AHRQ Patient Safety Education and Training Catalog

The Agency for Healthcare Research and Quality’s Patient Safety Education and Training
Catalog consists of patient safety programs currently available in the United States. The catalog,
which is featured on AHRQ’s Patient Safety Network, offers an easily navigable database of
patient safety education and training programs consisting of a robust collection of information
each tagged for easy searching and browsing. The new database identifies a number of
characteristics of the programs, including clinical area, program and learning objectives,
evaluation measures, and cost. The clinical areas in the database align with the PSNet

Healthcare Provider Toolkit

This toolkit will assist individuals and organizations with educating health care providers and
patients about safe injection practices. Any health care provider that gives injections (in the form
of medication, vaccinations, or other medical procedures) should be aware of safe injection
practices. Partners of the Safe Injection Practices Coalition (SIPC) helped to create the materials
in this toolkit and distribute these materials throughout their individual organizations.

Department of Veterans Affairs National Center for Patient Safety –Root Cause Analysis

The National Center for Patient Safety uses a multi-disciplinary team approach, known as Root
Cause Analysis – RCA – to study health care-related adverse events and close calls. The goal of
the RCA process is to find out what happened, why it happened, and how to prevent it from
happening again. Because the Center’s Culture of Safety is based on prevention, not punishment,
RCA teams investigate how well patient care systems function. The focus is on the “how” and
the “why,” not on the “who.” Through the application of Human Factors Engineering (HFE)
approaches, the National Center for Patient Safety aims to support human performance.

Decision Tree for Unsafe Acts Culpability

The decision tree for unsafe acts culpability is a tool available for download from the Institute for
Healthcare Improvement Web site. Staff can use this decision tree when analyzing an error or
adverse event in an organization to help identify how human factors and systems issues
contributed to the event. This decision tree is particularly helpful when working toward a
nonpunitive approach in an organization.

Improving Your Office Testing Process: A Toolkit for Rapid-Cycle Patient Safety and Quality Improvement

This toolkit provides information and resources to help physicians’ offices, clinics, and other
ambulatory care facilities assess and improve the testing process in their offices.

Group Primary Care Visits Improve Outcomes for Patients With Chronic Conditions

This featured profile is available on the Agency for Healthcare Research and Quality’s Health
Care Innovations Exchange Web site. An independent practice association in Northern California
offers 60- to 90-minute group appointments for patients with chronic conditions such as diabetes,
hypertension, and chronic obstructive pulmonary disease, as well as menopause, prenatal care,
and pre-colonoscopy. These group appointments can enhance physician productivity, as they
allow physicians to provide followup care and counseling to a greater number of patients (up to
15 patients are seen in an hour during the group visit, compared to 4 patients who can be seen
each hour via regular appointments). A study conducted by the independent practice association
found that diabetes patients receiving group care had better outcomes than those receiving usual
care, including being more likely to meet

Patient Safety Primer: Teamwork Training

Providing safe health care depends on highly trained individuals with disparate roles and
responsibilities acting together in the best interests of the patient. The Agency for Healthcare
Research and Quality’s Patient Safety Network explains this topic further and provides links for
more information on what is new in teamwork training.

Clinical Emergency: Are You Ready in Any Setting?

The Pennsylvania Patient Safety Authority is charged with taking steps to reduce and eliminate
medical errors by identifying problems and recommending solutions that promote patient safety
in various health care settings. This article discusses the issues associated with the location of
clinical emergencies and strategies for facilities to achieve rapid response preparedness.

Leadership Response to a Sentinel Event: Respectful, Effective Crisis Management

This page of resources was developed by the Institute for Healthcare Improvement. IHI
periodically receives urgent requests from organizations seeking help in the aftermath of a
serious organizational event, most often a significant medical error. In responding to such
requests, IHI has drawn on learning and examples assembled from many courageous
organizations over the last 15 years who have respectfully and effectively managed these crises.

Call to Action: Safeguarding the Integrity of Healthcare Quality and Safety Systems

The National Association for Healthcare Quality Call to Action: Safeguarding the Integrity of
Healthcare Quality and Safety Systems provides best practices to enhance quality, improve
ongoing safety reporting, and protect staff. It addresses accountability, protection of those who
report quality and safety concerns, and accurate reporting and response.


PSO Case Law: Ungurian v. Beyzman, et al., 2020 PA Super 105:

A recent Pennsylvania case shows how courts narrowly interpret the PSQIA, ignoring the D & A pathway and the clear language of the Final Rule. (Ungurian v. Beyzman, et al., 2020 PA Super 105). The cour

Joint Commission New Sentinel Event Alert 61: Managing the Risks of Direct Oral Anticoagulants:

The Center for Patient Safety wants to share this important harm-prevention advice from The Joint Commission and its Sentinel Event Alert: Managing the Risks of Direct Oral Anticoagulants. The Joint Commis

CPS Safety Watch/Alert – Culture Can Improve the Control of Multi-Drug Resistant Organisms:

Issue: A number of events reported co CPS’ Patient Safety Organization (PSO) demonstrate poor handoff communication about the patients’ infectious disease status Examples include: Patient with

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The Center for Patient Safety believes that collaboration and sharing are the best ways to drive improvement. We strive to provide the right solutions and resources to improve healthcare safety and quality.