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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.

Lessons Learned? Building a Culture of Patient Safety Within the Veterans Health Administration.

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US House of Representatives Committee on Veterans' Affairs Subcommittee on Health. 117th Cong. 1^st Sess (2021).

The Veterans Health Administration is a large complex system that faces various challenges to safe care provision. At this hearing, government administrators testified on current gaps that detract from safe care in the Veteran’s health system. The experts discussed several high-profile misconduct and systemic failure incidents, suggested that the culture and leadership within the system overall enables latency of issues, and outlined actions being taken to address weaknesses.

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.

Training Program for Nurses on Shift Work and Long Work Hours.

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NIOSH [2015]. NIOSH training for nurses on shift work and long work hours. By Caruso CC, Geiger-Brown J, Takahashi M, Trinkoff A, Nakata A. Cincinnati, OH: US Department of Health and Human Services, Centers for Disease Control and Prevention, National Institute for Occupational Safety and Health, DHHS (NIOSH) Publication No. 2015-115 (Revised 10/2021)

Nurse fatigue has been associated with diminished decision-making skills that can contribute to patient harm. This online training program for clinicians and administrators will explore hazards related to nurse fatigue and provide strategies to address behaviors and systems that increase these risks.

Can hospitals learn about safety from airlines?

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Pasztor A. Wall Street Journal. September 2, 2021.

Aviation continues to serve as an exemplar for healthcare safety efforts. This story highlights work toward the development of a National Patient Safety Board for medicine to establish a neutral centralized body to examine errors and share improvements driven by a robust self-reporting culture similar to that in commercial aviation.

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.

Ripped apart: medical misdiagnosis and malpractice.

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Kast S, Gerr M, Black D, et al. “On the Record.” WYPR. August 3, 2021

Misdiagnosis is a persistent challenge for patients and families to navigate. This audio news segment highlights one family's experience with poor care stemming from disrespect and premature closure that resulted in missed diagnosis, unnecessary care, and patient death. The story is coupled with a broader discussion on the extent of diagnostic errors and reasons they occur.

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.

Bearing the Burden: Black Mothers in America.

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Weiser S. The New Yorker and Retro Report; 2021.

Disparities in maternal care have become apparent as a public health concern during the COVID-19 pandemic. This short film spotlights inequities and biases that Black mothers face, that reduce the safety of their care. Midwives are offered as a strategy for improving the safety of maternal care in this patient population.

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 Sets for the AHRQ Surveys on Patient Safety Culture™ (SOPS®) Medical Office Survey focusing on diagnostic safety and presenters shared results from a pilot test.

Learning Management System.

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Patient Safety Authority.

This collection of educational modules covers both care delivery and administrative topics to enhance the safety of healthcare delivery.

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.

Certified Professional in Patient Safety Review Course.

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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 live session is October 7, 2021.

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