The PSNet Collection

Examining the Status of VA’s Electronic Health Record Modernization Program.

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US Senate Committee on Veterans Affairs. 117th Cong (2021-2022). (July 20, 2022).

Large-scale electronic health record (EHR) implementation projects encompass a myriad of problems to navigate to arrive at success. This Congressional panel explores challenges experienced during EHR implementation in the VA Health system. Panelists from the Veterans Administration, the investigator and the technology vendor involved in the program shared insights and next steps to direct improvement.

Finding & Creating Joy in Work.

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Institute for Healthcare Improvement. September 14--November 22, 2022.

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.

Diagnostic Excellence.

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JAMA. 2021-2022.

Diagnostic excellence achievement is becoming a primary focus in health care. This article series covers diagnosis as it relates to the Institute of Medicine quality domains, clinical challenges, and priorities for improvement across the system.

Root Cause Analysis-in-Action: Building Foundations.

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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.

Using TeamSTEPPS Tools and Strategies to Activate a Culture of Diagnostic Safety by Improving Communication and Teamwork

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CHPSO. July 13, 2022 - 2:00 PM – 3:00 PM (eastern).

Health care is recognizing that diagnostic accuracy is a team activity. This session will highlight the importance of teamwork in diagnosis and the role of the team leader to ensure safe diagnosis. The discussion will focus TeamSTEPPS strategies to improve diagnostic safety.

TeamSTEPPS Master Training Virtual Course.

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AHA Team Training. September 22 -- November 17, 2022.

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.

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.

ISMP Medication Safety Intensive.

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Institute for Safe Medication Practices. August 4-5, 2022.

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

Virtual Caring for the Caregiver: RISE.

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Armstrong Center for Patient Safety and Quality. September 29, 2022.

The Resilience in Stressful Events (RISE) program provides peer assistance for healthcare workers who experience psychological effects after involvement in stressful adverse care events. This virtual session presents RISE implementation education and orientation for staff to respond when peer support is needed.

2022 IHI Forum and Scientific Symposium.

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Institute for Healthcare Improvement. Orlando, FL, December 4-7, 2022.

This hybrid conference will offer workshops and interactive sessions exploring strategies from within health care and beyond to improve health care quality. A symposium will be held focusing on improvement science research and application.

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.

Medical middlemen: broken system making it harder for hospitals and patients to get some life-saving drugs.

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Whitaker B. CBS News. May 22, 2022.

Drug shortages represent a complex system level challenge in health care that can harm patients. This news segment details economic and production factors that affect the availability of generic medications. Clinicians and families were interviewed to share tactics for managing these situations to support patient safety despite shortages.

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.

Part 2 of the 9th Annual Communication, Apology, and Resolution (CARe) Forum.

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Betsy Lehman Center for Patient Safety. June 2, 2022.

Communication and resolution programs are a promising strategy for successful management of relationships and actions after medical error occurrence. This session explored elements of effective discussions after an adverse event through case simulation and dialogue.

Advancing Diagnostic Excellence for Older Adults.

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National Academies of Sciences, Engineering, and Medicine. Arnold and Mabel Beckman Center, Irvine, CA. July 21, 2022, 11:30 AM-6:30 PM (eastern).

The care of older adult patients can be complicated due to comorbidities and polypharmacy. This session will examine diagnostic challenges unique to the older adult population. The existing evidence base and research strategies for the future will be discussed.

The Power of Medical Malpractice Stories to Improve Patient Safety.

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The Collaborative for Accountability and Improvement. May 19, 2022.

The sharing of stories is a key approach for providing information and context to promote change. This webinar focused on stories drawn from lawsuits, the general patient and family motivation of legal action to minimize the repetition of similar errors, and the ironies involved in the adherence to legal confidentiality that can reduce learning from error.

The Color of Care.

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Chicago, IL: Harpo Productions, Smithsonian Channel: May 2022.

The COVID-19 pandemic revealed the impact of racial disparities and inequities on patient safety for patients of color. This film shares stories of families whose care was unsafe. The cases discussed highlight how missed and dismissed COVID symptoms and inattention to patient and family concerns due to bias reduces patient safety.

Redesigning Event Review with RCA2

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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.

Improving Patient Safety with Human Factors Methods.

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Armstrong Institute for Patient Safety and Quality. Sept 19, 26, 30, 2022.

Human factors engineering (HFE) is a primary strategy for advancing safety in health care. This virtual workshop will introduce HFE methods and discuss how they can be used to reduce risk through design improvements in a variety of process and interpersonal situations.

Using Human Factors Engineering and Design Thinking to Improve Clinical Operations.

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ECRI, Thomas Jefferson University's College of Population Health, College of Health Professions, and the School of Design and Engineering. March 15, 2022; April 19, 2022; May 17, 2022. 12:30-1:30 PM (eastern).

The complexity of health care delivery requires solutions designed with daily practice workflow in mind to reduce the need for individual resilience and work-arounds to ensure safe care. This three-session workshop will examine how design thinking can be coupled with human factors engineering to reduce challenges to safety and patient-centeredness.

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