This quarterly commentary explores a wide range of subjects associated with patient safety, such as the impact of disruptive behavior on teams, the value of apologies, and safety challenges due to COVID-19. Older materials are available online for free.

Racial and ethnic inequalities are emerging as a primary contributor to harmful maternal care. This guidance examines obstacles to safe care for mothers of color and shares recommendations to reduce disparities such as team-based care and implicit bias training.

Lack of access to obstetric care impedes safe treatment for mothers. This story describes challenges one mother experienced in finding care during a miscarriage due to abortion policies and the steps she and her family took to manage her condition.

A variety of factors can decrease the safety of community pharmacy practice such as production pressure and fatigue. This webinar will discuss a new set of best practices for community pharmacy to address common problems that reach patients and cause harm.

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.

This multidisciplinary international conference is designed around the theme of “Dream, Design, Dare.” Topics to be covered include strategic planning for improvement, artificial intelligence, and technologies as tools for safety care, and a peer exchange initiative to generate safety learnings.

The National Steering Committee for Patient Safety (NSC) was formed to engage with the health care community to plan and prioritize patient safety work to generate improvements. This short survey seeks comments from the field to determine current interest and status in efforts aligned with the National Action Plan to Advance Patient Safety.

This monthly commentary explores a wide range of subjects associated with patient safety, such as infection prevention, surgical quality improvement, and high reliability organizations.

This onsite conference offers an introduction to quality and safety improvement success and challenges drawing from international experiences. Course activities designed for a multidisciplinary audience supporting the theme of "Adapting to a changing world: equity, sustainability and wellbeing for all" will cover topics such as healthcare inequality, workforce wellbeing, and adverse events as learning opportunities. 

This funding opportunity will support collaborative learning strategies that enable individuals and organizations to employ rapid prototyping to engineer new approaches focused on improving diagnosis and treatment. This learning laboratory funding builds on prior initiatives to further improvements in patient safety. The project submission process will close January 25, 2023.

Telemedicine efforts harbor both risk and reward to patients and providers. The AHRQ Safety Program for Telemedicine is a national effort to develop and implement a bundle of evidence-based interventions designed to improve telemedicine care in two settings—the cancer diagnostic process and antibiotic use. To test the bundle of interventions, the program will involve two cohorts of healthcare professionals who utilize telemedicine as a care delivery model. It is an 18-month program, beginning in June 2023, that seeks to improve the cancer diagnostic process for patients who receive some or all of their care through telemedicine. Recruitment webinars start in late January and run through early May 2023; the antibiotic use cohort will begin recruitment in December 2023. 

The REPAIR (REParations and Anti-Institutional Racism) Project at the University of California, San Francisco, aims to repair racial injustices in medical care and research. This article discusses the development of the initiative, the three annual themes (reparations, abolition, decolonization), and outcomes from its first year.

Medication errors continue to occur despite long-standing efforts to reduce them. This article summarizes types of errors submitted to the Institute for Safe Medication Practices reporting program in 2021. The piece discusses the medications involved, recommendations for improvement, and technologies to be employed to minimize error occurrence.

This site provides data and analysis from two Oregon Patient Safety Commission patient safety initiatives: the Patient Safety Reporting Program (PSRP) and Early Discussion and Resolution (EDR) effort. The review of 2021 PSRP data discusses the impact of the state adverse event reporting program and upcoming initiative to examine how organizational safety effort prioritization affects care in Oregon. The 2022 EDR analysis discusses the uptake of the program to generate conversations with patients and providers after a patient safety incident occurred.