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National Academies of Sciences, Engineering, and Medicine. Washington, DC: The National Academies Press; 2021.

Misdiagnosis of severe cardiovascular events is a primary concern to the diagnostic safety community due to its prevalence and potential for harm. This report summarizes a session discussion on the existing evidence base on improving diagnosis for these conditions and explore opportunities for improvement.

Patient Safety Movement. September 17, 2021, 2:00-5:00 PM (eastern). 

Patient safety is a global challenge for the health care community. This webinar coincides with World Patient Safety Day and will present two tracks for both the profession and the public that highlight issues impacting maternal care safety and high reliability. Those who have lost their lives to medical error will also be honored during the event. The session speakers include Tedros Adhanom Ghebreyesus, PhD, MSc, Jeff Brady, MD, and Albert Wu, MD.  

Northwest Safety and Quality Partnership. June 22, 2021. 

Diagnostic radiology mistakes contribute to delays and ineffective treatments that contribute to patient harm. This webinar examined factors that contribute to errors in image interpretation and will highlight strategies to learn from those errors to improve diagnostic process reliability. Registering for the program provides access to the recording.

National Academies of Sciences, Engineering, and Medicine. June 7-8, 2021.

Maternal safety is challenged by clinical, equity, and social influences. This virtual event examined maternal health conditions in the United States to improve health system practice and performance for this population. Discussions addressed the need for better data collection, evidence-based practice, and social determinants knowledge integration to enhance the safety of care.

Patient Safety Movement Foundation. 2021. 

The Communication and Optimal Resolution (CANDOR) model was designed to support early error disclosure with patients and families after mistakes in care occur. This three-part webinar series introduced the CANDOR process, discussed CANDOR implementation, outlined the importance of organizational readiness assessment for the program, and described actions to sustain CANDOR after it has launched. Speakers include Dr. Timothy McDonald, the originator of the model.

Boston Children’s Hospital. April 15, 2021. 

A core tenant of patient safety improvement is to draw from the experiences of a range of high-risk industries to address system safety barriers. This session focused on adaptations that health care has made in response to the COVID-19 pandemic. Dr. Don Berwick is among the featured speakers.
Institute for Healthcare Improvement and British Medical Journal. June 9-11, 2021.
This virtual conference offered an introduction to quality and safety improvement success and challenges drawing from international experiences. Course activities designed for a multidisciplinary audience covered topics such as value, improvement methods, and leadership. Keynote speakers included Professor Amy Edmondson and Dr. Don Berwick.  
Agency for Healthcare Research and Quality.
Surveys are established mechanisms for organizational assessment of safety culture. This collection of webinars provides an overview of the AHRQ Surveys on Patient Safety Culture and a range of content related to the successful use of the surveys. Topics covered include organizational characteristics required for successful web-based distribution of the survey and best practices for formatting, programming, and administering the surveys in a variety of environments. 
Lin DM, Peden CJ, Langness SM, et al. Anesth Analg. 2020;131(1):e155-1159.
The anesthesia community has been a leader in patient safety innovation for over four decades. This conference summary highlights presented content related to the conference theme of “preventing, detecting, and mitigating clinical deterioration in the perioperative period.” The results of a human-centered design analysis exploring tactics to reduce failure to rescue were summarized.

Skin of Color Society Foundation, NEJM Group, and VisualDx. October 28--December 2, 2020.

Diagnostic decision making can be affected by implicit racial bias. This 4-part series explored tools and techniques to improve diagnosis in patients of color. Topics covered included structural racism, explicit analysis of disease patterns and treatments, cultural competency, and policy improvement.   

Cambridge, MA; CRICO Strategies: July 14, 2020.

Malpractice claims can generate data that informs safety efforts. This webinar discussed one large health system’s professional liability claim analysis and the factors contributing to indemnity payments. The session reviewed how examining liability results can proactively focus organizational training and improvement initiatives.

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.

US Health and Human Services Office of the Assistant Secretary for Preparedness and Response’s Technical Resources, Assistance Center, & Information Exchange; US Health and Human Services/FEMA COVID-19 Healthcare Resilience Task Force. June 2, 2020.

Health systems are rapidly adjusting processes to successfully respond to COVID-19 crisis demands. This webinar featured tactics used and discussed initiative results to inform continued improvement. The speaker roster included Jeff Brady, MD and Rollin (Terry) Fairbanks, MD.  

National Academy of Medicine. April-June 2020.

Nursing homes are care environments that are particularly challenged by the COVID-19 pandemic. This webinar series covered topics such as keeping nursing home residents and the staff that care for them safe, practice integration in skilled nursing facilities, communication and collaboration in times of crisis, testing and SARS-CoV-2 transmission prevention tactics.