The PSNet Collection: All Content

The AHRQ PSNet Collection comprises an extensive selection of resources relevant to the patient safety community. These resources come in a variety of formats, including literature, research, tools, and Web sites. Resources are identified using the National Library of Medicine’s Medline database, various news and content aggregators, and the expertise of the AHRQ PSNet editorial and technical teams.

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Displaying 1 - 20 of 302 Results

Voices from the Frontlines of Health Care Safety.

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Boston, MA; Betsy Lehman Center; April 2023.

Well-told stories can motivate change. This video translates the experience of Massachusetts patients and family members with medical error for a broad audience. Clinicians also participate and share perspectives on problems in care systems that contribute to patient harm.

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

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Agency for Healthcare Policy and Research: April 27, 2023.

Ambulatory surgery centers (ASC) experience a variety of error types that can be acerbated by poor safety culture. This webcast provided information on AHRQ’s Surveys on Patient Safety Culture™ (SOPS®) Ambulatory Surgery Center (ASC) Survey, including a review of the SOPS ASC program, survey administration, database submission, and available resources.

Redesigning Event Review with RCA2

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Institute for Healthcare Improvement. September 13 - November 7, 2023.

Root cause analysis (RCA) is a widely recognized retrospective strategy for learning from failure that is challenging to implement. This series of webinars will feature an innovative approach to RCA that expands on the concept to facilitate its use in incident investigations. Instructors for the series will include Dr. Terry Fairbanks and Dr. Tejal K. Gandhi.

Certified Professional in Patient Safety Review Course.

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Institute for Healthcare Improvement.

This online class prepares individuals to apply for the Institute for Healthcare Improvement patient safety certification program. The on-demand or live sessions cover key patient safety concepts to enhance participants' knowledge about safety culture, systems thinking, leadership, risk identification and analysis, information technology, and human factors. The next online session is August 2-3, 2023.

Just a Cup of Tea – an Introduction to the SEIPS Framework.

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Epsom and St Helier University Hospitals. Epsom, UK: National Health Service; March 21, 2023.

The Systems Engineering Initiative for Patient Safety (SEIPS) framework is an established human factors-based approach to designing care system improvements. This video introduces the concepts behind SEIPS and uses an everyday non-clinical activity to illustrate its use for a broad audience to identify problems.

Serious Reportable Events in Massachusetts.

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Fillo KT, Saunders K. Bureau of Health Care Safety and Quality, Department of Public Health. Boston, MA: Commonwealth of Massachusetts; 2023.

This reoccurring report compiles patient safety data collected by Massachusetts hospitals. The 2022 numbers document an increase in serious reportable events recorded in acute care hospitals, from 1430 the previous year to 1632. This presentation also includes events from ambulatory surgery centers. Older reports are also available.

Finding & Creating Joy in Work.

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Institute for Healthcare Improvement. September 13 - November 21, 2023.

Burnout among health care workers negatively affects system improvement. This webinar series will highlight strategies to establish a healthy work environment that strengthens teamwork, staff engagement, and resilience. Instructors include Dr. Donald Berwick and Derek Feeley.

Preventing Workplace Violence.

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National Action Alliance. June 27, 2023. 2:00- 3:00 PM (eastern)

Violence in the health care environment detracts from staff and clinician ability to provide safe care. Sponsored by the Centers for Disease Control and Prevention, this webinar will discuss the importance of violence prevention.

Understanding and Improving Everyday Work in Healthcare.

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Clinical Human Factors Group. May 16, 2023, 9:00 AM--12:30 PM (eastern).

Organizations and individuals learn by considering how humans interact while performing routine tasks. This seminar will examine the opportunities for improvement in examining what work-as-done efforts reveal, embedding human factors design considerations into daily work processes, and prioritizing front-line staff experience as a component of safety.

National Action Alliance to Advance Patient Safety Webinar Series.

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Health and Human Services. June 27, 2023. 2:00-3:00pm (eastern).

Work toward zero harm in health care is gaining national attention in the United States. This webinar aligns with efforts by the National Action Alliance to Advance Patient Safety. The session will explore the importance of preventing workplace violence in healthcare settings. This is the second in a series of offerings from the Alliance supporting its work to improve safety.

CUSP Implementation Training.

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Armstrong Institute for Patient Safety and Quality.

The comprehensive unit-based safety program (CUSP) approach emphasizes improving safety culture through a continuous process of reporting and learning from errors, improving teamwork, and engaging staff at all levels in safety efforts. Available on demand and live, this session covers how to utilize CUSP, including understanding and addressing challenges to implementation. The next virtual session will be held July 18, 2023.

Cancer drug shortages are creating dire circumstances for some patients.

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Lovelace B, Jr, Kopf M. NBC. April 11, 2023.

Shortages of life-saving cancer drugs have been a problem for many years and were exacerbated by the COVID-19 pandemic. This news article reports that low profitability of manufacturing generic drugs contributes to this shortage. Until these cancer drugs are available, many patients will receive no treatment, or treatment that is less than ideal.

ISMP Medication Safety Intensive.

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Institute for Safe Medication Practices. June 8-9, 2023.

This virtual workshop will explore tactics to ensure medication safety, including strategic planning, risk assessment, and Just Culture principles.

Saving Moms.

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Boswell B. KCET: April 2023.

Increasing attention is being placed on addressing inequities in maternal health care. This video shares stories of mothers experiencing harm during pregnancy and steps being taken to minimize the impact of implicit biases and lack of access to care to generate improvement.

Preventing home medication errors.

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Shaikh U, van der List L, Blumberg D. Kids Considered. March 27, 2023.

Medication administration at home can be problematic especially for parents caring for children. This podcast highlights common reasons for medication mistakes at home and how they can be avoided. Simple steps such as not using regular spoons as methods of delivering liquid medications are highlighted.

TeamSTEPPS Master Training Virtual Course.

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AHA Team Training. April 20 - June 8 2023.

The TeamSTEPPS program was developed to support effective communication and teamwork in health care. This online series will prepare participants to guide their organizations through implementation of the TeamSTEPPS program. It is designed for individuals that are new to TeamSTEPPS processes.

TeamSTEPPS Master Training Course.

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Armstrong Institute for Patient Safety and Quality. June 13 and June 15, 2023.

Team training programs seek to improve communication and coordination among team members to reduce the potential for medical error. This virtual workshop will train participants to design, implement, and evaluate team training programs in their organizations based on the TeamSTEPPS model.

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

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Agency for Healthcare Research and Quality. January 24, 2023.

Workplace safety became more apparent during the COVID pandemic as an essential component to support effective and safe care provision. This session introduced the AHRQ Workplace Safety Supplemental Item Set for use with the Surveys on Patient Safety Culture™ (SOPS®) Nursing Home Survey that examines staff perceptions of workplace safety. Background on the importance of workplace safety in nursing homes, results from a pilot test in 48 nursing homes, and one organization’s experience with the survey were shared.

Spotlight Series

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Healthcare Excellence Canada. 2020-2023.

This bi-monthly webinar series focuses on a variety of topics that support patient safety and quality improvement.

Emerging Topics in Quality Improvement.

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University of Washington Medicine Center for Scholarship in Patient Care and Quality and Safety and Seattle Children's Hospital.

Patient safety is a dynamic discipline that adjusts regularly to address clinical, organizational and policy changes, and disruptions. This webinar series presents sessions exploring insights on a variety of strategies and experiences to enhance care.

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