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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 165 Results

ECRI. ECRI Headquarters, Plymouth Meeting, PA, October 11-12, 2023. 9:00 AM – 4:45 PM (eastern).

Human factors engineering (HFE) is a core approach to improving the reliability and safety of complex practice. This conference will provide direction in understanding how to proactively define risks and design processes to reduce the potential for failure.
Rockville, MD: Agency for Healthcare Research and Quality; July 2023.
The TeamSTEPPS® program was developed to support effective communication and teamwork in health care. The curriculum offers training for participants to implement TeamSTEPPS® in their organizations. The 3.0 version of the material has an increased focus on patient engagement and a broader range of clinical, administrative and leadership roles. The course includes updated evidence reviews, trainer guidance, measurement tools, a pocket guide quick reference to keyTeamSTEPPS® concepts and tools, and new patient videos.
Institute for Healthcare Improvement. September 13 - November 21, 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.

GoodDx.

Effective feedback is an important component of individual, team and organizational learning in order to achieve safe diagnosis. GoodDx.org houses a variety of diagnostic performance feedback resources for use by clinicians, patient safety professionals, educators and patients. The website includes resources targeted towards a multitude of clinical specialties and organizational needs and readiness.
Drug Enforcement Administration. April 22, 2023.
Removing unused medications from the home can help prevent accidental exposure to unneeded medications and limit their availability for misuse. This semi-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.
Alper E, O'Malley TA, Greenwald J. UpToDate. February 3, 2023.
This review examines hospital discharge, details elements of the process that can increase risk of readmission, and reveals interventions to improve safety.

Healthcare Excellence Canada. 2020-2023.

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

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.

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. 

Farnborough, UK: Healthcare Safety Investigation Branch; 2022.

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.
Arnaoutakis GJ, Ogami T, Aranda‐Michel E, et al. J Am Heart Assoc. 2022;11:e025026.
Missed diagnosis of aortic emergencies can result in patient death, therefore patients with presumed aortic syndromes may be transferred to aortic referral centers. Because interhospital transfers present their own risks, these researchers evaluated emergency transfers of patients who did not ultimately have a diagnosis of acute aortic dissection, intramural hematoma, penetrating aortic ulcer, thoracic aortic aneurysm, or aortic pseudoaneurysm. Approximately 11% of emergency transfers were misdiagnosed, secondary to imaging misinterpretation.

Raffel K, Ranji S. UpToDate. July 25, 2022.

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.

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. 

University of California San Francisco, San Francisco, CA.

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.
Society for Simulation in Healthcare.
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.

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.
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.

RA-UK, the Faculty of Pain Medicine, RCoA Simulation and NHS Improvement

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.
Curated Libraries
January 14, 2022
The medication-use process is highly complex with many steps and risk points for error, and those errors are a key target for improving safety. This Library reflects a curated selection of PSNet content focused on medication and drug errors. Included resources explore understanding harms from preventable medication use, medication safety...