The PSNet Collection

Maternal Safety

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.

Toolkit for Engaging Patients to Improve Diagnostic Safety.

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.

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.

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.

TeamSTEPPS Video Toolkit.

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.

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.

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 Medication Safety Self Assessment® for Perioperative Settings.

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. The deadline for submitting data is December 10, 2021.

Diagnostic Safety Supplemental Items for Medical Office SOPS.

Agency for Healthcare Research and Quality.

Safe diagnosis in medical offices is challenged by staff workload, communication, and poor information sharing. This survey supplement examines elements contributing to time availability, testing and referrals, and provider and staff communication. The set is to be used in conjunction with the Agency for Healthcare Research and Quality's Medical Office Survey on Patient Safety Culture (MOSOPS®). The supplemental item set was released in time for the upcoming data submission window for the MOSOPS (September 1 - October 20, 2021).

"Talk About Your Medicines" Month.

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].

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.

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.

2022 Patient Safety Awareness Week.

Institute for Healthcare Improvement.

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

Cutaneous Procedures Adverse Events Reporting (CAPER).

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.

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.

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

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.

Sentinel Event Data Summary.

Joint Commission.

This website provides sentinel event data reported to The Joint Commission, which includes information on 437 sentinel events reported in 2020 through the end of June. 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 2020.

Escape Room

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.

Hospital Preparedness for a COVID-19 Surge: Assessment Tool.

Boston, MA: Institute for Healthcare Improvement; 2020.

Hospital crisis management, preparation, and planning are of heightened interest due to the COVID-19 emergency. This assessment tool examines hospital readiness for the patient surge due to the pandemic. The assessment tool helps organizations examine support structures, monitoring, infection control, supply and space capabilities, and staff support mechanisms to proactively address concerns to prepare for future challenges.

Optimizing Medication Management During the Covid-19 Pandemic: Implementation Guide for Post-acute and Long Term Care.

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.

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