The PSNet Collection

The Uneven Burden of Maternal Mortality in the U.S.

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NIHCM Foundation. Washington DC: National Institute for Health Care Management. August 2, 2022.

Preventable maternal morbidity is an ongoing challenge in the United States. This infographic shares general data and statistics that demonstrate the presence of racial disparities in maternal care that are linked to structural racism. The resource highlights several avenues for improvement such as diversification of the perinatal staffing and increased access to telehealth.

Measure Dx: A Resource to Identify, Analyze, and Learn from Diagnostic Safety Events.

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Rockville, MD: Agency for Healthcare Research and Quality; July 2022. AHRQ Publication No. 22-0038.

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.

Supplemental Item Set for Nursing Home SOPS: Call for Pilot Participants.

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Rockville, MD: Agency for Health Quality and Research; June 2022.

The potential for workplace violence degrades patient and staff safety. AHRQ is developing a survey item set that will help nursing homes identify and improve factors associated with workplace safety. The Workplace Safety Supplemental Item Set will assess the extent to which nursing homes’ organizational culture supports workplace safety. The new supplemental item set can be administered optionally at the end of the SOPS Nursing Home Survey. AHRQ will build this new measure of workplace safety upon its existing and highly successful SOPS program. This announcement calls for nursing homes to participate in a pilot study to test the application of the supplemental item set in the field.

Common Formats for Event Reporting - Diagnostic Safety Version 1.0

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Agency for Healthcare Research and Quality.

Effective measurement of diagnostic error is essential for understanding the problem and generating improvements. The Common Formats provide a standard terminology for voluntary reporting of diagnostic errors to patient safety organizations. This website provides access to tools supporting use of the Common Formats that include forms and a users' guide.

Toolkit for Preventing CLABSI and CAUTI in ICUs.

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Rockville, MD: Agency for Healthcare Research and Quality; April 2022.

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.

Safer Dx Checklist: 10 High-Priority Practices for Diagnostic Excellence.

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Houston TX; Baylor College of Medicine: 2022.

Assessment can identify the current state of a process or program to reveal areas of weakness and inform improvement implementation efforts. This scenario-based tool focuses on 10 areas of an organization’s journey to support diagnostic safety.

TeamSTEPPS® for Diagnosis Improvement.

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Rockville, MD: Agency for Healthcare Research and Quality; March 2022.

The recognition of diagnosis as a team activity is energizing new diagnostic process initiatives. Building on the established TeamSTEPPS® principles, this new TeamSTEPPS course includes seven training modules, team and knowledge assessment tools, and implementation guidance to develop or enhance communication across the care team to improve the accuracy and timeliness of diagnosis.

Sentinel Event Data Summary.

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Joint Commission.

This website provides sentinel event data reported to The Joint Commission, which includes information on 1197 sentinel events reported in 2021 through the end of December. Unintended retained foreign bodies, falls and wrong–patient, wrong-site, wrong-procedures were the most frequently submitted incidents in this time period. The data and graphs are updated regularly and include specific analysis associated with event type by year from 1995 through the fourth quarter of 2021.

Prep, Stop, Block.

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RA-UK, the Faculty of Pain Medicine, RCoA Simulation and NHS Improvement

Standardization is a common strategy for preventing practice deviations that can contribute to harm. This tool outlines a three-step process for minimizing the occurrence of wrong-side peripheral nerve blocks that involves preparing for the procedure, stopping to perform a two-person site confirmation, and then administering the block.

Targeted Medication Safety Best Practices for Hospitals.

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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.

ISMP Medication Safety Self Assessment® for Perioperative Settings.

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Institute for Safe Medication Practices

The perioperative setting is a high-risk area for medication errors, should they occur. This assessment provides hospitals and outpatient surgical providers a tool to examine their medication use processes and share data nationwide for comparison. Organizational participation can identify strengths and gaps in their systems to design opportunities that prevent patient harm.

Patient Safety Awareness Week.

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Institute for Healthcare Improvement.

This website provides resources for promoting patient safety during Patient Safety Awareness Week. The annual observance is held in March.

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.

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