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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
Measurement Tool/Indicator
Rockville, MD: Agency for Healthcare Research and Quality; October 2020.
Ambulatory surgery centers (ASCs) 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. Voluntary data submission will be open June 1-22 for ASCs that have administered the survey.
Measurement Tool/Indicator
Classic
Rockville MD: Agency for Healthcare Research and Quality; 2020.
Culture has been described as a key to establishing high reliability organizations. The National Quality Forum's Safe Practices for Healthcare and the Leapfrog Group both mandate hospitals to regularly assess their safety culture. This AHRQ Web site provides validated safety culture survey tools (Hospital, Medical Office, Nursing Home, Community Pharmacy, Ambulatory Surgery Center), user guides health care organizations can use to implement the surveys and a bibliography of articles discussing the use of SOPS in the field. Organizations can also use the AHRQ database to compare their Surveys on Patient Safety Culture™ (SOPS®) results. In addition, reports are available that summarize the benchmarking data across cohorts nationwide. An AHRQ WebM&M perspective discussed how to establish a safety culture.
Organizational Policy/Guidelines
Horsham, PA; Institute for Safe Medication Practices: April 2023.
Community pharmacies are common providers of medication delivery that harbor process weaknesses affecting safety. This guidance shares evidence-based steps to address problems such as wrong patient errors and lack of consistent barcode system use in the community setting.
Measurement Tool/Indicator
Joint Commission.
This website provides sentinel event data reported to The Joint Commission, which includes information on sentinel events reported from January through December 2022. Falls, unintended retained foreign bodies, and delays in treatment were among the most frequently submitted incidents in this time period which represents a 19% increase over 2021. The data and graphs are updated regularly and include a 5 year trend analysis and specific analysis associated with event type by year from 2018 through 2022.
All Toolkits (10)
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Measurement Tool/Indicator
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.
Measurement Tool/Indicator
Horsham, PA: Institute for Safe Medication Practices; March 2017.
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.
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.
Measurement Tool/Indicator
Institute for Safe Medication Practices.
This reporting program collects data on errors and concerns associated with vaccines.
Center for Drug Evaluation and Research, US Food and Drug Administration. June 4, 2018.
This FAQ provides information on and access to quarterly reports and an interactive dashboard of medication-related incidents culled from FDA's Adverse Event Reporting System (FAERS) database and identifies potential safety issues.
Fact Sheet/FAQs
FDA Consumer Health Information. Silver Spring, MD: US Food and Drug Administration; February 27, 2009.
This fact sheet provides information for consumers about how to report adverse drug events and product complaints to the US Food and Drug Administration (FDA) through the Consumer Complaint Reporting system and MedWatch.
Multi-use Website
Institute for Healthcare Improvement; IHI
This Web page provides summaries of and links to the various trigger tools available from the Institute for Healthcare Improvement to use in identifying adverse events.
Press Release/Announcement
Centers for Medicare and Medicaid Services; CMS
This fact sheet provides information regarding the Centers for Medicare and Medicaid Services' initiative to better understand and minimize never events.
Measurement Tool/Indicator
Institute for Safe Medication Practices
The Institute for Safe Medication Practices (ISMP) administers this national reporting program, which collects confidential reports of medication errors and near misses directly from practitioners. Information is forwarded to the US Food and Drug Administration and product manufacturers. The program also provides access to ISMP's patient safety organization reporting mechanism and publishes the National Alert Network or NAN Alerts to share information generated from report analysis broadly to support learning.
Toolkit
American Hospital Association; Health Research and Educational Trust; Institute for Safe Medication Practices
A compendium of risk assessment tools to assist in the prevention of medication errors. The tools emphasize the importance of a multidisciplinary approach to managing risk with key sections focusing on physicians, nurses, pharmacists, risk managers, and administrators.
