Table of Contents
Overview
Definition of Patient Safety
Patient safety is defined as the absence of preventable harm to a patient and the reduction of risk of unnecessary harm associated with health care to an acceptable minimum.[3.1] It involves a framework of organized activities that promote cultures, processes, procedures, behaviors, technologies, and environments in health care to consistently and sustainably lower risks and reduce avoidable harm.[3.1] The field identifies adverse events as instances of patient harm resulting from medical care rather than the underlying disease.[6.1] Common adverse events include medication errors, unsafe surgical procedures, health care-associated infections, diagnostic errors, patient falls, pressure ulcers, patient misidentification, unsafe blood transfusions, and venous thromboembolism.[3.1] The goals of patient safety are to prevent harm from care intended to help, mitigate harm from errors of omission or commission, and establish operational systems and processes that minimize errors and maximize interception opportunities.[5.1] To tackle patient safety complexities, a framework categorizes major topics into the structure, process, and outcomes of unsafe care.[4.1] This comprehensive approach aims to enhance public awareness and mobilize stakeholder action to eliminate avoidable harm in health care, thereby improving overall patient safety.[3.1]Importance of Patient Safety in Healthcare
Patient safety is a fundamental aspect of healthcare, defined as the absence of preventable harm to patients during the process of health care delivery. It involves minimizing risks associated with healthcare to an acceptable level, influenced by current knowledge, available resources, and the context of care provision.[19.1] Beyond mere compliance, patient safety is a shared responsibility among all healthcare stakeholders and serves as a foundation for enhancing the overall quality of care.[7.1] To improve patient safety, healthcare organizations must foster collaboration among team members, aligning everyone with the common goal of enhancing safety outcomes. Community engagement in patient safety initiatives can amplify these efforts, promoting a culture of transparency and trust.[8.1] The American Hospital Association's Patient Safety Initiative, launched in 2023, exemplifies this commitment by equipping hospitals with tools and data to advance patient safety and encouraging the sharing of improvement stories among peers.[9.1] Effective communication is crucial in promoting patient safety, as it directly impacts patient satisfaction and the quality of care. High levels of communication among healthcare professionals ensure accurate information sharing and reduce the likelihood of errors.[15.1] However, hierarchical structures within healthcare teams can impede open dialogue, which is essential for fostering innovation and effective communication.[13.1] Strategies to promote open communication include creating spaces for team members to exchange ideas and address concerns, thereby enhancing teamwork and ultimately improving patient care.[14.1] Patient safety is increasingly recognized as a critical component of healthcare quality, with patient engagement playing a vital role in its enhancement. Effective strategies for promoting patient and family engagement include encouraging their participation as advisors in safety initiatives and fostering better communication among patients, family members, and healthcare professionals from the point of admission.[18.1] Engaging patients in their care journey begins with collecting information about their experiences and outcomes, which serves as a foundation for integrating their feedback into safety protocols.[20.1] To advance patient safety comprehensively, healthcare organizations must commit to fully engaging patients, families, and care partners in all aspects of care.[21.1] This holistic approach not only empowers patients but also contributes to improved safety and quality of care within healthcare settings.History
Origins of Patient Safety as a Discipline
The origins of patient safety as a discipline can be traced to the early recognition of risks in medical care, guided by the principle "Primum non-nocere," or "first, do no harm." However, formal recognition of patient safety emerged in the mid-20th century. In 1964, Schimmel highlighted hospitalization risks, emphasizing the need for a systematic approach to patient safety.[47.1] From the 1960s to the 1980s, concerns about high hospital mortality rates led to increased scrutiny of safety practices, marking the start of focused inquiries into adverse events in medical settings.[48.1] The movement gained momentum in 2000 with the Institute of Medicine (IOM) report, which stressed the urgent need for improvements.[47.1] The evolution of patient safety has been significantly influenced by frontline clinicians, patients, and families advocating for safer healthcare practices. This grassroots involvement has been crucial in shaping the discourse, extending beyond institutional leadership.[49.1] In response to growing awareness, initiatives like the WHO's "Safe Surgery Saves Lives" checklist and the Joint Commission's "Speak UP" initiative have been developed to standardize safety practices and emphasize communication and verification to prevent errors.[50.1][50.1] The terminology in patient safety has evolved, with "adverse events" describing harm from medical care rather than the disease itself.[51.1] The Agency for Healthcare Research and Quality (AHRQ) has played a pivotal role, publishing reports based on evidence-based medicine to improve safety practices. The AHRQ's "Making Health Care Safer" report, first issued in 2001, laid the foundation for ongoing efforts, culminating in the 2024 report showing significant declines in preventable harm rates.[51.1] Today, the commitment to patient safety remains strong, with healthcare teams across the United States striving to deliver high-quality care. This dedication involves identifying factors that enhance patient outcomes and implementing changes to improve safety.[52.1] The collective efforts of healthcare professionals highlight the importance of viewing safety as a shared responsibility, aiming for zero harm to patients.[52.1]Key Milestones in Patient Safety Development
The release of the Institute of Medicine's (IOM) report, To Err Is Human: Building a Safer Health System, in 1999 marked a pivotal moment in the history of patient safety. This report highlighted that preventable medical errors were responsible for as many as 98,000 deaths annually in the United States, urging that improving patient safety should become a national health policy priority.[76.1] Following this, the IOM recommended the establishment of a National Center for Patient Safety within the Agency for Healthcare Research and Quality (AHRQ) to address the significant safety gaps in healthcare, which were noted to be lagging behind other high-risk industries.[60.1] In response to the IOM report, various initiatives were launched to enhance patient safety. For instance, the World Health Organization (WHO) developed the "Safe Surgery Saves Lives" checklist, which includes critical safety verifications to mitigate universal surgical hazards.[61.1] Additionally, the Joint Commission introduced the "Speak UP" initiative, aimed at reducing wrong site and wrong patient surgical errors by emphasizing preoperative safety checkpoints.[61.1] Despite these efforts, challenges in implementing patient safety practices persist. Hospital officials have identified three main obstacles: the substantial time and resources required to gather data on adverse events, the limited evidence supporting the effectiveness of certain safety practices, and the need for consistent implementation by healthcare staff.[58.1] Furthermore, while some progress has been made in reducing specific adverse events, overall improvements in patient outcomes have been difficult to document, indicating that the journey toward enhanced patient safety is ongoing.[64.1] The Institute of Medicine (IOM) report, "To Err Is Human," published in 1999, highlighted the critical need for healthcare organizations to foster safety cultures to improve patient safety.[71.1] The report specifically recommended the establishment of a nationwide mandatory reporting system to gather standardized data on adverse events.[74.1] However, efforts to implement this national system have encountered significant delays, primarily due to systemic breakdowns within healthcare organizations, which have been identified by state legislatures and regulatory bodies as major obstacles to achieving a robust safety culture.[74.1] While some progress has been made since the IOM report, it is evident that realizing the full potential of a safety culture will require sustained commitment over many years.[71.1]Recent Advancements
Technological Innovations in Patient Safety
Technological innovations have significantly transformed patient safety in healthcare settings, particularly through the application of artificial intelligence (AI) and health information technology (health IT). AI, employing machine learning algorithms and natural language processing, has been systematically reviewed for its role in enhancing safety measures within healthcare systems by addressing and reporting patient safety outcomes.[102.1] One prominent application of AI is in diagnostics, where algorithms analyze vast datasets of medical images to identify anomalies and suggest diagnoses for conditions such as cancer, pneumonia, and neurological disorders. This capability not only improves diagnostic accuracy but also reduces the likelihood of errors that could compromise patient safety.[103.1] Additionally, AI can detect inconsistencies or missing information in electronic health records (EHRs), thereby minimizing errors that could lead to misdiagnosis or incorrect treatment.[104.1] Beyond diagnostics, AI contributes to personalized patient care by analyzing patient data, including genetic information and medical history, to tailor treatment plans. This personalized approach enhances treatment strategies and facilitates proactive preventive care recommendations, ultimately lowering healthcare costs and improving patient outcomes.[105.1] While health IT has the potential to significantly improve patient safety, it also introduces challenges that can lead to unintended consequences and new safety concerns.[119.1] These challenges can be categorized according to the stages of the health IT lifecycle, which include developing models and tools for risk assessment, ensuring software safety in network-enabled environments, and managing information technology system transitions.[118.1] To effectively address these challenges, it is essential to facilitate change management and cultivate a culture of innovation within healthcare organizations, where change is embraced and encouraged.[120.1] Engaging staff early in the process and providing adequate training are critical strategies for overcoming the unique challenges faced in health informatics.[121.1]Emerging Trends in Patient Safety Practices
Recent advancements in patient safety practices have been significantly influenced by federally funded programs, particularly those sponsored by the Agency for Healthcare Research and Quality (AHRQ) and the Department of Defense (DoD)-Health Affairs. These initiatives have focused on understanding medical errors and implementing strategies to enhance patient safety over the past five years.[90.1] The AHRQ has published comprehensive reports that compile years of research, highlighting various aspects of patient safety, including reporting systems, risk assessment, safety culture, and health information technology.[91.1] Technological advancements, such as the digitization of healthcare processes, have played a crucial role in improving patient safety by standardizing clinical workflows, thereby increasing efficiency and reducing errors across healthcare settings.[93.1] However, it is essential to recognize that poorly designed or implemented technological solutions can inadvertently increase the burden on healthcare systems and patients.[92.1] Interdisciplinary teamwork has emerged as a vital component in enhancing patient safety. Effective communication and collaboration among healthcare professionals are linked to improved quality of care and patient safety outcomes. Studies indicate that failures in communication and teamwork can lead to significant safety risks, underscoring the importance of fostering a culture of psychological safety within healthcare teams.[95.1] Training programs aimed at improving teamwork have been shown to enhance safety performance, demonstrating the value of collaborative approaches in healthcare settings.[95.1] Patient engagement is another critical trend in advancing patient safety. Initiatives such as the WHO Patients for Patients Safety program emphasize the importance of involving patients and families in their care, which has been associated with improved safety and health outcomes.[100.1] Strategies to empower patients include encouraging their participation as advisors and promoting better communication between patients, families, and healthcare professionals.[18.1] Evidence suggests that when patients are treated as partners in their care, significant improvements in safety and satisfaction can be achieved.[101.1] Recent research by the Agency for Healthcare Research and Quality (AHRQ) has significantly advanced patient safety practices in healthcare settings. The third Making Healthcare Safer report, published in 2020, identifies 47 evidence-based practices targeting specific types of harm, providing a more detailed focus than previous reports.[107.1] Following this, the fourth Making Healthcare Safer report was commissioned in 2022 to continuously update findings related to patient safety harms.[107.1] These reports are crucial for informing healthcare providers about effective strategies to enhance patient safety, as they reflect the latest evidence and address ongoing challenges in the field.[106.1] Notably, a study funded by AHRQ, published in the Journal of the American Medical Association (JAMA), indicates that rates of in-hospital adverse events related to patient harm have significantly decreased in the U.S. over the decade leading up to the COVID-19 pandemic.[106.1]In this section:
Key Concepts In Patient Safety
Safety Culture in Healthcare Organizations
A safety culture in healthcare organizations is essential for enhancing patient safety and improving care quality. It involves a shared responsibility among all stakeholders, including patients, caregivers, and healthcare providers, who collectively contribute to patient safety.[7.1] In 2020, the Institute for Healthcare Improvement (IHI) and the Agency for Healthcare Research and Quality (AHRQ) introduced the National Action Plan to Advance Patient Safety. This plan outlines four critical pillars for fostering a safer healthcare environment: Culture, Leadership and Governance; Patient and Family Engagement; Learning Systems; and Continuous Improvement.[138.1] The framework underscores that patient safety is a foundational element requiring active participation from everyone involved in the care process.[7.1] Developing a safety culture necessitates more than just implementing policies; it requires a leadership-driven commitment to prioritizing safety in every decision, action, and communication.[139.1] This commitment is crucial for minimizing avoidable harm and maintaining patient safety at an acceptable level.[127.1] Effective communication is vital, as breakdowns in communication are leading causes of adverse events, especially during handovers.[131.1] Tools like SBAR (Situation, Background, Assessment, Recommendation) have been developed to improve handover quality and are believed to enhance patient safety outcomes.[131.1] By integrating these practices into the organizational framework, healthcare institutions can create a sustainable culture that consistently reduces risks and minimizes harm when it occurs.[127.1] Furthermore, healthcare organizations are evaluated based on patient experience and safety metrics, highlighting the importance of a safety culture in delivering compassionate, effective, and safe care.[126.1] By fostering such a culture, organizations can significantly decrease the frequency of adverse events, such as medication errors, surgical complications, and healthcare-associated infections, thereby improving overall patient outcomes.[127.1]In this section:
Challenges In Patient Safety
Barriers to Implementation of Safety Initiatives
Patient safety initiatives encounter several barriers that impede their effective implementation in healthcare organizations. A major challenge is the inconsistent dissemination of knowledge and best practices, which is essential for enhancing patient safety. This inconsistency can result in care gaps and increased patient risks, despite the presence of common risk factors and adverse events.[171.1] A 2025 report identified both longstanding challenges and emerging risks as top threats to patient safety, highlighting the dynamic landscape healthcare providers must navigate.[172.1] Notably, "medical gaslighting" and the integration of artificial intelligence (AI) have emerged as critical concerns, potentially disrupting the provider-patient relationship while also fostering patient engagement.[173.1] Adverse events such as medication errors, unsafe surgical procedures, healthcare-associated infections, and diagnostic errors emphasize the need for a structured approach to patient safety, defined by the absence of preventable harm and the reduction of unnecessary healthcare risks.[174.1] Workload and staffing issues further complicate patient safety efforts. High patient-to-nurse ratios and excessive workloads can lead to nurse fatigue, increasing the likelihood of errors due to decreased attention to detail.[175.1] Ensuring adequate staffing levels is crucial for maintaining a safe healthcare environment. Engaging patients in safety improvement initiatives is also vital for sustainable healthcare. Studies show that involving patients in healthcare redesign and delivery can improve outcomes, such as reduced hospital admissions and enhanced service quality.[179.1] However, effective patient engagement strategies must be personalized and adaptable, utilizing technology to enhance communication and care plans.[178.1]Addressing Health Inequities in Patient Safety
Addressing health inequities in patient safety is a critical concern within the healthcare system, particularly as issues such as medical gaslighting emerge as significant threats to patient outcomes. Medical gaslighting, where healthcare providers may unintentionally dismiss or minimize patients' concerns, can lead to serious consequences, including delayed diagnoses and mismanagement of care. This issue is particularly pronounced among marginalized populations, exacerbating existing health disparities and contributing to unnecessary suffering.[202.1] Research indicates a scarcity of studies evaluating the ethical implications of medical gaslighting, highlighting a gap in the literature that limits the understanding of this phenomenon.[199.1] Furthermore, the lack of comprehensive studies on the demographics and conditions associated with gaslighting complaints suggests that healthcare systems have much to learn about the interplay of gender, class, race, disability, and age in these situations.[201.1] Addressing these gaps is essential for developing effective interventions that can mitigate the risks associated with medical gaslighting and improve patient safety outcomes. The consequences of medical gaslighting can be severe, leading to diagnostic errors and delays in treatment, ultimately worsening patients' conditions.[203.1] Therefore, it is imperative that healthcare organizations implement evidence-based guidelines to optimize patient care and address systemic issues contributing to health inequities.[186.1] By fostering a culture of safety and promoting effective communication and teamwork among healthcare providers, organizations can enhance their response to patient concerns and improve overall safety.[197.1]Future Directions
Role of Artificial Intelligence in Patient Safety
The integration of artificial intelligence (AI) into telemedicine holds significant promise for enhancing patient safety by addressing various healthcare needs. AI is making notable impacts in areas such as patient monitoring, healthcare information technology (IT), intelligent diagnosis, and collaborative information analysis.[221.1] However, the successful application of AI requires careful consideration of existing clinical processes and technologies within the healthcare environment.[219.1] As institutions adopt these innovations, they must navigate challenges in integrating them into current frameworks to fully realize their potential in improving patient safety.[219.1] Despite its potential, AI faces challenges such as biases in models that can lead to inequitable healthcare outcomes. A systematic review found that less than 25% of AI studies implemented adequate data privacy controls, underscoring the need for stringent measures to protect sensitive patient information.[222.1] Additionally, the reliability of AI models is contingent upon the quality of their training data; biased or underrepresented data can worsen existing disparities in healthcare.[222.1] AI's role in telemedicine has been particularly impactful, especially during the COVID-19 pandemic. For example, teleurology leverages telecommunication technology to provide remote urological care, showcasing the benefits of digital health applications in enhancing patient safety.[221.1] Nonetheless, integrating AI into telemedicine requires a cautious approach, prioritizing ethical considerations related to data privacy and security.[222.1]Strategies for Enhancing Patient Safety Systems
Continued exploration in patient safety research is essential for ensuring the well-being of patients and fostering environments where safety can thrive.[208.1] A significant strategy for enhancing patient safety is the implementation of the World Health Organization's (WHO) "Safe Surgery Saves Lives" checklist, which includes critical safety verifications performed at various stages of the perioperative process to protect against universal safety hazards.[209.1] The use of this checklist has been shown to dramatically improve patient outcomes, including reductions in perioperative mortality, postoperative infections, and complications.[227.1] However, the widespread implementation of the checklist faces significant challenges, particularly in low-income and middle-income countries (LMICs), where barriers to universal adoption exist.[227.1] Overcoming these obstacles requires a collaborative environment and effective education, which are critical factors for improving compliance with the WHO Surgical Safety Checklist.[228.1] Reports indicate that successful implementation of the checklist has led to significant reductions in surgical complications globally, with notable improvements in surgical outcomes observed in various countries, including the Netherlands and Liberia, where the introduction of the checklist was associated with significant enhancements in surgical processes and outcomes.[229.1] To enhance patient safety systems, it is essential to foster a collaborative environment and provide effective instruction, as these elements are critical in overcoming obstacles to implementing safety protocols, such as the WHO Surgical Safety Checklist.[228.1] The integration of technology into healthcare education plays a significant role in developing clinical and professional skills, thereby improving the overall learning experience and prioritizing patient safety.[213.1] Furthermore, the COVID-19 pandemic has accelerated the adoption of technology-driven strategies, including the use of video platforms for meetings and quick response codes, which have become vital in maintaining educational continuity and enhancing communication in clinical settings.[214.1] Moreover, enhancing communication and teamwork among surgical teams is crucial for ensuring adherence to patient safety protocols. Effective strategies include conducting briefings before and debriefings after surgical procedures, which facilitate information sharing and reinforce the importance of safety measures.[217.1] Studies have indicated that such practices improve communication, teamwork, and ultimately patient outcomes.[215.1]References
[3] Patient safety - World Health Organization (WHO) — Common adverse events that may result in avoidable patient harm are medication errors, unsafe surgical procedures, health care-associated infections, diagnostic errors, patient falls, pressure ulcers, patient misidentification, unsafe blood transfusion and venous thromboembolism. Patient safety is defined as “the absence of preventable harm to a patient and reduction of risk of unnecessary harm associated with health care to an acceptable minimum." Within the broader health system context, it is “a framework of organized activities that creates cultures, processes, procedures, behaviours, technologies and environments in health care that consistently and sustainably lower risks, reduce the occurrence of avoidable harm, make error less likely and reduce impact of harm when it does occur." The global campaign, with its dedicated annual theme, is aimed at enhancing public awareness and global understanding of patient safety and mobilizing action by stakeholders to eliminate avoidable harm in health care and thereby improve patient safety.
[4] Patient safety research: an overview of the global evidence — Methods: Major patient safety topics were identified through a consultative and investigative process and were categorised into the framework of structure, process and outcomes of unsafe care. Lead experts examined current evidence and identified major knowledge gaps relating to topics in developing, transitional and developed nations.
[5] Patient Safety 101 | PSNet — Patient safety goals include avoiding harm to patients from care that is intended to help them, the prevention and mitigation of harm caused by errors of omission or commission in healthcare, and the establishment of operational systems and processes that minimize the likelihood of errors and maximize the likelihood of intercepting them when they occur.
[6] Patient Safety 101 - PSNet — The patient safety field uses the term adverse events to describe patient harm that arises as a result of medical care (rather than from the underlying disease). The seminal Agency for Healthcare Research and Quality (AHRQ) Making Health Care Safer report, issued in 2001, was the first effort to use evidence-based medicine principles in identifying practices to improve patient safety. The AHRQ Making Health Care Safer IV report, published in 2024, added to the evidence base behind patient safety interventions, and data from AHRQ indicates that rates of preventable harm have declined significantly over the past several years.
[7] Patient Safety in Healthcare: Why It Matters | GCU Blog — In healthcare, patient safety is more than just a priority — it's a shared responsibility and a foundation for improving the quality of care.
[8] PSAW 2025: Turning Awareness into Action for Patient Safety — By prioritizing collaboration, healthcare organizations can ensure that every team member is aligned with the shared goal of enhancing patient safety. ... Engaging the community in patient safety initiatives can amplify the impact of these efforts and foster a culture of transparency and trust. By showcasing their commitment to safety
[9] Prioritizing Patient Safety and Quality Care Every Day for Everyone — The reports are part of the AHA's Patient Safety Initiative, which was launched in 2023 to reaffirm hospital and health system leadership and commitment to patient safety. The initiative provides hospitals with tools and data to advance patient safety, offers a platform for sharing their stories of improvement with peers, and highlights
[13] Encourage Open Communication: 6 Strategies for Team Leaders — One key challenge in encouraging open communication in teams is the hierarchical nature of healthcare teams. Many professionals feel intimidated to share their ideas, hindering efforts in fostering open dialogue in teams. This can lead to missed opportunities for innovation and impedes effective communication strategies for managers.
[14] 5 Strategies to Improve Team Communication in 2024 — Quality communication within a healthcare team is essential to providing quality patient care. ... Building a quality workplace culture begins with promoting good teamwork and effective communication. ... Encourage open communication channels and create spaces for team members to exchange ideas, share insights, and address concerns.
[15] Effective Communication in Healthcare: Key Strategies and Insights — The importance of communication in healthcare cannot be overstated—it ensures accurate information sharing, reduces errors and improves patient safety and satisfaction. Collaborative communication improves teamwork, ensuring everyone involved in patient care is aligned on goals and updates. Communication can help patients take charge of their health through accessible tools, reminders, and personalized plans. Overcoming barriers like language differences, hierarchical challenges, and outdated technology helps healthcare teams communicate effectively and improve care delivery. Clear communication in healthcare delivery is one of the most direct ways to improve patient outcomes. Communication channels like secure messaging or apps can keep patients updated on their medications or appointments, while tailored, culturally sensitive communication ensures care aligns with their beliefs and circumstances.
[18] Guide to Patient and Family Engagement in Hospital Quality and Safety — The Guide to Patient and Family Engagement in Hospital Quality and Safety focuses on four primary strategies for promoting patient/family engagement in hospital safety and quality of care:. Encourage patients and family members to participate as advisors. Promote better communication among patients, family members, and health care professionals from the point of admission.
[19] Patient engagement for patient safety - World Health Organization (WHO) — Patient safety is the absence of preventable harm to a patient during the process of health care, including the reduction of risk of unnecessary harm associated with health care to an acceptable minimum. An acceptable minimum refers to the collective notions of given current knowledge, resources available and the context in which care is delivered, weighed against the risk of non-treatment or
[20] Patient and Health Professional Perspectives about Engaging Patients in ... — Different examples of patient engagement in patient safety can be found in the existing literature. A starting point for patient engagement is the point at which information is collected from the patient about their experience of care and of the outcomes that have been achieved.
[21] Engaging Patients and Families in Safety: Recommendations, Resources ... — The following excerpt (adapted from the Implementation Resource Guide: A National Action Plan to Advance Patient Safety) focuses on patient and family engagement. To develop a total systems approach to advance patient safety, health care organizations must commit to the goal of fully engaging patients, families, and care partners in all aspects
[47] PDF — The History of Patient Safety The history of patient safety is a long and well-recognized one. Primum non-nocere is the motto by which all physicians practice. In 1964, Schimmel first documented the risks of hospitalization. The patient safety "movement" per se reached a tipping point in 2000 following the publication of the IOM
[48] PDF — While there were minor advancements in patient safety throughout the course of history, the term wasn't created until late in the 20th century. However, at this point it was very apparent that patient safety was lacking. Between the 1960s and 1980s, many people began to inquire about the high rate of mortality in hospitals and medical facilities.
[49] Looking back on the history of patient safety: an opportunity to ... — The idea of writing 'history from below' rather than just focusing on founding fathers and generals has taken root based on the work of Howard Zinn and others.17 18 The safety movement has been both activated and propelled by tens of thousands of frontline clinicians, patients and families.19 20 They are the ones who have witnessed and
[50] Patient Safety Movement: History and Future Directions - PMC — For example, the World Health Organization (WHO) created a “Safe Surgery Saves Lives” checklist that features checkpoints of certain safety verifications that should be performed at different times in all perioperative processes to protect against universal safety hazards.10 An important component of this checklist is marking of the surgical site by the surgeon while the patient is awake, a process that has also been advocated for by the American Academy of Orthopaedic Surgeons (AAOS) “Sign Your Site” campaign, which was first introduced in 1998.11 Additionally, the Joint Commission developed a preoperative safety initiative called “Speak UP”, which emphasizes similar checkpoints in the preoperative time period to reduce wrong site and wrong patient surgical errors.
[51] Patient Safety 101 - PSNet — The patient safety field uses the term adverse events to describe patient harm that arises as a result of medical care (rather than from the underlying disease). The seminal Agency for Healthcare Research and Quality (AHRQ) Making Health Care Safer report, issued in 2001, was the first effort to use evidence-based medicine principles in identifying practices to improve patient safety. The AHRQ Making Health Care Safer IV report, published in 2024, added to the evidence base behind patient safety interventions, and data from AHRQ indicates that rates of preventable harm have declined significantly over the past several years.
[52] 20 years of patient safety - AAMC — “As we work toward achieving the goal of zero harm to patients, every person on the health care team needs to think of safety as their job and focus on the best ways to work with all other members of the team to prevent mistakes.” “As we work toward achieving the goal of zero harm to patients, every person on the health care team needs to think of safety as their job and focus on the best ways to work with all other members of the team to prevent mistakes,” says Orlowski. Other AAMC patient safety efforts include the annual Integrating Quality Conference, a major professional development conference for faculty, students, and other stakeholders on improving quality care and patient safety.
[58] Hospitals Face Challenges in Implementing Patient Safety Practices — Hospital officials identified 3 main challenges in implementing patient safety practices: substantial time and resources needed to gather data about adverse events, limited evidence of effectiveness of some patient safety practices, and ensuring consistent implementation of patient safety practices by staff.
[60] An Overview of To Err is Human: Re-emphasizing the Message of Patient ... — ♦ Part 1: National Center for Patient Safety - The IOM recommended the creation of a National Center for Patient Safety in the U.S. Department of Health and Human Services's Agency for Healthcare Research and Quality (AHRQ), because health care is a decade or more behind other high-risk industries in its attention to ensuring basic safety, establishing national safety goals, tracking
[61] Patient Safety Movement: History and Future Directions - PMC — For example, the World Health Organization (WHO) created a “Safe Surgery Saves Lives” checklist that features checkpoints of certain safety verifications that should be performed at different times in all perioperative processes to protect against universal safety hazards.10 An important component of this checklist is marking of the surgical site by the surgeon while the patient is awake, a process that has also been advocated for by the American Academy of Orthopaedic Surgeons (AAOS) “Sign Your Site” campaign, which was first introduced in 1998.11 Additionally, the Joint Commission developed a preoperative safety initiative called “Speak UP”, which emphasizes similar checkpoints in the preoperative time period to reduce wrong site and wrong patient surgical errors.
[64] A Research Framework for Reducing Preventable Patient Harm — As we mark the 10-year anniversary of the To Err is Human report, limited progress has been made in reducing patient harm [1-3].Although the rates of certain adverse health care-associated events have recently declined , it has been difficult to document overall improvement in patient outcomes [].Moreover, measures to evaluate health care performance are not widely used or not
[71] 7 Creating and Sustaining a Culture of Safety - National Center for ... — The Institute of Medicine (IOM) report To Err Is Human calls attention to the need to create such safety cultures within all health care organizations (HCOs) (IOM, 2000). The committee finds that while some progress has been made to this end, a safety culture is unlikely to reach its full potential without years of substantial commitment.
[74] Regulation of Health Policy: Patient Safety and the States — In its 1999 report on patient safety, the Institute of Medicine recommended a nationwide mandatory reporting system to collect standardized information about adverse events. Efforts at instituting a national system have stalled, and both State legislatures and private or quasi-regulatory organizations have highlighted systemic breakdowns as being chiefly responsible for the "safety
[76] Health Care Quality: Improving Patient Safety by Promoting Medical ... — Patient safety emerged as a major health policy issue in late 1999 with the release of the Institute of Medicine's (IOM) report To Err Is Human.1 The IOM report concluded that preventable medical errors cause as many as 98,000 deaths each year and called on all parties to make improving patient safety a national health policy priority.
[90] Advances in Patient Safety - Agency for Healthcare Research and Quality ... — Advances in Patient Safety: From Research to Implementation describes what federally funded programs have accomplished in understanding medical errors and implementing programs to improve patient safety over the last 5 years. This compendium is sponsored jointly by the Agency for Healthcare Research and Quality (AHRQ) and the Department of Defense (DoD)-Health Affairs.
[91] Advances in Patient Safety: New Directions and Alternative Approaches ... — Advances in Patient Safety: New Directions and Alternative Approaches represents years of study by AHRQ-funded patient safety researchers and others. It includes articles on reporting systems, risk assessment, safety culture, medical simulation, patient safety tools and practices, health information technology, medication safety, and other topics related to improving patient safety.
[92] New top patient safety concerns emerge while other measures improve — New top patient safety concerns emerge while other measures improve . Week of March 23 - March 29, 2025 Mar 28, 2025. ... and puts a greater burden of care on the patient and the health system. Advancements in technology have the potential to provide value to healthcare delivery and improve safety, but they can have risks. For example, AI tools
[93] Technology as a Tool for Improving Patient Safety - PSNet — In the past several decades, technological advances have opened new possibilities for improving patient safety. Using technology to digitize healthcare processes has the potential to increase standardization and efficiency of clinical workflows and to reduce errors and cost across all healthcare settings.1 However, if technological approaches are designed or implemented poorly, the burden on
[95] Interdisciplinary and interprofessional communication intervention: How ... — While functioning teamwork is associated with quality of care and patient safety, communication and teamwork failures in interdisciplinary teams lead to deficient patient care and thus pose safety risks (Weller et al., 2014; Rosen et al., 2018; Parker et al., 2019). Psychological safety is associated with patient safety, collaboration, involvement in quality improvement work, learning from mistakes, and adverse events (Hirak et al., 2012; Arnetz et al., 2019), which indicates the connection between communication, safety performance, and environments that are perceived as safe (similar as psychological safety). The large literature depicts that healthcare team trainings are related to improve effectiveness specifically in terms of learning, reactions, transfer, and results (e.g., organizational and patient outcomes), which demonstrated that team interventions are associated with improving safety performances (Hughes et al., 2016).
[100] Patients for patient safety - World Health Organization (WHO) — Meaningful engagement of patients, families and communities can improve health care quality and patient safety. WHO Patients for Patients Safety (PFPS) is a programme of WHO Flagship Initiative “A Decade of Patient Safety 2021-2030” that engages and empowers patients and families and facilitates their partnership with health professionals and policy-makers to make health care services safer worldwide. Its vision, expressed in the London Declaration, is to engage, empower, encourage and facilitate patients and families to build and/or participate in global networks advocating for, and partnering with health professionals and policy makers to make health care services safer, more integrated, and people-centred for all. Patient, family, and community partnerships with health professionals (health-care providers, policy-makers, researchers).
[101] Improving Patient Engagement: 5 Empowerment Tips - PSMF — “It’s well recognised through evidence that when patients are treated as partners in their care, significant gains are made in safety, in patient satisfaction, and their health outcomes are also very improved,” says Dhingra. “We truly draw our inspiration to work in patient safety from people who have suffered harm due to the weaknesses in the healthcare system,” says Dhingra. “I wish there was some venue for patients in Canada to share what their healthcare experience is like, and then our hospitals adjust and make themselves better based on that,” she says. “To get patients to promote their own healthcare and indeed quality of care, you’ve got to give them the basic building blocks,” she says.
[102] Role of artificial intelligence in patient safety outcomes ... - PSNet — This systematic review explored how artificial intelligence (AI) based on machine learning algorithms and natural language processing is used to address and report patient safety outcomes.
[103] How Does Ai Reduce Human Error In Healthcare — Here are some specific examples of how AI is currently being used in healthcare to reduce errors Diagnostics: Image analysis: AI algorithms are trained on vast datasets of medical images to identify anomalies and suggest diagnoses for conditions like cancer, pneumonia, and neurological disorders.
[104] 12 examples of AI in healthcare (+Pros and cons) | Sendbird — AI can also help detect inconsistencies or missing information in electronic health records (EHRs), reducing errors that could lead to misdiagnosis or incorrect treatment. ... For example, AI healthcare companies like Toi Labs and Cera Care are developing innovative technologies to improve elder care and alleviate the strain on healthcare
[105] AI in Healthcare: Examples, Use Cases, and Benefits - Acropolium — AI in healthcare extends beyond data processing, offering benefits like enhanced diagnostic accuracy, personalized patient care, and efficient administrative task automation. By using AI in the healthcare industry for patient data analysis, medical professionals can deliver more precise diagnoses and treatment strategies. Furthermore, AI enhances healthcare by analyzing big data to develop proactive preventive care recommendations for patients. By optimizing processes, reducing medical errors, and facilitating preventive care, AI can help lower healthcare costs for both providers and patients. AI applications in healthcare encompass diagnosis, treatment optimization, and patient monitoring.AI algorithms can analyze medical data to predict diseases, recommend personalized treatment plans, and monitor patient vitals in real-time. In personalized treatment, AI healthcare solutions analyze patient data like genetic information, medical history, and lifestyle factors, to tailor treatment plans.
[106] Major Study Finds Significant National Patient Safety Improvement — An official website of the Department of Health and Human Services
[107] AHRQ's Making Healthcare Safer Reports: Shaping Patient Safety Efforts ... — AHRQ's third Making Healthcare Safer report, published in 2020, includes 47 evidence-based patient safety practices in selected harm areas. It includes evidence for more specific harm areas than the preceding reports. The fourth Making Healthcare Safer report was commissioned in 2022 as a continuous updating of patient safety harms and
[118] Current Challenges in Health Information Technology-related Patient Safety — Categorized according to the stage of the health IT lifecycle where they appear, these challenges relate to: 1) Developing models, methods, and tools to enable risk assessment; 2) Developing standard user interface design features and functions; 3) Ensuring the safety of software in an interfaced, network-enabled clinical environment; 4) Implementing a method for unambiguous patient identification (1–4 Design and Development stage); 5) Developing and implementing decision support which improves safety; 6) Identifying practices to safely manage information technology system transitions (5–6 Implementation and Use stage); and 7) Developing real-time methods to enable automated surveillance and monitoring of system performance and safety; 8) Establishing the cultural and legal framework/safe harbor to allow sharing information about hazards and adverse events; and 9) Developing models and methods for consumers/patients to improve health IT safety (7–9 Monitoring, Evaluation, and Optimization stage).
[119] Measuring and improving patient safety through health information ... — Health information technology (health IT) has potential to improve patient safety but its implementation and use has led to unintended consequences and new safety concerns. A key challenge to improving safety in health IT-enabled healthcare systems
[120] Strategies For Successful Digital Transformation in Healthcare | HCI — Strategic Approaches to Overcoming Healthcare Technology Challenges. Facilitating Change Management: Change management is pivotal in the transition to digital healthcare systems. Cultivating a culture of innovation, where change is embraced and encouraged, is crucial for adapting to new technologies and processes.
[121] 8 Challenges and Solutions in Health Informatics Implementation: Expert ... — In a compelling compilation of eight insights, the discussion kicks off by emphasizing the need to engage staff early and provide training, concluding with the importance of adopting effective change management strategies. Each of these insights serves as a vital lesson for overcoming the unique challenges faced in the world of health informatics.
[126] Enhancing Patient Safety Culture in Hospitals - PMC — Importance of patient safety Healthcare organizations undergo evaluations based on patient experience and safety to ensure that they provide compassionate, effective, and safe care. According to national rules and regulations, the General Medical Council, quality indicators, and local monitoring measures are used . Patient safety is intended to reduce the frequency of negative conclusions
[127] Patient safety - World Health Organization (WHO) — Common adverse events that may result in avoidable patient harm are medication errors, unsafe surgical procedures, health care-associated infections, diagnostic errors, patient falls, pressure ulcers, patient misidentification, unsafe blood transfusion and venous thromboembolism. Patient safety is defined as “the absence of preventable harm to a patient and reduction of risk of unnecessary harm associated with health care to an acceptable minimum." Within the broader health system context, it is “a framework of organized activities that creates cultures, processes, procedures, behaviours, technologies and environments in health care that consistently and sustainably lower risks, reduce the occurrence of avoidable harm, make error less likely and reduce impact of harm when it does occur." The global campaign, with its dedicated annual theme, is aimed at enhancing public awareness and global understanding of patient safety and mobilizing action by stakeholders to eliminate avoidable harm in health care and thereby improve patient safety.
[131] Impact of the communication and patient hand-off tool SBAR on patient ... — Objectives Communication breakdown is one of the main causes of adverse events in clinical routine, particularly in handover situations. The communication tool SBAR (situation, background, assessment and recommendation) was developed to increase handover quality and is widely assumed to increase patient safety. The objective of this review is to summarise the impact of the implementation of
[138] Ensuring Patient and Workforce Safety Culture in Healthcare — Introduction. In 2020, the Institute for Healthcare Improvement (IHI) and the Agency for Healthcare Research and Quality (AHRQ) unveiled the National Action Plan to Advance Patient Safety. 1 Within this framework, four pillars were identified as critical to fostering a safer health care environment: Culture, Leadership and Governance; Patient and Family Engagement; Learning Systems; and
[139] Culture of Safety in Healthcare: Elevating Patient Outcomes and Trust — Yet, creating a culture of safety in healthcare requires more than policies and protocols—it demands a leadership-driven commitment to fostering an environment where safety is at the forefront of every decision, action, and communication. Culture of Safety in Healthcare: Impact on Clinical Indicators and Reducing Adverse Events
[171] Learning Health Systems for Patient Safety - PSNet — Patient safety initiatives vary widely across healthcare organizations despite common identifiable risk factors, adverse events, and patient safety goals. One clear challenge in improving patient safety has been to disseminate knowledge and implement best practices consistently across the entire healthcare system.
[172] 10 top threats to patient safety in 2025: ECRI — In 2025, the top threats to patient safety reflect a mix of long-standing challenges and emerging risks, according to a new report from ECRI and the Institute for Safe Medication Practices.
[173] New top patient safety concerns emerge while other measures improve — "Medical gaslighting" and AI are among top concerns as the information age encourages patient engagement but disrupts provider-patient relationships. Systemic measures can improve trust and safety.
[174] Patient safety - World Health Organization (WHO) — Common adverse events that may result in avoidable patient harm are medication errors, unsafe surgical procedures, health care-associated infections, diagnostic errors, patient falls, pressure ulcers, patient misidentification, unsafe blood transfusion and venous thromboembolism. Patient safety is defined as “the absence of preventable harm to a patient and reduction of risk of unnecessary harm associated with health care to an acceptable minimum." Within the broader health system context, it is “a framework of organized activities that creates cultures, processes, procedures, behaviours, technologies and environments in health care that consistently and sustainably lower risks, reduce the occurrence of avoidable harm, make error less likely and reduce impact of harm when it does occur." The global campaign, with its dedicated annual theme, is aimed at enhancing public awareness and global understanding of patient safety and mobilizing action by stakeholders to eliminate avoidable harm in health care and thereby improve patient safety.
[175] What are Common Challenges in Ensuring Patient Safety? — Workload and Staffing Issues High patient-to-nurse ratios and excessive workloads can compromise patient safety. Overworked nurses may experience fatigue, leading to decreased attention to detail and increased likelihood of errors. Ensuring adequate staffing levels and manageable workloads is essential for maintaining patient safety.
[178] 12 Strategies to Increase Patient Engagement in Healthcare — 12 Strategies to Increase Patient Engagement in Healthcare | Levo Health Levo Health > Levo Health – Healthcare Insights > Thought Leadership > 12 Strategies to Increase Patient Engagement in Healthcare 12 Strategies to Increase Patient Engagement in Healthcare Top Strategies to Improve Patient Engagement in Healthcare Whether targeted toward improving the patient experience or enhancing healthcare outcomes, successful patient engagement strategies should be personalized and adaptable. The Future of Patient Engagement in Healthcare As we move forward, the integration of digital patient engagement tools and personalized care models is not just a trend but a necessity for enhancing healthcare experiences and outcomes. With its ability to analyze vast amounts of data and provide tailored recommendations, AI can help healthcare practices improve communication, create personalized care plans, and engage patients more effectively.
[179] Engaging patients to improve quality of care: a systematic review — Increasing literature indicates that it is not only feasible to involve patients in the delivery or re-design of health care but that such engagement can lead to reduced hospital admissions , improved effectiveness, efficiency and quality of health services [28–31], improved quality of life, and enhanced quality and accountability of health services . Governments and health care institutions are urged by some experts to engage patients and other service users, including caregivers and relatives in more robust ways where patients are actively involved as partners or co-leads in organizational re-design and evaluation of health care delivery, as depicted by the red section in Carman’s framework (Fig. 1).
[186] Guidelines and Safety Practices for Improving Patient Safety — The U.S. National Guideline Clearinghouse (NGC) of the Agency for Healthcare Research and Quality (AHRQ) also uses the definition of clinical practice guidelines developed by the IOM, stating that “clinical practice guidelines are statements that include recommendations intended to optimize patient care that are informed by a systematic review of evidence and an assessment of the benefits and harms of alternative care options” . Guidelines are expected to be focused on broad and complex topics, on developing standards to guide healthcare organizations, on providing best practice recommendations for patient care, and on informing the clinical decision-making of health professionals. The improvement of patient safety should be based on evidence-based recommendations included in well-developed guidelines, which should in turn be rigorously implemented in clinical practice as the best safety practice.
[197] PDF — ABSTRACT: This report presents 10 case studies of health care organizations, clinical teams, and learning collaborations that have designed innovations in five areas that hold great promise for improving patient safety nationally: promoting an organizational culture of safety, improving
[199] Why are nurses indifferent to the phenomenon of gaslighting of patients ... — The scarcity of research on gaslighting from an ethical perspective suggests that this area has not been a focus for medical ethicists and researchers. This gap in the literature means that ethical discussions about gaslighting in practice are limited.
[201] Turning Down the Flame on Medical Gaslighting - PMC — Determining which patient demographics, medical conditions, physician behaviors, and health system pressures are correlated with gaslighting complaints will enable the healthcare system to learn more about gender, class, race, disability, age, and time as factors in medical gaslighting and then create the appropriate solutions.
[202] Medical gaslighting, where healthcare providers unintentionally dismiss ... — Medical gaslighting, a phenomenon whereby healthcare providers may unintentionally dismiss or minimize patients' concerns, is an emerging issue that poses a significant risk to patient safety. It can contribute to delayed diagnoses, mismanagement of care, and the exacerbation of health disparities, particularly among marginalized populations.
[203] Medical gaslighting, where healthcare providers unintentionally dismiss ... — The consequences of medical gaslighting on patient safety can be serious, as it can contribute to diagnostic errors, delays in treatment, and unnecessary suffering.(18) Physicians risk underdiagnosis or misdiagnosis by not fully acknowledging a patient's symptoms,(18-21) which can delay appropriate care and worsen the patient's condition.
[208] Patient Safety Research: Insights and Future Directions — In summary, patient safety research holds invaluable information that impacts healthcare. Continued exploration in this area is necessary to ensure the well-being of patients and to foster environments where safety can thrive. ... Understanding future directions not only shapes methodologies but also informs policy changes and practice
[209] Patient Safety Movement: History and Future Directions - PMC — For example, the World Health Organization (WHO) created a “Safe Surgery Saves Lives” checklist that features checkpoints of certain safety verifications that should be performed at different times in all perioperative processes to protect against universal safety hazards.10 An important component of this checklist is marking of the surgical site by the surgeon while the patient is awake, a process that has also been advocated for by the American Academy of Orthopaedic Surgeons (AAOS) “Sign Your Site” campaign, which was first introduced in 1998.11 Additionally, the Joint Commission developed a preoperative safety initiative called “Speak UP”, which emphasizes similar checkpoints in the preoperative time period to reduce wrong site and wrong patient surgical errors.
[213] Technology usage for teaching and learning in nursing education: An ... — Furthermore, integration of technology usage with clinical settings has ... thus improving teaching and learning and prioritising patient safety. The use of technology in simulation lab was ... 'Evaluating practice of smartphone use among university students in undergraduate nursing education', Health Professions Education 6(2), 238
[214] Influence of Technology in Supporting Quality and Safety in Nursing ... — Keywords: Distance education, Educational technology, Innovation, Professional education, Quality of health care, Patient safety, Simulation Key points The COVID-19 pandemic and the subsequent need for social distancing accelerated the adoption of technology-driven strategies for work meetings on video platforms and use of quick response codes
[215] PDF — For example, the surgical residents led the checklist in one study19 whereas the nurses led the checklist completion in another.20 A few studies suggested that the implementation of the SSC in the perioperative setting improved patient outcomes, improved patient safety, improved communication and teamwork and decreased complications.18 21-25
[217] PPTX — There is an opportunity for us to improve patient care by improving teamwork and communication. Ways to improve teamwork and communication. Have the entire team perform a briefing before every case and a debriefing at the end of every case. Bring briefing and debriefing into the surgical environment by using the surgical checklist.
[219] What is the role of technology in improving patient safety? A French ... — The working group summarised that the application of technology to enhance patient safety should be considered with respect to current clinical processes, employed technologies and the environment of care; 14 there is little doubt that innovative technology is an important tool for improving patient safety, but institutions may need to be
[221] Addressing the challenges of AI-based telemedicine: Best practices and ... — Integrating artificial intelligence (AI) into telemedicine has the potential to enhance and expand its capabilities in addressing various healthcare needs, such as patient monitoring, healthcare information technology (IT), intelligent diagnosis, and assistance. Four emerging trends in which AI is impacting telemedicine are as follows: 1) monitoring of patients, 2) using information technology in health care, 3) use of intelligent assistance and diagnosis, and 4) collaborative information analysis. Teleurology involves the use of telecommunication technology to remotely provide urological care to patients. The utilization of teleurology and digital health applications proved to be highly advantageous, particularly amid the COVID-19 pandemic. In urology, AI can help with the analysis of medical images and the identification of abnormalities or patterns that may be indicative of certain conditions or diseases.
[222] Artificial Intelligence and Patient Safety: Promise and Challenges - PSNet — AI models are only as good as the data they are trained on, and if the training data are biased or underrepresent certain groups, the results of that model will not be equitable.9 A systematic review by the AHRQ Evidence-based Practice Center found that algorithms can exacerbate racial and ethnic disparities, but also have the potential to reduce them.10 Researchers and developers are attempting to mitigate the effects of bias in several different ways, including regular analysis of model metrics to detect bias, editing input variables, and by exploring the use of synthetic data, which involves creating artificial data that mimic real patient data but without the inherent biases.10, 11, 12 Data-sharing privacy is another ethical consideration.13 Healthcare data are highly sensitive, as they contain personal and private information about patients, and sharing such data for AI model training and research purposes must be done with utmost caution and adherence to strict privacy and security measures.
[227] PDF — What is already known about this topic? Use of the WHO Surgical Safety Checklist dramatically improves patient outcomes in surgery, including reductions of perioperative mortality, postoperative infections and complications. Wide-scale implementation of the checklist has been dificult worldwide, and significant challenges exist in low-income and middle-income countries (LMICs).
[228] Compliance With the World Health Organization Surgical Safety Checklist ... — The study suggests that overcoming the obstacles to implementing the checklist requires a collaborative environment and effective instruction. It emphasizes the importance of adhering … The study showed that education is a critical factor in improving compliance with the WHO Surgical Safety Checklist.
[229] WHO safe surgery checklist: Barriers to universal acceptance — In this article, we would like to highlight the barriers in universal adoption and implementation of the WHO Surgical Checklist and measures that can be taken to overcome these hurdles. The initial results generated an awareness about surgical safety and were followed by reports about significant reduction in surgical complications all over the globe. The Netherlands Surgical Patient Safety System found a significant reduction in in-hospital mortality (1.5%–0.8%) and in overall complications (27.3–16.7/100) after implementation of a comprehensive surgical checklist. Introduction of the checklist in the hospitals in Liberia was associated with significant (P < 0.05) improvements in terms of overall surgical processes and surgical outcome. The maiden study from India reported reduction in mortality and improved postoperative outcomes following implementation of the WHO Surgical Safety Checklist in a tertiary care hospital.