Recognizing Unsafe Care: What It Is and How to Report It.

Meeting/Conference Proceedings

Recognizing Unsafe Care: What It Is and How to Report It.

August 18, 2021

Patient Safety Foundation. August 26, 2021.

This webinar introduced medical error and harm as related concepts to identify unsafe care and enhance response, engagement, and reporting efforts of clinicians, patients and families.

Available at

Related Resources From the Same Author(s)

Joint Statement on Multiple Patients Per Ventilator.

April 22, 2020

Do patient engagement interventions work for all patients? A systematic review and realist synthesis of interventions to enhance patient safety.

September 15, 2021

Evaluation of Quality, Safety, and Value in Veterans Health Administration Facilities, FY 2020.

September 15, 2021

Influences of physical layout and space on patient safety and communication in ambulatory oncology practices: a multisite, mixed method investigation.

July 14, 2021

CANDOR Webinar Series.

May 27, 2021 - May 27, 2021

Pump up the volume: tips for increasing error reporting and decreasing patient harm.

September 8, 2021

Electronic prescribing vulnerabilities: height and weight mix-up leads to dosing error.

September 8, 2010

2009 Older Adults' Knowledge About Medications That Can Impact Driving.

September 16, 2009

Administration of concentrated potassium chloride for injection during a code: still deadly!

June 30, 2021

Pediatric transport safety collaborative: adverse events with parental presence during pediatric critical care transport.

November 10, 2021

Medication errors in overweight and obese pediatric patients: a systematic review.

February 9, 2022

Safety Is Personal: Partnering With Patients and Families for the Safest Care.

April 2, 2014

Cardinal Health recalls Argyle UVC insertion tray due to missing instructions for use for the Safety Scalpel N11.

September 1, 2021

FDA Safety Communication: update--robotically-assisted surgical devices in mastectomy.

August 20, 2021

Rethinking use of air-safety principles to reduce fatal hospital errors.

September 7, 2022

Why doctors still offer treatments that may not help.

September 4, 2019

Review of Alleged Patient Deaths, Patient Wait Times, and Scheduling Practices at the Phoenix VA Health Care System.

September 10, 2014

Selection of incorrect medication pump leads to chemotherapy overdose.

September 16, 2015

Through the Eyes of the Workforce: Creating Joy, Meaning, and Safer Health Care.

March 20, 2013

The Uneven Burden of Maternal Mortality in the U.S.

August 10, 2022

Enhancing patient safety by integrating ethical dimensions to critical incident reporting systems.

April 28, 2021

Patient safety and quality improvement: ethical principles for a regulatory approach to bias in healthcare machine learning.

July 22, 2020

Optimizing post-acute care patient safety: a scoping review of multifactorial fall prevention interventions for older adults.

July 13, 2022

Engaging with ethnic minority consumers to improve safety in cancer services: a national stakeholder analysis.

May 25, 2022

Effect on patient safety of a resident physician schedule without 24-hour shifts.

July 15, 2020

Reimagining Healing after Healthcare Harm: The Potential for Restorative Practices.

July 29, 2020

World Patient Safety, Science & Technology Summit.

June 1, 2023 - June 2, 2023

Lewis Blackman Leadership Award.

January 19, 2022

We Can’t Do This Alone! The Role That Patients, Family Members, and the General Public Play in Advancing Patient Safety.

January 27, 2022 - January 27, 2022

Anesthesia Patient Safety Podcast.

July 12, 2023

Shining a Light: Safer Health Care Through Transparency.

January 28, 2015

Free From Harm: Accelerating Patient Safety Improvement Fifteen Years After To Err Is Human.

December 16, 2015

RCA2: Improving Root Cause Analyses and Actions to Prevent Harm.

June 24, 2015

Unmet Needs: Teaching Physicians to Provide Safe Patient Care.

March 17, 2010

Health Information Technology and Patient Safety: A Dynamic Discussion.

August 17, 2011

Transforming Health Care: A Compendium of Reports From the National Patient Safety Foundation's Lucian Leape Institute.

June 1, 2016

Health Information Technology through the Lens of Patient Safety.

November 20, 2013

Reducing Diagnostic Errors.

November 21, 2012

Order from Chaos: Accelerating Care Integration.

November 7, 2012

Best Practices for Safe Medication Administration During Anesthesia Care.

May 2, 2018

Optimizing a Business Case for Safe Health Care: An Integrated Approach to Safety and Finance.

July 12, 2017

Call to Action: Preventable Health Care Harm Is a Public Health Crisis and Patient Safety Requires a Coordinated Public Health Response.

March 22, 2017

Closing the Loop: A Guide to Safer Ambulatory Referrals in the EHR Era.

December 13, 2017

Dental Patient Safety Foundation.

March 7, 2018

APSF Stoelting Conference.

September 6, 2023 - September 7, 2023

Anesthesia Patient Safety Foundation (APSF) Grant Program.

February 5, 2024

Anesthesia Patient Safety Foundation Newsletter.

January 4, 2006

Lessons in Patient Safety.

August 24, 2005

First, Do No Harm Part 1: A Case Study of Systems Failure.

March 27, 2005

A Tale of Two Stories: Contrasting Views of Patient Safety.

March 27, 2005

The National Patient Safety Foundation Research Program.

March 27, 2005

Preventing Infections in the Hospital—What You As a Patient Can Do.

March 27, 2005

Safety as You Go from Hospital to Home.

March 6, 2005

Pharmacy Safety and Service—What You Should Expect.

March 6, 2005

Enhancing Patient Safety and Reducing Errors in Health Care.

March 6, 2005

National Agenda for Action: Patients and Families in Patient Safety.

March 6, 2005

National Patient Safety Foundation.

March 27, 2005

10 Facts on Patient Safety.

June 27, 2018

Wrong administration route of medications in the domestic setting: a review of an underestimated public health topic.

February 10, 2021

Health IT Safe Practices for Closing the Loop.

August 22, 2018

We're not your enemy: an appeal from a consumer to re-imagine tort reform.

August 8, 2007

Disruptive clinician behavior: a persistent threat to patient safety.

August 9, 2006

My life was upended for 35 years by a cancer diagnosis. A doctor just told me I was misdiagnosed.

April 7, 2021

5 pandemic mistakes we keep repeating. We can learn from our failures.

March 17, 2021

Families are struggling to use medicines at home — we must truly involve them in their own safety.

March 10, 2021

The calm before the storm: utilizing in situ simulation to evaluate for preparedness of an alternative care hospital during COVID-19 pandemic.

June 2, 2021

Clinical and economic impacts of explicit tools detecting prescribing errors: a systematic review.

May 26, 2021

Important Actions Community Pharmacists Need to Take Now to Reduce Potentially Harmful Dispensing Errors.

October 26, 2021 - October 26, 2021

Reporting of death in US Food and Drug Administration medical device adverse event reports in categories other than death.

August 11, 2021

Filling a gap in safety metrics: development of a patient-centred framework to identify and categorise patient-reported breakdowns related to the diagnostic process in ambulatory care.

October 27, 2021

Changes in safety and teamwork climate after adding structured observations to patient safety WalkRounds.

October 27, 2021

Patient safety trends in 2021: an analysis of 288,882 serious events and incidents from the nation’s largest event reporting database.

July 6, 2022

Looking back on the history of patient safety: an opportunity to reflect and ponder future challenges.

November 3, 2021

"Some version, most of the time": the surgical safety checklist, patient safety, and the everyday experience of practice variation.

January 19, 2022

COVID-19 and patient safety: time to tap into our investment in high reliability.

May 12, 2021

Exploring the theory, barriers and enablers for patient and public involvement across health, social care and patient safety: a systematic review of reviews.

February 10, 2021

The association between health care staff engagement and patient safety outcomes: a systematic review and meta-analysis.

February 3, 2021

Patient safety monitoring in acute care in a decentralized national health care system: conceptual framework and initial set of actionable indicators.

July 28, 2021

Understanding the "Swiss cheese model" and its application to patient safety.

July 21, 2021

Safety checklists for emergency response driving and patient transport: experiences from emergency medical services.

July 7, 2021

Implementation of patient safety structures and processes in the patient-centered medical home.

June 30, 2021

Support for healthcare professionals after surgical patient safety incidents: a qualitative descriptive study in 5 teaching hospitals.

May 26, 2021

Hemodialysis bleeding events and deaths: an 18-year retrospective analysis of patient safety and root cause analysis reports in the Veterans Health Administration.

November 24, 2021

Hospital cultural competency and attributes of patient safety culture: a study of U.S. hospitals.

November 17, 2021

Registered nurses' and medical doctors' experiences of patient safety in health information exchange during interorganizational care transitions: a qualitative review.

November 10, 2021

Identifying electronic medication administration record (eMAR) usability issues from patient safety event reports.

November 3, 2021

Patient safety strategies in psychiatry and how they construct the notion of preventable harm: a scoping review.

November 3, 2021

Patient safety and ethical implications of healthcare sick leave policies in the pandemic era.

September 15, 2021

Barriers and facilitators to patient engagement in patient safety from patients and healthcare professionals' perspectives: a systematic review and meta-synthesis.

August 25, 2021

A crisis within a crisis.

September 15, 2021

Toolkit for Engaging Patients to Improve Diagnostic Safety.

September 8, 2021

‘He thought what he was doing was good for people.’ Why is it so difficult to prevent unnecessary medical procedures in the U.S. health-care system?

September 1, 2021

Use purple bracelets or wristbands only for do not resuscitate status - letter to industry.

August 25, 2021

The pain was unbearable. So why did doctors turn her away?

August 25, 2021

Use systems redesign and the law to prevent medical errors and accidents.

August 18, 2021

Ripped apart: medical misdiagnosis and malpractice.

August 18, 2021

A System in Need of Repair: Addressing Organizational Failures of the U.S.’s Organ Procurement and Transplantation Network.

August 17, 2022

Mirror, Mirror 2021: Reflecting Poorly

August 1, 2021

Unite for Safe Care.

September 17, 2021 - September 17, 2021

Emergency physician perceptions of electronic health record usability and safety.

May 12, 2021

Related Resources

National Action Alliance to Advance Patient and Workforce Safety Webinar Series.

September 26, 2023 - September 26, 2023

Annual Perspective

Equity in Patient Safety

March 27, 2024

Prioritizing Patient Safety Through Quality Measurement.

February 28, 2024

Patient Safety Innovations

Patient and Family Centered I-PASS (Family-Centered Communication Program to Reduce Medical Errors and Improve Family Experience and Communication Processes)

January 31, 2024

Best Practices for Administering SOPS Surveys.

January 24, 2024 - January 24, 2024

Spotlight Series

January 27, 2022 - January 27, 2022

Unequal Treatment Revisited: A Workshop Series.

September 26, 2023 - September 27, 2023

SOPS Surveys.

November 28, 2023

Bringing a ‘Systemness’ Focus to Quality, Safety, and Patient Experience.

December 7, 2023 - December 7, 2023

Annual Communication, Apology, and Resolution (CARe) Forum.

August 10, 2023

Advancing Diagnostic Excellence in Maternal Health Care.

July 27, 2023 - July 27, 2023

Patient Safety Innovations

Remote Response Team and Customized Alert Settings Help Improve Management of Sepsis

May 31, 2023

SOPS Ambulatory Surgery Center Survey: What You Need to Know.

April 27, 2023 - April 27, 2023

APSF Stoelting Conference.

September 6, 2023 - September 7, 2023

Cancer drug shortages are creating dire circumstances for some patients.

April 26, 2023

World Patient Safety, Science & Technology Summit.

June 1, 2023 - June 2, 2023

Preventing home medication errors.

April 12, 2023

Maternal and Infant Health Inequality: New Evidence from Linked Administrative Data.

February 22, 2023

New AHRQ SOPS Workplace Safety Supplemental Item Set for Nursing Homes.

February 15, 2023

Emerging Topics in Quality Improvement.

February 14, 2023 - February 14, 2023

A deadly epidural, delivered by a doctor with a history of mistakes.

February 1, 2023

Driving Learning and Improvement After RCA2 Event Reviews.

January 11, 2023

The National Healthcare System Action Alliance for Patient and Workforce Safety.

November 14, 2022 - November 14, 2022

Opportunities to Improve Patient Safety, Advancing U.S. Innovation, and Innovation Hubs.

October 5, 2022

Addressing the Loss of Trust in Safety Culture.

September 7, 2022

Creating a Communication Coaching Structure and Support for your CRP Program.

September 12, 2022 - September 12, 2022

Abortion bans have consequences for wanted pregnancies, too.

August 17, 2022

The Uneven Burden of Maternal Mortality in the U.S.

August 10, 2022

Examining the Status of VA’s Electronic Health Record Modernization Program.

August 10, 2022

Healthcare Safety Investigations Conference 2022.

August 3, 2022

See More About The Topic

General Public

Health Care Providers

Medical Complications

Error Reporting and Analysis

Recognizing Unsafe Care: What It Is and How to Report It.

Patient and Family Centered I-PASS (Family-Centered Communication Program to Reduce Medical Errors and Improve Family Experience and Communication Processes)

Remote Response Team and Customized Alert Settings Help Improve Management of Sepsis

Connect With Us

Sign up for Email Updates

Agency for Healthcare Research and Quality

Recognizing Unsafe Care: What It Is and How to Report It.

Patient and Family Centered I-PASS (Family-Centered Communication Program to Reduce Medical Errors and Improve Family Experience and Communication Processes)

Remote Response Team and Customized Alert Settings Help Improve Management of Sepsis

Connect With Us

Sign up for Email Updates

Agency for Healthcare Research and Quality

Submit Your Innovations

Continue as a Guest

Continue Logged In

Submit Your Innovations

Continue as a Guest

Continue logged in

New Users to the PSNet site