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.
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 April 18-19, 2023.
Armstrong Institute for Patient Safety and Quality. January 31 and February 2, 2023.
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.
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.
The COVID-19 crisis requires cooperation and coordination of organizations and providers to address the persistent challenges presented by the pandemic. This on-demand video collection reinforces core TeamSTEPPS; methods that enhance clinician teamwork and communication skills to manage care safety during times of crisis.
American Association for Clinical Chemistry; AACC.
This certificate program for laboratory professionals offers six courses aimed at enhancing participants' skills in establishing a just culture, identifying safety hazards, and assessing gaps in processes to reduce risks of specimen management errors.
Hospitals and health systems face challenges in implementing electronic health records that can affect safety. This webinar introduced the SAFER guides, which highlight strategies to improve safety related to electronic health record use, and educate participants about ways to implement these guides in their organizations. The session featured Hardeep Singh and Dean F. Sittig as speakers.
Hearing Before the Committee on Veterans' Affairs United States Senate. 113th Cong (September 9, 2014).
In this hearing Veterans Affairs leadership provide an update on the current investigation into data and scheduling manipulation in the VA system. The testimonies discuss the scope of the problem, suggest that the culture at the hospitals enabled record falsification to become normalized, and outline actions being taken to address weaknesses in processes and access to care.
Schneider EB, Hirani SA, Hambridge HL, et al. J Surg Res. 2012;177:295-300.
Being admitted to the hospital on a weekend is potentially dangerous, as studies have shown that preventable complications and mortality are increased across a range of common diagnoses for weekend admissions compared with weekdays. One exception appears to be trauma, as a prior study found equal outcomes in patients with traumatic injuries regardless of the day of admission, a finding ascribed to the protocolized and closely supervised nature of trauma care. However, this study of older adults admitted with traumatic brain injury did find increased mortality for those patients admitted on the weekend, despite the fact that patients admitted on the weekend were less severely injured. A limitation of this study is that the authors were not able to analyze outcomes for patients cared for at specialized trauma centers. Nevertheless, the study adds to the considerable body of research documenting the dangers of weekend hospital admission.
Nagpal K, Arora S, Abboudi M, et al. Ann Surg. 2010;252:171-6.
This qualitative study interviewed 18 providers and found that postoperative handovers are informal, unstructured, and fraught with inconsistent and incomplete information transfer. These data were used to develop and validate a formal handover protocol. Prior studies have used insights from Formula One auto racing to inform improvement strategies for postoperative handoffs, and the World Health Organization's Surgical Safety Checklist explicitly emphasizes structured handoffs at the time of patient transfer from the operating room to the postoperative area.
The Joint Commission has traditionally focused on accreditation of health care organizations and, through its Joint Commission Resources arm, on quality improvement (QI) in areas related to its accreditation functions. In the first major initiative under the leadership of new president Dr. Mark Chassin, The Joint Commission launched this Center, which will focus on applying rigorous QI methods to improve safety in a number of challenging areas (the first three are hand hygiene, handoff communication, and preventing wrong site surgery) and disseminating the lessons from these efforts. This video set provides information about the Center and its goals.
Agency for Healthcare Research and Quality; AHRQ; Clancy C.
This podcast features an interview with Agency for Healthcare Research and Quality (AHRQ) Director Carolyn Clancy discussing handoffs in health care and how a patient can help in making handoffs more reliable. A companion piece for the clinician is also available.
Agency for Healthcare Research and Quality; AHRQ; Clancy C.
This podcast features an interview with Agency for Healthcare Research and Quality (AHRQ) Director Carolyn Clancy discussing transitions in care and how providers can make the process more reliable. A companion piece for the consumer is also available.
This article reports on the abduction of a newborn by an individual masquerading as a hospital employee. Infant abduction is one of the patient safety "never events" defined by the National Quality Forum.
The Agency for Healthcare Research and Quality (AHRQ) hosted the 2005 Annual Patient Safety and Health Information Technology Conference. Transcripts and slide presentations are available from the five-day event.
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