All Content

Organizational factors can contribute to the occurrence of patient safety events and how health systems respond to such events. This webinar highlighted lessons learned in the aftermath of a fatal medication error, and strategies to improve patient safety at the organizational level through system design and accountability.

This onsite program will cover key patient safety concepts and how to apply them to improve safety. To help prepare attendees for designing and sustaining safety initiatives at their organizations, preconference activities will discuss safety culture, human factors, communication, and leadership development.

Healthcare-associated infections can result in significant morbidity and mortality. Developed by AHRQ, this customizable, educational toolkit uses the Comprehensive Unit-based Safety Program (CUSP) and other evidence-based practices to provide clinical and cultural guidance to support practice changes to prevent and reduce central line-associated bloodstream infection (CLABSI) and catheter-associated urinary tract infection (CAUTI) rates in intensive care units (ICUs). Sections of the kit include items such an action plan template, implementation playbook, and team interaction aids.

The Institute for Safe Medication Practices (ISMP) highlights the negative impacts the recent criminal conviction of a nurse could have for patient safety, including fear of reporting errors and clinicians leaving the profession. 

Improving patient safety related to radiology and radiation oncology is an ongoing priority. This special issue explores themes related to radiology and radiation oncology, including monitoring and improving quality of care, promoting a culture of safety, and measuring, reporting, and learning from errors.

Reporting medical errors, learning from them, and improving systems is a cornerstone of improving patient safety. A just culture centers on moving from blaming individuals for medical errors towards a systems-based approach to learning what went on, in order to prevent similar errors in the future. The recent conviction of a nurse involved in the death of a patient has raised concerns that clinicians may not disclose medical errors out of fear of criminal prosecution and conviction.

The AHRQ Medical Office Survey on Patient Safety Culture  is designed to assess safety culture in outpatient clinics. The 2022 comparative data report includes data from 1,100 US medical offices and over 13,000 providers and staff. The highest-scoring composite measures are patient care tracking/follow-up and teamwork. Like the 2020 report, the lowest-scoring measure was work pressure and pace.

Improving patient safety related to radiation delivery is an ongoing priority. This study explores the interpersonal and institutional factors which influence the overall perception of radiation safety culture among U.S. radiologic technologists.

Experts are concerned that convictions for medical error have the potential to limit dialogue on the front line about medical mistakes. This article summarizes discussions regarding the verdict to convict a nurse due to a workaround that resulted in a medication error and patient death.