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 139 Results

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.

The National Healthcare System Action Alliance to Advance Patient Safety.

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US Department of Health and Human Services.

The large system change required to reduce patient harm requires multi-stakeholder engagement and sustained commitment. This alliance will work with healthcare systems, federal partners, patients and families, and other stakeholders to implement a national plan to ensure the safety of patients and healthcare workers. The webinar introducing the program, featuring Department of Health and Human Services Secretary Xavier Becerra, was held November 14, 2022.

Understanding SOPS Surveys--A Quick Primer for New Users.

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Rockville, MD: Agency for Healthcare Research and Quality. November 7, 2022.

An organization’s understanding of its culture is foundational to patient safety. This webinar introduced the AHRQ Surveys on Patient Safety Culture™ (SOPS®) program. The session covered the types of surveys available and review resources available to best use the data to facilitate conversations and comparisons to inform improvement efforts.

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

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President’s Council of Advisors on Science and Technology. Washington, DC: White House; September 21, 2022.

National efforts are required to adjust the health care system and embed safety in programs and processes. Speakers participating in this webinar discussed the impact of errors on families, adverse event prevalence, aviation safety lessons, nursing’s improvement role, the current state of patient safety and what needs to be done to reduce the impact and associated cost of harm.

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

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Collaborative for Accountability and Improvement. September 15, 2022.

Communication and resolution program (CRP) success draws from the participation of staff skilled in constructive dialogue after adverse events. This webinar described a coaching program to prepare individuals for CRP conversations to ensure their effectiveness for patients, families, and professionals involved in adverse incidents.

Addressing the Loss of Trust in Safety Culture.

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Philadelphia, PA: Building Trust and the ABIM Foundation; September 13, 2022.

Trust in patient safety processes encourages reporting of concerns, learning from error, and development of safety-focused patient/family partnerships. This session discussed how criminal actions against clinicians who err, challenge the balance needed to ensure that patients can trust the health care system to hold those accountable when error occurs, while enabling clinicians to trust their reported mistakes to be managed appropriately.

Healthcare Safety Investigations Conference 2022.

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Healthcare Safety Investigation Branch. September 21, 2022.

Incident investigations are important tools for uncovering latent factors that facilitate patient harm. This conference drew from experience in the United Kingdom and Norway to discuss how adverse event examinations can improve care provision and highlighted efforts in the United Kingdom to focus on maternity care safety.

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

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AHA Team Training. June 8, 2022.

Physicians are instrumental to the success of health care improvement efforts, and yet their involvement in safety work can be a challenge. This seminar highlighted strategies to motivate physician engagement that address barriers to those actions which include skill development and team training. Slides and a recording of the seminar are available.

Part 2 of the 9th Annual Communication, Apology, and Resolution (CARe) Forum.

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Betsy Lehman Center for Patient Safety. June 2, 2022.

Communication and resolution programs are a promising strategy for successful management of relationships and actions after medical error occurrence. This session explored elements of effective discussions after an adverse event through case simulation and dialogue.

The Power of Medical Malpractice Stories to Improve Patient Safety.

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The Collaborative for Accountability and Improvement. May 19, 2022.

The sharing of stories is a key approach for providing information and context to promote change. This webinar focused on stories drawn from lawsuits, the general patient and family motivation of legal action to minimize the repetition of similar errors, and the ironies involved in the adherence to legal confidentiality that can reduce learning from error.

Lessons Learned from the COVID-19 Pandemic to Improve Diagnosis. Proceedings of a Workshop–in Brief.

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

The COVID-19 crisis affected most health care processes, including diagnosis. This report recaps a session examining impacts of the pandemic on diagnostic approaches, inequities, and innovations that may inform future diagnostic improvement efforts.

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

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Institute for Safe Medication Practices and the Just Culture Company. May 6, 2022.

Organizational factors can contribute to the occurrence of patient safety events and how health systems respond to such events. This webinar highlighted lessons learned in the aftermath of a fatal medication error, and strategies to improve patient safety at the organizational level through system design and accountability.

A Conversation Among Stakeholders on Medical Malpractice.

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Collaborative for Accountability and Improvement. April 26, 2022.

Communication and resolution programs (CRP) can improve response to patients and families after a harmful medical error. This session examined how silos negatively impact transparency after error and how CRPs can reduce siloed communication. The session features Dr. Jo Shapiro as a panelist.

Diversion is a Threat to Patient Safety: Adopting Best Practices.

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Institute for Safe Medication Practices. April 6, 2022.

Drug diversion can result in patient harm due to reduced medication availability, impaired clinician performance, and loss of trust. This webinar discussed the impact of drug diversion at a system level and outlined steps an organization can take to minimize this risk through workplace health strategies and stewardship programs.

Achieving Excellence in Cancer Diagnosis: Proceedings of a Workshop—in Brief.

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

Diagnostic errors remain an ongoing challenge in many medical specialties, including oncology. This workshop reviewed the evidence base examining challenges in cancer diagnosis, discussed suggestions for improvement in the field, and looked toward a safer future for cancer patients.

Spotlight Series

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Healthcare Excellence Canada. 2020-2022

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

We Can’t Do This Alone! The Role That Patients, Family Members, and the General Public Play in Advancing Patient Safety.

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Patient Safety Movement Foundation. January 25, 2022.

Successful patient safety improvements engage individuals across the continuum of care and administrative processes, including patients as advocates for change. This webinar highlighted the role of the patient in influencing legislation designed to affect systems of care to ensure safe practice.

New AHRQ SOPS® Workplace Safety Supplemental Items for Hospitals.

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Rockville, MD: Agency for Healthcare Research and Quality; December 16, 2021.

The release of the Workplace Safety supplemental items for use in conjunction with the AHRQ Hospital Survey on Patient Safety Culture™ helps hospitals assess how their organizational culture supports workplace safety for providers and staff. This webinar provided background on the importance of workplace safety and introduce the Workplace Safety supplemental items.

Patient, Medical, and Legal Perspectives of Unsafe Care.

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Patient Safety Movement. October 29, 2021.

Effective response to medical harm involves a variety of perspectives that are aligned in purpose. This webinar discussed how different stakeholders might view approaches to medical error management. It described how strategies have changed from paternalistic to inclusive processes that consider the impact of mistakes on patients and families and the role of communication is key to achieving fair and honest resolution to adverse incidents.

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

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Institute for Safe Medication Practices. October 26, 2021.

Community pharmacies encounter a variety of challenges to medication safety. This webinar focused on high-alert medications and discuss unreliable medication delivery methods. The session also covered vaccination errors and how to prevent them.

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