The PSNet Collection

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.

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.

Lessons Learned? Building a Culture of Patient Safety Within the Veterans Health Administration.

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US House of Representatives Committee on Veterans' Affairs Subcommittee on Health. 117th Cong. 1^st Sess (2021).

The Veterans Health Administration is a large complex system that faces various challenges to safe care provision. At this hearing, government administrators testified on current gaps that detract from safe care in the Veteran’s health system. The experts discussed several high-profile misconduct and systemic failure incidents, suggested that the culture and leadership within the system overall enables latency of issues, and outlined actions being taken to address weaknesses.

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.

Bearing the Burden: Black Mothers in America.

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Weiser S. The New Yorker and Retro Report; 2021.

Disparities in maternal care have become apparent as a public health concern during the COVID-19 pandemic. This short film spotlights inequities and biases that Black mothers face, that reduce the safety of their care. Midwives are offered as a strategy for improving the safety of maternal care in this patient population.

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.

Think health care workers are tested often for the Coronavirus? Think again.

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Wamsley L. National Public Radio and WBUR. December 7, 2020.

Testing for COVID-19 is a core public safety strategy for pandemic management. This news story discusses how a lack of health care workers’ virus status knowledge could contribute to spread. Barriers inherent to a universal testing strategy include operational challenges, patient testing volume, and availability of health care workers to provide care during the pandemic should clinicians test positive.

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.

How a Doctor Confronts Medical Error.

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People’s Pharmacy. Show 1209. April 28, 2020.

Accidental harm to patients is a persistent challenge in health care. This interview features Dr. Danielle Ofri who provides an overview of error in medicine. She draws from both general and COVID-19 pandemic care experiences to illustrate the difficulties involved in measuring, understanding and improving patient safety.

People with disabilities fear pandemic will worsen medical biases.

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Shaprio J. National Public Radio. April 15, 2020.

Access to care has been strained by the COVID-19 pandemic. This radio segment discusses how implicit biases can affect care of patients with disabilities. It highlights how preconceptions about this patient population could limit their access to treatments should they become ill.

How to reduce maternal mortality rates in the United States.

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Livingston E, Howell EA. JAMA Clin Rev. April 2, 2019.

Maternal mortality in the United States is gaining increased attention as a patient safety concern. This podcast discusses conditions known to challenge maternal safety, the high incidence of preventable harm in this population, and care bundles as an improvement strategy. A recent Annual Perspective summarized national initiatives to improve safety in maternity care.

Speak Up video posters.

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The Joint Commission.

These free downloadable posters from the Speak Up video series, available in English and Spanish, aim to raise awareness of the patient's role in safe care.

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