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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 1082 Results

Agency for Healthcare Policy and Research: April 27, 2023.

Ambulatory surgery centers (ASC) experience a variety of error types that can be acerbated 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.
Rockville, MD: Agency for Healthcare Research and Quality; October 2020.
Ambulatory surgery centers (ASCs) are increasingly being used to provide surgical care. The AHRQ Surveys on Patient Safety Culture™ (SOPS®) Ambulatory Surgery Center Survey seeks opinions from the field regarding safety culture in the ambulatory surgical center environment. The survey is presented with additional resources to help organizations assess their safety culture, including the results of a pilot program testing the survey and a user's guide. Voluntary data submission will be open June 1-22 for ASCs that have administered the survey.
Institute for Healthcare Improvement.
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.

Epsom and St Helier University Hospitals. Epsom, UK: National Health Service; March 21, 2023.

The Systems Engineering Initiative for Patient Safety (SEIPS) framework is an established human factors-based approach to designing care system improvements. This video introduces the concepts behind SEIPS and uses an everyday non-clinical activity to illustrate its use for a broad audience to identify problems.
Fillo KT, Saunders K. Bureau of Health Care Safety and Quality, Department of Public Health. Boston, MA: Commonwealth of Massachusetts; 2023.
This reoccurring report compiles patient safety data collected by Massachusetts hospitals. The 2022 numbers document an increase in serious reportable events recorded in acute care hospitals, from 1430 the previous year to 1632. This presentation also includes events from ambulatory surgery centers. Older reports are also available.

National Action Alliance. June 27, 2023. 2:00- 3:00 PM (eastern)

Violence in the health care environment detracts from staff and clinician ability to provide safe care. Sponsored by the Centers for Disease Control and Prevention, this webinar will discuss the importance of violence prevention.
May 4, 2023
The implementation of effective patient safety initiatives is challenging due to the complexity of the health care environment. This curated library shares resources summarizing overarching ideas and strategies that can aid in successful program execution, establishment, and sustainability.

Massachusetts Healthcare Safety and Quality Consortium. Boston, MA: Betsy Lehman Center for Patient Safety; April 2023.

Collective engagement and focus are required to attain large system change. This plan centers on five goals to improve patient safety in Massachusetts: leadership and culture, operations and engagement, patient and family support, workforce wellbeing, and measurement and transparency. The document provides guidance for implementation of strategies targeting each goal to generate sustainable improvements.

Health and Human Services. June 27, 2023. 2:00-3:00pm (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 importance of preventing workplace violence in healthcare settings. This is the second in a series of offerings from the Alliance supporting its work to improve safety.
Leapfrog Group
Drawing from data reported by the Leapfrog Hospital Survey, the Agency for Healthcare Research and Quality (AHRQ), the Centers for Disease Control and Prevention (CDC), and the Centers for Medicare and Medicaid Services (CMS), this website provides grades for hospitals in the United States based on their safety. The Spring 2023 hospital safety grade results, documenting the impact of COVID-19 on patient satisfaction and healthcare associated infection, are available. 
World Health Organization
This global initiative raises awareness about hand hygiene as a strategy to reduce health care–associated infections. The initiative includes an annual promotional campaign that takes place on May 5. The theme for 2023 is "Accelerate action together".
Rockville MD: Agency for Healthcare Research and Quality; 2020.
Culture has been described as a key to establishing high reliability organizations. The National Quality Forum's Safe Practices for Healthcare and the Leapfrog Group both mandate hospitals to regularly assess their safety culture. This AHRQ Web site provides validated safety culture survey tools (Hospital, Medical Office, Nursing Home, Community Pharmacy, Ambulatory Surgery Center), user guides health care organizations can use to implement the surveys and a bibliography of articles discussing the use of SOPS in the field. Organizations can also use the AHRQ database to compare their Surveys on Patient Safety Culture™ (SOPS®) results. In addition, reports are available that summarize the benchmarking data across cohorts nationwide. An AHRQ WebM&M perspective discussed how to establish a safety culture.

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.
Patient Safety Surveillance Unit. Department of Health, Perth: Western Australia.
This annual report shares the results of Western Australia's sentinel event reporting program. Medication errors were the highest recorded sentinel event in the latest period. The data is placed in the context of the overall data collected over the last 5 years of the program.

Washington, DC: VA Office of the Inspector General; March 29, 2023. Report no. 21-03680-80.

Care systems for alcohol use disorder (AUD) patients are suboptimal. This report examines the case of a patient with AUD whose emergency care was mismanaged, uncoordinated, and incomplete, contributing to his death two days after discharge. The safety recommendations shared include improving discharge planning, assessment, and consideration of mental health conditions when caring for AUD patients.
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.

Rockville, MD: Agency for Healthcare Research and Quality; March 2023. AHRQ Pub. No. 23-0032.

The Network of Patient Safety Databases (NPSD) serves a central role in understanding the current state of care as tracked by patient safety measures. The 2023 Chartbook offers an overview of nonidentifiable, aggregated patient safety event, and near-miss information, voluntarily reported to data collection initiatives across the United States between 2000 and 2020. The Chartbook includes a summary of trends, disparities findings, and figures illustrating select patient safety measures.

PAR-23-120. Bethesda, MD: National Institutes of Health; March 7, 2023

Approaching diagnosis as a team activity is seen as a key approach to diagnostic effectiveness. This notice highlights a funding opportunity to launch Diagnostic Centers of Excellence to improve diagnosis of undiagnosed and unknown disease and research to inform improvement. The application period is now closed. 
Leapfrog Group.
This website offers resources related to the Leapfrog Hospital Survey investigating hospitals' progress in implementing specific patient safety practices. Updates to the survey include increased time allotted to complete computerized provider order entry evaluation, staffing of critical care physicians on intensive care units, and use of tools to measure safety culture. Reports discussing the results are segmented into specific areas of focus such as health care-associated infections and medication errors. The 2023 survey session opens April 1, 2023.
Curated Libraries
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.