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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

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.
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.
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.

All Toolkits (269)

Displaying 1 - 20 of 269 Results

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.
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.
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.
Multi-use Website
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.
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 is October 20, 2023.

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.
Department of Health and Human Services, Agency for Healthcare Research and Quality, Department of Defense.
Effective teamwork plays an essential role in providing safe patient care. The Team Strategies and Tools to Enhance Performance and Patient Safety (TeamSTEPPS) program was developed inititally in collaboration by the United States Department of Defense and AHRQ in order to support effective communication and teamwork in health care. The 3.0 version of the widely implemented program is organized around 5 key strategies: patient focus, integrated platform, modular course design, active adult learning and emergent team challenges and opportunities. It provides new tools to measure its impact, supports increased emphasis on the role of patients in teams, and includes a new pocket guide. A PSNet WebM&M commentary discussed how improved teamwork and shared decision-making might have prevented a missed diagnosis of sepsis that lead to the death of a patient.

Maxwell A. Washington, DC: US Department of Health and Human Services, Office of the Inspector General; July 2023. Report no. OEI-06-21-00031.

Trigger tools are a strategy for identifying and classifying patient injuries associated with care. This toolkit provides guidance for problem exploration on 29 specific clinical conditions. The document is designed to assist teams in the review of medical record data resources that can elucidate preventability and identify harm. This toolkit provides an 18-element trigger tool oriented to hospitals with worksheets to translate its use to a variety of care environments.
Rockville, MD: Agency for Healthcare Research and Quality; October 2020.
Ambulatory surgery centers (ASCs) are increasingly being used to provide surgical care. The AHRQ Surveys on Patient Safety Culture™ (SOPS®) Ambulatory Surgery Center Survey seeks opinions from the field regarding safety culture in the ambulatory surgical center environment. The survey is presented with additional resources to help organizations assess their safety culture, including the results of a pilot program testing the survey and a user's guide. Voluntary data submission will be open June 1-22 for ASCs that have administered the survey.
Fact Sheet/FAQs
Oakbrook Terrace, IL: Joint Commission. 2002-2023.
A series of patient safety brochures, videos and infographics directed toward specific areas of care that encourages patients to take an active role by asking questions and addressing problems with their providers. Topics include preventing falls, medication safety, and safe surgery. Available in both English and Spanish.
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.

Horsham, PA; Institute for Safe Medication Practices: April 2023.

Community pharmacies are common providers of medication delivery that harbor process weaknesses affecting safety. This guidance shares evidence-based steps to address problems such as wrong patient errors and lack of consistent barcode system use in the community setting.
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 2022. Falls, unintended retained foreign bodies, and delays in treatment were among the most frequently submitted incidents in this time period which represents a 19% increase over 2021. The data and graphs are updated regularly and include a 5 year trend analysis and specific analysis associated with event type by year from 2018 through 2022.

Oregon Patient Safety Commission: 2023.

Gaslighting has been identified as a contributor to maternal mortality and morbidity. This toolkit of compiled resources aims to help inform organizational activities to establish programs and strategies to reduce the impact of disrespect, implicit bias and inequities that affect the care of pregnant persons.
Food and Drug Administration and Institute for Safe Medication Practices. Plymouth Meeting, PA; Institute for Safe Medication Practices; January 2023.
Mistakes associated with look-alike medication names are a safety concern in health care. Tall man, or mixed case, lettering is one recommended strategy to reduce confusion associated with similarities in drug names. This list includes medications recognized by clinicians and professional organizations as those suited for the application of mixed case lettering to make their use safer.