Patient Safety Fundamentals
The concepts, frameworks and vocabulary underlying hospital patient safety and quality practice: high-reliability organising, systems thinking and human factors, the Swiss cheese model, safety culture measurement, harm taxonomies and severity classification, the difference between error, harm and preventable harm, and the landmark reports and bodies that shaped the field. The entry point for anything in this cluster that does not sit inside a more specific area of practice.
Guides
Clinical Order Sets: Evidence-Based Design, ISMP Safety Rules, and HL7 FHIR PlanDefinition
A patient-safety and clinical informatics guide to clinical order sets and evidence-based order sets in CPOE systems, detailing Institute for Safe Medication Practices (ISMP) design standards, HL7 FHIR PlanDefinition and ActivityDefinition structures, default selection behavioral architecture, and P&T governance.
Manchester Triage System (MTS) and Canadian Triage and Acuity Scale (CTAS): 5 Acuity Levels, Target Times, and Discriminators
Clinical guide to the Manchester Triage System (MTS) and Canadian Triage and Acuity Scale (CTAS): 5 color tiers, waiting times, discriminators, and ESI comparison.
The 5 Rights of CDS (Five Rights of Clinical Decision Support): Framework, HL7 CDS Hooks Mapping, and EHR Audit Checklist
Reference guide to the 5 Rights of Clinical Decision Support (Osheroff/AHRQ): framework breakdown, HL7 CDS Hooks mapping, and alert audit checklist.
Suicide Risk Stratification: VA MIRECC Acute vs. Chronic Matrix, NPSG 15.01.01, and How It Improves Clinical Documentation
How two-dimensional suicide risk stratification (VA MIRECC acute vs. chronic tiers) improves clinical documentation, disposition decisions, and EHR safety workflows.
NEWS2 Score (National Early Warning Score 2): Royal College of Physicians Scoring Chart, SpO2 Scale 1 vs. Scale 2, and 0–20 Escalation Triggers
A clinical and methodological reference to the Royal College of Physicians National Early Warning Score 2 (NEWS2, December 2017), detailing the 6 physiological parameters, SpO2 Scale 1 vs. Scale 2 for hypercapnic respiratory failure, worked arithmetic examples, 0–20 escalation thresholds, and Python/R implementations.
Hendrich II Fall Risk Model: The 8 Intrinsic Risk Factors, Scoring Table, and ≥5 Cutoff
Clinical guide to the Hendrich II Fall Risk Model: the 8 weighted intrinsic risk factors, Get-Up-and-Go scoring, ≥5 high-risk cutoff, and nursing workflows.
Schmitt-Thompson Protocols (STCC): Clinical Telephone Triage Decision Trees, Acuity Dispositions, ClearTriage, and EHR Integration
A clinical informatics reference to the Schmitt-Thompson Clinical Content (STCC) telephone triage protocols developed by Dr. Barton Schmitt and Dr. David Thompson, detailing the top-down acuity decision-tree structure, disposition tiers, Office-Hours vs. After-Hours sets, and EHR integration.
Alert Fatigue in Healthcare: EHR CDSS Overrides, Bedside Alarm Safety, and Prevention
What alert fatigue is in healthcare: EHR CDSS override rates (49%–96%), physiologic alarm desensitization, NPSG.06.01.01, and reduction strategies.
PEWS Score (Pediatric Early Warning Score): Brighton/Monaghan 3-Domain Matrix, Bedside PEWS, and Escalation Thresholds
Clinical guide to the Pediatric Early Warning Score (PEWS): Brighton/Monaghan 3-domain scoring table, Bedside PEWS comparison, and PICU escalation rules.
SOFA Score (Sequential Organ Failure Assessment): 6-Organ Scoring Matrix, Sepsis-3 Criteria, and EHR Integration
Technical and clinical research guide to the Sequential Organ Failure Assessment (SOFA) score, detailing the 0–24 six-organ scoring matrix, Sepsis-3 operational definitions, qSOFA vs. SOFA, and automated EHR calculation.
Emergency Severity Index (ESI): 5-Level Triage Algorithm, Decision Points A–D, and Resource Counting
How the 5-level Emergency Severity Index (ESI) triage algorithm works, including Decision Points A–D, resource counting rules, Danger Zone vitals, and EHR use.
Columbia-Suicide Severity Rating Scale (C-SSRS): Subscales, FDA Guidance, and EHR Integration
The Columbia-Suicide Severity Rating Scale (C-SSRS) is a validated clinical and research instrument that assesses suicidal ideation severity, ideation intensity, suicidal behavior, and attempt lethality.
CPHQ Exam Preparation: Study Timeline, NAHQ Prep Resources and Practice-Question Strategy
How to prepare for the CPHQ exam: NAHQ’s own study-timeline guidance, its official review courses and practice tests, and how to build a study plan around the exam’s published item-count weighting.
What Is a Stethoscope?
A plain-language guide to what a stethoscope is, how acoustic and electronic types work, what clinicians listen for, and hygiene and procurement basics.
What Is Root Cause Analysis? (RCA in Patient Safety)
Root cause analysis (RCA) is the structured process healthcare and research-safety teams use to find the systemic causes behind an adverse event, not just the immediate action that preceded it.
Patient Safety Event Severity Classification
A graded severity scale for patient safety events — near miss through sentinel — and how the classification decides investigation depth (common-cause analysis, apparent cause analysis, or root cause analysis) and reporting obligation.
Designing a Good Catch Program That Doesn’t Undermine Reporting Culture
A good catch recognition programme sits on top of a hospital’s event-reporting system, not inside it. This guide covers submission mechanics, review cadence, criteria-based selection, and the guardrails that keep recognition from turning into a competition or quietly undermining non-punitive reporting culture.
AHRQ Surveys on Patient Safety Culture (SOPS)
How to pick the right SOPS survey by care setting, administer it correctly, score the composite measures, and benchmark results against the AHRQ database.
Designing a Hospital Incident Reporting System People Actually Use
Most hospitals already have an incident-reporting system; the gap is design, not software. This guide covers non-punitive intake, ease of entry, taxonomy and harm scoring done after intake rather than at the door, closing the loop with reporters, and why a rising reporting rate is usually good news, not bad.
Serious Reportable Events and Never Events
The NQF’s Serious Reportable Events list has 7 categories and 29 events. “Never event” is the looser, non-official term for it — here’s how the terminology, TJC sentinel events, CMS HACs, and state mandatory-reporting laws actually relate.
