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.

In this annual publication, AHRQ reviews the results of the National Healthcare Quality Report and National Healthcare Disparities Report. The 2022 report discusses a decrease in life expectancy due to the COVID-19 pandemic. It also reviews the current status of special areas of interest such as maternity care, child and adolescent mental health, and substance abuse disorders. 

Surgical equipment sterilization can be hampered by equipment design, production pressures, process complexity and policy misalignment. This report examines a case of unclean surgical instrument use. It recommends external sterile service assessment and competency review as steps toward improving the reliability of instrument decontamination processes in the National Health Service.

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.

Maternal harm during and after pregnancy is a sentinel event. This campaign encourages women, families, and health providers to identify and speak up with concerns about maternal care and act on them. The program seeks to inform the design of support systems and tool development that enhance maternal safety.

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.

Nursing home residents are especially vulnerable to COVID-19 due to their age, and communal living conditions, and nursing home staff are among the most at-risk essential workers. In partnership with the University of New Mexico’s ECHO Institute and the Institute for Healthcare Improvement (IHI), AHRQ has established this network to prevent infections among nursing home residents and staff. All nursing homes that are certified to participate in the Medicare and Medicaid programs will be able to participate in a 16-week training program that includes peer-to-peer, case-based learning and additional mentorship from local and national experts. The training program will include best practices for using personal protective equipment, COVID-19 testing, clinical management of asymptomatic and mild cases, and other topics. 

Organizations worldwide are focusing efforts on reducing the conditions that contribute to medical error. This website provides a collection of reports and other resources that cover activities and concerns of the 37 member countries active in the organization to address universal challenges to patient safety.

Communication strategies are important for engaging staff in behaviors that support effective teamwork. This website highlights a process that involves briefings, supportive conversations, and debriefings as a communication structure for use during COVID-19 care episodes and other complex interactions.

This website for independent community pharmacy owners across the United Kingdom features both free and members-only guidance, reporting platforms, and document templates to support patient safety. It includes reporting tools and incident analysis reports for providers in England, Scotland, and Northern Ireland. Topics covered in the communications include look-alike and sound-alike drugs, patient safety audits, and safe dispensing of liquid medications.

Eliminating hospital-acquired harm requires policy, organizational, and individual approaches to motivate the necessary changes. This website provides information and data collected from a Centers for Medicare and Medicaid Services financial incentive program reducing reimbursements to hospitals with elevated rates of hospital-acquired conditions.

Clostridium difficile infections are considered a serious hospital-acquired infection. This grassroots foundation employs educational, policy, and advocacy strategies aimed at reducing C. difficile infections. The website provides information for patients, families, health care providers, and advocates. The foundation hosts an annual C. difficile awareness campaign in November.

Falls are a primary focus of quality and patient safety improvement efforts in hospitals. This training program provides educational webinars and implementation guidance to help hospitals use an AHRQ toolkit to decrease risk of falls. The toolkit draws from a 2-year pilot project that achieved sustained improvements for organizations in the program.

Health literacy is important for effective care communications and safe medication use. This toolkit provides resources associated with medication therapy management and patient health literacy. Materials include health literacy assessments and guidance for prescription medicine instructions. A past PSNet perspective discussed the role of health literacy in patient safety.