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Healthcare Safety Investigations Conference 2022.

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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.

Virtual Ambulatory CUSP Training.

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Armstrong Institute for Patient Safety and Quality. September 22-23, 2022.

The comprehensive unit-based safety program (CUSP) approach emphasizes active teamwork as a core element of improving safety culture through reporting and learning from errors. This virtual conference will cover how to engage teams in the ambulatory environment, address barriers to safe care, and learn from the experiences of others.

Patient Safety Executive Development Program.

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Institute for Healthcare Improvement. Boston, MA and online. August 31-October 14, 2022.

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.

Patient Safety Awareness Week.

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Institute for Healthcare Improvement.

This website provides resources for promoting patient safety during Patient Safety Awareness Week. The annual observance is held in March.

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

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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.

Important Actions Community Pharmacists Need to Take Now to Reduce Potentially Harmful Dispensing Errors.

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Institute for Safe Medication Practices. October 26, 2021.

Community pharmacies encounter a variety of challenges to medication safety. This webinar focused on high-alert medications and discuss unreliable medication delivery methods. The session also covered vaccination errors and how to prevent them.

Unite for Safe Care.

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Patient Safety Movement. September 17, 2021.

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.

Advancing Maternal Health Equity and Reducing Maternal Mortality Workshop.

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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.

SOPS Surveys.

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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™ (SOPS®) 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.

The Impact of Skin Color and Ethnicity on Clinical Diagnosis and Research.

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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.

Enhancing Your Medication Error Reporting Program to Improve Global Medication Safety.

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Institute for Safe Medication Practices. September 15, 2020.

Medication error reporting is key to understanding failures, identifying risk and informing improvement. This webinar discussed approaches to internal reporting and challenges to reporting success.

Reimagining Healing after Healthcare Harm: The Potential for Restorative Practices.

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Patients for Patient Safety Canada. Canadian Patient Safety Institute. August 4, 2020.

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.

The Power to Predict: Leveraging Medical Malpractice Data to Reduce Patient Harm and Financial Loss.

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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.

COVID-19 Webinars.

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The International Society for Quality in Health Care. March - May 2020.

The COVID-19 pandemic is a worldwide crisis that requires organizations, governments, and individuals to draw from the collective experience and rapidly improve practice. This series of webinars discuss a variety of foci to share experience from the field. Topics covered include human factors engineering, clinician support, and communication.

Respectful, trusting relationships are essential for patient safety, especially the surgeon-anesthesiologist dyad.

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Cooper J. Respectful, trusting relationships are essential for patient safety, especially the surgeon-anesthesiologist dyad. Anesthesiology 2019. October 19th, 2019; Orlando, FL.

This recording of the 2019 ASA/APSF Ellison C. Pierce Memorial Lecture features Jeff Cooper, PhD. Dr. Cooper discusses the history of the anesthesia patient safety movement and shares personal experiences with leadership in the development of his focus on the application of crew resource management in the perioperative environment to understand error. The session explores the important role of respect and relationships in health care as an influence on safe care delivery.

Communicating Clearly About Medicines: Proceedings of a Workshop—in Brief.

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National Academies of Sciences, Engineering, and Medicine; NAS.

Medication safety is a global health care concern. This workshop proceedings report highlights expert opinion on how to improve the clarity of medication information and the way it is communicated to patients. Panelists focused on elements of the process such as the patient experience, health literacy, medication instructions, and design of medication packaging.

Introducing the AHRQ Ambulatory Surgery Center Survey on Patient Safety Culture.

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Agency for Healthcare Research and Quality. July 15, 2015.

Ambulatory surgery centers have been the focus of patient safety concerns due to high-profile incidents of harm. This webinar highlighted the AHRQ AHRQ Surveys on Patient Safety Culture™ (SOPS®) Ambulatory Surgery Center Survey, results of its pilot test, and insights from hospitals using the survey.

Facilitating Patient Understanding of Discharge Instructions: Workshop Summary.

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Alper J, Hernandez LM; Roundtable on Health Literacy, Board on Population Health and Public Health Practice, Institute of Medicine. Washington, DC: National Academies Press; December 2014. ISBN: 9780309307383.

Poor health literacy has been identified as an important threat to patient safety, particularly through potentially contributing to adverse drug events. This workshop report reveals how health literacy affects patients' abilities to follow discharge instructions and makes recommendations to improve after-visit summaries to augment patient understanding of directions.

The Role of Human Factors in Home Health Care: Workshop Summary.

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Olson S. Committee on the Role of Human Factors in Home Healthcare, National Research Council. Washington, DC: National Academies Press; 2010.

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.

Standardizing Medication Labels: Confusing Patients Less, Workshop Summary.

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Hernandez LM; for Roundtable on Health Literacy, Board on Population Health and Public Health Practice, Institute of Medicine. Washington, DC: National Academies Press; 2008.

Depicting how medication labels and instructions confuse patients, this report addresses ambulatory medication safety and offers recommendations on how to standardize pharmacy labels to help prevent errors.

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