The PSNet Collection

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.

Canadian Patient Safety Week.

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Healthcare Excellence Canada.

This site provides promotional materials and registration information for an awareness campaign on patient safety that takes place in the autumn. The annual observance will take place October 23-27, 2023.

Mark Graber Diagnostic Quality & Safety Award.

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Society to Improve Diagnosis in Medicine.

Inspired by the work and leadership of Dr. Mark Graber, this award will annually recognize either lifetime achievements or stand-alone innovations that enhance efforts to improve the safety and quality of diagnosis. The deadline to submit a 2023 nomination is September 12, 2023.

IHI Fellowship Program.

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Institute for Healthcare Improvement.

This virtual fellowship program focuses on developing competencies for leading patient safety efforts. The deadline for submitting an application for the 2023–2024 class has passed.

Judy Smetzer Just Culture Champion Scholarships.

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Institute for Safe Medication Practices.

A Just Culture supports effective reporting and learning from mistakes. This scholarship, inspired by the work and leadership of Judy Smetzer, former editor of the ISMP Medication Safety Alert! newsletter, will support three team or individual certifications in Just Culture practice. The 2023 application process is now closed.

ISMP Survey on the 2022-2023 Targeted Medication Safety Best Practices for Hospitals.

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Institute for Safe Medication Practices. May 2023.

The integration of best practices into daily work is an indication of their usefulness and sustainability. This survey seeks to understand the broad use of 2022-2023 Targeted Medication Safety Best Practices for Hospitals throughout health care to determine implementation successes and barriers. Data submission closes June 30, 2023.

Challenge Competition: Impact of Patient Safety Tools.

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Agency for Healthcare Research and Quality, Rockville, MD. 2023.

The Agency for Healthcare Research and Quality (AHRQ) offers many practical tools and resources to help healthcare organizations, providers, and others make patient care safer These tools are based on research, and they can assist staff in hospitals, emergency departments, long-term care facilities, and ambulatory settings to prevent avoidable complications of care. The purpose of this challenge is to elicit new narratives of how AHRQ toolkits are being used. Up to ten winners will receive $10,000 each. Submissions are due October 27, 2023.

Diagnostic Centers of Excellence (X01 Clinical Trial Not Allowed).

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PAR-23-120. Bethesda, MD: National Institutes of Health; March 7, 2023

Approaching diagnosis as a team activity is seen as a key approach to diagnostic effectiveness. This notice highlights a funding opportunity to launch Diagnostic Centers of Excellence to improve diagnosis of undiagnosed and unknown disease and research to inform improvement. The application period is now closed.

Lewis Blackman Patient Safety Award.

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Chicago, IL: American College of Graduate Medical Education.

Lewis Blackman was a young man who lost his life to medical error when the severity of his condition after elective surgery was unrecognized by clinicians caring for him. This award will acknowledge residents and fellows engaged in developing educational programs on patient safety. Nominations for the 2024 award cycle are due March 15, 2023.

The Joint Commission and National Quality Forum Announce 2022 Eisenberg Award Recipients.

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Oakbrook Terrace, IL: Joint Commission and National Quality Forum: January 23, 2023.

The annual Eisenberg Award recognizes leaders and organizations who have made substantial contributions toward patient safety and quality improvement. The 2022 honorees are Jason S. Adelman, MD, MS, North American Partners in Anesthesia (NAPA) and Parkland Health, Dallas County, Texas. The awards were presented at the National Quality Forum's annual conference on February 20, 2023, in Washington, DC.

Safer Together Survey: Advancing Patient and Workforce Safety

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Cambridge, MA: Institute for Healthcare Improvement: January 2023.

The National Steering Committee for Patient Safety (NSC) was formed to engage with the health care community to plan and prioritize patient safety work to generate improvements. This short survey seeks comments from the field to determine current interest and status in efforts aligned with the National Action Plan to Advance Patient Safety.

AHRQ Safety Program for Telemedicine.

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Agency for Healthcare Research and Quality.

Telemedicine efforts harbor both risk and reward to patients and providers. The AHRQ Safety Program for Telemedicine is a national effort to develop and implement a bundle of evidence-based interventions designed to improve telemedicine care in two settings—the cancer diagnostic process and antibiotic use. To test the bundle of interventions, the program will involve two cohorts of healthcare professionals who utilize telemedicine as a care delivery model. It is an 18-month program, beginning in June 2023, that seeks to improve the cancer diagnostic process for patients who receive some or all of their care through telemedicine. Recruitment webinars start in late January and run through early May 2023; the antibiotic use cohort will begin recruitment in December 2023.

Request for Information: Creating a National Healthcare System Action Alliance to Advance Patient Safety.

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Agency for Healthcare Research and Quality. Fed Register. December 12, 2022;87:76046-76048.

Partnerships are needed to motivate, design, and implement lasting innovation in complex situations. This announcement calls for stakeholder insights on the work of the National Healthcare System Action Alliance to Advance Patient Safety and how it can best realize its mission and goals. The deadline for submitting comments has passed.

Rise to Health Coalition.

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Boston, MA; Institute for Healthcare Improvement: December 2022.

Systemic efforts to improve health equity support patient safety. This announcement highlights an initiative for collective work to address four areas of effort to reduce inequity in health care: access, workforce, social and structural drivers, and quality and safety.

The National Healthcare System Action Alliance to Advance Patient Safety.

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US Department of Health and Human Services.

The large system change required to reduce patient harm requires multi-stakeholder engagement and sustained commitment. This alliance will work with healthcare systems, federal partners, patients and families, and other stakeholders to implement a national plan to ensure the safety of patients and healthcare workers. The webinar introducing the program, featuring Department of Health and Human Services Secretary Xavier Becerra, was held November 14, 2022.

Golden State Medical Supply, Inc. Issues a Voluntary Nationwide Recall of Atenolol 25 mg Tablets and Clopidogrel 75 mg Tablets Due to a Label Mix-up.

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MedWatch Safety Alert. Silver Spring, MD: US Food and Drug Administration; September 29, 2022.

Recalls of medications due to labeling errors are an established approach to minimize the potential for harm. This announcement highlights a labeling mistake with hypertension and antiplatelet medications that could result in dose omissions or bleeding risk.

Agency Information Collection Activities: Proposed Collection; Comment Request, "Hospital Survey on Patient Safety Culture Comparative Database.''

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Agency for Healthcare Quality and Research. Fed Register. June 3, 2022;87: 33795-33796.

Surveys are recognized tools to inform hospitals of the current status of their safety culture. This notice calls for public comment on the intention of the Agency for Healthcare Research and Quality to launch the Hospital Survey on Patient Safety Culture Comparative Database data collection process. The deadline for submitting comments on this notification is now passed.

AHRQ Challenge on Innovative Solutions To Update or Re-Create TeamSTEPPS Videos.

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Rockville, MD; Agency for Healthcare Research and Quality: April 2022.

TeamSTEPPS promotes effective teamwork, collaboration, and communication in health care while focusing on strategies known to improve patient safety. This challenge competition seeks submissions to revise existing TeamSTEPPS videos to improve health literacy, equity, and cultural sensitivity.

Use duodenoscopes with innovative designs to enhance safety: FDA Safety Communication.

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Silver Spring, MD: US Food and Drug Administration; April 5, 2022.

The challenge of medical device sterilization has shifted the design of some products with disposable elements in order to reduce opportunities for human error that increase infection potential during reuse. The publication supports the complete adoption of disposable duodenoscopes or scope components as a safety measure.

Disrespectful behavior in your workplace.

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Institute for Safe Medication Practices.

Workplace bullying and disrespectful behavior have been shown to negatively affect fall rates, medication errors, and other adverse events. The Institute for Safe Medication Practices sought clinician input on and experiences with disrespectful behaviors in the ambulatory care setting (e.g., community, specialty, and long-term care pharmacies, physician practices, and outpatient visits) and how organizations have been working to improve the culture of respect. The data collection period has now passed.

COVID-19 Focused Inspection Initiative in Healthcare.

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Occupational Safety and Health Administration. March 2, 2022.

The impact of nursing home inspections to ensure the quality and safety of the service environment is lacking. Weaknesses in the process became more explicit as poor long-term care infection control was determined to be a contributor to the early spread of COVID amongst nursing home residents. This announcement outlines a targeted inspection initiative to assess whether organizations previously sited have made progress toward improving workforce safety.

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