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Web Resource > Government Resource
National Patient Safety Alerting System.
National Health Service England.
In response to the Francis report, this three-stage reporting system was launched to help National Health Service organizations learn from incidents and incorporate changes to reduce similar risks. The first stage alerts organizations of a new patient safety hazard, the second distributes practices or resources to address the issue, and the third disseminates a checklist to ensure safety strategies have been implemented. In April 2016 the alerts program was integrated into the new NHS Improvement initiative.
Web Resource > Multi-use Website
Safe Surgery 2015.
Harvard School of Public Health.
This Web site provides resources for the Safe Surgery initiative to implement the World Health Organization surgical safety checklist in every US hospital by 2015.
Audiovisual
Healthcare 411: medication safety toolkit.
Bethesda, MD; Agency for Healthcare Research and Quality. February 25, 2009.
This interview introduces an AHRQ-funded PIPS toolkit to help small and rural hospitals implement medication safety initiatives.
Book/Report
Windows into Safety and Quality in Health Care 2008.
Sydney, Australia: Australian Commission on Safety and Quality in Health Care; 2008. ISBN: 9780980346275.
This report compiles public and private data to provide insight into the quality and safety of patient care in Australian hospitals.
Audiovisual
Healthcare 411: Consumer insider—handwashing.
Rockville, MD: Agency for Healthcare Research and Quality. June 20, 2007.
This podcast discusses the importance of handwashing to reduce infections in hospitals as well as how consumers can help improve clinician compliance.
Newsletter/Journal
Innovations to improve patient safety.
Agency for Healthcare Research and Quality. Health Care Innovations Exchange. May 18, 2016.
This issue highlights innovations that can be applied in a variety of health care environments to prevent hospital-acquired conditions. The resources include the Chartbook on Patient Safety and checklist, decision support, and screening programs.
Web Resource > Multi-use Website
CampaignZERO.
Lake Forest, IL.
Having a family member accompany a patient to the hospital to act as an advocate has been suggested as a way to enhance patient safety. This Web site provides resources to support collaboration and communication between health care workers and consumers, including information about medical errors (such as risks of falls and surgical complications) and safety checklists to help prevent adverse events like hospital-acquired infections.
Tools/Toolkit > Government Resource
AHRQ Safety Program for End-Stage Renal Disease Facilities—Toolkit.
Rockville, MD: Agency for Healthcare Research and Quality; January 2015.
Health care–associated infections are a known contributor to adverse events among patients on dialysis. Building on evidence and insights from clinicians, this four-part toolkit includes videos, assessment tools, and slide presentations regarding how to apply principles of teamwork, patient engagement, and safety culture to ensure dialysis centers provide safe care to patients with end-stage renal disease.
Web Resource > Multi-use Website
Safe Surgery Saves Lives.
Canadian Patient Safety Institute.
This site supports the effort to adopt the World Alliance for Patient Safety surgical checklist program in Canada.
Web Resource > Multi-use Website
Patient Safety Committee.
American Academy of Orthopaedic Surgeons.
This Web site includes patient safety-related materials for orthopedic surgeons such as checklists, educational modules, tips, and American Academy of Orthopaedic Surgeons (AAOS) official statements.
Book/Report
The Silent Treatment: Why Safety Tools and Checklists Aren't Enough to Save Lives.
- Classic
Maxfield D, Grenny J, Lavandero R, Groah L. Provo, UT: VitalSmarts; 2011.
Silence Kills was a 2005 report that highlighted communication failures that contribute to patient harm. These included broken rules, poor teamwork, and disruptive behaviors. This report builds on those findings based on a survey of more than 6500 nurses and nurse managers. Key findings suggested that existing safety tools, such as checklists, are not in themselves solutions to these communication failures. Nurses identified dangerous shortcuts, incompetence, and disrespect as three concerns that undermine systems designed to provide safer care. A past AHRQ WebM&M perspective and interview discuss the role of checklists in health care settings.
Tools/Toolkit > Fact Sheet/FAQs
Check Your Medicines: Tips for Taking Medicines Safely.
Rockville, MD: Agency for Healthcare Research and Quality; September 2010. AHRQ Publication No. 10-M052-C.
This 5-point checklist provides consumers with steps to help ensure the safety of their medication use.
Tools/Toolkit > Government Resource
Professional Conduct Toolkit.
Washington, DC: US Department of Defense, Patient Safety Program.
This toolkit provides a checklist, a planning guide, and other tools to help address disruptive staff behavior.
Newspaper/Magazine Article
A success story in American health care: eliminating infections and saving lives in Michigan.
Herzer K, Seshamani M. HealthReform.Gov. July 2009.
This piece highlights the Michigan Keystone ICU project as an example for other organizations that plan to launch programs to reduce hospital-acquired infections.
Tools/Toolkit > Multi-use Website
Safe Surgery Saves Lives: The Second Global Patient Safety Challenge.
- Classic
Geneva, Switzerland: WHO World Alliance for Patient Safety; June 25, 2008.
This initiative provides a surgical safety checklist and related educational and training materials to encourage international adoption of a core set of safety standards. Implementation of this World Health Organization's checklist has resulted in dramatic reductions in surgical mortality and complications across diverse international hospitals. Surgical checklists have now become one of the clearest success stories in the patient safety movement, although some have described challenges to effective implementation. Dr. Atul Gawande discussed the history of checklists as a quality and safety tool in his book, The Checklist Manifesto: How to Get Things Right.
Tools/Toolkit
Patient Safety Tools: Improving Safety at the Point of Care.
Rockville, MD: Agency for Healthcare Research and Quality; 2007.
Produced in conjunction with its Partnerships in Implementing Patient Safety (PIPS) grant program, AHRQ has released 17 freely available toolkits to help hospitals and health care providers reduce medical errors. Along with educational materials, the toolkits include medication guides and checklists, all of which are adaptable to most health care settings and designed for use by multidisciplinary teams.
Book/Report
Quality of Care in Cranial Implant Surgeries at James A. Haley VA Medical Center, Tampa, Florida.
Health Care Inspection. Washington, DC: VA Office of Inspector General; April 10, 2006. Report No. 06-01642-126.
This report shares the results of an inspection into two mistakes at a Veterans Affairs (VA) health facility involving appropriate sterilization of implantable medical devices.