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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.

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Displaying 1 - 20 of 157 Results

Institute for Safe Medication Practices.

Mixed case letters are one suggested strategy to reduce look-alike medication name errors. This survey announcement calls for insight from the field to update an existing resource of problematic drug name pairs and examine the effectiveness of mixed case letter use to minimize confusion. The deadline for comment submission is December 2, 2022.

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

Diagnostic improvement engages a variety of activities to achieve excellence. This announcement highlights ten organizations AHRQ funded to establish Diagnostic Safety Centers of Excellence. Their focused efforts will work to improve diagnostic safety and quality. Areas of project focus include use of information technology to improve diagnostic accuracy and teamwork as an improvement strategy.

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.

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.

National Institutes of Health.  August 11, 2022. RFA-HD-23-035.

Maternity care is increasingly being recognized as vulnerable to implicit biases and social inequities. This funding announcement aims to support initiatives that promote equity as a primary component of efforts to study preventable maternal harm in a variety of disadvantaged and ethnic populations. The application process is now closed.
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 process for submitting a 2022 nomination is closed.
Healthcare Excellence Canada
This site provides promotional materials for an annual awareness campaign on patient safety that takes place in the autumn. The 2022 observance will be held October 24th through 28th. The theme of the week will be “Press play on Safety Conversations.” 
Drug Enforcement Administration. October 29, 2022.
Removing unused medications from the home can help prevent accidental exposure to unneeded medications and limit their availability for misuse. This annual program provides patients with an opportunity to discard medications safely. The sponsors also provide education to highlight the importance of appropriate disposal of unused prescription drugs as a medication safety activity.

Rockville, MD: Agency for Health Quality and Research; June 2022.

The potential for workplace violence degrades patient and staff safety. AHRQ is developing a survey item set that will help nursing homes identify and improve factors associated with workplace safety. The Workplace Safety Supplemental Item Set will assess the extent to which nursing homes’ organizational culture supports workplace safety. The new supplemental item set can be administered optionally at the end of the SOPS Nursing Home Survey. AHRQ will build this new measure of workplace safety upon its existing and highly successful SOPS program. This announcement calls for nursing homes to participate in a pilot study to test the application of the supplemental item set in the field.

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 application process is now closed.

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 August 2, 2022.

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. 

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.

Health Care Futures. June-July 2022.

Strategies to educate new health professionals in patient safety and quality improvement can ensure commitment to improvement work. This fellowship will help learners understand the evolution of patient safety and develop skills in quality improvement and human factors engineering. The application period is now closed.

Occupational Safety and Health AdministrationMarch 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.

Palo Alto CA; Gordon and Betty Moore Foundation: February 22, 2022. 

A lack of consensus on measures for the effectiveness and accuracy of diagnosis represents a gap in improvement methods. This announcement seeks proposals to examine quality measures to motivate excellence in three primary areas of diagnostic concern:  acute vascular events, infections, and cancer. The deadline to submit for the next round of funding is May 16, 2022.

Bethesda, MD: National Institute of Neurological Disorders and Stroke. February 10, 2022. Publication No. NOT-NS-22-071.

Approaching diagnosis as a team activity is seen as a key approach to diagnostic effectiveness. This notice highlights the pending funding opportunity to launch Diagnostic Centers of Excellence to improve diagnosis of undiagnosed and unknown disease and research to inform improvement. In addition, a pending data coordination and management call for proposals to support the centers has been released.

Fed Register. February 10, 2022;87: 7838-7840.

The 2016 Centers for Disease Control opioid guidelines have raised concerns as to their potential to contribute to patient harm. This announcement calls for comments from the field to inform and update current policy in response to safety issues that emerged as unintended consequences of the 2016 recommendation. Comments are due to be submitted by April 11, 2022.

National Academy of Medicine.

Diagnostic error reduction is gaining momentum as a primary focus of patient safety achievement. This educational program will draw from the 2015 Institute of Medicine Improving Diagnosis in Health Care report to support a multidisciplinary cohort of scholars to advance diagnostic improvement. The application process for the 2023 class will open in January 2023.
Society to Improve Diagnosis in Medicine.
Diagnostic error is garnering increased attention as a key area of focus in patient safety improvement. This fellowship program for physicians who have completed their residency will provide the opportunity to build expertise in enhancing diagnostic safety. The application process for the 2022-2023 program is now closed.