Narrow Results Clear All
- Communication Improvement 7
- Culture of Safety 4
- Education and Training 11
- Error Reporting and Analysis 6
- Human Factors Engineering 2
- Quality Improvement Strategies 5
- Teamwork 2
- Technologic Approaches 2
- Device-related Complications 3
- Diagnostic Errors 1
- Discontinuities, Gaps, and Hand-Off Problems 1
- Medical Complications 5
- Medication Safety 2
- Surgical Complications 1
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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.
Davis K, Collier S, Situ J, Coe M, Cleary-Fishman M. Rockville, MD: Agency for Healthcare Research and Quality; December 2017. AHRQ Publication No. 1800051EF.
Rockville, MD: Agency for Healthcare Research and Quality; November 2017.
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.
Institute for Healthcare Improvement, National Patient Safety Foundation. Boston, 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.
Rockville, MD: Agency for Healthcare Research and Quality; October 2016.
Lopreiato JO, Downing D, Gammon W, et al; Terminology & Concepts Working Group. Rockville, MD: Agency for Healthcare Research and Quality; October 2016. AHRQ Publication No. 16(17)-0043.
Developed by AHRQ in partnership with the Society for Simulation in Healthcare, this dictionary represents an effort to standardize language associated with simulation in order to improve communication about and application of the strategy. The terms in the initial collection will be expanded and revised over time.
Designing and Delivering Whole-Person Transitional Care: Hospital Guide to Reducing Medicaid Readmissions.
Boutwell A, Bourgoin A , Maxwell J, DeAngelis K, Genetti S, Savuto M, Snow J. 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.
Leeds, UK: Clinical Support Audit Unit, Health and Social Care Information Centre. December 9, 2015. ISBN: 9781783865697.
The NHS Safety Thermometer is a tool developed by the National Health Service to facilitate staff participation in measuring patient harm in various care environments. This report 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 1-year period.
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.
Oakbrook, IL: Joint Commission Resources; January 2014.
Arlington, VA: Association for the Advancement of Medical Instrumentation; October 2013.
To help prevent tubing misconnections, this toolkit offers frequently asked questions and corresponding answers about small-bore connectors.
Chicago, IL: Health Research & Educational Trust; July 2013.
Aligning Forces for Quality. Princeton, NJ: Robert Wood Johnson Foundation; 2013.
This compendium includes strategies and tools to engage patients in health care improvement that have been implemented in Maine, Oregon, and Humboldt County, California.
Horsham, PA: Institute for Safe Medication Practices; 2013.
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.
Thomas V, Dixon A. London, UK: The King's Fund; March 2012. ISBN: 9781857176384.
This publication discusses how to improve teamwork, communication, training, guidance, and staffing to enhance safety in obstetrics.
Edmonton, AB, Canada: Canadian Patient Safety Institute; March 2011.
Explaining the importance of hand hygiene in the health care setting, this publication provides strategies for patients and families to prevent spreading health care–associated infections.