Skip to main content

All Content

Search Tips
Save
Selection
Format
Download
Published Date
Original Publication Date
Original Publication Date
PSNet Publication Date
Narrow Results By
1 - 20 of 26
Horsham, PA: Institute for Safe Medication Practices; 2022.
This updated report outlines 19 consensus-based best practices to ensure safe medication administration, such as diluted solutions of vincristine in minibags and standardized metrics for patient weight. The set of recommended practices has been reviewed and updated every two years since it was first developed in 2014 to include actions related to eliminating the prescribing of fentanyl patches for acute pain and use of information about medication safety risks from other organizations to motivate improvement efforts. The 2022 update includes new practices that are associated with oxytocin, barcode verification in vaccine administration, and high-alert medications. 
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.
Boston, MA: Institute for Healthcare Improvement; 2019.
This toolkit provides access to nine key tools to help organizations improve teamwork, incident analysis, and communication as well as templates to support their use and instructions to begin associated processes. Featured tools include the Situation-Background-Assessment-Recommendation approach, huddle agendas, and failure modes and effects analysis.
Partnership for Health IT Patient Safety. Plymouth Meeting, PA: ECRI; August 2018.
Inadequate follow-up of test results can contribute to missed and delayed diagnoses. Developing optimal test result management systems is essential for closing the loop so that results can be acted upon in a timely manner. The Partnership for Health IT Patient Safety convened a working group to identify how technology can be used to facilitate improved communication and timely action regarding test results. This report summarizes the methods used by the working group and their findings. Recommendations include improving communication by standardizing the format of test results, including required timing for diagnostic testing responses, automating the notification process in electronic health records, and optimizing alerts to reduce alert fatigue. A past WebM&M commentary discussed a case involving ambulatory test result management.
Agency for Healthcare Research and Quality; AHRQ.
Preventing surgical complications including surgical site infections are a worldwide target for improvement. This toolkit builds on the success of the Comprehensive Unit-based Safety Program to initiate change. The tools represent practical strategies that helped members of a large-scale collaborative to identify areas of weakness, design improvements, and track the impact of the interventions.
Davis K, Collier S, Situ J, et al. Rockville, MD: Agency for Healthcare Research and Quality; December 2017. AHRQ Publication No. 1800051EF.
Transitions are known to be vulnerable to communication errors. This toolkit focuses on patient transitions between ambulatory care environments and encourages staff to engage patients and families in their care to prevent errors during care transitions.
Institute for Healthcare Improvement, National Patient Safety Foundation. Cambridge, MA: Institute for Healthcare Improvement; 2017.
Although patient safety is considered a noble goal in health care, garnering the resources for improvement efforts can be hindered by other demands. This toolkit provides strategies for health care leaders to develop a business case for patient safety efforts to generate support for organizational investments. Materials include assessments and templates for financial documents and presentation materials.
Incident Analysis Collaborating Parties. Edmonton, AB: Canadian Patient Safety Institute; 2012.
Performing incident analysis can help organizations understand why adverse events occur and how to prevent them. This toolkit provides a framework to help organizations gather insights from staff, patients, and family members regarding what caused the failure and why it happened and to guide efforts to prevent similar incidents.
Lioce L, Lopreiato J, Downing D, et al, eds and the Terminology and Concepts Working Group. Rockville, MD: Agency for Healthcare Research and Quality; January 2020. AHRQ Publication No. 20-0019.
The terms in the initial collection have been expanded to reflect changes in the field which now inlcudes artificial intelligence  and gamification. The document will continue to be refined and expanded over time.
Rockville, MD: Agency for Healthcare Research and Quality; October 2016.
Antimicrobial stewardship is one strategy to reduce health care–associated infections in a variety of settings. This guide provides detailed instructions and four adaptable toolkits to establish antimicrobial stewardship programs in nursing homes.
Boutwell A, Bourgoin A , Maxwell J, et al. Rockville, MD: Agency for Healthcare Research and Quality; September 2016. AHRQ Publication No. 16-0047-EF.
This toolkit provides information for hospitals to help reduce preventable readmissions among Medicaid patients. Building on hospital experience with utilizing the materials since 2014, this updated guide explains how to determine root causes for readmissions, evaluate existing interventions, develop a set of improvement strategies, and optimize care transition processes.
Chicago, IL: American Hospital Association, Health Research & Educational Trust; 2016.
Checklists are a recommended method to reduce omissions in care, despite controversies regarding their impact on safety. This toolkit provides a collection of checklists that have been developed and field tested by participants in the Hospital Engagement Network to prevent harm associated with the use of central lines, adverse drug events, and falls.
Partnership for Health IT Patient Safety. Plymouth Meeting, PA: ECRI; February 2016.
Electronic health records have potential to improve health care, but they may also introduce unanticipated risks. This report describes the results of a group convened to explore strategies to enhance health IT safety. Focusing on copying and pasting health data from one record to another as the first area of concern, the report recommends enabling systems to identify what data has been copied in the electronic health record and where it came from, providing training to ensure the safe use of copy and paste, and regularly track and assess copying and pasting practices. The report includes tools to related to the recommendations. A WebM&M commentary explores the hazards associated with the use of copy and paste.
Horsham, PA: Institute for Safe Medication Practices; 2013.
Root cause analysis offers a structured way to detect and address system weaknesses. This workbook illustrates how root cause analysis can be applied to community pharmacy services to identify problems and design an action plan to implement improvement strategies.
Leeds, UK: Clinical Support Audit Unit, Health and Social Care Information Centre. 2012-2017.
The NHS Safety Thermometer was a tool developed by the National Health Service to facilitate staff participation in measuring patient harm in various care environments. This report collection explores the data collected on four types of health care–acquired conditions (pressure ulcers, falls, catheter–associated urinary tract infections, and venous thromboembolisms) in NHS patients over a 5-year period. The NHS Safety Thermometer is no longer used as an official data type. 
WHO Regional Office for the Eastern Mediterranean. Cairo, Egypt: World Health Organization; 2015. ISBN: 9789290220596.
Patient safety programs should reflect local needs, motivate clinician and leadership engagement, and support sustainable enhancements. This toolkit provides information about how to establish a patient safety program, implement interventions, determine areas needing improvement, and build a culture of safety.