Patient safety requires a systems approach to identify problems and arrive at lasting solutions that reduce harm. This document encourages discussion amongst a broad base of stakeholders to address all forms of harm, such as discrimination, inequality, and psychological stress, in addition to physical injury. The resource insists these components be incorporated in work to close quality and safety gaps across the health care system.

Reducing preventable harm associated with health care is a worldwide goal. This Canadian initiative developed a measure to track unintended harm in acute care hospitals, a toolkit to accompany reduction efforts, and reports that assess the results of improvement efforts and provide data analysis.

Obstetric hemorrhage and severe high blood pressure during pregnancy are leading known causes of preventable maternal harms in the United States. The AHRQ Safety Program for Perinatal Care, Phase 2 developed toolkits consisting of case scenarios, slides, and facilitators guides to work in tandem to address these threats to maternal safety. The materials inform training opportunities to improve the safety culture of labor and delivery units and decrease maternal and neonatal adverse events that result from poor communication and system failures.

A strong patient safety culture needs nurturing to serve as a foundation for launching and sustaining improvements. This toolkit provides access to existing tools that support teamwork and communication, fairness, psychological safety, promotion of diversity and inclusivity, and civility as elements of a safety culture.

Effective teamwork plays an essential role in providing safe patient care. The Team Strategies and Tools to Enhance Performance and Patient Safety (TeamSTEPPS) program was developed inititally in collaboration by the United States Department of Defense and AHRQ in order to support effective communication and teamwork in health care. The 3.0 version of the widely implemented program is organized around 5 key strategies: patient focus, integrated platform, modular course design, active adult learning and emergent team challenges and opportunities. It provides new tools to measure its impact, supports increased emphasis on the role of patients in teams, and includes a new pocket guide. A PSNet WebM&M commentary discussed how improved teamwork and shared decision-making might have prevented a missed diagnosis of sepsis that lead to the death of a patient.

Gaslighting has been identified as a contributor to maternal mortality and morbidity. This toolkit of compiled resources aims to help inform organizational activities to establish programs and strategies to reduce the impact of disrespect, implicit bias and inequities that affect the care of pregnant persons.

Improving the culture of safety within health care is an essential component of preventing or reducing errors. Designed for users of the AHRQ safety culture surveys, this updated tool will help organizations develop an action plan and proactively discuss potential barriers to safety culture improvement efforts and how to address them. The revision is structured around a 3-step process that focuses on areas to improve, initiative planning, and plan communication. The kit now includes an action plan template.

The AHRQ Surveys on Patient Safety Culture™ (SOPS®) Community Pharmacy Survey and accompanying toolkit were developed to collect opinions of community pharmacy staff on the safety culture at their pharmacies.

Delayed, wrong, and missed diagnoses are common challenges for patients, families, and clinicians, yet physicians rarely receive feedback on their actions to enhance diagnostic decision making. This publication provides clinicians with tools to assess and calibrate diagnostic performance in support of individual learning and improvement.

This tool provides a printable template and step-by-step instructions for patients to create a visual reference for keeping track of medications.

Effective response to medical error requires a comprehensive systemic and process-focused incident examination approach to ensure organizational learning. This framework will replace the current method used by the UK National Health Service (NHS) to support overarching patient safety strategic aims for the agency.

Challenges to establishing and sustaining a safety culture in a nursing home include insufficient staffing and a tendency to blame individuals for problems. This website hosts the AHRQ Surveys on Patient Safety Culture™ (SOPS®) Nursing Home Survey along with additional materials to assist organizations in using the management tool effectively. It includes a user's guide that explains how to conduct a survey on patient safety in a nursing home and report the results. The resource provides guidance on topics such as data collection, data organization, survey forms, and nursing home staff selection. The 2022 data collection period is now closed.

Diagnostic improvement continues to gain focus as a goal in health care. The Measure Dx tool provides teams with guidance and strategies to detect and learn from diagnostic errors in their organizations. It includes a checklist to gauge readiness for implementation, measurement strategies, and recommendations for analyzing data and translating findings into front line care. 

Healthcare-associated infections can result in significant morbidity and mortality. Developed by AHRQ, this customizable, educational toolkit uses the Comprehensive Unit-based Safety Program (CUSP) and other evidence-based practices to provide clinical and cultural guidance to support practice changes to prevent and reduce central line-associated bloodstream infection (CLABSI) and catheter-associated urinary tract infection (CAUTI) rates in intensive care units (ICUs). Sections of the kit include items such an action plan template, implementation playbook, and team interaction aids.

The AHRQ Surveys on Patient Safety Culture™ (SOPS®) Medical Office Survey collects information from outpatient providers and staff about the culture of patient safety in their medical offices. The survey is intended for offices with at least three providers, but it also can be used as a tool for smaller offices to stimulate discussion about quality and patient safety issues. The survey is accompanied by a set of resources to support its use. The data submission window for 2023 is open until September 23.

Problems in communication are common contributors to patient care mistakes. This toolkit draws from experience with the TeamSTEPPS model to highlight best practices in the use of huddles, debriefs and other teamwork improvement strategies.