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 52 Results

We Can’t Do This Alone! The Role That Patients, Family Members, and the General Public Play in Advancing Patient Safety.

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Patient Safety Movement Foundation. January 25, 2022.

Successful patient safety improvements engage individuals across the continuum of care and administrative processes, including patients as advocates for change. This webinar highlighted the role of the patient in influencing legislation designed to affect systems of care to ensure safe practice.

New AHRQ SOPS® Workplace Safety Supplemental Items for Hospitals.

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Rockville, MD: Agency for Healthcare Research and Quality; December 16, 2021.

The release of the Workplace Safety supplemental items for use in conjunction with the AHRQ Hospital Survey on Patient Safety Culture™ helps hospitals assess how their organizational culture supports workplace safety for providers and staff. This webinar provided background on the importance of workplace safety and introduce the Workplace Safety supplemental items.

Patient, Medical, and Legal Perspectives of Unsafe Care.

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Patient Safety Movement. October 29, 2021.

Effective response to medical harm involves a variety of perspectives that are aligned in purpose. This webinar discussed how different stakeholders might view approaches to medical error management. It described how strategies have changed from paternalistic to inclusive processes that consider the impact of mistakes on patients and families and the role of communication is key to achieving fair and honest resolution to adverse incidents.

Important Actions Community Pharmacists Need to Take Now to Reduce Potentially Harmful Dispensing Errors.

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Institute for Safe Medication Practices. October 26, 2021.

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.

The Good, The Bad, and The Ugly: Patient Experiences with CRPs.

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Collaborative for Accountability and Improvement. October 21, 2021.

Communication-and-resolution program (CRP) initiatives are a valuable strategy for improving support and transparency after an adverse incident. This webinar discussed how patients and families feel about support mechanisms after they have experienced medical error, if they were involved in a CRP process and the types of information they required after a harmful incident.

Achieving Excellence in the Diagnosis of Acute Cardiovascular Events: Proceedings of a Workshop–in Brief.

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National Academies of Sciences, Engineering, and Medicine. Washington, DC: The National Academies Press; 2021.

Misdiagnosis of severe cardiovascular events is a primary concern to the diagnostic safety community due to its prevalence and potential for harm. This report summarizes a session discussion on the existing evidence base on improving diagnosis for these conditions and explore opportunities for improvement.

Recognizing Unsafe Care: What It Is and How to Report It.

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Patient Safety Foundation. August 26, 2021.

This webinar introduced medical error and harm as related concepts to identify unsafe care and enhance response, engagement, and reporting efforts of clinicians, patients and families.

Unite for Safe Care.

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Patient Safety Movement. September 17, 2021.

Patient safety is a global challenge for the health care community. This webinar coincided with World Patient Safety Day and presented two tracks for both the profession and the public that highlighted issues impacting maternal care safety and high reliability. Those who have lost their lives to medical error were also honored during the event. The session speakers included Tedros Adhanom Ghebreyesus, PhD, MSc, Jeff Brady, MD, and Albert Wu, MD.

Fundamentals of Diagnostic Error in Imaging.

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Northwest Safety and Quality Partnership. June 22, 2021.

Diagnostic radiology mistakes contribute to delays and ineffective treatments that contribute to patient harm. This webinar examined factors that contribute to errors in image interpretation and will highlight strategies to learn from those errors to improve diagnostic process reliability. Registering for the program provides access to the recording.

Advancing Maternal Health Equity and Reducing Maternal Mortality Workshop.

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National Academies of Sciences, Engineering, and Medicine. June 7-8, 2021.

Maternal safety is challenged by clinical, equity, and social influences. This virtual event examined maternal health conditions in the United States to improve health system practice and performance for this population. Discussions addressed the need for better data collection, evidence-based practice, and social determinants knowledge integration to enhance the safety of care.

CANDOR Webinar Series.

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Patient Safety Movement Foundation. 2021.

The Communication and Optimal Resolution (CANDOR) model was designed to support early error disclosure with patients and families after mistakes in care occur. This three-part webinar series introduced the CANDOR process, discussed CANDOR implementation, outlined the importance of organizational readiness assessment for the program, and described actions to sustain CANDOR after it has launched. Speakers include Dr. Timothy McDonald, the originator of the model.

TeleDx: How is Telemedicine Working - and not Working - to Support Diagnosis?

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Society to Improve Diagnosis in Medicine. June 3, 2021.

The use of telemedicine has expanded during the COVID-19 pandemic into the mental health and diagnostic realms. This session explored how the practice of telediagnosis has emerged and share concerns about its safety and quality. Dr. Mark Graber is a featured speaker.

New AHRQ Surveys on Patient Safety Culture™ Diagnostic Safety Supplemental Items for Medical Offices.

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Agency for Healthcare Research and Quality. June 2, 2021.

Measuring and improving safety culture are essential patient safety activities. This webinar introduced the Diagnostic Safety Supplemental Item Set for the AHRQ Surveys on Patient Safety Culture™ (SOPS®) Medical Office Survey focusing on diagnostic safety and presenters shared results from a pilot test.

Do No Harm: Are We Preventing Medication Errors in Children with Medical Complexity?

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Children's Healthcare Canada. April 7, 2021.

Children are particularly vulnerable to medication errors. This session discussed risk factors in children with complex care needs and reviewed existing strategies to reduce the potential for harm due to mistakes in their medication therapies.

SOPS Surveys.

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Agency for Healthcare Research and Quality.

Surveys are established mechanisms for organizational assessment of safety culture. This collection of webinars provides an overview of the AHRQ Surveys on Patient Safety Culture™ (SOPS®) and a range of content related to the successful use of the surveys. Topics covered include organizational characteristics required for successful web-based distribution of the survey and best practices for formatting, programming, and administering the surveys in a variety of environments.

The Impact of Skin Color and Ethnicity on Clinical Diagnosis and Research.

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Skin of Color Society Foundation, NEJM Group, and VisualDx. October 28--December 2, 2020.

Diagnostic decision making can be affected by implicit racial bias. This 4-part series explored tools and techniques to improve diagnosis in patients of color. Topics covered included structural racism, explicit analysis of disease patterns and treatments, cultural competency, and policy improvement.

Enhancing Your Medication Error Reporting Program to Improve Global Medication Safety.

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Institute for Safe Medication Practices. September 15, 2020.

Medication error reporting is key to understanding failures, identifying risk and informing improvement. This webinar discussed approaches to internal reporting and challenges to reporting success.

Reimagining Healing after Healthcare Harm: The Potential for Restorative Practices.

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Patients for Patient Safety Canada. Canadian Patient Safety Institute. August 4, 2020.

Patients injured while receiving health care are susceptible to physical, financial and psychological harm. This webinar introduced strategies to rebuild the physical health of these patients and the trust that they and their loved ones have in the system of care.

The Power to Predict: Leveraging Medical Malpractice Data to Reduce Patient Harm and Financial Loss.

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Cambridge, MA; CRICO Strategies: July 14, 2020.

Malpractice claims can generate data that informs safety efforts. This webinar discussed one large health system’s professional liability claim analysis and the factors contributing to indemnity payments. The session reviewed how examining liability results can proactively focus organizational training and improvement initiatives.

Medication Safety During the COVID-19 Pandemic: What Have We Learned in the United States.

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Institute for Safe Medication Practices and US Food and Drug Administration Division of Drug Information. June 23, 2020.

The COVID-19 pandemic response is creating a need for care delivery adjustments that include changes in pharmacy and medication practices. This webinar discussed process alterations that have the potential to impact safe medication administration and provide context for the changes to help ensure they are effectively implemented.

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