The PSNet Collection

2021 Fall Science of High Reliability.

American Association for Physician Leadership. October 30-31, 2021.

Attaining high reliability remains a challenge throughout health care. This virtual session will focus on human error, safety culture, system thinking, and leadership as primary concepts driving progress toward reliable healthcare delivery.

Achieving Excellence in the Diagnosis of Acute Cardiovascular Events: Proceedings of a Workshop–in Brief.

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.

Northwest Patient Safety Conference.

Washington Patient Safety Coalition. October 6-7, 2021.

This annual virtual conference will highlight regional and local experiences driving improvement in health equity, diagnostic safety, and patient engagement. Sidney Dekker and John D. Banja are among the speakers.

Applying Human Factors to Patient Safety, Reliability and Investigation in Healthcare SEIPS in Action.

Clinical Human Factors Group. October 19, 2021. 9:00AM - 12:00 PM (eastern).

The application of human factors and ergonomics methods to healthcare process design results in proactive failure reduction opportunities. This virtual conference will discuss the Systems Engineering Initiative for Patient Safety (SEIPS) framework to describe how this sociotechnical model supports system safety. Speakers include Pascale Carayon, Andrew Petrosoniak and Richard Holden.

Root Cause Analysis-in-Action: Building Foundations.

ECRI, Institute for Safe Medication Practices. September 28 and 30, 2021.

Root cause analysis (RCA) is a recognized approach to examining failures by identifying causal factors to target improvement work. This session will build on a Patient Safety Organization's experience in conducting 450 RCAs to aid participants in leading RCAs and planning implementation strategies to address detected contributors to failure.

Recognizing Unsafe Care: What It Is and How to Report It.

Patient Safety Foundation. August 26, 2021.

This webinar introduced medical error and harm as related concepts to identify unsafe care and enhance response, engagement, and reporting efforts of clinicians, patients and families.

Communication and Resolution Programs: An Emerging Best Practice for Addressing Patient Harm.

National Association for Healthcare Quality. August 26, 2021, 1:00–2:00 PM (eastern).

Communication and Resolution Programs (CRPs) are a successful multidisciplinary coordination strategy to align healing actions with the patient and family after medical error. This session will discuss the impact of CRPs and share program implementation insights. The session features Thomas H. Gallagher, MD, as a speaker.

Patient Safety Certificate Program.

American Society for Healthcare Risk Management. Henry B. Gonzalez Convention Center, San Antonio, TX; October 9-10 2021.

This onsite program will cover key patient safety concepts and how to apply them to improve safety. To help prepare attendees for designing and sustaining safety initiatives at their organizations, preconference activities will discuss safety culture, human factors, communication, and leadership development.

2022 IHI Patient Safety Congress

Institute for Healthcare Improvement. Dallas TX. May 16-18, 2022.

This annual conference will host pre-session workshops, panels, and presentations covering a variety of patient safety topics which include the continuum of care, learning systems and leadership.

ISMP Medication Safety Intensive.

Institute for Safe Medication Practices. December 2-3, 2021.

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

Leadership Development Program: High Reliability Health Care Academy

Thomas Jefferson University, College of Population Health. Oct 1 - Dec 17, 2021.

Leaders have a distinct role in creating a culture that supports a high reliability organization(HRO). This virtual series will train senior acute care, long-term care, or skilled nursing facility staff to apply HRO concepts that support safe healthcare environments.

Finding & Creating Joy in Work.

Institute for Healthcare Improvement. September 14 - November 30, 2021.

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.

Redesigning Event Review with RCA2

Institute for Healthcare Improvement. September 7 - November 16, 2021.

Root cause analysis (RCA) is a widely recognized retrospective strategy for learning from failure that is challenging to implement. This series of webinars will feature an innovative approach to RCA that expands on the concept to facilitate its use in incident investigations. Instructors for the series will include Dr. Terry Fairbanks and Dr. Tejal K. Gandhi.

Unite for Safe Care.

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.

Improving Patient Safety with Human Factors Methods.

Armstrong Institute for Patient Safety and Quality. October 11, 15 and 20, 2021.

Human factors engineering (HFE) is a primary strategy for advancing safety in health care. This virtual workshop will introduce HFE methods and discuss how they can be used to reduce risk through design improvements in a variety of process and interpersonal situations.

TeamSTEPPS Master Training Virtual Course.

AHA Team Training. September 13--November 17, 2021.

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.

Fundamentals of Diagnostic Error in Imaging.

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.

Advancing Maternal Health Equity and Reducing Maternal Mortality Workshop.

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.

CANDOR Webinar Series.

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.

TeleDx: How is Telemedicine Working - and not Working - to Support Diagnosis?

Society to Improve Diagnosis in Medicine. June 3, 2021.

The use of telemedicine has expanded during the COVID-19 pandemic into the mental health and diagnostic realms. This session explored how the practice of telediagnosis has emerged and share concerns about its safety and quality. Dr. Mark Graber is a featured speaker.

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