What’s New in the Patient Safety World


February 2009                      Some More New AHRQ Patient Safety Primers






Some More New AHRQ Patient Safety Primers



In our August 2008 What’s New in the Patient Safety World column we highlighted “AHRQ's New Patient Safety Primers”. AHRQ has added 3 more patient safety primers to the original eight.


As we noted previously they are, in fact, primers – meaning they are very introductory works on several important areas related to patient safety. However, each has extensive links to both classic and contemporary bibliographic references and tools. The new ones are no different and are equally useful resources.


The primer on Safety Culture begins with the key characteristics seen in other high-reliability organizations (acknowledgement of hi-risk activities, determination to achieve consistently safe operations, blame-free environment, encouragement of collaboration across ranks and disciplines, and organizational commitment to safety). They go on to discuss enablers and barriers to a culture of safety and many of the tools we often discuss to improve safety (teamwork and communication, patient safety walk rounds, culture measurement tools, etc.). They stress the concept of “just culture” and avoiding hierarchical structures that may impede patient safety progress. Once again, a real strength of the primer is its links to other patient safety tools and a very useful bibliography.


The primer on Adverse Events after Hospital Discharge stresses that 20% of patients discharged from the hospital will suffer an adverse event, most of which were preventable. They focus on various failed communication opportunities and discontinuities in care. They stress the importance of discharge planning, medication reconciliation, followup on pending tests, and attention to health literacy issues. Good discussion of our favorite tools, checklists and structured communication tools, as cornerstones. And the links and bibliography are what you’ve come to expect of these fine AHRQ primers.


The primer on Teamwork Training focuses on crew resource management and lessons from the realm of human factors. As you’d expect, there is a huge emphasis on TeamSTEPPS™ (see our Our May 22, 2007 Patient Safety Tip of the Week “More on TeamSTEPPS™”), SBAR, handoffs, debriefing, and other tools.


The entire collection of patient safety primers is an extremely useful resource not only for those new to the patient safety movement but even for experienced patient safety and quality improvement personnel.






AHRQ Patient Safety Primers (home page)



AHRQ Patient Safety Primer “Safety Culture”



AHRQ Patient Safety Primer “Adverse Events after Hospital Discharge”



AHRQ Patient Safety Primer “Teamwork Training”














Patient Safety Tip of the Week Archive


What’s New in the Patient Safety World Archive