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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.

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. 

ECRI and Institute for Safe Medication Practices. January 2022 through May 2022.

Collaboratives provide teams with active learning and improvement opportunities based on the experiences of others working toward a collective goal. This collaborative will target safety during surgical procedures. The discussions protected under the sponsors’ Patient Safety Organization status will explore improvement topics such as medication errors and surgical site infections.

Rockville, MD: Agency for Healthcare Research and Quality; December 16, 2021.

The release of the Workplace Safety supplemental items for use in conjunction with the AHRQ Hospital Survey on Patient Safety Culture™ helps hospitals assess how their organizational culture supports workplace safety for providers and staff. This webinar provided background on the importance of workplace safety and introduce the Workplace Safety supplemental items.

US House of Representatives Committee on Veterans' Affairs Subcommittee on Health.  117th Cong. 1st 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.
NIOSH [2015]. NIOSH training for nurses on shift work and long work hours. By Caruso CC, Geiger-Brown J, Takahashi M, Trinkoff A, Nakata A. Cincinnati, OH: US Department of Health and Human Services, Centers for Disease Control and Prevention, National Institute for Occupational Safety and Health, DHHS (NIOSH) Publication No. 2015-115 (Revised 10/2021)
Nurse fatigue has been associated with diminished decision-making skills that can contribute to patient harm. This online training program for clinicians and administrators will explore hazards related to nurse fatigue and provide strategies to address behaviors and systems that increase these risks.

Agency for Healthcare Research and Quality. June 2, 2021.

Measuring and improving safety culture are essential patient safety activities. This webinar introduced the Diagnostic Safety Supplemental Item Sets for the AHRQ Surveys on Patient Safety Culture™ (SOPS®) Medical Office Survey focusing on diagnostic safety and presenters shared results from a pilot test.

Patient Safety Authority.

This collection of educational modules covers both care delivery and administrative topics to enhance the safety of healthcare delivery.
Institute for Healthcare Improvement.
This online class prepares individuals to apply for the Institute for Healthcare Improvement patient safety certification program. The on-demand or live sessions cover key patient safety concepts to enhance participants' knowledge about safety culture, systems thinking, leadership, risk identification and analysis, information technology, and human factors. The next live session is October 7, 2021.
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. 

Harrisburg, PA: Pennsylvania Safety Authority; 2020.

Time pressure can negatively impact critical thinking, information gathering, and communication abilities. This tool builds teamwork and decision-making skills by testing participants as they work through a time-delimited scenario with a sick child to gather clues and determine a diagnosis. 
Fillo KT. Bureau of Health Care Safety and Quality, Department of Public Health. Boston, MA: Commonwealth of Massachusetts; 2020.
This annual report compiles patient safety data documented by Massachusetts hospitals. The 2019 numbers represent a modest increase in serious reportable events recorded in acute care hospitals, from 1066 the previous year to 1189. This presentation also includes events from ambulatory surgery centers. Previous years reports are also available.

US Health and Human Services Office of the Assistant Secretary for Preparedness and Response’s Technical Resources, Assistance Center, & Information Exchange; US Health and Human Services/FEMA COVID-19 Healthcare Resilience Task Force. June 2, 2020.

Health systems are rapidly adjusting processes to successfully respond to COVID-19 crisis demands. This webinar featured tactics used and discussed initiative results to inform continued improvement. The speaker roster included Jeff Brady, MD and Rollin (Terry) Fairbanks, MD.  
Agency for Healthcare Research and Quality. October 30, 2019.
This webinar recording provides information on the updated Hospital Survey on Patient Safety Culture™ (SOPS™) 2.0. The hospital survey was revised and pilot tested after incorporating user feedback. The Hospital SOPS survey, which has been used by hundreds of hospitals in the U.S. and overseas, allows healthcare providers and staff to assess a hospital’s patient safety culture. Speakers at the webinar discussed what’s different and what to expect when transitioning to the revised survey. Access the SOPS Hospital Survey 2.0, including a user’s guide, as well as results from a 2019 Pilot Test of Version 2.0 and frequently asked questions.
CDC Vital Signs. May 7, 2019.
Maternal morbidity and mortality is a worldwide patient safety problem. This analysis describes the prevalence of pregnancy-related death and areas of concern during pregnancy, at delivery, and up to a year postpartum. It reports that 60% of these deaths are preventable and provides suggestions for families, clinicians, and systems to reduce risks.
Agency for Healthcare Research and Quality. July 25, 2018. 
Tracking the intersection of organizational culture with health information technology use can inform patient safety improvement efforts. This webinar introduced supplemental items to the AHRQ Hospital Survey on Patient Safety Culture and discussed the results of a pilot project integrating the items into assessment efforts. Featured speakers included Dr. Jeff Brady and Dr. Tejal Gandhi.
Lebanon, NH: Aquifer and the Society to Improve Diagnosis in Medicine.
Diagnostic error has become an explicit focus of improvement and educational efforts in health care. This online program provides an information about diagnostic error and reviews cognitive and system issues that can contribute to mistakes.
American Society of Health-System Pharmacists, Institute for Safe Medication Practices.
Leadership commitment to reduce medication errors can help address this safety problem. This certificate program presents key concepts that support organizational efforts to augment medication safety, including event analysis, safety culture, risk identification, and change management.
VA National Center for Patient Safety; NCPS.
The Department of Veterans Affairs consistently contributes to innovation and improvement efforts in patient safety. This podcast series offers short interviews with experts in the field that explore topics such as the VA National Center for Patient Safety leadership development program and a checklist for use in mental health facilities.
Agency for Healthcare Research and Quality. February 7, 2017.
Incomplete clinical notes create potential for treatment errors. This webinar discussed voice-generated electronic records as a strategy to augment clinical documentation and highlight natural language processing technologies as a component of this strategy.