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 12797 Results

Adverse Health Events in Minnesota: Annual Reports.

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St Paul, MN: Minnesota Department of Health.

The National Quality Forum has defined 29 never events—patient safety problems that should never occur, such as wrong-site surgery. Since 2003, Minnesota hospitals have been required to report such incidents. The 2022 report summarizes information about 572 adverse events that were reported, representing a significant increase in the year covered. Earlier reports prior to the last two years reflect a fairly consistent count of adverse events. The rise documented here is likely due to demands on staffing and care processes associated with COVID-19 and general increases in patient complexity and subsequent length of stay. Pressure ulcers and fall-related injuries were the most common incidents recorded. Reports from previous years are available.

Maryland Hospital Patient Safety Program Annual Report.

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Office of Health Care Quality. Baltimore, MD: Maryland Department of Health and Mental Hygiene.

This annual report summarizes never events in Maryland hospitals over the previous year. During fiscal year 2022, reported events increased due to the COVID pandemic, workforce shortages and other system demands. Events contributing to patient deaths and severe harm from preventable medical errors during the time period doubled. The authors recommend several corrective actions to enhance improvement work, including board and executive leadership engagement in safety work and application of high-reliability concepts to enhance safety culture.

Strategies for Improving Clinician Psychological Safety in Reporting and Discussing Diagnostic Error.

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Amin D, Cosby K. Rockville, MD: Agency for Healthcare Research and Quality; September 2023. Publication No. 23-0040-6-EF.

Psychological safety to report errors stems from a robust safety culture. This issue brief examines how these two concepts intersect to enhance the self-reporting of diagnostic errors to facilitate organizational learning from mistakes.

Speak Up Initiative.

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Joint Commission.

The Speak Up campaign provides sets of materials to enable patients and families to engage in making their health care experiences as safe as possible. Topics covered include safe surgery, pain management, medication safety, and most recently, how preventive care helps to keep patients healthy and out of the hospital. Each topical package includes infographics, videos, and distribution guidance. Some written materials are available in Spanish.

DAISY Award for Extraordinary Nurses in Patient Safety.

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The Daisy Foundation and Institute for Healthcare Improvement.

Nurses have a fundamental role in safe care delivery by fostering a healthy work environment. This award recognizes nurses that exhibit compassion, patient and family centeredness, and a commitment to workplace safety. The award will be presented at annual IHI Patient Safety Congress. The award nomination process for 2023 closes on December 3.

Making Healthcare Safer IV: A Continuous Updating of Patient Safety Harms and Practices.

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Rockville, MD: Agency for Healthcare Research and Quality: September 2023.

Patient safety progress is dynamic, consistently producing evidence for application to generate improvements. This report is the fourth in a series funded by the Agency for Healthcare Research and Quality to track a prioritized set of emerging and existing safety approaches to confirm their value and effectiveness. This report will be compiled as new conclusions are formulated. Each review will be posted to the collection as they are completed. The first three Making Healthcare Safer reports, published in 2001, 2013, and 2020, have each served as a consolidated evidence source for clinicians, health system leadership, researchers, and government agencies. Chapter protocols and the results of an examination of harms associated with video-based telehealth are now available.

Pediatric Diagnostic Safety: State of the Science and Future Directions.

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Grubenhoff JA, Cifra CL, Marshall T, et al. Rockville, MD: Agency for Healthcare Research and Quality; September 2023. AHRQ Publication No. 23-0040-5-EF.

Unique challenges accompany efforts to study and reduce diagnostic error in children. This issue brief discusses addressing obstacles associated with testing and care access limitations that affect diagnosis across a variety of pediatric care environments. It also provides recommendations for building capacity to advance pediatric diagnostic safety. This issue brief is part of a series on diagnostic safety.

Annual Diagnostic Excellence Summit.

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The Armstrong Institute Center for Diagnostic Excellence. Johns Hopkins University, Baltimore, MD, September 27, 9:00 AM-4:00 PM (eastern).

Advanced computer technologies and data analysis are an increasing focus in diagnostic safety efforts. The theme of this annual event is “Diagnostic Digital Health Research”. Ethical use of artificial intelligence, consumer diagnostic technology and digital diagnostics and amongst the topics to be covered.

ISMP Survey on High-Alert Medications in Acute Care Settings.

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Plymouth Meeting, PA: Institute for Safe Medication Practices; 2023.

Experience from the sharp end helps to inform safety improvement initiatives. The results from this field survey will inform the revision of a high-alert medication list used to raise awareness about certain drugs that have heightened potential to cause patient harm if used incorrectly. The deadline for submitting comments is October 20, 2023.

ISMP Medication Safety Intensive.

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Institute for Safe Medication Practices. October 4-5, 2023, 10:45 AM - 7:45 PM (eastern).

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

Understanding and Improving Diagnostic Safety in Ambulatory Care.

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Rockville, MD: Agency for Healthcare Quality and Research; August 22, 2023.

The articulation of diagnostic error in the ambulatory setting is emerging. These newly released funding announcements seek proposals that focus on understanding the factors contributing to diagnostic error and strategies to improve diagnostic safety in the ambulatory care environment. The application deadline for both opportunities has passed.

Certified Professional in Patient Safety Review Course.

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Institute for Healthcare Improvement. September 28–29, 2023. 12:00 PM - 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. The next online session is August 2-3, 2023.

Improving Patient Safety with Human Factors Methods.

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Armstrong Institute for Patient Safety and Quality, Baltimore, MD. October 3-4, 2023.

Human factors engineering (HFE) is a primary strategy for advancing safety in health care. This virtual workshop will introduce HFE methods and discuss how they can be used to reduce risk through design improvements in a variety of process and interpersonal situations.

Canadian Patient Safety Week.

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Healthcare Excellence Canada.

This site provides promotional materials and registration information for an awareness campaign on patient safety that takes place in the autumn. The annual observance will take place October 23-27, 2023.

Mark Graber Diagnostic Quality & Safety Award.

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Society to Improve Diagnosis in Medicine.

Inspired by the work and leadership of Dr. Mark Graber, this award will annually recognize either lifetime achievements or stand-alone innovations that enhance efforts to improve the safety and quality of diagnosis. The deadline to submit a 2023 nomination is September 12, 2023.

Patient Safety Executive Development Program.

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Institute for Healthcare Improvement. Boston, MA and online. August 30-October 13, 2023.

Organization executives influence the success of patient safety improvement. This hybrid workshop will highlight how leaders can use assessments, planning, and evidence to improve the safety culture at their organizations.

National Action Alliance to Advance Patient Safety Webinar Series.

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US Department of Health and Human Services. September 26, 2023. 2:00-3:00 PM (eastern).

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 session will explore the successful application of high reliability concepts at the Veterans Health Administration. This is the fifth in a series of offerings from the Alliance supporting its work to improve safety.

Virtual Research Meeting on Patient Experience, Patient Safety, and Provider Well-Being: Associations and Paths for Quality Improvement.

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CAHPS Research Meetings. Agency for Healthcare Research and Quality, Rockville, MD. October 19, 2023; 11:00 AM—4:00 PM (eastern).

Patient narrative is an important resource for understanding care delivery. This webinar will discuss how Consumer Assessment of Healthcare Providers and Systems (CAHPS) surveys can provide patient experience insights that could inform safety culture improvement efforts and lower risks stemming from poor patient/team communication.

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 is October 16, 2023.

Notice of Intent to Publish Funding Opportunity Announcements to Understand and Improve Diagnostic Safety in Ambulatory Care.

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Rockville, MD: Agency for Research and Quality; July 27, 2023. Notice Number NOT-HS-23-018.

Diagnostic errors occur in all settings of care and are a primary challenge to safe health care. This announcement raises awareness of two upcoming funding opportunities for understanding and improving diagnostic safety in diverse ambulatory care environments. The funding will target the incidence and contributory factors of diagnostic error within the array of ambulatory care services and the development of strategies and interventions to improve diagnostic safety in ambulatory care.

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