The Agency for Healthcare Research and Quality (AHRQ) is the lead Federal agency charged with improving the safety and quality of America’s health care system. AHRQ develops the knowledge, tools, and data needed to improve the health care system and help Americans, health care professionals, and policymakers make informed health decisions.

“Annie’s Story” is an example of how healthcare organizations seeking high reliability embrace a just culture in all they do. This includes a system’s approach to analyzing near misses and harm events—looking to analyze events without the knee-jerk blame and shame approach of old. This video specifically focused on Nurse Andrea’s personal experience with an adverse health event with a patient who underwent a hypoglycemic emergency due to a misreading of a glucometer. The video then details the steps she and the hospital took to prevent future adverse health events, as well as other ways to increase overall patient safety and quality.

From the Canadian Patient Safety Institute

Prevent Patient Safety Incidents and Minimize Harm When They Do Occur
When a patient’s safety is compromised, or even if someone just comes close to having an incident, you need to know you are taking the right measures to address it, now and in the future. CPSI provides you with practical strategies and resources to manage incidents effectively and keep your patients safe. This integrated toolkit considers the needs and concerns of patients and their families, and how to properly engage them throughout the process.

Drawn from the best available evidence and expert advice, this newly designed toolkit is for those responsible for managing patient safety, quality improvement, risk management, and staff training in any healthcare setting.

The Handbook of Human Factors and Ergonomics in Health Care and Patient Safety offers a detailed overview of ergonomics and and human factors, theories, methods, and models that are pertinent to patient care and safety. Specific topics included in this book include telemedicine, infection prevention, and anesthesia safety.

The Institute for Healthcare Improvement (IHI) and the National Patient Safety Foundation (NPSF) started collaborating together to utilize its combined resources and knowledge to further  patient safety efforts and create safety systems in various healthcare settings.

The COVID-19 pandemic has exacerbated well understood challenges that exist in our sophisticated health systems. This article discusses how to apply a human factors approach to best respond to the many unprecedented challenges that have been brought about by the COVID-19 pandemic to the healthcare system.

In this narrative medicine essay, an internist asks the doctors who for 5 months could not diagnose her son’s agonizing illness to apologize and, when most could not, asks that the medical community shift focus from promoting a false sense of perfection to one that embraces humility enough to apologize as essential to the healing process.

The goal of the VA National Center for Patient Safety (NCPS) is to offer tool kits, resources, and event analysis methods to help promote patient safety. The NCPS program is based on a systems approach to problem solving that focuses on prevention, not punishment. The organization uses human factors engineering methods and applies concepts from high-reliability organizations, such as aviation, to target and eliminate system vulnerabilities.