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Toolkits
Patient safety toolkits provide practical applications of PSNet research and concepts for front line providers to use in their day to day work. These toolkits contain resources necessary to implement patient safety systems and protocols.
Latest Toolkits
Toolkit
AAAHC Quality Institute. Skokie, IL: Accreditation Association for Ambulatory Health Care.
This collection of toolkits provides resources to support safety in ambulatory care and includes information about allergy documentation, safe injection practices and medication reconciliation.
Tools/Toolkit
Rockville, MD: Agency for Healthcare Research and Quality; June 2024.
The recognition of diagnosis as a team activity is energizing new diagnostic process initiatives. Building on the established TeamSTEPPS® principles, this new TeamSTEPPS course includes seven training modules, team and knowledge assessment tools, and implementation guidance to develop or enhance communication across the care team to improve the accuracy and timeliness of diagnosis. Training opportunities for August, September, and October 2024 are now available for registration.
Brach C, ed. Rockville, MD: Agency for Healthcare Research and Quality; March 2024. AHRQ Publication No. 15-0023-EF.
The AHRQ Health Literacy Universal Precautions Toolkit, 3rd edition, can help primary care practices implement improvement actions to reduce the complexity of health care, increase patient understanding of health information, and enhance support for patients of all health literacy levels.
Measurement Tool/Indicator
Classic
Rockville MD: Agency for Healthcare Research and Quality; 2020.
Culture has been described as a key to establishing high reliability organizations. The National Quality Forum's Safe Practices for Healthcare and the Leapfrog Group both mandate hospitals to regularly assess their safety culture. This AHRQ Web site provides validated safety culture survey tools (Hospital, Medical Office, Nursing Home, Community Pharmacy, Ambulatory Surgery Center), user guides health care organizations can use to implement the surveys and a bibliography of articles discussing the use of SOPS in the field. Organizations can also use the AHRQ database to compare their Surveys on Patient Safety Culture™ (SOPS®) results. In addition, reports are available that summarize the benchmarking data across cohorts nationwide. An AHRQ WebM&M perspective discussed how to establish a safety culture. The 2024 Nursing Home Survey data collection period is open October 1-21, 2024.
All Toolkits (266)
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Toolkit
AAAHC Quality Institute. Skokie, IL: Accreditation Association for Ambulatory Health Care.
This collection of toolkits provides resources to support safety in ambulatory care and includes information about allergy documentation, safe injection practices and medication reconciliation.
Tools/Toolkit
Rockville, MD: Agency for Healthcare Research and Quality; June 2024.
The recognition of diagnosis as a team activity is energizing new diagnostic process initiatives. Building on the established TeamSTEPPS® principles, this new TeamSTEPPS course includes seven training modules, team and knowledge assessment tools, and implementation guidance to develop or enhance communication across the care team to improve the accuracy and timeliness of diagnosis. Training opportunities for August, September, and October 2024 are now available for registration.
Brach C, ed. Rockville, MD: Agency for Healthcare Research and Quality; March 2024. AHRQ Publication No. 15-0023-EF.
The AHRQ Health Literacy Universal Precautions Toolkit, 3rd edition, can help primary care practices implement improvement actions to reduce the complexity of health care, increase patient understanding of health information, and enhance support for patients of all health literacy levels.
Measurement Tool/Indicator
Classic
Rockville MD: Agency for Healthcare Research and Quality; 2020.
Culture has been described as a key to establishing high reliability organizations. The National Quality Forum's Safe Practices for Healthcare and the Leapfrog Group both mandate hospitals to regularly assess their safety culture. This AHRQ Web site provides validated safety culture survey tools (Hospital, Medical Office, Nursing Home, Community Pharmacy, Ambulatory Surgery Center), user guides health care organizations can use to implement the surveys and a bibliography of articles discussing the use of SOPS in the field. Organizations can also use the AHRQ database to compare their Surveys on Patient Safety Culture™ (SOPS®) results. In addition, reports are available that summarize the benchmarking data across cohorts nationwide. An AHRQ WebM&M perspective discussed how to establish a safety culture. The 2024 Nursing Home Survey data collection period is open October 1-21, 2024.
Horsham, PA; Institute for Safe Medication Practices; April 17, 2024.
A handy list for medical personnel to ensure and implement safe prescribing practices by avoiding use of these dangerous shortcuts.
Measurement Tool/Indicator
Joint Commission.
This website provides sentinel event data reported to The Joint Commission, which includes information on sentinel events reported from January through December 2023. Falls, wrong surgery and unintended retained foreign bodies were among the most frequently submitted incidents in this time period. The data and graphs are updated regularly and include a 10 year trend analysis and specific analysis associated with event source by year from 2013 through 2023.
Multi-use Website
Agency for Healthcare Research and Quality.
Safe diagnosis in medical offices is challenged by staff workload, communication, and poor information sharing. This Supplemental Item Set for the AHRQ Surveys on Patient Safety Culture™ (SOPS®) Medical Office Survey (MOSOPS) examines elements contributing to time availability, testing and referrals, and provider and staff communication. The Diagnostic Safety Supplemental Item Set 2024 survey results report is now available.
Seattle, WA: Collaborative for Accountability and Improvement; 2023.
There is a need for patients and families to understand effective routes for action should they experience harm. This FAQ shares steps for patients and families to take to help them get the communication and resolution they need from organizations and clinicians to effectively resolve concerns.
Fact Sheet/FAQs
Centers for Disease Control and Prevention (CDC)
The hand hygiene guidelines represent part of a U.S. Centers for Disease Control and Prevention (CDC) strategy to promote patient safety by reducing infections in health care settings. The site includes fact sheets, a press kit, and other materials to help implement the guidelines.
Organizational Policy/Guidelines
Plymouth Meeting, PA: Institute for Safe Medication Practices; 2024.
This updated report outlines 22 consensus-based best practices to ensure safe medication administration, such as diluted solutions of vincristine in minibags and standardized metrics for patient weight. The set of recommended practices has been reviewed and updated every two years since it was first developed in 2014 to include actions related to eliminating the prescribing of fentanyl patches for acute pain and use of information about medication safety risks from other organizations to motivate improvement efforts. The 2024-2025 edition includes new practices that are associated with tranexamic acid wrong-route errors, transitions of care, and vaccines.
Alpharetta, GA: Society to Improve Diagnosis in Medicine; February 2024.
Patient and Family Advisory Councils (PFACs) can help to operationalize patient engagement in healthcare safety improvement work. This toolkit targets diagnostic excellence and educating PFAC members on the diagnostic process to enable their rich involvement in improvement work. The kit features videos, sections on the role of PFACs in diagnostic improvement, selected readings, letter templates and a glossary.
Fact Sheet/FAQs
FDA Consumer Health Information. Silver Spring, MD: US Food and Drug Administration; February 15, 2024.
Highlighting how aging affects medication absorption that may lead to complications, this fact sheet offers recommendations for older patients to follow instructions, maintain a medication list, be aware of drug interaction potential, and perform an annual review of medications with clinicians to help them take prescriptions safely.
Fact Sheet/FAQs
Horsham, PA; Institute for Safe Medication Practices: 2024.
This fact sheet lists medications with a high risk of causing significant harm to patients when incorrectly administered. The 2024 publication reflects insights gathered through a survey of current medication use in acute care facilities. The update includes the addition of tranexamic acid injections as a high alert medication based on survey results, error reports and expert review.
Gilbert R, Asselbergs M, Davis D, et al. Healthcare Excellence Canada; 2023.
Patient safety requires a systems approach to identify problems and arrive at lasting solutions that reduce harm. This document encourages discussion amongst a broad base of stakeholders to address all forms of harm, such as discrimination, inequality, and psychological stress, in addition to physical injury. The resource insists these components be incorporated in work to close quality and safety gaps across the health care system.
Toolkit
Canadian Institute for Health Information, Health Excellence Canada.
Reducing preventable harm associated with health care is a worldwide goal. This Canadian initiative developed a measure to track unintended harm in acute care hospitals, a toolkit to accompany reduction efforts, and reports that assess the results of improvement efforts and provide data analysis.
Measurement Tool/Indicator
Plymouth Meeting, PA: Institute for Safe Medication Practices; 2023.
Experience from the sharp end helps to inform safety improvement initiatives. The results from this field survey will inform the revision of a high-alert medication list used to raise awareness about certain drugs that have heightened potential to cause patient harm if used incorrectly. The deadline for submitting comments has passed.
Rockville, MD: Agency for Healthcare Research and Quality; July 2023.
Obstetric hemorrhage and severe high blood pressure during pregnancy are leading known causes of preventable maternal harms in the United States. The AHRQ Safety Program for Perinatal Care, Phase 2 developed toolkits consisting of case scenarios, slides, and facilitators guides to work in tandem to address these threats to maternal safety. The materials inform training opportunities to improve the safety culture of labor and delivery units and decrease maternal and neonatal adverse events that result from poor communication and system failures.
London, UK: NHS England; July 2023.
A strong patient safety culture needs nurturing to serve as a foundation for launching and sustaining improvements. This toolkit provides access to existing tools that support teamwork and communication, fairness, psychological safety, promotion of diversity and inclusivity, and civility as elements of a safety culture.
Measurement Tool/Indicator
Classic
Agency for Healthcare Research and Quality
The AHRQ Patient Safety Indicators (PSIs) represent quality measures that make use of a hospital's available administrative data. The PSIs reflect the quality of inpatient care but also focus on preventable complications and iatrogenic events. Investigators have found PSIs to be a useful tool for understanding adverse events and identifying possible areas of improvement within health care delivery systems. Although relying on administrative data has clear limitations, select PSIs have been shown to accurately identify certain accidental inpatient injuries. The AHRQ Web site offers publicly available comparative data, along with resources and tools. Patient safety measurement methods are discussed in an AHRQ WebM&M perspective. Originally released in 2005, the PSI were most recently updated in August 2023.
Fact Sheet/FAQs
Classic
Horsham, PA; Institute for Safe Medication Practices: July 2023.
Drawing on information gathered from the ISMP Medication Errors Reporting Program, this fact sheet provides a comprehensive list of commonly confused medication names, including look-alike and sound-alike name pairs. Drug name confusion can easily lead to medication errors, and the ISMP has recommended interventions such as the use of tall man lettering in order to prevent such errors. An error due to sound-alike medications is discussed in this AHRQ WebM&M commentary.
