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 309 Results

Certified Professional in Patient Safety Review Course.

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Institute for Healthcare Improvement. March 7–8 2024, 12:00-4:00 PM (eastern).

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.

Creating Workforce Joy and Wellbeing.

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Institute for Healthcare Improvement. March 6 - May 20, 2024.

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.

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

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American Hospital Association. December 7, 2023. 1:00-2:00 PM (eastern).

Health care organizations require a systems approach to address patient safety challenges and sustain improvements. This session will feature three health care executives who will discuss how to align quality and safety efforts to effectively measure performance, create value, and support transparency.

Redesigning Event Review with RCA2.

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Institute for Healthcare Improvement. March 13 - April 23, 2024.

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.

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 January 16, 2024.

Diagnostic Safety and Quality Webinar Series: Overview and Implications for Hospitals.

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The Leapfrog Group. November 28, 2023, 3:00--4:00 PM (eastern).

Diagnostic errors in hospitals are the focus on continued improvement efforts as they are common, costly, and harmful. This last in a three-part series of webinars will focus on existing learning strategies to improve diagnosis in hospitals. Dr. Divvy Upadhyay is the featured speaker.

The hospital ran out of her child's cancer drug. Now she's fighting to end shortages.

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Noguchi Y. Health Shots and All Things Considered. National Public Radio. October 23, 2023.

Drug shortages, while often discussed as a system failure, demonstrate harm at an individual level. This story highlights the work of a patient activist who was inspired by the threat to her daughter’s care posed by a lack of chemotherapy availability, to provide needed medications during system disruptions to keep patients safe.

TeamSTEPPS Master Training Course.

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Armstrong Institute for Patient Safety and Quality. January 30 and February 1, 2024.

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.

ISMP Medication Safety Intensive.

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Institute for Safe Medication Practices. November 30-December 1, 2023, 7:30 AM - 4:30 PM (eastern).

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

Cybersecurity for the Clinician.

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Chicago, IL: American Medical Association; 2023.

The vulnerability of healthcare information technologies and devices to malicious interruptions is increasingly recognized as a patient safety hazard. This eight-episode video series provides an overview for non-technologists on how cyberattacks happen, their potential to degrade care provision, and strategies to keep practices safe.

Healthcare Failure Mode and Effects Analysis.

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ECRI and the Institute for Safe Medication Practices. November 14, 2023, 12:00-5:00 PM (eastern).

Failure mode and effect analysis (FMEA) is a proactive method to identify risks at each step in the process. Attendees of this training will learn how and why healthcare FMEA is performed, and apply their learning to case studies.

Why admitting to mistakes can help doctors (and patients).

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McDonald T. TEDxSanDiego. September 23, 2023.

The lack of a safety culture fundamentally restricts the ability of clinicians to address mistakes, psychologically deal with them and learn. The CANDOR system is highlighted in this presentation by one of the originators of the concept as a strategy for successful resolution, learning and support for those involved in medical error.

Smart Healthcare Safety.

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Plymouth Meeting PA, ECRI. 2019-2023.

A wide variety of considerations must converge to inform an understanding of system vulnerabilities and the application of strategies to address them. This series of webinars covers a range of topics affecting the reliability of the health care environment. A recent presentation discussed the “5 rights of medication safety.”

National Action Alliance to Advance Patient Safety Webinar Series.

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US Department of Health and Human Services. 2023.

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 most recent session explored the successful application of high reliability concepts at the Veterans Health Administration. There have been five videos in this series of offerings from the Alliance supporting its work to improve safety.

Uncovering the shocking dangers of misdiagnosis.

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Graedon T. People’s Pharmacy. Show 1355. September 8, 2023.

Misdiagnosis continues to impact the safety of health care. This podcast with David Newman-Toker discusses foundational issues that detract from diagnostic safety and examines how teamwork, training, technology, tuning can make the process more reliable. Strategies for patients to play a role in their diagnostic process are also discussed.

‘The Retrievals’ reveals painful experiences of female patients are often ignored.

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Desjardins L. PBS NewsHour. August 29, 2023.

Disregard for women’s pain is a persistent problem in health care. This news segment discusses a podcast highlighting a pattern of dismissal of patient concerns that resulted in harm and allowed fentanyl diversion by a nurse with substance abuse disorder to go undetected.

Striving for diagnostic excellence.

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Centor RM, Dhaliwal G. Annals On Call. July 2023.

Diagnostic accuracy requires both cognitive and team-focused skill development. This podcast interview shares problem-solving tactics that support diagnostic excellence and how to measure it. Tracking diagnosis outcomes at a patient level is one strategy discussed.

IHI Fellowship Program.

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Institute for Healthcare Improvement.

This virtual fellowship program focuses on developing competencies for leading patient safety efforts. The deadline for submitting an application for the 2023–2024 class has passed.

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

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Betsy Lehman Center for Patient Safety.

Communication and resolution programs are a promising strategy for successful management of relationships and actions after medical error occurrence. This annual hybrid session explores elements of effective discussions after an adverse event through case simulation and dialogue. The site also includes an archive of videos and materials from previous forums.

The Retrievals.

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Burton S. New York Times and Serial Productions. June 30-July 27, 2023.

Unnoticed drug diversion can result in harm to patients, clinicians, and organizations. This series describes how diversion contributed to unnecessary pain in fertility clinic patients. The problem was compounded by a lack of attention to women voicing their concerns about procedural pain.

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