans all phases of primary, specialty, inpatient, and community-based care.
PATIENT SAFETY PRIMERS
Surgical Site Infections
Infections after surgery are common and frequently lead to hospital readmission and other adverse consequences for patients. Recent programs, including several led by the Agency for Healthcare Research and Quality, have demonstrated how hospitals can successfully prevent these infections.
PATIENT SAFETY PRIMERS
The Pharmacist's Role in Medication Safety
Pharmacists in all settings play a crucial role in medication safety.
PATIENT SAFETY PRIMERS
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.
PATIENT SAFETY PRIMERS
Electronic Health Records
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.
PATIENT SAFETY PRIMERS
Individual Clinician Performance Issues
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.
PATIENT SAFETY PRIMERS
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.
PATIENT SAFETY PRIMERS
Falls
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.
PATIENT SAFETY PRIMERS
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.
PATIENT SAFETY PRIMERS
Health Literacy
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.
PATIENT SAFETY PRIMERS
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.
PATIENT SAFETY PRIMERS
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.
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