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)

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

September 15, 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

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

April 7, 2021

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

October 26, 2021 - October 26, 2021

Lewis Blackman Leadership Award.

January 19, 2022

Anesthesia Patient Safety Foundation (APSF) Grant Program.

April 25, 2022

Pharmacy Safety and Service—What You Should Expect.

March 6, 2005

National Patient Safety Foundation.

March 27, 2005

Anesthesia Patient Safety Podcast.

July 12, 2023

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

September 8, 2010

Selection of incorrect medication pump leads to chemotherapy overdose.

September 16, 2015

APSF Stoelting Conference.

September 6, 2023 - September 7, 2023

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

Best Practices for Safe Medication Administration During Anesthesia Care.

May 2, 2018

Why doctors still offer treatments that may not help.

September 4, 2019

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

September 7, 2022

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

August 10, 2022

Anesthesia Patient Safety Foundation Newsletter.

January 4, 2006

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

March 17, 2021

World Patient Safety, Science & Technology Summit.

June 1, 2023 - June 2, 2023

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

July 12, 2017

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

December 13, 2017

Joint Statement on Multiple Patients Per Ventilator.

April 22, 2020

Patient Safety Resource Centre.

June 5, 2013

The MacArthur Fellows Program: Eric Coleman.

October 17, 2012

Safer Patients Network.

June 21, 2006

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

September 10, 2014

Diagnostic Excellence Initiative.

November 7, 2018

Safer Clinical Systems.

May 13, 2015

Decontamination of Surgical Instruments.

June 8, 2022

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

March 10, 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

Failure to cap IV tubing and disinfect IV ports place patients at risk for infections.

August 15, 2007

Nurturing Creativity: 2006 MacArthur Fellows.

October 4, 2006

The MacArthur Fellows Program: Peter Pronovost.

October 8, 2008

The MacArthur Fellows Program: Michael Cohen.

September 28, 2005

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

August 20, 2021

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

September 1, 2021

Students have a key role in a culture of safety: analysis of student-associated medication incidents.

August 8, 2018

Raising the index of suspicion: red flags that represent credible threats to patient safety.

August 8, 2012

Fatal outcome after inadvertent injection of topical epinephrine.

April 8, 2009

Inattentional blindness: what captures your attention?

March 11, 2009

Josie's Story: A Patient Safety Curriculum.

June 1, 2016

ISMP updates its list of drug names with tall man (mixed case) letters based on survey results.

February 8, 2023

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

August 25, 2021

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

August 18, 2021

‘I felt like I was dying’: how women with postpartum depression fall through the cracks of U.S. health care.

July 5, 2023

Driving Learning and Improvement After RCA2 Event Reviews.

January 26, 2023 - January 26, 2023

Peer Support Toolkit.

September 29, 2021

A Conversation Among Stakeholders on Medical Malpractice.

April 26, 2022 - April 26, 2022

Electronic medicine can send you test results quickly. But what if they're scary?

April 11, 2018

Care transitions know-how not just for clinicians.

October 11, 2017

Analysis of ISMP National Vaccine Errors Reporting Program—part 1 and part 2.

April 8, 2015

Embedded bias: how medical records sow discrimination.

October 5, 2022

Antifatness in the surgical setting.

June 8, 2022

Prescription for disaster: America's broken pharmacy system in revolt over burnout and errors.

November 8, 2023

A medical detective story: why doctors make diagnostic errors.

October 7, 2015

Hospital safety records, CEO pay increasingly linked.

December 5, 2007

Nearly 90 major medical mistakes logged at Utah hospitals in 2008.

July 8, 2009

Medical misdiagnoses can have fatal consequences.

July 6, 2011

As cancer drug shortages grow, some doctors are forced to ration doses or delay care.

June 7, 2023

Safe Practices to Reduce CPOE Alert Fatigue through Monitoring, Analysis, and Optimization.

March 10, 2021

Optimizing Health IT for Safe Integration of Behavioral Health and Primary Care.

February 17, 2021

How the coronavirus is delaying life-altering surgeries.

May 6, 2020

Kaiser learns from tragic medical errors.

June 4, 2008

Reducing preventable harm in hospitals.

February 3, 2016

Bar code label requirement for human drug products and biological products.

March 27, 2005

Mirror, Mirror 2021: Reflecting Poorly

August 1, 2021

The National Patient Safety Foundation Research Program.

March 27, 2005

A Systems Approach to Quality Improvement in Long-Term Care: Safe Medication Practices Workbook.

April 18, 2007

BMJ Quality & Safety.

March 6, 2005

Clash in the name of care.

November 4, 2015

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

Artificial Intelligence in Health Care: Benefits and Challenges of Technologies to Augment Patient Care.

December 9, 2020

Ten Years After Keeping Patients Safe: Have Nurses' Work Environments Been Transformed?

April 2, 2014

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

June 24, 2015

Reducing Diagnostic Errors.

November 21, 2012

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

December 16, 2015

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

June 1, 2016

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

March 6, 2005

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

July 29, 2020

Wrong Site Surgery - Wrong Patient: Invasive Procedures in Outpatient Settings.

June 23, 2021

Wrong Site Surgery–Wrong Tooth Extraction.

June 9, 2021

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

March 22, 2017

Health Information Technology through the Lens of Patient Safety.

November 20, 2013

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

September 16, 2009

A Thematic Analysis of HSIB's First 22 Investigations.

September 29, 2021

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

March 27, 2005

Analysis of transdermal medication patch errors uncovers a “patchwork” of safety challenges.

March 24, 2021

Leaving a discontinued FentaNYL infusion attached to the patient leads to a tragic error

July 14, 2021

Good for You, Good for Us, Good for Everybody.

October 6, 2021

Before mea culpa, Children’s was confident its air systems weren’t source of infection

December 11, 2019

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

April 2, 2014

Any new process poses a risk for errors: learning from 4 months of Coronavirus disease 2019 (COVID-19) vaccinations.

May 12, 2021

A recurring call to action: every healthcare organization needs a medication safety officer!

March 10, 2021

Updated guidance needed for longstanding large volume parenteral (LVP) labeling and packaging problems.

March 3, 2021

Start the year off right by preventing these top 10 medication errors and hazards from 2020.

February 10, 2021

Learning from errors with the new COVID-19 vaccines.

January 27, 2021

Related Resources

National Action Alliance to Advance Patient Safety Webinar Series.

September 26, 2023 - September 26, 2023

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

August 10, 2023

Advancing Diagnostic Excellence in Maternal Health Care.

July 27, 2023 - July 27, 2023

Deficient Care of a Patient Who Died by Suicide and Facility Leaders' Response at the Charlie Norwood VA Medical Center in Augusta, Georgia.

July 5, 2023

Unequal Treatment Revisited: A Workshop Series.

September 26, 2023 - September 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

Why hospitals still make serious medical errors—and how they are trying to reduce them.

March 29, 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

Spotlight Series

January 27, 2022 - January 27, 2022

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 26, 2023 - January 26, 2023

The National Healthcare System Action Alliance to Advance Patient Safety.

November 14, 2022 - November 14, 2022

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

October 5, 2022

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

September 12, 2022 - September 12, 2022

Addressing the Loss of Trust in Safety Culture.

September 7, 2022

Abortion bans have consequences for wanted pregnancies, too.

August 17, 2022

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

August 10, 2022

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

August 10, 2022

Healthcare Safety Investigations Conference 2022.

August 3, 2022

Engaging Physicians in Teamwork Training for Quality and Safety - Or Why Don’t Your Physicians Get Engaged?

June 8, 2022 - June 8, 2022

The Power of Medical Malpractice Stories to Improve Patient Safety.

May 19, 2022 - May 19, 2022

The Color of Care.

May 11, 2022

Lessons Learned about Human Fallibility, System Design, and Justice in the Aftermath of a Fatal Medication Error.

May 6, 2022 - May 6, 2022

See More About The Topic

General Public

Health Care Providers

Medical Complications

Error Reporting and Analysis