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.
Chicago, IL: American Hospital Association, Health Research & Educational Trust; 2016.
Checklists are a recommended method to reduce omissions in care, despite controversies regarding their impact on safety. This toolkit provides a collection of checklists that have been developed and field tested by participants in the Hospital Engagement Network to prevent harm associated with the use of central lines, adverse drug events, and falls.
Rockville, MD: Agency for Healthcare Research and Quality; May 2016.
Traditionally, health systems have disclosed adverse events to patients only through a lengthy process that involves providing limited information to patients and families, avoiding admissions of fault, and emphasizing protection of the clinicians involved. This approach may harm safety culture and has been criticized as not being patient-centered. Some pioneering institutions, such as the University of Michigan Health System, began implementing an alternative approach known as "communication and resolution," which emphasizes early disclosure of adverse events and proactive attempts to reach an amicable solution. Early adopters of this method have achieved notable results, including a decline in malpractice lawsuits. The CANDOR toolkit, developed by AHRQ as part of the Medical Liability Reform and Patient Safety Initiative, provides tools for health care organizations to implement a communication-and-resolution program. The toolkit includes videos, slides, gap analysis assessments and teaching materials. It has been tested in 14 hospitals in several different states. A PSNet interview with the chief risk officer of the University of Michigan Health System discusses the organization's pioneering efforts to implement a communication-and-response system.
Patient safety organizations collect data across various systems and states. This site supports review and comment of versions of common formats developed to provide a standardized method to collect and report incident data to patient safety organizations.
Electronic health records have potential to improve health care, but they may also introduce unanticipated risks. This report describes the results of a group convened to explore strategies to enhance health IT safety. Focusing on copying and pasting health data from one record to another as the first area of concern, the report recommends enabling systems to identify what data has been copied in the electronic health record and where it came from, providing training to ensure the safe use of copy and paste, and regularly track and assess copying and pasting practices. The report includes tools to related to the recommendations. A WebM&M commentary explores the hazards associated with the use of copy and paste.
Horsham, PA: Institute for Safe Medication Practices; 2013.
Root cause analysis offers a structured way to detect and address system weaknesses. This workbook illustrates how root cause analysis can be applied to community pharmacy services to identify problems and design an action plan to implement improvement strategies.
Leeds, UK: Clinical Support Audit Unit, Health and Social Care Information Centre. 2012-2017.
The NHS Safety Thermometer was a tool developed by the National Health Service to facilitate staff participation in measuring patient harm in various care environments. This report collection explores the data collected on four types of health care–acquired conditions (pressure ulcers, falls, catheter–associated urinary tract infections, and venous thromboembolisms) in NHS patients over a 5-year period. The NHS Safety Thermometer is no longer used as an official data type.
The National Quality Forum (NQF) has been a leader in defining patient safety reporting measures. This website provides information about the third cycle of an NQF patient safety project that solicited new measures and reviewed existing patient safety metrics. A final report is now available.
Agency for Healthcare Research and Quality; AHRQ; Sorra J; Gray L; Franklin M; Streagle S; Tesler R; Vithidkul A.
Improving the culture of safety within health care is an essential component of preventing or reducing errors. Designed for users of the AHRQ safety culture surveys, this tool will help organizations develop an action plan and proactively discuss potential barriers to safety culture improvement efforts and how to address them.
Parents can help to recognize and report problems that occur when their children receive inpatient care. This quality measure has been developed to assist hospitals in tracking how often clinicians prevent mistakes while providing care for pediatric patients and whether they inform parents about ways to report concerns.
Rockville, MD: Agency for Healthcare Research and Quality; October 2015.
Catheter–associated urinary tract infections (CAUTIs) are common complications in hospitalized patients. This toolkit was developed as part of a national implementation project to reduce rates of CAUTIs in hospitals and apply principles of the comprehensive unit-based safety program. The toolkit includes modules that focus on implementation, sustainability, and resources to help hospitals design CAUTI prevention efforts at the unit level.
Chicago. IL: AHA Trustee Services, Health Research and Education Trust; February 2018.
Leadership commitment to improvement efforts is key to sustain patient safety initiatives. This toolkit consists of a workbook, board engagement self-assessment tool, and video modules to help leadership translate efforts from the board room to the front line to reduce medical errors in their hospitals.
Joint Commission Center for Transforming Healthcare; TST.
Patient falls are preventable and can be addressed through quality and safety strategies. This toolkit provides a process to help health care organizations determine factors that contribute to falls in their facilities and design interventions to drive improvement.
Violence in health care settings can result in harm for staff and patients. Spotlighting the issue of workplace violence in hospitals, this fact sheet offers resources and recommendations for organizations that want to reduce risks and provide support for staff affected by violence.
World Health Organization; Regional Office for the Eastern Mediterranean.
Patient safety programs should reflect local needs, motivate clinician and leadership engagement, and support sustainable enhancements. This toolkit provides information about how to establish a patient safety program, implement interventions, determine areas needing improvement, and build a culture of safety.
Engaging patients and families in safety can uncover concerns and inform improvement efforts. This three-component toolkit provides resources that focus on incident management, patient safety management, and system factors to prevent and respond to failures or near misses.
Rockville, MD: Agency for Healthcare Research and Quality; October 2020.
Ambulatory surgery centers are increasingly being used to provide surgical care. This 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. The 2021 data collection cycle is closed.
There is a noted lack of agreement on measures to study and track safety hazards and the effectiveness of improvement strategies. This survey sought input from the field to inform the development of a list of medication-related measures to communicate concerns related to drug class, technology use, and medication administration practices as a way to provide data to senior management in an easily accessible format.
National Coordinating Council for Medication Error Reporting and Prevention; NCCMERP.
Medication errors are a common factor in health care–associated harm. Lack of clarity on types of medication-related incidents has the potential to create confusion and hinder improvement efforts. This tool provides a decision tree to distinguish whether an incident is an adverse drug reaction, adverse drug event, or medication error and determine if it was preventable.
Nurses play an important role in reducing catheter–associated urinary tract infections (CAUTIs). This toolkit, developed as a Partnership for Patients strategy, focuses on promoting nursing behaviors to prevent CAUTIs including decreasing catheter use and improving catheter maintenance.
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.
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