This review examines hospital discharge, details elements of the process that can increase risk of readmission, and reveals interventions to improve safety.

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.

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. 

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.

Distinct individual skills and organizational factors strengthen patient safety incident analysis efforts. This series of educational video modules encapsulates a curriculum for investigation teams associated with a national United Kingdom program. It covers topics such as safety science and analysis initiative strategy.

Diagnostic mistakes are common contributors to preventable patient harm. This review highlights primary areas of diagnostic error concerns (vascular events, infections, and cancers) and summarizes evidence related to their measurement and error reduction.

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. 

Removing unused medications from the home can help prevent accidental exposure to unneeded medications and limit their availability for misuse. This annual program provides patients with an opportunity to discard medications safely. The sponsors also provide education to highlight the importance of appropriate disposal of unused prescription drugs as a medication safety activity.

Systemic racism reduces the effectiveness and safety of the care people of color receive. The REPAIR (REParations and Anti-Institutional Racism) Project is examining the impact of racism on Black individuals in medicine and the sciences. Each year of the 3-year initiative is focused on a distinct theme: medical reparations, medical abolitionism and decolonizing the health sciences.

Simulation provides a safe space to observe behaviors and generate constructive feedback to enhance individual and team performance. This website provides promotional materials for an annual campaign to raise awareness of professionals that use simulation to develop teamwork, communication, and crisis management skills in health care. The yearly observance is held in September.

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.

Patient safety improvement has made progress but more can be done. This organization supports community efforts in the United States to engage policymakers in work toward aligning efforts to reduce preventable patient harm at a national level. It will build its efforts on the World Health Organization plan by moving forward with a framework to collaborate on a variety of strategies to enhance the safety of health care.

Standardization is a common strategy for preventing practice deviations that can contribute to harm. This tool outlines a three-step process for minimizing the occurrence of wrong-side peripheral nerve blocks that involves preparing for the procedure, stopping to perform a two-person site confirmation, and then administering the block.

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

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.

This fact sheet provides a list of high-alert medications commonly used in ambulatory care and recommends strategies to reduce risk of errors.