Toolkits

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. 

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.

Behavioral and mental health patients have unique concerns that affect their safety. This toolkit provides strategies, insights, and research to address vulnerabilities to this patient population. Design interventions to improve the service environment are also available.

Mistakes associated with look-alike medication names are a safety concern in health care. Tall Man lettering is one recommended strategy to reduce confusion associated with similarities in drug names. This list includes medications recognized by clinicians and professional organizations as those suited for the application of Tall Man lettering to make their use safer.

Checklists are a recommended method to reduce omissions in care, despite controversies regarding their impact on safety. This toolkit provides a collection of checklists that have been developed and field tested by participants in the Hospital Engagement Network to prevent harm associated with the use of central lines, adverse drug events, and falls.

Patient falls are preventable and can be addressed through quality and safety strategies. This toolkit provides a process to help health care organizations determine factors that contribute to falls in their facilities and design interventions to drive improvement.

Engaging patients and families in safety can uncover concerns and inform improvement efforts. This three-component toolkit provides resources that focus on incident management, patient safety management, and system factors to prevent and respond to failures or near misses.

Health care–associated infections are a known contributor to adverse events among patients on dialysis. Building on evidence and insights from clinicians, this four-part toolkit includes videos, assessment tools, and slide presentations regarding how to apply principles of teamwork, patient engagement, and safety culture to ensure dialysis centers provide safe care to patients with end-stage renal disease.

Alarm fatigue has been identified as a serious problem that affects the safety of nursing care. This toolkit provides checklists, resources, and implementation guidance to help clinical nurse specialists develop and lead alarm management programs with the goal of reducing fatigue and distraction related to nuisance alarms.

This toolkit provides a checklist, a planning guide, and other tools to help address disruptive staff behavior.

This Web site provides toolkits and information to help Washington hospitals adopt standard practices for emergency code calls, surgery preparation, isolation precautions, and wristband use.

This toolkit offers policy information and educational materials regarding a voluntary, statewide initiative to standardize wristband colors.

This initiative provides a surgical safety checklist and related educational and training materials building on the Second Global Patient Safety Challenge vision to encourage international adoption of a core set of safety standards. Implementation of this World Health Organization’s checklist has resulted in dramatic reductions in surgical mortality and complications across diverse international hospitals. Surgical checklists have now become one of the clearest success stories in the patient safety movement, although some have described challenges to effective implementation. Dr. Atul Gawande discussed the history of checklists as a quality and safety tool in his book, The Checklist Manifesto: How to Get Things Right.

This set of materials provides checklists, worksheets, and other aids to help implement a reliable critical test result communication program. A previous AHRQ WebM&M commentary addressed the issue of communication surrounding critical laboratory values. 

Produced in conjunction with its Partnerships in Implementing Patient Safety (PIPS) grant program, AHRQ has released 17 freely available toolkits to help hospitals and health care providers reduce medical errors. Along with educational materials, the toolkits include medication guides and checklists, all of which are adaptable to most health care settings and designed for use by multidisciplinary teams.

This website offers information and a toolkit regarding standardizing the colors of wristbands, stickers, and placards to signify risk alert status for hospital-based patient care.

This manual provides nursing home staff with a step-by-step guide for medication management to reduce medication errors in long-term care.

This article lists common risks associated with opiates, a high-alert medication, as well as recommended safety improvements to reduce these risks.

This 5-point checklist provides consumers with steps to help ensure the safety of their medication use.

These materials provide an introduction to the purpose of healthcare failure mode and effect analysis (HFMEA), the steps of the HFMEA process, and how to apply the technique to address the Joint Commission proactive risk assessment standard.