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 3470 Results

How providers can optimize effective and safe scribe use: a qualitative study.

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Corby S, Ash JS, Florig ST, et al. J Gen Intern Med. 2022;Epub Nov 16.

Medical scribes are increasingly being utilized to reduce the time burden on clinicians for electronic health record (EHR) documentation. In this secondary analysis, researchers identified three themes for safe use of medical scribes: communication aspects, teamwork efforts, and provider characteristics.

The impact of TeamSTEPPS training on obstetric team attitudes and outcomes on the labor and delivery unit of a regional perinatal center.

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Kwon CS, Duzyj C. Am J Perinatol. 2022;Epub Dec 30.

Effective teamwork is critical for patient safety and numerous training strategies exist for improving team dynamics. The labor and delivery unit of an American hospital offered Team Strategies and Tools to Enhance Performance and Patient Safety (TeamSTEPPS) training to all physicians and nurses on the ward, and assessed perceptions of teamwork and safety both before and six months after training. Results were mixed, and physician and nurse perceptions of safety significantly differed.

Respiratory Distress after Neck Surgery: Two Cases of Postoperative Cervical Hematoma.

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WebM&M Case February 1, 2023

These cases describe the rare but dangerous complication of hematoma following neck surgery. The first case involves a patient with a history of spinal stenosis who was admitted for elective cervical discectomy and cervical disc arthroplasty who went into cardiopulmonary arrest three days post-discharge and could not be intubated due to excessive airway swelling and could not be resuscitated. Autopsy revealed a large hematoma at the operative site, causing compression of the upper airway, which was the suspected cause of respiratory and cardiac arrest.

2023 IHI Patient Safety Congress.

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Institute for Healthcare Improvement. Gaylord National Resort and Convention Center, National Harbor, MD, May 22–24, 2023.

This annual conference will host pre-session workshops, panels, and presentations covering a variety of patient safety topics that align with the national agenda for patient safety improvement such as learning systems and leadership. Sessions will take place in-person.

Bad things can happen: are medical students aware of patient centered care and safety?

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Gillissen A, Kochanek T, Zupanic M, et al. Diagnosis (Berl). 2022;Epub Nov 9.

Medical students do not always feel competent when it comes to patient safety concepts. In this study of German medical students, most understood the importance of patient safety, though few could identify concrete patient safety topics, such as near miss events or conditions that contribute to errors. Incorporating patient safety formally into medical education could improve students’ competence in these concepts.

Introducing ISMP’s New Targeted Medication Safety Best Practices for Community Pharmacy: 2023-2024.

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Institute for Safe Medication Practices. January 31, 2023, 1:00-2:00 PM (eastern).

A variety of factors can decrease the safety of community pharmacy practice such as production pressure and fatigue. This webinar will discuss a new set of best practices for community pharmacy to address common problems that reach patients and cause harm.

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.

Patient Safety Learning Laboratories: Advancing Patient Safety through Design, Systems Engineering, and Health Services Research (R18 Clinical Trial Optional).

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Rockville, MD: Agency for Healthcare Research and Quality. PA-21-266.

This funding opportunity will support collaborative learning strategies that enable individuals and organizations to employ rapid prototyping to engineer new approaches focused on improving diagnosis and treatment. This learning laboratory funding builds on prior initiatives to further improvements in patient safety. The project submission process will close January 25, 2023.

AHRQ Safety Program for Telemedicine.

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Agency for Healthcare Research and Quality.

Telemedicine efforts harbor both risk and reward to patients and providers. The AHRQ Safety Program for Telemedicine is a national effort to develop and implement a bundle of evidence-based interventions designed to improve telemedicine care in two settings—the cancer diagnostic process and antibiotic use. To test the bundle of interventions, the program will involve two cohorts of healthcare professionals who utilize telemedicine as a care delivery model. It is an 18-month program, beginning in June 2023, that seeks to improve the cancer diagnostic process for patients who receive some or all of their care through telemedicine. Recruitment webinars start in late January and run through early May 2023; the antibiotic use cohort will begin recruitment in December 2023.

The REPAIR Project: a prospectus for change toward racial justice in medical education and health sciences research: REPAIR project steering committee.

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REPAIR Project Steering Committee. Acad Med. 2022;97(12):1753-1759.

The REPAIR (REParations and Anti-Institutional Racism) Project at the University of California, San Francisco, aims to repair racial injustices in medical care and research. This article discusses the development of the initiative, the three annual themes (reparations, abolition, decolonization), and outcomes from its first year.

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.

Driving Learning and Improvement After RCA2 Event Reviews.

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Collaborative for Accountability and Improvement. January 26, 2023, 2:00-3:00 PM (eastern).

Root cause analysis (RCA) is a recognized approach to examining failures by identifying causal factors to define improvement effort. This session will discuss challenges to the effective use of RCA results and examine an approach to present them that supports effective improvement action.

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.

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