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1 - 20 of 38

ECRI and the Institute for Safe Medication Practices. September 29, 2022. 12:00pm-5:00pm (EST)

Root cause analysis (RCA) is an established adverse event identification method. This webinar will highlight the importance of a just culture to ensure reporting is robust. It will introduce RCA techniques, patient communication strategies and the importance of appropriate post-analysis response to support improvement.

September 21, 2022. 5:00 AM – 11:00 AM (eastern).

Incident investigations are important tools for uncovering latent factors that facilitate patient harm. This conference will draw from experience in the United Kingdom to discuss how adverse event examinations can improve care provision and will highlight efforts in the United Kingdom to focus on maternity care safety.

ECRI, Institute for Safe Medication Practices. October 4 and 6, 2022.

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.

National Association for Healthcare Quality. September 12–14, 2022.

Quality and safety improvement efforts need to address intersecting influences to achieve lasting change. This conference will provide content on seven themes that contribute to improvement. Topics discussed specific to patient safety will include culture assessment, safety science, and event reporting.

Institute for Healthcare Improvement. Sept 7 - Nov 15, 2022.

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.

Collaborative for Accountability and ImprovementApril 26, 2022.

Communication and resolution programs (CRP) can improve response to patients and families after a harmful medical error. This session examined how silos negatively impact transparency after error and how CRPs can reduce siloed communication. The session features Dr. Jo Shapiro as a panelist.

Health Service Journal. September 15-16, 2022. Manchester Central Convention Complex, Manchester UK.

Patient safety is challenged worldwide due to the daily complexity of care. This session will focus on never events. Areas of specific exploration will include what factors in the environment enable never events, the value of proactive assessment of practice to prevent never events, and the viability of never event classification schemes. 

Rockville, MD: Agency for Healthcare Research and Quality. January 12, 2022.

An organization’s understanding of its culture is foundational to patient safety. This webinar introduced the AHRQ Surveys on Patient Safety Culture™ (SOPS®) program. The session covered the types of surveys available and review resources available to best use the data to facilitate conversations and comparisons to inform improvement efforts. 

Patient Safety Movement. October 29, 2021. 

Effective response to medical harm involves a variety of perspectives that are aligned in purpose. This webinar discussed how different stakeholders might view approaches to medical error management. It described how strategies have changed from paternalistic to inclusive processes that consider the impact of mistakes on patients and families and the role of communication is key to achieving fair and honest resolution to adverse incidents.

Collaborative for Accountability and Improvement. October 21, 2021. 

Communication-and-resolution program (CRP) initiatives are a valuable strategy for improving support and transparency after an adverse incident. This webinar discussed how patients and families feel about support mechanisms after they have experienced medical error, if they were involved in a CRP process and the types of information they required after a harmful incident.

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.

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.
Project Hope.
To Err Is Human was released almost 2 decades ago and continues to influence a growing area of study aimed at improving health care and reducing medical error. This in-person and streaming event covered topics discussed in a special issue that explored progress since the report was released, new challenges, and success stories such as communication-and-resolution programs and the use of checklists.
Health Services Research and the Health Research and Educational Trust. March 2, 2017.
Communication-and-resolution programs emphasize transparency and respect in discussions with patients and families following an adverse event. This webinar highlighted AHRQ-funded research and programs that explored the impact of communication-and-resolution programs and other strategies that focus on improving patient safety and reducing liability. Researchers from a recent special issue devoted to this work were featured speakers.

Forstag EH; Committee on Pain Management and Regulatory Strategies to Address Prescription Opioid Abuse; Health and Medicine Division. Washington, DC: National Academy of Science; 2016. ISBN: 9780309451901.

Efforts to ensure safe pain management in the context of the opioid epidemic have focused on prescribing behaviors and policies. This publication reports on the results of a workshop convened to explore factors that contribute to opioid overuse and to identify areas for improvement that require further research.