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.
National Confidential Inquiry into Suicide and Safety in Mental Health. Manchester, UK: University of Manchester; May 31, 2021
System failures require multifactorial assessment to install targeted improvements. This toolkit examines 10 areas of focus for organizations to assess the safety of mental health services in emergent and primary care settings to minimize patient suicide and self-harm. Areas of focus include post-discharge follow-up, admissions, and family engagement.
Clinicians involved in adverse events that harm patients can struggle to come to terms with error. This toolkit is designed to assist organizations in the development of initiatives to support clinicians and staff after an adverse event. Areas of focus include leadership buy-in, policy development, and training. An implementation guide is also provided.
Rockville, MD: Agency for Healthcare Research and Quality; August 2021. AHRQ Publication No. 21-0047-2-EF.
Patient and family engagement is core to effective and safe diagnosis. This new toolkit from the Agency for Healthcare Research and Quality promotes two strategies to promote meaningful engagement and communication with patients to improve diagnostic safety: (1) a patient note sheet to help patients share their story and symptoms and (2) orientation steps to support clinicians listening and “presence” during care encounters.
Standardized practices have not been uniformly adopted to support safe IV medication therapy. This risk assessment tool will help organizations proactively identify process weaknesses that could contribute to patient harm. Users of the guide can also contribute to a national effort to collect data on current IV push practices. The data collection process is now closed.
Chicago, IL: Health Research & Educational Trust; 2018.
Proactive identification of conditions that degrade the diagnostic process can drive improvement. This toolkit provides resources to help organizations seeking to improve diagnosis. The publication includes case studies that illustrate implementation challenges and provides infrastructure enhancement suggestions for hospital teams as they design interventions to reduce diagnostic errors.
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.
SIDM Patient Engagement Committee. Evanston, IL: Society to Improve Diagnosis in Medicine; October 2018.
Patient engagement has been promoted as a strategy to enhance safety in health care. This toolkit helps patients organize information about their medical history, current concerns, symptoms, and medications to prepare them for medical appointments.
Inadequate follow-up of test results can contribute to missed and delayed diagnoses. Developing optimal test result management systems is essential for closing the loop so that results can be acted upon in a timely manner. The Partnership for Health IT Patient Safety convened a working group to identify how technology can be used to facilitate improved communication and timely action regarding test results. This report summarizes the methods used by the working group and their findings. Recommendations include improving communication by standardizing the format of test results, including required timing for diagnostic testing responses, automating the notification process in electronic health records, and optimizing alerts to reduce alert fatigue. A past WebM&M commentary discussed a case involving ambulatory test result management.
Patient Safety and Risk Management Service Delivery and Safety. Geneva, Switzerland; World Health Organization: August 2019.
This publication highlights statistics that illustrate the global impact of patient harm. The information provided includes the number of hospitalized patients injured during the care process, global costs of medication-related harms, and risks associated with radiation use.
Data surveillance and transparency are core to measuring and informing improvement efforts. This website provides detailed data that links ambulatory care prescribing activity to National Health Service hospitalizations in an effort to clarify potential adverse medication events. The dashboard launched tracking gastrointestinal bleeding as an indicator of a medication-related adverse result and will expand to other indicators and conditions over time.
University of Utah Drug Information Service; ASHP; American Society of Health-System Pharmacists.
Efforts to limit the availability of opioids has led to a shortage of needed medications. This fact sheet provides strategies for organizations who seek to improve management of injectable opioids while taking into account both safety and supply availability.
Although focusing on system failure has been highlighted as key to improving patient safety, individual behaviors must also be recognized as contributors to risks. This guide provides tactics for managers to address concerns associated with practitioner performance that arise during incident investigations. The guide helps managers initiate constructive conversations with clinical staff when their performance creates conditions for unsafe care delivery.
Rockville, MD: Agency for Healthcare Research and Quality. June 2017.
Communication in labor and delivery units can be challenging. This AHRQ-funded program draws from comprehensive unit-based safety program principles to reduce errors in maternal and neonatal care. The toolkit provides guidance and materials focused on enhancing teamwork skills, implementing perinatal safety strategies, and utilizing in situ simulation. Team training modules and care bundles are shared to enable skill development. A previous WebM&M commentary explored a near miss with a neonate.
Rockville, MD: Agency for Healthcare Research and Quality; March 2018.
Organizational culture can affect the use of tools and processes implemented to improve safety. This release of supplemental items to be used in conjunction with the AHRQ Hospital Survey on Patient Safety Culture can help organizations explore how culture affects the use of health information technology. Included with the data set is a report of initial results regarding its use in the field.
Smart infusion pumps help prevent dosage errors and capture metrics on therapy delivery and omissions. This survey sought to gather data on how clinicians use infusion pump data to inform improvement efforts.
Opioid misuse is a concern in both the United States and Canada. This campaign shares 14 specialty-specific recommendations to improve opioid safety in Canadian hospitals. An Annual Perspective discussed the opioid crisis as a patient safety concern.
Center for Health Design. Concord, CA: Center for Health Design; 2018.
Behavioral and mental health patients have unique concerns that affect their safety. This toolkit provides strategies, insights, and research to address vulnerabilities to this patient population. Design interventions to improve the service environment are also available.
Society for Healthcare Epidemiology of America; SHEA.
Engaging patients and families in their care can reduce risks. This brochure provides information about hospital-acquired infections and offers several tactics patients and families can adopt to protect themselves and others from infection. Recommendations include ensuring hand hygiene compliance by clinicians and visitors, taking antibiotics as prescribed, and recognizing infection symptoms.
Health Education England, Public Health England, National Health Service England; NHS England and Community Health and Learning Foundation.
Limits in patients' ability to understand health instructions and information affects the safety of their care. This toolkit provides resources related to health literacy including a business case for interventions, educational materials, and guides for engaging patients in discussions about low health literacy.
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.
Davis K, Collier S, Situ J, et al. Rockville, MD: Agency for Healthcare Research and Quality; December 2017. AHRQ Publication No. 1800051EF.
Transitions are known to be vulnerable to communication errors. This toolkit focuses on patient transitions between ambulatory care environments and encourages staff to engage patients and families in their care to prevent errors during care transitions.
Clinical reasoning can be flawed due to bias, fatigue, or knowledge deficits. This tool provides a five-component mechanism to help instructors assess students' diagnostic reasoning abilities and guide feedback. Faculty development videos are also provided to guide in use of the tool.
The opioid crisis is a persisting patient safety problem. One approach to prevent misuse of opioids is to raise awareness of the addictive nature of the medication. This national campaign enlists communities and individual clinicians to provide patient education to address the opioid epidemic. The website offers videos and other resources to assist community-level efforts to reduce risk for opioid addiction.
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