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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.

Drug diversion can result in patient harm due to reduced medication availability, impaired clinician performance, and loss of trust. This webinar discussed the impact of drug diversion at a system level and outlined steps an organization can take to minimize this risk through workplace health strategies and stewardship programs.

Initiative appraisal is a necessary step toward shared learning and quality and safety program improvement. This virtual session will focus on the development of evaluation skills and strategies, with an emphasis on critique, design, and qualitative assessment.

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.  

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.

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.

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

Patients injured while receiving health care are susceptible to physical, financial and psychological harm. This webinar introduced strategies to rebuild the physical health of these patients and the trust that they and their loved ones have in the system of care.

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.

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.

This publication summarizes content from a 2009 AHRQ-funded workshop that explored the effect of behavior and human factors on home health care quality and safety.

This audio program shares insights from the Lucian Leape Institute report on incorporating safety fundamentals into medical school curriculum.

This article summarizes results from a conference regarding heparin errors, their epidemiology, and error types along with ways to increase safety.

This special issue features proceedings from a symposium on nursing and patient safety, held in tribute to the accomplishments of Ada Sue Hinshaw, PhD, upon her retirement from the deanship at the University of Michigan School of Nursing.

The authors summarize sessions from an annual nurse executive conference that focused on leadership, just culture, disclosure, change management, and mentorship.

The author discusses medical error in the neonatal intensive care unit (NICU) and the role of teamwork in achieving safety. Continuing education credit is available.

The authors summarize the plenary talks and panel discussions on topics such as leadership's role in leading change, the importance of disclosure and apology, and the role of nurses in achieving patient safety.

The University of Pennsylvania School of Nursing, the Hospital of the University of Pennsylvania, the Infusion Nurses Society, and the American Journal of Nursing held an invitational symposium in Philadelphia on July 16-17, 2004. The goals of the symposium were to determine research priorities and to make clinical education and policy recommendations to ensure safe medication administration. The symposium, supported by a conference grant from the Agency for Healthcare Research and Quality (AHRQ 1 R13 HS14836-01) and by unrestricted grants from manufacturers of pharmaceuticals and other products designed to promote safe medication administration, was attended by 40 nursing and professional experts. This supplemental issue reports on the symposium proceedings.