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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 (161)

Published Date
PSNet Publication Date
1 - 20 of 161 Results

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.
Tools/Toolkit

Betsy Lehman Center. September 2021.

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.

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.
Rockville, MD: Agency for Healthcare Research and Quality; October 2020.
This survey collects information from outpatient providers and staff about the culture of patient safety in their medical offices. The survey is intended for offices with at least three providers, but it also can be used as a tool for smaller offices to stimulate discussion about quality and patient safety issues. The survey is accompanied by a set of resources to support its use. The current data submission window launched on September 1 and runs through October 20, 2021.

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.

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

The use of antibiotics should be monitored to reduce the potential for infection in care facilities. This toolkit outlines offers a methodology for launching or invigorating an antibiotic stewardship program. Designed to align with four time elements of antibiotic therapy, its supports processes that enable safety for nursing home residents.

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.

Agency for Healthcare Research and Quality. April 2021.

Safe diagnosis in medical offices is challenged by staff workload, communication, and poor information sharing. This survey supplement examines elements contributing to time availability, testing and referrals, and provider and staff communication. The set is to be used in conjunction with the Agency for Healthcare Research and Quality's Medical Office Survey on Patient Safety Culture (MOSOPS®). The supplemental item set was released in time for the scheduled Fall 2021 MOSOPS data submission.

AHA Physician Alliance. Chicago, IL: American Hospital Association. February 2021. 

Human factors engineering approaches improve safety, efficiency, and effectiveness in both normal and challenging times. This tool shares a human-factors structured approach to improving technology integration and adaptation into work processes to reduce burnout and its negative effects on worker and clinician wellbeing. 

The American Society for Dermatologic Surgery Association and the Northwestern University Department of Dermatology.

Voluntary reporting systems collect adverse event data to inform improvement and education efforts. This site provides a platform for physicians and their staff to submit adverse experiences associated with dermatologic surgery equipment, medications or biologics.
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.
Measurement Tool/Indicator
Joint Commission.
This website provides sentinel event data reported to The Joint Commission, which includes information on 437 sentinel events reported in 2020 through the end of June. Unintended retained foreign bodies, falls and wrong–patient, wrong-site, wrong-procedures were the most frequently submitted incidents in this time period. The data and graphs are updated regularly and include specific analysis associated with event type by year from 1995 through the fourth quarter of 2020.

Boston, MA:  Institute for Healthcare Improvement; 2020.

Hospital crisis management, preparation, and planning are of heightened interest due to the COVID-19 emergency. This assessment tool examines hospital readiness for the patient surge due to the pandemic. The assessment tool helps organizations examine support structures, monitoring, infection control, supply and space capabilities, and staff support mechanisms to proactively address concerns to prepare for future challenges.

Baltimore MD: University of Maryland School of Pharmacy; 2020.

Medication management has been affected in a variety of settings due to the COVID-19 pandemic. This guide highlights strategies to ensure safe medication delivery in long term care. Tactics highlighted include medication discontinuation and alignment of medication administration times.

Child Health Patient Safety Organization. Washington DC: Children's Hospital Association; May 2020.

Effective communication is an important component of diagnostic accuracy. Shaped with data collected by a patient safety organization, this five section toolkit features tactics to support effective communication across diagnostic process in children’s hospital care, including the use of time outs, case analysis and communication gap assessment.
Krukas A, Franklin ES, Bonk C, et al. Patient Safety. 2020;2.
Intravenous vancomycin is an antibiotic with known medication safety risk factors. This assessment is designed to assist organizations to review clinician and organizational knowledge, medication administration activities and health information technology as a risk management strategy to minimize hazards associated with vancomycin use. 
Choosing a Patient Safety Organization. Rockville, MD: Agency for Healthcare Research and Quality; March 2020. AHRQ Publication No. 20-0030
Patient safety organizations (PSOs) collect and analyze protected incident data from across the United States. Expert analysis of PSO data can be utilized to inform design and implementation of local initiatives. This brochure provides guidance for health care organizations regarding benefits of working with a PSO and what to consider when choosing one.