The PSNet Collection

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.

Advancing Diagnostic Excellence for Maternal Health Care: Proceedings of a Workshop–in Brief.

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National Academies of Sciences, Engineering, and Medicine. Washington, DC: The National Academies Press; 2023. ISBN: 9780309711937.

Maternal health care is rapidly emerging as a high-risk service that is vulnerable to communication, equity, and diagnostic challenges. This report examines the role of disparities in care across the maternal care continuum and strategies to drive diagnostic improvement such as care bundles, midwives, and health information technology. This publication is from a series of programs and resultant publications on improving diagnostic excellence.

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.

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.

Advancing Diagnostic Excellence in Maternal Health Care.

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Board on Health Care Services, National Academies of Science, Engineering, and Medicine. Irvine, CA: Arnold and Mabel Beckman Center: 2021-2023.

These free workshops discussed current challenges in diagnostic excellence, identifications of knowledge gaps, and strategies to decrease maternal disparities, cancer misdiagnoses and problems in the care of older adults that affect diagnosis.

Unequal Treatment Revisited: A Workshop Series.

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Committee on Unequal Treatment, National Academies. 2023.

Health disparities and unequal care contribute to patient and family harm. This 3-component workshop series explored ethnic and racial disparities in health care. A planned September workshop will revisit the findings from the three sessions.

After Roe: Challenges in the Provision of Lifesaving Care.

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National Academies of Health.

Delay in access to obstetric care hinders safe treatment for patients experiencing pregnancy complications. This webinar discussed a range of factors affected by abortion restrictions and reviewed options to ensuring safety given legal and other structural impediments. A written brief is forthcoming.

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 exacerbated 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.

APSF Stoelting Conference.

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Anesthesia Patient Safety Foundation. September 6–7, 2023.

Anesthesia is a high-risk activity that has achieved safety successes. This hybrid conference explored topics related to the theme of “Emerging Medical Technologies – A Patient Safety Perspective on Wearables, Big Data and Remote Care.” Videos of the sessions are available.

World Patient Safety, Science & Technology Summit.

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Patient Safety Movement Foundation. VEA Newport Beach, Newport Beach, CA, June 1-2, 2023.

Multidisciplinary educational opportunities promote cross-industry learning to improve patient safety. This session highlighted safety culture and patient advocacy as topics.

Curated Libraries

Value and Patient Safety

March 8, 2023

Value as an element of patient safety is emerging as an approach to prioritize and evaluate improvement actions. This library highlights resources that explore the business case for cost effective, efficient and impactful efforts to reduce medical errors.

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.

Driving Learning and Improvement After RCA2 Event Reviews.

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Collaborative for Accountability and Improvement. January 26, 2023.

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

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.

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.

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.

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.

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. A video, PDFs, and relevant links are available.

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