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Patient Safety Primers Available from AHRQ

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Patient safety in hospitals is a topic important to everyone, but it can be difficult to understand all of the issues involved. The Agency for Healthcare Research and Quality’s Patient Safety Network provides a series of Patient Safety Primers to guide people through key concepts in patient safety: http://psnet.ahrq.gov/primerHome.aspx

There are over 20 Primers available.  Some of the topics are:

  • Adverse Events after Hospital Discharge: 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. http://psnet.ahrq.gov/primer.aspx?primerID=11
  • Checklists: 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. http://psnet.ahrq.gov/primer.aspx?primerID=14
  • 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. http://psnet.ahrq.gov/primer.aspx?primerID=12
  • Disruptive and Unprofessional Behavior:  Popular media often depicts physicians as brilliant, intimidating, and condescending in equal measures. This stereotype obscures the fact that disruptive and unprofessional behavior by clinicians poses a definite threat to patient safety. http://psnet.ahrq.gov/primer.aspx?primerID=15
  • 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. http://psnet.ahrq.gov/primer.aspx?primerID=2
  • 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. http://psnet.ahrq.gov/primer.aspx?primerID=22
  • 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. http://psnet.ahrq.gov/primer.aspx?primerID=18

Patients also have a part to play in ensuring that they have safe healthcare, as described in the following Primer:

  • The Role of the Patient in 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. http://psnet.ahrq.gov/primer.aspx?primerID=17

Would you like to know more?  Go here for the complete list of Patient Safety Primers http://psnet.ahrq.gov/primerHome.aspx

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