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Rosen M, Ali KJ, Buckley BO, et al. Rockville, MD; Agency for Healthcare Research and Quality: June 2021.

The mindset on diagnostic error improvement has gone from a focus on individual skills to that of system factors. This issue brief highlights the influence health system executives have on amending the care environment to facilitate the most effective environment for diagnostic accuracy. This is the latest in a publication series examining diagnostic improvement across health care.
Rockville, MD: Agency for Healthcare Research and Quality; December 6, 2019. PA-20-068.
Communication during patient transitions carries the potential for mistakes that can result in patient harm. This program (funding) announcement will support the testing of interventions to improve communication and coordination during care transitions within and between a variety of care environments. Applicants are encouraged to incorporate a care transitions model such as Project RED into their research design. Applications are reviewed three times per year- February 5, June 5, and October 5, through 2022
Agency for Healthcare Research and Quality Webinar, October 30, 2019.
This webinar recording provides information on the updated Hospital Survey on Patient Safety Culture™ (SOPS™) 2.0. The hospital survey was revised and pilot tested after incorporating user feedback. The Hospital SOPS survey, which has been used by hundreds of hospitals in the U.S. and overseas, allows healthcare providers and staff to assess a hospital’s patient safety culture. Speakers at the webinar discussed what’s different and what to expect when transitioning to the revised survey. Access the SOPS Hospital Survey 2.0, including a user’s guide, as well as results from a 2019 Pilot Test of Version 2.0 and frequently asked questions.
Famolaro T, Yount N, Hare, R, et al. Rockville, MD: Agency for Healthcare Research and Quality; March 2018. AHRQ Publication No. 18-0025-EF.
Establishing a culture of safety is a cornerstone of efforts to develop high reliability organizations that ensure patient safety. The AHRQ Hospital Survey on Patient Safety Culture is a validated survey that is widely used to assess safety culture. The survey examines organizational perceptions of 12 domains of culture ranging from communication about errors to teamwork within and across units. AHRQ has provided comparative benchmarking user data since 2007. The 2018 report includes data from 630 hospitals, 306 of which provided data for both the 2018 and 2016 databases. Notable changes since 2016 include improvement in the overall perception of safety, with most participating hospitals reporting positive perceptions of management support for safety, teamwork within units, and organizational responses to errors. In contrast, handoffs, staffing, and nonpunitive response to error remained patient safety concerns for nearly half of respondents, with little to no improvement since 2016. A PSNet interview with Professor Mary Dixon-Woods discussed the evolving understanding of safety culture and recent insights into mechanisms driving safety culture improvement.