Toolkits

This website provides sentinel event data reported to The Joint Commission, which includes information on 1197 sentinel events reported in 2021 through the end of December. 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 2021.

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. 

Safe diagnosis in medical offices is challenged by staff workload, communication, and poor information sharing. This Supplemental Item Set for the AHRQ Surveys on Patient Safety Culture™ (SOPS®) Medical Office Survey (MOSOPS) examines elements contributing to time availability, testing and referrals, and provider and staff communication. The Diagnostic Safety Supplemental Item Set was released in time for the scheduled Fall 2021 MOSOPS data submission.

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.

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 Chartbook 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.

This toolkit provides access to nine key tools to help organizations improve teamwork, incident analysis, and communication as well as templates to support their use and instructions to begin associated processes. Featured tools include the Situation-Background-Assessment-Recommendation approach, huddle agendas, and failure modes and effects analysis.

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. 

This tool provides institutions with the capacity to assess use of antithrombotic agents, submit data to the Institution for Safe Medication Practices for self-assessment scores, compare practices with other hospitals, and allow the development of an ongoing progress report.

Performing incident analysis can help organizations understand why adverse events occur and how to prevent them. This toolkit provides a framework to help organizations gather insights from staff, patients, and family members regarding what caused the failure and why it happened and to guide efforts to prevent similar incidents.

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 a report that explains how the measure can help assess the results of improvement efforts.

The usability of electronic health record (EHR) systems can affect clinicians' ability to provide safe patient care. This fact sheet summarizes the results of a stakeholder meeting that explored usability problems and identified three improvement strategies that focused on effective testing, user assessment of EHR safety, and sharing of lessons learned.

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. 

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.

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.

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.

Ambulatory surgery centers 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.

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.

Although victims of adverse events have clearly expressed their preferences for full error disclosure, most physicians remain uncomfortable with disclosing and apologizing for errors. This leaflet offers information to help clinicians understand the value of effective apologies along with tips for organizations to support open disclosure efforts.