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 340 Results

National Quality Forum. 2023 Annual Conference.

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National Quality Forum. Omni Shoreham Hotel, Washington DC, February 20-22, 2023.

This hybrid annual conference will focus motivating innovation through effective measurement in health care. The content will be directed toward a multidisciplinary audience to support healthcare improvement in all communities in areas such as maternal outcomes and equity. The session will feature a presentation of the John Eisenberg award winners and Atul Gawande as a key note speaker.

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 April 18-19, 2023.

Redesigning Event Review with RCA2

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Institute for Healthcare Improvement. Mar 14 - May 16, 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.

9th International Patient Safety Conference 2023.

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Indraprastha Apollo Hospitals. The Taj Palace, New Delhi, India. February 13-14, 2023.

This multidisciplinary international conference is designed around the theme of “Dream, Design, Dare.” Topics to be covered include strategic planning for improvement, artificial intelligence, and technologies as tools for safety care, and a peer exchange initiative to generate safety learnings.

Implicit racial bias, health care provider attitudes, and perceptions of health care quality among African American college students in Georgia, USA.

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Armstrong-Mensah E, Rasheed N, Williams D, et al. J Racial Ethn Health Disparities. 2022;Epub Nov 4.

Black patients who experience racism from their providers report receiving lower quality of care. Black public health students were asked about racist behaviors exhibited by their healthcare providers and the impacts the behaviors had on their care. The students recommend education and accountability to reduce providers’ racist attitudes, as well as increasing the number of Black clinicians.

The International Forum on Quality and Safety in Healthcare Europe.

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Institute for Healthcare Improvement and British Medical Journal. Bella Center, Copenhagen, Denmark, May 15-17, 2023.

This onsite conference offers an introduction to quality and safety improvement success and challenges drawing from international experiences. Course activities designed for a multidisciplinary audience supporting the theme of "Adapting to a changing world: equity, sustainability and wellbeing for all" will cover topics such as healthcare inequality, workforce wellbeing, and adverse events as learning opportunities.

Using the Assessment of Reasoning Tool to facilitate feedback about diagnostic reasoning.

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Cohen AL, Sur M, Falco C, et al. Diagnosis (Berl). 2022;9:476-484.

Clinical reasoning is now a common method to improve diagnostic decision making, and several tools have been developed to assess learners’ clinical reasoning. In this study, hospital faculty and pediatric interns used the Assessment of Reasoning Tool (ART) to assess, teach, and guide feedback on the interns’ clinical reasoning. Faculty and interns report the ART framework was highly structured, specific, formative, and facilitated goal setting.

Structural racism and impact on sickle cell disease: sickle cell lives matter.

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Smith WR, Valrie C, Sisler I. Hematol Oncol Clin North Am. 2022;36:1063-1076.

Racism exacerbates health disparities and threatens patient safety. This article summarizes the relationship between structural racism and health disparities in the United States and highlights how racism impacts health care delivery and health outcomes for patients with sickle cell disease.

International Society for Quality in Health Care Conference.

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International Society for Quality in Health Care, Korean Society for Quality in Health Care, Health Insurance Review and Assessment Service, and the Korea Institute for Healthcare Accreditation, COEX Convention and Exhibition Center, Seoul, Republic of Korea, August 27-30, 2023.

This conference will explore the theme of “'Technology, Culture, and Coproduction: Looking to the Horizon of Quality and Safety” and will provide sessions on patient safety topics such as learning from mistakes, human factors and Safety II. The call for papers closes January 26, 2023.

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 February 7-8, 2023.

TeamSTEPPS Master Training Course.

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Armstrong Institute for Patient Safety and Quality. January 31 and February 2, 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.

Strategies for a safe interhospital transfer with an intubated patient or where readiness for intubation is needed: a critical incidents study.

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Almqvist D, Norberg D, Larsson F, et al. Intensive Crit Care Nurs. 2022;74:103330.

Interhospital transfers pose a serious risk to patients. In this study, nurse anesthetists and intensive care nurses described strategies to ensure safe transport for patients who are intubated or who may require intubation. Strategies include clear and adequate communication between providers prior to transport, stabilizing and optimizing the patient’s condition, and ensuring that appropriate drugs and equipment are prepared and available.

ISMP Medication Safety Intensive.

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Institute for Safe Medication Practices. February 1-2, 2023.

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

Rise to Health Coalition.

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Boston, MA; Institute for Healthcare Improvement: December 2022.

Systemic efforts to improve health equity support patient safety. This announcement highlights an initiative for collective work to address four areas of effort to reduce inequity in health care: access, workforce, social and structural drivers, and quality and safety.

Global Ministerial Summit on Patient Safety.

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Federal Office of Public Health. 2m2c Convention Centre, Montreux, Switzerland, February 23-24, 2023.

Medical errors continue to cause harm worldwide despite the planning and efforts to reduce them. This bi-yearly session will feature topics exploring the theme of “Less Harm, Better Care – from Resolution to Implementation.” It will cover weaknesses in improvement initiative implementation surfaced by the COVID-19 pandemic and offer approaches for addressing unsustainable program launches and implementation practices.

Preventing errors when preparing and administering medications via enteral feeding tubes.

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ISMP Medication Safety Alert! Acute care edition. November 17, 2022;27(23).

Enteral feeding tube medication delivery presents safety challenges that can cause harm. This article highlights problems with feed tube medication administration. It shares improvement recommendations that include best practice adherence, standardization, monitoring, and patient engagement.

Finding & Creating Joy in Work.

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Institute for Healthcare Improvement. March 8 - May 16, 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.

TeamSTEPPS Master Training Virtual Course.

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AHA Team Training. January 12 - March 2, 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.

Critical care resource nurse team: a patient safety and quality outcomes model.

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Patient Safety Innovation November 16, 2022

Rapid response teams are intended to improve timely identification and management of clinically deteriorating patients, such as in-hospital cardiac arrest or stroke.

Advancing Diagnostic Excellence for Older Adults: Proceedings of a Workshop in Brief.

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National Academies of Sciences, Engineering, and Medicine. Washington, DC: The National Academies Press; 2022. ISBN 9780309696333.

The care of older adult patients can be complicated due to comorbidities, bias and polypharmacy. This publication reports on a session that examined diagnostic challenges unique to the older adult population. The existing evidence base and strategies for the future are reviewed.

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