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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

NIHCM Foundation. Washington DC: National Institute for Health Care Management. August 2, 2022.

Preventable maternal morbidity is an ongoing challenge in the United States. This infographic shares general data and statistics that demonstrate the presence of racial disparities in maternal care that are linked to structural racism. The resource highlights several avenues for improvement such as diversification of the perinatal staffing and increased access to telehealth.

Rockville, MD: Agency for Healthcare Research and Quality; July 2022.  AHRQ Publication No. 22-0038.

Diagnostic improvement continues to gain focus as a goal in health care. The Measure Dx tool provides teams with guidance and strategies to detect and learn from diagnostic errors in their organizations. It includes a checklist to gauge readiness for implementation, measurement strategies, and recommendations for analyzing data and translating findings into front line care. 

Rockville, MD: Agency for Health Quality and Research; June 2022.

The potential for workplace violence degrades patient and staff safety. AHRQ is developing a survey item set that will help nursing homes identify and improve factors associated with workplace safety. The Workplace Safety Supplemental Item Set will assess the extent to which nursing homes’ organizational culture supports workplace safety. The new supplemental item set can be administered optionally at the end of the SOPS Nursing Home Survey. AHRQ will build this new measure of workplace safety upon its existing and highly successful SOPS program. This announcement calls for nursing homes to participate in a pilot study to test the application of the supplemental item set in the field.

Agency for Healthcare Research and Quality. 

Effective measurement of diagnostic error is essential for understanding the problem and generating improvements. The Common Formats provide a standard terminology for voluntary reporting of diagnostic errors to patient safety organizations. This website provides access to tools supporting use of the Common Formats that include forms and a users' guide.

All Toolkits (17)

1 - 17 of 17 Results
Measurement Tool/Indicator
Joint Commission.
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.
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 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.
Boston, MA: Institute for Healthcare Improvement; 2019.
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.
Institute for Safe Medication Practices; ISMP.
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. 
Incident Analysis Collaborating Parties. Edmonton, AB: Canadian Patient Safety Institute; 2012.
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.
Canadian Institute for Health Information, Canadian Patient Safety Institute.
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.
Philadelphia, PA: Pew Charitable Trusts; September 6, 2016.
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.
Measurement Tool/Indicator
National Quality Forum.
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. 
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. 
Measurement Tool/Indicator
National Quality Forum; NQF.
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.
National Quality Measures Clearinghouse; NQMC.
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.
Center for Patient Safety.
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.
Rockville, MD: Agency for Healthcare Research and Quality; October 2020.
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.
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.
Griffin FA, Resar RK. IHI Innovation Series white paper. Cambridge, MA: Institute for Healthcare Improvement; 2009.
This white paper describes a tool that employs triggers to identify adverse events and measure their rate of occurrence. The authors discuss the development and methodology of the tool, suggestions for training, and the experiences of organizations that have used it.