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 106 Results

ISMP Medication Safety Intensive.

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Institute for Safe Medication Practices. October 4-5, 2023, 10:45 AM - 7:45 PM (eastern).

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

Certified Professional in Patient Safety Review Course.

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Institute for Healthcare Improvement. September 28–29, 2023. 12:00 PM - 4:00 PM (eastern)

This online class prepares individuals to apply for the Institute for Healthcare Improvement patient safety certification program. The on-demand or live sessions cover key patient safety concepts to enhance participants' knowledge about safety culture, systems thinking, leadership, risk identification and analysis, information technology, and human factors. The next online session is August 2-3, 2023.

Patient Safety Executive Development Program.

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Institute for Healthcare Improvement. Boston, MA and online. August 30-October 13, 2023.

Organization executives influence the success of patient safety improvement. This hybrid workshop will highlight how leaders can use assessments, planning, and evidence to improve the safety culture at their organizations.

National Action Alliance to Advance Patient Safety Webinar Series.

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US Department of Health and Human Services. September 26, 2023. 2:00-3:00 PM (eastern).

Work toward zero harm in health care is gaining national attention in the United States. This webinar aligns with efforts by the National Action Alliance to Advance Patient Safety. The session will explore the successful application of high reliability concepts at the Veterans Health Administration. This is the fifth in a series of offerings from the Alliance supporting its work to improve safety.

TeamSTEPPS Master Training Course.

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Armstrong Institute for Patient Safety and Quality. October 3 and 5, 2023.

Team training programs seek to improve communication and coordination among team members to reduce the potential for medical error. This virtual workshop will train participants to design, implement, and evaluate team training programs in their organizations based on the TeamSTEPPS model.

CUSP Implementation Training.

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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 virtual session will be held October 17-18, 2023.

Unequal Treatment Revisited: A Workshop Series.

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Committee on Unequal Treatment, National Academies. 2023.

Health disparities and unequal care contribute to patient and family harm. This 3-component workshop series explored ethnic and racial disparities in health care. A planned September workshop will revisit the findings from the three sessions.

TeamSTEPPS Master Training Virtual Course.

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AHA Team Training. September 7 - November 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.

What Happened to Patient Safety.

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Sheridan S. Turn on the Lights. Institute for Healthcare Improvement. May 2023

Patient engagement is an important component in patient safety. This episode from the Turn on the Lights podcast (hosted by Institute for Healthcare Improvement leaders Don Berwick, MD and Kedar Mate, MD) features a discussion with Sue Sheridan from Patients for Patient Safety US about the importance of involving patients and patient perspectives in the development of patient safety solutions.

SOPS Ambulatory Surgery Center Survey: What You Need to Know.

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Agency for Healthcare Policy and Research: April 27, 2023.

Ambulatory surgery centers (ASC) experience a variety of error types that can be exacerbated by poor safety culture. This webcast provided information on AHRQ’s Surveys on Patient Safety Culture™ (SOPS®) Ambulatory Surgery Center (ASC) Survey, including a review of the SOPS ASC program, survey administration, database submission, and available resources.

Just a Cup of Tea – an Introduction to the SEIPS Framework.

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Epsom and St Helier University Hospitals. Epsom, UK: National Health Service; March 21, 2023.

The Systems Engineering Initiative for Patient Safety (SEIPS) framework is an established human factors-based approach to designing care system improvements. This video introduces the concepts behind SEIPS and uses an everyday non-clinical activity to illustrate its use for a broad audience to identify problems.

Serious Reportable Events in Massachusetts.

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Fillo KT, Saunders K. Bureau of Health Care Safety and Quality, Department of Public Health. Boston, MA: Commonwealth of Massachusetts; 2023.

This reoccurring report compiles patient safety data collected by Massachusetts hospitals. The 2022 numbers document an increase in serious reportable events recorded in acute care hospitals, from 1430 the previous year to 1632. This presentation also includes events from ambulatory surgery centers. Older reports are also available.

Finding & Creating Joy in Work.

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Institute for Healthcare Improvement. September 13 - November 21, 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.

New AHRQ SOPS Workplace Safety Supplemental Item Set for Nursing Homes.

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Agency for Healthcare Research and Quality. January 24, 2023.

Workplace safety became more apparent during the COVID pandemic as an essential component to support effective and safe care provision. This session introduced the AHRQ Workplace Safety Supplemental Item Set for use with the Surveys on Patient Safety Culture™ (SOPS®) Nursing Home Survey that examines staff perceptions of workplace safety. Background on the importance of workplace safety in nursing homes, results from a pilot test in 48 nursing homes, and one organization’s experience with the survey were shared.

Emerging Topics in Quality Improvement.

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University of Washington Medicine Center for Scholarship in Patient Care and Quality and Safety and Seattle Children's Hospital.

Patient safety is a dynamic discipline that adjusts regularly to address clinical, organizational and policy changes, and disruptions. This webinar series presents sessions exploring insights on a variety of strategies and experiences to enhance care.

Understanding SOPS Surveys--A Quick Primer for New Users.

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Rockville, MD: Agency for Healthcare Research and Quality. November 7, 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.

Curated Libraries

Diagnostic Safety

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.

Opportunities to Improve Patient Safety, Advancing U.S. Innovation, and Innovation Hubs.

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President’s Council of Advisors on Science and Technology. Washington, DC: White House; September 21, 2022.

National efforts are required to adjust the health care system and embed safety in programs and processes. Speakers participating in this webinar discussed the impact of errors on families, adverse event prevalence, aviation safety lessons, nursing’s improvement role, the current state of patient safety and what needs to be done to reduce the impact and associated cost of harm.

Addressing the Loss of Trust in Safety Culture.

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Philadelphia, PA: Building Trust and the ABIM Foundation; 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.

Medication Safety Certificate Program.

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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.

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