The PSNet Collection

Workplace Safety Supplemental Item Set for Hospital SOPS.

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

The AHRQ Surveys on Patient Safety Culture™ (SOPS®) Hospital Survey Hospital Survey on Patient Safety Culture ask health care providers and staff about the extent to which their organizational culture supports patient safety. The release of the Workplace Safety Supplemental Item Set for use in conjunction with the AHRQ Hospital Survey helps hospitals assess how their workplace culture supports workplace safety for providers and staff. Included with the data set is a report of the pilot test of the finding.

Safer Services: A Toolkit for Specialist Mental Health Services and Primary Care.

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National Confidential Inquiry into Suicide and Safety in Mental Health. Manchester, UK: University of Manchester; May 31, 2021

System failures require multifactorial assessment to install targeted improvements. This toolkit examines 10 areas of focus for organizations to assess the safety of mental health services in emergent and primary care settings to minimize patient suicide and self-harm. Areas of focus include post-discharge follow-up, admissions, and family engagement.

ISMP List of High-Alert Medications in Community/Ambulatory Healthcare.

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Horsham, PA: Institute for Safe Medication Practices; 2021.

This fact sheet provides a list of high-alert medications commonly used in ambulatory care and recommends strategies to reduce risk of errors.

Peer Support Toolkit.

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Betsy Lehman Center. September 2021.

Clinicians involved in adverse events that harm patients can struggle to come to terms with error. This toolkit is designed to assist organizations in the development of initiatives to support clinicians and staff after an adverse event. Areas of focus include leadership buy-in, policy development, and training. An implementation guide is also provided.

Curated Libraries

Maternal Safety

Toolkit for Engaging Patients to Improve Diagnostic Safety.

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Rockville, MD: Agency for Healthcare Research and Quality; August 2021. AHRQ Publication No. 21-0047-2-EF.

Patient and family engagement is core to effective and safe diagnosis. This new toolkit from the Agency for Healthcare Research and Quality promotes two strategies to promote meaningful engagement and communication with patients to improve diagnostic safety: (1) a patient note sheet to help patients share their story and symptoms and (2) orientation steps to support clinicians listening and “presence” during care encounters.

Infection Prevention Compendium For Long-Term Care Facilities.

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Center for Healthy Aging--New York Academy of Medicine, Yale School of Nursing.

Healthcare-associated infections (HAIs) challenge safety in long-term care. This toolkit highlights multidisciplinary approaches to reducing HAIs and teaching tools focused on distinct audiences across the continuum to share principles and tactics supporting improvement.

Medical Office Survey on Patient Safety Culture.

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Rockville, MD: Agency for Healthcare Research and Quality; October 2020.

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 2021 is now closed.

TeamSTEPPS Video Toolkit.

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AHA Team Training and Project Firstline. Chicago, IL: American Hospital Association, Center for Disease Control and Prevention; July 2021.

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.

Accidental exposures to fentanyl patches continue to be deadly to children.

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Rockville, MD: US Food and Drug Administration; 2021.

To protect children and pets from accidental exposure to prescription medications, this consumer alert outlines the dangers of inappropriate storage and disposal of medication skin patches.

Toolkit to Improve Antibiotic Use in Long-Term Care.

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

The use of antibiotics should be monitored to reduce the potential for infection in care facilities. This toolkit outlines offers a methodology for launching or invigorating an antibiotic stewardship program. Designed to align with four time elements of antibiotic therapy, its supports processes that enable safety for nursing home residents.

ISMP List of High-Alert Medications in Long-Term Care (LTC) Settings.

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Horsham, PA: Institute of Safe Medication Practices; 2021

Long-term care patients often have concurrent conditions that increase their risk of medication error. This fact sheet provides a list of potential high-alert medications prevalent in long-term care settings that should be administered with particular care due to the heightened potential for harm. A past PSNet perspective discussed medication safety in nursing homes.

Diagnostic Safety Supplemental Item Set for Medical Office SOPS.

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Agency for Healthcare Research and Quality. April 2021.

Safe diagnosis in medical offices is challenged by staff workload, communication, and poor information sharing. This Supplemental Item Set for the AHRQ Surveys on Patient Safety Culture™ (SOPS®) Medical Office Survey (MOSOPS) examines elements contributing to time availability, testing and referrals, and provider and staff communication, and is to be used in conjunction with AHRQ Surveys on Patient Safety Culture™ (SOPS®) Medical Office Survey. The Diagnostic Safety Supplemental Item Set was released in time for the scheduled Fall 2021 MOSOPS data submission.

"Talk About Your Medicines" Month.

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BeMedWise Program at NeedyMeds, Gloucester, MA.

This Web site provides information and tools that support an educational campaign to encourage high-quality communication about medication use. The annual observance is in October and the last observance focused on the theme of "Medication Adherence – On track with your meds and your health".

Speak Up [brochures].

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Oakbrook Terrace, IL: Joint Commission. 2002-2020.

A series of patient safety brochures, videos and infographics directed toward specific areas of care that encourages patients to take an active role by asking questions and addressing problems with their providers. Topics include preventing falls, medication safety, and safe surgery. Available in both English and Spanish.

Well-Being Playbook 2.0. A COVID-19 Resource for Hospital and Health System Leaders.

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AHA Physician Alliance. Chicago, IL: American Hospital Association. February 2021.

Human factors engineering approaches improve safety, efficiency, and effectiveness in both normal and challenging times. This tool shares a human-factors structured approach to improving technology integration and adaptation into work processes to reduce burnout and its negative effects on worker and clinician wellbeing.

Cutaneous Procedures Adverse Events Reporting (CAPER).

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The American Society for Dermatologic Surgery Association and the Northwestern University Department of Dermatology.

Voluntary reporting systems collect adverse event data to inform improvement and education efforts. This site provides a platform for physicians and their staff to submit adverse experiences associated with dermatologic surgery equipment, medications or biologics.

National Healthcare Quality and Disparities Report: Chartbook on Patient Safety.

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Azam I, Gray D, Bonnett D et al. Rockville, MD: Agency for Healthcare Research and Quality; February 2021. AHRQ Publication No. 21-0012.

The National Healthcare Quality and Disparities Reports review analysis specific to tracking patient safety challenges and improvements across ambulatory, home health, hospital, and nursing home environments. The most recent Chartbook documented improvements in approximately half of the patient safety measures tracked. This set of tools includes summaries drawn from the reports for use in presentations to enhance distribution and application of the data.

ISMP List of Error-Prone Abbreviations, Symbols, and Dose Designations.

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Horsham, PA; Institute for Safe Medication Practices; February 12, 2021.

A handy list for medical personnel to ensure and implement safe prescribing practices by avoiding use of these dangerous shortcuts.

Escape Room.

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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.

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