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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

Rockville, MD: Agency for Healthcare Research and Quality; 2021.

AHRQ’s Hospital Survey on Patient Safety Culture™ (SOPS®) ask health care providers and staff about the extent to which their organizational culture supports patient safety. The release of the Workplace Safety supplemental items for use in conjunction with the AHRQ Hospital Survey on Patient Safety Culture™ helps hospitals assess how their workplace culture supports workplace safety for providers and staff. Included with the data set is a report of the pilot test of the finding. You can learn more about the supplemental items and can register for a webcast introducing the Workplace Safety items here: Surveys on Patient Safety Culture™ (SOPS®) | Agency for Healthcare Research and Quality (ahrq.gov)  

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.

All Toolkits (88)

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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.

Center for Healthy Aging--New York Academy of Medicine, Yale School of Nursing.

Healthcare-associated infections (HAIs) challenge safety in long-term care. This toolkit highlights multidisciplinary approaches to reducing HAIs and teaching tools focused on distinct audiences across the continuum to share principles and tactics supporting improvement.

AHA Team Training and Project Firstline. Chicago, IL: American Hospital Association, Center for Disease Control and Prevention; July 2021.

Problems in communication are common contributors to patient care mistakes. This toolkit draws from experience with the TeamSTEPPS model to highlight best practices in the use of huddles, debriefs and other teamwork improvement strategies.

Institute for Safe Medication Practices

The perioperative setting is a high-risk area for medication errors, should they occur. This assessment provides hospitals and outpatient surgical providers a tool to examine their medication use processes and share data nationwide for comparison. Organizational participation can identify strengths and gaps in their systems to design opportunities that prevent patient harm. The deadline for submitting data is December 10, 2021.
Horsham, PA: Institute of Safe Medication Practices; 2021
Long-term care patients often have concurrent conditions that increase their risk of medication error. This fact sheet provides a list of potential high-alert medications prevalent in long-term care settings that should be administered with particular care due to the heightened potential for harm. A past PSNet perspective discussed medication safety in nursing homes.
Azam I, Gray D, Bonnett D et al. Rockville, MD: Agency for Healthcare Research and Quality; February 2021. AHRQ Publication No. 21-0012.
The National Healthcare Quality and Disparities Reports review analysis specific to tracking patient safety challenges and improvements across ambulatory, home health, hospital, and nursing home environments. The most recent update documented improvements in approximately half of the patient safety measures tracked. This set of tools includes summaries drawn from the reports for use in presentations to enhance distribution and application of the data.
Horsham, PA: Institute for Safe Medication Practices; 2020.
This updated report outlines 16 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 2020 update includes new practices that are associated with opioids and automated dispensing cabinet overrides. ISMP is currently seeking insights as to the implementation of the current best practices. Survey responses are due by July 30, 2021.
Horsham, PA: Institute for Safe Medication Practices; 2019.
Hospitalized patients are at risk for medication errors. This set of tips seeks to help hospitalized patients contribute to the safe use of medications in their care. Recommendations include that patients know the reason they are taking each medication, speak up if any medications look different than previously, and talk with pharmacists when picking up discharge medications.
Canadian Patient Safety Institute: 2019.
Structured approaches to managing negative psychological consequences of medical errors on health care professionals, patients, and families are important for emotional healing and organizational learning. This webinar series featured discussions on peer support efforts and a toolkit for Canadian health care workers.

ISMP Medication Safety Alert! Acute Care Edition. April 25, 2019.

Newborns assigned temporary names are at increased risk for patient misidentification and wrong-patient errors. This newsletter article reports on the role of electronic health records in newborn misidentification and the unintended consequences associated with a Joint Commission set of recommendations to reduce risk. 
Commentary
Spine Intervention Society; SIS.
This resource provides newsletters that target concerns associated with spinal pain interventions and offers safety strategies. The collection focuses on three primary areas: procedural contraindications, procedure-related complications, and injectate-related complications such as the safe use of multi-dose and single-dose vials.
ISMP; Institute for Safe Medication Practices.
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.
Itasca, IL: American Academy of Pediatrics; 2018.
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.
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.
Agency for Healthcare Research and Quality; AHRQ.
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.
Institute for Safe Medication Practices; ISMP.
High-alert medications have the potential to cause substantial patient harm if administration mistakes occur. This assessment tool will enable organizations across a range of care environments to determine opportunities for improvement in 11 high-alert medication categories. In addition, the tool provides an opportunity for organizations to submit their data anonymously to a national data collection effort led by the Institute for Safe Medication Practices to define the current state of high-alert medication practices in health care. The data submission process is now closed.
Rockville, MD: Agency for Healthcare Research and Quality; 2017.
Both organizational culture and the physical environment affect the safety of care delivery. This toolkit provides resources to help organizations assess hazards related to the design of their facilities. The toolkit focuses on six areas of safety: infections, falls, medication errors, security, injuries of behavioral health, and patient handling.
Measurement Tool/Indicator
Institute for Safe Medication Practices; ISMP.
Drug shortages can contribute to treatment delays and complications that lead to patient harm. This survey sought insights from hospital directors of pharmacy regarding their experiences with drug shortages over the past 6 months.