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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 133 Results

Washington State Hospital Association. December 8, 2022, 4:00-5:00 PM (eastern).

Diagnostic error reduction is increasingly embraced as an element of patient safety strategic planning. This session will discuss the role of collaboratives as an approach to improvement and highlight opportunities for improving diagnosis on an organizational level.
Institute for Healthcare Improvement. March 8 - May 16, 2023.
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.
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.
AHA Team Training. January 12 - March 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. 
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.
Curated Libraries
October 10, 2022
Selected PSNet materials for a general safety audience focusing on improvements in the diagnostic process and the strategies that support them to prevent diagnostic errors from harming patients.

JAMA. Nov 2021-Sep 2022. 

Diagnostic excellence achievement is becoming a primary focus in health care. This 20 article series covers diagnosis as it relates to the Institute of Medicine quality domains, clinical challenges, and priorities for improvement across the system. 

Building Trust and the ABIM Foundation. Addressing the Loss of Trust in Safety Culture. 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.
American Society of Health-System Pharmacists, Institute for Safe Medication Practices.
Leadership commitment to reduce medication errors can help address this safety problem. This certificate program presents key concepts that support organizational efforts to augment medication safety, including event analysis, safety culture, risk identification, and change management.

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.

National Patient Safety Board. 2021-2022.

Patient safety expertise builds on a wide range of subjects to inform progress. This webinar series features discussions on topics spanning concerns that impact effective care delivery such as peer evaluation, systemic failures, human factors, and big data. A June 2022 discussion guide accompanies the series to support conversation and reflection.

Institute for Healthcare Improvement. Orlando, FL, December 4-7, 2022.

This hybrid conference will offer workshops and interactive sessions exploring strategies from within health care and beyond to improve health care quality. A symposium will be held focusing on improvement science research and application.

Chicago, IL: Harpo Productions, Smithsonian Channel: May 2022.

The COVID-19 pandemic revealed the impact of racial disparities and inequities on patient safety for patients of color. This film shares stories of families whose care was unsafe. The cases discussed highlight how missed and dismissed COVID symptoms and inattention to patient and family concerns due to bias reduces patient safety.

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.

Healthcare Excellence Canada. 2020-2022

This bi-monthly webinar series focuses on a variety of topics that support patient safety and quality improvement.
NIOSH [2015]. NIOSH training for nurses on shift work and long work hours. By Caruso CC, Geiger-Brown J, Takahashi M, Trinkoff A, Nakata A. Cincinnati, OH: US Department of Health and Human Services, Centers for Disease Control and Prevention, National Institute for Occupational Safety and Health, DHHS (NIOSH) Publication No. 2015-115 (Revised 10/2021)
Nurse fatigue has been associated with diminished decision-making skills that can contribute to patient harm. This online training program for clinicians and administrators will explore hazards related to nurse fatigue and provide strategies to address behaviors and systems that increase these risks.

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.  

Agency for Healthcare Research and Quality. June 2, 2021.

Measuring and improving safety culture are essential patient safety activities. This webinar introduced the Diagnostic Safety Supplemental Item Set for the AHRQ Surveys on Patient Safety Culture™ (SOPS®) Medical Office Survey focusing on diagnostic safety and presenters shared results from a pilot test.