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Tools/Toolkit > Government Resource
TeamSTEPPS for Office-Based Care Version.
Rockville, MD: Agency for Healthcare Research and Quality; April 2016.
The TeamSTEPPS program was developed to support effective communication and teamwork in health care. This toolkit provides resources to help organizations implement TeamSTEPPS in the office-based setting, including information about how to create a handoff checklist and when to have a huddle along with the benefits of using one. The material also includes an instructor guide and training videos.
Web Resource > Course Material/Curriculum
TeamSTEPPS 2.0 Core Curriculum.
Rockville, MD: Agency for Healthcare Research and Quality; September 2015.
The TeamSTEPPS program was developed to support effective communication and teamwork in health care. This curriculum offers training for participants to implement TeamSTEPPS in their organizations. The course includes evidence reviews, trainer guidance, measurement tools, and a pocket guide for frontline staff.
Book/Report
Patient Safety 2015: Final Technical Report.
Washington, DC: National Quality Forum; 2016.
The value of current measures to track patient safety has been called into question. This technical report provides information about a consensus-driven initiative to evaluate the reliability of existing patient safety measures in tracking and assessing safety in hospitals, across various populations and settings. The related website offers resources related to the project history.
Tools/Toolkit > Government Resource
Toolkit for Reduction of Clostridium difficile Infections Through Antimicrobial Stewardship.
Boston University School of Public Health. Rockville, MD: Agency for Healthcare Research and Quality; September 2012. AHRQ Publication No. 120082EF.
This toolkit will help hospitals reduce Clostridium difficile infections by developing a stewardship initiative to prevent antimicrobial misuse.
Web Resource > Multi-use Website
Computer-based Provider Order Entry--CPOE.
ClinfoWiki: The Clinical Informatics Wiki.
This wiki article includes a definition of computer-based provider order entry and other information, such as system elements, implementation tips, and unintended consequences.
Tools/Toolkit > Fact Sheet/FAQs
Reducing Errors in Health Care: Translating Research Into Practice.
Rockville, MD: Agency for Healthcare Research and Quality; 2000. AHRQ Publication 00-PO58.
This fact sheet on medical errors provides information based on current research. Patients at risk, types of medical errors, and ways to improve and promote patient safety are discussed. References to programs and publications on medical errors and patient safety are provided.
Web Resource > Multi-use Website
Safety.
Center for Health Design.
Elements of the health care work environment can affect the care delivery. This website highlights design considerations for health care facilities that can help reduce noise, falls, and hospital-acquired infections. The collection includes an assessment and interactive tools to test ideas for improvement.
Newspaper/Magazine Article
Measuring patient safety events: opportunities and challenges.
Rosen AK, Chen Q. National Quality Measures Clearinghouse: Expert Commentaries; June 13, 2016.
The current measures designed to enable transparency and accountability are falling short of helping to reach those goals. This article discusses weaknesses in the existing metrics used to track patient safety improvement. Factors contributing to the problem include the myriad of measure sets, reliance on retrospective data collection and analysis, and gaps due to inconsistent methods of engaging patients and families in reporting safety-related events.
Bibliography
Improving Patient Safety in Ambulatory Surgery Centers: A Resource List for Users of the AHRQ Ambulatory Surgery Center Survey on Patient Safety Culture.
Rockville, MD; Agency for Healthcare Quality and Research; March 2016.
Patient safety culture surveys uncover insights into organizational culture and practice areas that require improvement. This selective resource list offers materials for ambulatory surgery centers that seek to implement changes in response to survey results.
Book/Report
Patient and Family Engagement in Primary Care: Case Studies.
Rockville, MD: Agency for Healthcare Research and Quality; September 2016. AHRQ Publication No. 16-0035-2-EF.
Patient safety in ambulatory care is receiving increased attention. This guide includes case studies that explore how Open Notes, team-based care delivery, and patient and family advisory committees have shown promise as patient engagement and safety improvement mechanisms in primary care settings.
Book/Report
Safety Considerations for Product Design to Minimize Medication Errors: Guidance for Industry.
Rockville, MD: Center for Drug Evaluation and Research, US Food and Drug Administration; April 2016.
Strategies to prevent medication errors are a continuing focus of ongoing safety initiatives. This guidance outlines factors to consider when creating drug products to reduce design-associated medication errors.
Book/Report
Reducing Risk and Promoting Patient Safety for NIH Intramural Clinical Research—Draft Report.
The Clinical Center Working Group Report to the Advisory Committee to the Director, National Institutes of Health. Bethesda, MD; National Institutes of Health; April 2016.
This publication outlines system problems at a large research institution that could compromise patient safety, including supervisors' failure to address staff-reported concerns, prioritization of research productivity over safety, insufficient processes for reporting and tracking problems, and fragmented accountability for ensuring quality and safety at the institution.
Web Resource > Multi-use Website
National Coalition for Alarm Management Safety.
Healthcare Technology Safety Institute and Association for the Advancement of Medical Instrumentation.
Alarm fatigue has been recognized as a contributor to serious errors in hospitals. This Web site provides a way for hospitals, industry representatives, regulators, and professional societies to compile resources and discuss strategies to reduce unnecessary alarms.
Audiovisual > Audiovisual Presentation
TeamSTEPPS 2.0 Online Master Trainer Course.
Agency for Healthcare Research and Quality.
This online education program will present both group-focused and self-paced opportunities for participants to learn how to apply TeamSTEPPS 2.0 curriculum methods to develop staff training and improve team communication in their organizations.
Book/Report
AHRQ Nursing Home Survey on Patient Safety Culture: 2014 User Comparative Database Report.
Sorra J, Famolaro T, Yount N, Burns W, Liu H, Shyy M. Rockville, MD: Agency for Healthcare Research and Quality; November 2014. AHRQ Publication No. 15-0004-EF.
The AHRQ Nursing Home Survey on Patient Safety Culture, a validated tool for measuring safety culture, was initially released in 2008. This comprehensive national survey of registered nurses, nursing aides, and support staff garnered a high response rate. While respondents rated overall safety perceptions highly, similar to outpatient and hospital safety culture surveys, they expressed concerns about adequacy of staffing, as prior reports of adverse events in nursing homes would suggest. Even though most respondents believed that feedback and communication about safety problems was positive, many did not endorse a nonpunitive response to error. Instead, there was concern about individual blame. As with multiple studies, managers reported a more positive safety climate than frontline staff, suggesting that leadership on safety climate has not changed on-the-ground staff perceptions despite increasing awareness of safety culture. Given that prior work has demonstrated a link between positive safety climate and patient outcomes in nursing homes, it will be critical to address the problems raised in this analysis. A past AHRQ WebM&M commentary discussed the safety and quality of long-term care, and a previous AHRQ WebM&M interview with Nicholas Castle explored unique issues surrounding patient safety in the nursing home population.
Legislation/Regulation > Federal Legislation
Veterans' Access to Care through Choice, Accountability, and Transparency Act of 2014.
HR 3230, 113th Congress (2014).
The Veterans Affairs (VA) health system has both achieved success and struggled to provide safe care to its patients. In an effort to address shortcomings in care, this bill allocates additional funding to the VA. Goals of this legislation include regulating and improving staffing levels, enabling veterans to access non-VA facilities, and enhancing patient access to telemedicine.
Tools/Toolkit
My Medicines.
Silver Spring, MD: US Food and Drug Administration. Office of Women's Health and National Association of Chain Drug Stores.
This toolkit offers tips for patients to prevent adverse drug events and provides a way to record important medication information such as a list of allergies, prescriptions, dosages, and conditions being treated.
Web Resource > Government Resource
Sign up to Safety.
National Health Service.
Through a coordinated effort to set goals and devise plans to improve safety in hospitals, the Sign up to Safety campaign aims to prevent 6000 patient deaths in the next 3 years in National Health Service facilities. A primary component of this work is adopting safety culture behaviors, such as continuous learning, transparency, collaboration, and commitment reducing harm.
Special or Theme Issue
Alarm Fatigue in Hospital Setting.
Agency for Healthcare Research and Quality. Health Care Innovations Exchange. June 18, 2014.
This issue covers two successful initiatives to prevent alarm fatigue: the implementation of a 24-hour pulse oximetry monitoring and a series of interventions to reduce alarms in a cardiac unit. The innovation profiles are accompanied by tools used to help hospitals improve alarm safety.
Newspaper/Magazine Article
Multifaceted initiative to reduce "alarm fatigue" on cardiac unit reduces alarms and increases nurse and patient satisfaction.
Agency for Healthcare Research and Quality. Health Care Innovations Exchange. June 18, 2014.
Clinical alarms have been described as a serious patient safety issue. This article relates how one hospital implemented a series of actions reduce nuisance alarms in a cardiac unit and reports a substantial decrease in audible alerts with no subsequent adverse effects. Interventions included expanding limits for triggering heart rate alarms and collaboration between two nurses to design customized alarm parameters for individual patients.