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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 20 Results
Armstrong Institute for Patient Safety and Quality.
The comprehensive unit-based safety program (CUSP) approach emphasizes improving safety culture through a continuous process of reporting and learning from errors, improving teamwork, and engaging staff at all levels in safety efforts. Available on demand and live, this session covers how to utilize CUSP, including understanding and addressing challenges to implementation. The next live session will be held January 17, 2023.
Institute for Safe Medication Practices. December 1-2, 2022.
This virtual workshop will explore tactics to ensure medication safety, including strategic planning, risk assessment, and Just Culture principles.

Healthcare Safety Investigation Branch. November 22, 2022, 7:00 AM – 10:30 AM (eastern).

Incident examinations rely on transparency, psychological safety, and just culture to facilitate learning from failure. This session is anchored on one health system’s reaction to failure to examine the value of just culture, barriers, and facilitators to its establishment and how human factors play a role in engineering safety systems.
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 27, 2022.

Healthcare Safety Investigation Branch. September 21, 2022. 

Incident investigations are important tools for uncovering latent factors that facilitate patient harm. This conference drew from experience in the United Kingdom and Norway to discuss how adverse event examinations can improve care provision and highlighted efforts in the United Kingdom to focus on maternity care safety.
Institute for Healthcare Improvement.
This website provides resources for promoting patient safety during Patient Safety Awareness Week. The annual observance is held in March.

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.
National Academies of Sciences, Engineering, and Medicine. Washington, DC: National Academies Press; 2018. ISBN: 9780309474290.
Health literacy affects patients' ability to comprehend information about their health and participate effectively with clinicians to ensure their care is safe, appropriate, and effective. This workshop report summarizes discussions about health literacy programs and provides case studies of health organizations that have adopted such programs. A PSNet perspective discusses the intersection of patient safety and health literacy.

Forstag EH; Committee on Pain Management and Regulatory Strategies to Address Prescription Opioid Abuse; Health and Medicine Division. Washington, DC: National Academy of Science; 2016. ISBN: 9780309451901.

Efforts to ensure safe pain management in the context of the opioid epidemic have focused on prescribing behaviors and policies. This publication reports on the results of a workshop convened to explore factors that contribute to opioid overuse and to identify areas for improvement that require further research.
World Innovation Summit for Health 2015. Doha, Qatar: Qatar Foundation; February 2015.
This conference focused on persisting barriers to patient safety worldwide and recommended strategies to achieve lasting improvement, including dedication to systems engineering, patient-centeredness, and process integration. The session summarized findings of a report developed for the event, Transforming Patient Safety: a Sector-wide Systems Approach. The proceedings collection includes the full text of the report, video of the panel, and podcasts with Margaret Murphy, Dr. Mary Dixon-Woods, Dr. Peter Pronovost, and other participants.
National Academy of Sciences; National Academy of Medicine; IOM; NAS.
In recognition of the 15th anniversaries since To Err Is Human and Crossing the Quality Chasm were published, this symposium discussed accomplishments and persisting challenges in the fields of patient safety and quality improvement since those reports were released. The session featured Dr. Donald Berwick, Dr. Lucian Leape, and Carolyn Clancy as speakers.

Imrie KR, Frank JR, Parshuram CS, eds. BMC Med Educ. 2014;14(suppl1):S1-S18.

Articles in this special issue discuss the impact of resident duty hours (such as how they can affect education, resident well-being, and patient outcomes), explore challenges associated with addressing resident fatigue, and describe strategies for hospitals to adapt to changing work hour requirements.
Denham CR, Bagian JP, Daley J, et al. J Patient Saf. 2005;1:154-169.
The authors discuss six barriers to implementing patient safety efforts in hospitals. The article is a companion piece to the plenary session from the 2005 National Patient Safety Foundation (NPSF) Congress.
Rockville MD: Agency for Healthcare Research and Quality; April 2005.
On April 4, 2005, AHRQ hosted "Improving Health Care for All Americans: Celebrating Success, Measuring Progress, Moving Forward." The meeting showcased successful efforts to improve health care quality and reduce racial and ethnic disparities.