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Ensuring maternal safety is a patient safety priority. This library reflects a curated selection of PSNet content focused on improving maternal safety. Included resources explore strategies with the potential to improve maternal care delivery and outcomes, such as high reliability, care standardization, teamwork, unit-based safety initiatives, and trigger tools.

Rockville, MD: Agency for Healthcare Research and Quality; October 2020.
This 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 current data submission window launched on September 1 and runs through October 20, 2021.

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.

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.
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".
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 update 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.

Baltimore MD: University of Maryland School of Pharmacy; 2020.

Medication management has been affected in a variety of settings due to the COVID-19 pandemic. This guide highlights strategies to ensure safe medication delivery in long term care. Tactics highlighted include medication discontinuation and alignment of medication administration times.

Circle Up for COVID-19 Training. Center for Medical Simulation.

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.

American Society of Anesthesiologists, American Academy of Orthopaedic Surgeons. Pain Alleviation Toolkit.  March 12, 2020.

Communication and shared decision-making are fundamental tactics to guide clinical team and patient efforts to minimize the potential for prescription opioid misuse. This tool kit includes modules for providers that outline practice and communication strategies to help with postoperative pain. Patient and family materials in the kit focus on safe medication disposal and instructions for tracking pre- and post-surgery pain levels.

Stanford, CA; California Maternal Quality Care Collaborative: January 22, 2020. 

This toolkit focuses on identification of, and rapid response to, sepsis in obstetric patients. It includes screening, evaluation and monitoring, and antibiotic use recommendations for maternal sepsis patient.
Duke Center for Healthcare Safety and Quality.
Improving teamwork and communication is a continued focus in the hospital setting. This toolkit is designed to help organizations create a culture that embeds teamwork into daily practice routines. Topics covered include team leadership, learning and continuous improvement, clarifying roles, structured communication, and support for raising concerns.
Institute for Healthcare Improvement; IHI.
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.
ISMP; Institute for Safe Medication Practices.
Standardized practices have not been uniformly adopted to support safe IV medication therapy. This risk assessment tool will help organizations proactively identify process weaknesses that could contribute to patient harm. Users of the guide can also contribute to a national effort to collect data on current IV push practices. The data collection process is now closed.
Chicago, IL: Health Research & Educational Trust; 2018.
Proactive identification of conditions that degrade the diagnostic process can drive improvement. This toolkit provides resources to help organizations seeking to improve diagnosis. The publication includes case studies that illustrate implementation challenges and provides infrastructure enhancement suggestions for hospital teams as they design interventions to reduce diagnostic errors.
Itasca, IL: American Academy of Pediatrics; 2018.
Diagnostic error prevention in primary care is a persistent challenge. This AHRQ-funded toolkit provides guidance for ambulatory care organizations that seek to improve the reliability of diagnosis in children. The material focuses on tactics to enhance how practices recognize, track, and follow up on adolescent depression, pediatric elevated blood pressure, and actionable laboratory results.
SIDM Patient Engagement Committee. Chicago; IL: Society to Improve Diagnosis in Medicine; October 2018.
Patient engagement has been promoted as a strategy to enhance safety in health care. This toolkit helps patients organize information about their medical history, current concerns, symptoms, and medications to prepare them for medical appointments.
Partnership for Health IT Patient Safety; ECRI.
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.
Rockville, MD: Agency for Healthcare Research and Quality. June 2017.
Communication in labor and delivery units can be challenging. This AHRQ-funded program draws from comprehensive unit-based safety program principles to reduce errors in maternal and neonatal care. The toolkit provides guidance and materials focused on enhancing teamwork skills, implementing perinatal safety strategies, and utilizing in situ simulation. Team training modules and care bundles are shared to enable skill development. A previous WebM&M commentary explored a near miss with a neonate.