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 27 Results

Creating Workforce Joy and Wellbeing.

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Institute for Healthcare Improvement. March 6 - May 20, 2024.

Burnout among health care workers negatively affects system improvement. This webinar series will highlight strategies to establish a healthy work environment that strengthens teamwork, staff engagement, and resilience. Instructors include Dr. Donald Berwick and Derek Feeley.

CUSP Implementation Training.

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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 virtual session will be held January 16, 2024.

TeamSTEPPS Master Training Course.

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Armstrong Institute for Patient Safety and Quality. January 30 and February 1, 2024.

Team training programs seek to improve communication and coordination among team members to reduce the potential for medical error. This virtual workshop will train participants to design, implement, and evaluate team training programs in their organizations based on the TeamSTEPPS model.

ISMP Medication Safety Intensive.

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Institute for Safe Medication Practices. November 30-December 1, 2023, 7:30 AM - 4:30 PM (eastern).

This virtual workshop will explore tactics to ensure medication safety, including strategic planning, risk assessment, and Just Culture principles.

TeamSTEPPS Master Training Virtual Course.

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AHA Team Training. September 7 - November 2, 2023.

The TeamSTEPPS program was developed to support effective communication and teamwork in health care. This online series will prepare participants to guide their organizations through implementation of the TeamSTEPPS program. It is designed for individuals that are new to TeamSTEPPS processes.

Curated Libraries

Value and Patient Safety

March 8, 2023

Value as an element of patient safety is emerging as an approach to prioritize and evaluate improvement actions. This library highlights resources that explore the business case for cost effective, efficient and impactful efforts to reduce medical errors.

Addressing the Loss of Trust in Safety Culture.

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Philadelphia, PA: Building Trust and the ABIM Foundation; September 13, 2022.

Trust in patient safety processes encourages reporting of concerns, learning from error, and development of safety-focused patient/family partnerships. This session discussed how criminal actions against clinicians who err, challenge the balance needed to ensure that patients can trust the health care system to hold those accountable when error occurs, while enabling clinicians to trust their reported mistakes to be managed appropriately.

Lessons Learned about Human Fallibility, System Design, and Justice in the Aftermath of a Fatal Medication Error.

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Institute for Safe Medication Practices and the Just Culture Company. May 6, 2022.

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.

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.

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.

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.

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.

Deprescribing Guidelines: Special Section on Symposium Results.

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Res Social Adm Pharm. 2019;15(6):780-810.

Appropriate deprescribing can reduce the risks associated with polypharmacy, overuse, and accidental overdose. Articles in this special section cover findings from a symposium discussing guidelines for safe discontinuation of medications and research needed to support further understanding of deprescribing practices.

Creating a Safe Space: Psychological Health and Safety of Healthcare Workers.

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Canadian Patient Safety Institute: 2019.

Structured approaches to managing negative psychological consequences of medical errors on health care professionals, patients, and families are important for emotional healing and organizational learning. This webinar series featured discussions on peer support efforts and a toolkit for Canadian health care workers.

Communicating Clearly About Medicines: Proceedings of a Workshop.

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National Academies of Sciences, Engineering, and Medicine. Washington, DC: The National Academies Press: 2017. ISBN: 9780309461856.

Patient health literacy is a known challenge in health care safety. This publication reports on results of a multidisciplinary workshop that explored health literacy improvement strategies and tools to enhance the clarity of labels, patient instructions, and decision aids to support safe medication use.

Pain Management and Prescription Opioid-related Harms: Exploring the State of the Evidence: Proceedings of a Workshop—in Brief.

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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.

A Hospital Accident: Lessons Learned – A Death, A Conviction, and A Healing.

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Texas Medical Institute of Technology. June 16, 2011.

This archived webinar covered how medical errors affect both the family and provider involved, and offered recommendations for best practices following a medical error.

The Safe Use Initiative and Health Literacy: Workshop Summary.

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Vancheri C; Roundtable on Health Literacy; Institute of Medicine. Washington, DC: National Academies Press; 2010. ISBN-10: 0309159318.

This publication summarizes the content delivered at a workshop discussing the FDA's Safe Use Initiative and other medication label improvement programs.

Proceedings of a summit on preventing patient harm and death from IV medication errors.

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American Journal of Health-System Pharmacy. 2008;65.

Experts convened to discuss best practices for safe intravenous medication administration. This article reports on the results of that conference along with ways to implement the suggested practices.

AHRQ 2007 Annual Conference.

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Agency for Healthcare Research and Quality; AHRQ.

This Web site provides access to presentation materials from AHRQ's first annual conference, held in September 2007.

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