The Agency for Healthcare Research and Quality is part of the U.S. Department of Health and Human Services. Its Patient Safety Primers are topical resources for people seeking information on everything from Adverse Events After Hospital Discharge to Wrong-Site, Wrong-Procedure, and Wrong-Patient Surgery
Because it’s a government compilation replete with acronyms and abbreviations, and because each explanation is evidence-based, it’s rather wonky reading. As the introduction says, “Patient Safety Primers guide you through key concepts in patient safety. Each primer defines a topic, offers background information on its epidemiology and context, and highlights relevant content from both AHRQ PSNet and AHRQ WebM&M.”
But each topic is explained clearly enough to get your arms around without Too Much Information, and if you want to pursue a topic further, the site offers links to additional resources.
Among the topics we find especially relevant:
- Diagnostic Errors 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.
- Error Disclosure 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.
- 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.
- Medication Errors 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.
- Never Events 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.
- Patient Safety in Ambulatory Care 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.
- Radiation Safety 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.
- Voluntary Patient Safety Event Reporting (Incident Reporting)
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.