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Audiovisual > Audiovisual Presentation
Eliminating Harm, Improving Patient Care: A Trustee Guide. 2018 Update.
Chicago. IL: AHA Trustee Services, Health Research and Education Trust; February 2018.
Leadership commitment to improvement efforts is key to sustain patient safety initiatives. This toolkit consists of a workbook, board engagement self-assessment tool, and video modules to help leadership translate efforts from the board room to the front line to reduce medical errors in their hospitals.
Book/Report
Toolkit to Promote Safe Surgery.
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.
Tools/Toolkit > Multi-use Website
Enteral Nutrition Safety Toolkit.
American Society for Parenteral and Enteral Nutrition; 8630 Fenton Street, Suite 412, Silver Spring, MD 20910.
This Web site includes a toolkit, posters, and educational materials to support safe tube feedings and prevent tubing misconnections.
Tools/Toolkit > Multi-use Website
Quality & Safety Research Group.
Johns Hopkins University, Department of Anesthesiology & Critical Care Medicine.
This Web site provides information on the multidisciplinary safety team at Johns Hopkins University, including research projects, presentations, and useful tools for patients, families, and practitioners.
Tools/Toolkit > Government Resource
Reducing Diagnostic Errors in Primary Care Pediatrics (Project RedDE!) Toolkit.
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.
Book/Report
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.
Tools/Toolkit > Measurement Tool/Indicator
High Reliability in Health Care.
Joint Commission Center for Transforming Healthcare.
Development of high reliability remains an elusive goal for health care organizations. The Joint Commission has also advocated for achieving high reliability in health care. This website collects evidence and existing tools to help organizations work toward high reliability, including the ORO 2.0 assessment tool to enable hospital leaders evaluate their culture, leadership, and performance.
Book/Report
Eliminating Catheter-Associated Urinary Tract Infections.
Chicago, IL: Health Research & Educational Trust; July 2013.
This toolkit reveals how to apply strategies from the Comprehensive Unit-based Safety Program to drive reductions in catheter–associated urinary tract infections.
Tools/Toolkit > Fact Sheet/FAQs
ISMP List of High-Alert Medications in Community/Ambulatory Healthcare.
Institute for Safe Medication Practices. 2011.
This fact sheet provides a list of high-alert medications commonly used in ambulatory care and recommends strategies to reduce risk of errors.
Tools/Toolkit > Toolkit
Taking Care of Myself: A Guide for When I Leave the Hospital.
Rockville, MD: Agency for Healthcare Research and Quality; April 2010. AHRQ Publication No. 10-0059.
This guide provides patients with information they need to care for themselves after leaving the hospital. The tool was developed based on findings from the AHRQ-funded initiative Project RED (Re-Engineered Discharge), which showed that patient-centered discharge planning can improve patient safety and reduce re-hospitalization rates.
Tools/Toolkit > Fact Sheet/FAQs
Questions to ask about radiation safety.
Fairfax, VA: The American Society for Radiation Oncology; March 9, 2010.
This Web site offers information to help patients understand both safety issues and risks involved in radiation therapy.
Book/Report
Patient-Centered Care Improvement Guide.
Frampton S, Guastello S, Brady C, et al. Derby, CT: Planetree; Camden, ME: Picker Institute; 2008.
This guide contains comprehensive information about best practices and implementation tools to help health care facilities build a culture of patient-centered care.
Tools/Toolkit > Multi-use Website
BOOSTing Care Transitions Resource Room.
Project BOOST (Better Outcomes for Older adults through Safe Transitions), Society of Hospital Medicine.
This Web site provides a multistep toolkit, implementation guide, and best practice resources to support safe hospital discharge for older patients.
Tools/Toolkit > Toolkit
A Systems Approach to Quality Improvement in Long-Term Care: Safe Medication Practices Workbook.
Waltham, MA: Masspro, Massachusetts Coalition for the Prevention of Medical Errors, Massachusetts Extended Care Foundation; 2007.
This manual provides nursing home staff with a step-by-step guide for medication management to reduce medication errors in long-term care.
Tools/Toolkit > Multi-use Website
National Time Out Day.
Association of periOperative Registered Nurses.
This Web site includes information and resources for National Time Out Day, an initiative to raise awareness on the importance of surgical team time outs. The observation typically takes place in the month of June.
Newspaper/Magazine Article
Reducing patient harm from opiates.
ISMP Medication Safety Alert! Acute Care Edition. February 22, 2007;12:1-3.
This article lists common risks associated with opiates, a high-alert medication, as well as recommended safety improvements to reduce these risks.
Newspaper/Magazine Article
Improving the safety of telephone or verbal orders.
PA-PSRS Patient Saf Advis. June 2006;3:1-5.
This article shares several examples of errors made while verbally communicating medication orders and includes recommendations for safe practices. A set of tools for educating hospital personnel about this issue is available via the link below.
Tools/Toolkit > Fact Sheet/FAQs
Patient Safety Research Highlights: Program Brief.
Rockville, MD: Agency for Healthcare Research and Quality; May 2006. AHRQ Publication No. 06-P023.
This document briefly describes a selection of AHRQ-funded patient safety research projects.
Tools/Toolkit > Fact Sheet/FAQs
Medication safety issue brief. Counterfeit drug prevention and identification.
American Hospital Association, American Society of Health-System Pharmacists, Hospitals and Health Networks. Hosp Health Netw. August 2005;79.29-30.
This brief addresses strategies to prevent the growth of counterfeit drugs. It is the third in a series of six briefs focusing on medication errors.
Tools/Toolkit > Toolkit
National Center for Patient Safety Falls Toolkit 2004.
Ann Arbor, MI: National Center for Patient Safety; 2004.
The National Center for Patient Safety created the Falls Toolkit to assist VA facilities in implementing or improving falls prevention efforts. The toolkit provides information on (1) designing a falls prevention and management program; (2) effective interventions for high-risk fall patients; (3) implementing hip protectors for high-risk fall patients; and (4) educating patients, families, and staff on falls and fall-injury prevention. The web version of the toolkit includes a falls notebook for practitioners implementing a program, media tools, and additional resources.