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.

TeamSTEPPS Master Training Course.

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Armstrong Institute for Patient Safety and Quality. January 30 and February 1, 2024.

Team training programs seek to improve communication and coordination among team members to reduce the potential for medical error. This virtual workshop will train participants to design, implement, and evaluate team training programs in their organizations based on the TeamSTEPPS model.

Curated Libraries

Diagnostic Safety

October 10, 2022

Selected PSNet materials for a general safety audience focusing on improvements in the diagnostic process and the strategies that support them to prevent diagnostic errors from harming patients.

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.

TeamSTEPPS for the COVID-19 Crisis.

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AHA Team Training.

The COVID-19 crisis requires cooperation and coordination of organizations and providers to address the persistent challenges presented by the pandemic. This on-demand video collection reinforces core TeamSTEPPS; methods that enhance clinician teamwork and communication skills to manage care safety during times of crisis.

Patient.

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Canadian Patient Safety Institute;

Patient stories and insights related to medical mishaps can inspire and motivate work to enhance health care safety. This annual podcast series uses patient accounts of medical errors to collaboratively explore solutions with health care providers.

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.

Unprofessional Behavior Leads to Complications.

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JN Learning. 2020.

Disruptive behavior is a recognized deterrent to safe communication, sharing of concerns and teamwork. This educational program highlights a study that measured the impact of unprofessional physician behavior on patient care and features Dr. William Cooper and Dr. Gerald Hickson as speakers.

Creating a Safe Space: Psychological Health and Safety of Healthcare Workers.

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Canadian Patient Safety Institute: 2019.

Structured approaches to managing negative psychological consequences of medical errors on health care professionals, patients, and families are important for emotional healing and organizational learning. This webinar series featured discussions on peer support efforts and a toolkit for Canadian health care workers.

Making health care safer. Think sepsis. Time matters.

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CDC; Centers for Disease Control and Prevention.

Delayed diagnosis of sepsis can have serious consequences. This article and accompanying set of infographics spotlight the importance of prompt identification and treatment of sepsis and suggest how providers, organizations, patients, and families can help improve recognition of sepsis.

Raising and Responding to Concerns.

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Health Education England. London, England: National Health Service; February 2015.

Staff willingness to speak up when they are concerned about unsafe behaviors and conditions is a hallmark of a safety culture. These videos use vignettes to demonstrate challenges to speaking up in health care, how open communication can prevent errors, strategies to raise concerns on the frontline, and the value of checklist use in supporting conversation.

Patient Stories.

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This Web site hosts documentary accounts of medical errors to encourage clinicians to discuss quality and safety issues in health care.

Partnering to Heal: Teaming-Up Against Healthcare-Associated Infections.

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Washington, DC: US Department of Health and Human Services; May 2011.

This training program explores how to create a culture of safety and prevent health care–associated infections.

A Hospital Accident: Lessons Learned – A Death, A Conviction, and A Healing.

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Texas Medical Institute of Technology. June 16, 2011.

This archived webinar covered how medical errors affect both the family and provider involved, and offered recommendations for best practices following a medical error.

When Things Go Wrong: Voices of Patients and Families.

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CRICO/RMF; Harvard Risk Management Foundation

This educational video shares patient and family perspectives on how medical error affected their lives.

Postoperative handover: problems, pitfalls, and prevention of error.

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Nagpal K, Arora S, Abboudi M, et al. Ann Surg. 2010;252:171-6.

This qualitative study interviewed 18 providers and found that postoperative handovers are informal, unstructured, and fraught with inconsistent and incomplete information transfer. These data were used to develop and validate a formal handover protocol. Prior studies have used insights from Formula One auto racing to inform improvement strategies for postoperative handoffs, and the World Health Organization's Surgical Safety Checklist explicitly emphasizes structured handoffs at the time of patient transfer from the operating room to the postoperative area.

To ask or not to ask?: the results of a formative assessment of a video empowering patients to ask their health care providers to perform hand hygiene.

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Garcia-Williams A; Brinsley-Rainisch K; Schillie S; Sinkowitz-Cochran R.

Focus group participants were significantly more likely to ask their nurses and physicians to wash their hands after viewing a Hand Hygiene Saves Lives video.

Physician, say you're sorry.

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Delbanco T, Bell SK. New York Times Video. November 24, 2008.

This video features patient and physician commentary on the power of apology in response to medical error.

How a simple checklist can dramatically reduce medical errors.

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Pronovost PJ. On Call. IHI Open School for Health Professionals. November 3, 2008.

This audio program features Peter Pronovost discussing his experience with checklist development and how it might be applied to support other quality improvement targets.

Medication error death rate up 500 percent.

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Spiesel S, Chadwick A. "Day to Day." National Public Radio. August 27, 2008.

This radio program discusses the results of a study on the risk of fatal medication errors involving prescribed medications taken at home.

NHS drug error 'crackdown' urged.

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BBC News

This story reports findings from the UK Healthcare Commission's assessment of medication error in the National Health Service. The story is accompanied by an audiovisual news report.

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