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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
Food and Drug Administration and Institute for Safe Medication Practices. Plymouth Meeting, PA; Institute for Safe Medication Practices; January 2023.
Mistakes associated with look-alike medication names are a safety concern in health care. Tall man, or mixed case, 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 mixed case lettering to make their use safer.
Collaborative for Accountability and Improvement Policy Committee. Seattle, WA: University of Washington; 2022
Communication and resolution programs (CRP) show promise for improving patient and clinician communication after a harmful preventable adverse event. This tool provides a framework for organizational messaging on CRPs for patients and families.
Multi-use Website
Institute for Healthcare Improvement.
This website provides resources for promoting patient safety during Patient Safety Awareness Week. The 2023 observance will be held March 12-18.
Yount N, Edelman S, Sorra J, et al. Rockville, MD: Agency for Healthcare Research and Quality; November 2022. AHRQ Publication No. 23-0011.
Improving the culture of safety within health care is an essential component of preventing or reducing errors. Designed for users of the AHRQ safety culture surveys, this updated tool will help organizations develop an action plan and proactively discuss potential barriers to safety culture improvement efforts and how to address them. The revision is structured around a 3-step process that focuses on areas to improve, initiative planning, and plan communication. The kit now includes an action plan template.
All Toolkits (157)
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Rockville, MD: Agency for Healthcare Research and Quality; April 2022.
Healthcare-associated infections can result in significant morbidity and mortality. Developed by AHRQ, this customizable, educational toolkit uses the Comprehensive Unit-based Safety Program (CUSP) and other evidence-based practices to provide clinical and cultural guidance to support practice changes to prevent and reduce central line-associated bloodstream infection (CLABSI) and catheter-associated urinary tract infection (CAUTI) rates in intensive care units (ICUs). Sections of the kit include items such an action plan template, implementation playbook, and team interaction aids.
Tools/Toolkit
Rockville, MD: Agency for Healthcare Research and Quality; March 2022.
The recognition of diagnosis as a team activity is energizing new diagnostic process initiatives. Building on the established TeamSTEPPS® principles, this new TeamSTEPPS course includes seven training modules, team and knowledge assessment tools, and implementation guidance to develop or enhance communication across the care team to improve the accuracy and timeliness of diagnosis.
Tools/Toolkit
RA-UK, the Faculty of Pain Medicine, RCoA Simulation and NHS Improvement
Standardization is a common strategy for preventing practice deviations that can contribute to harm. This tool outlines a three-step process for minimizing the occurrence of wrong-side peripheral nerve blocks that involves preparing for the procedure, stopping to perform a two-person site confirmation, and then administering the block.
Organizational Policy/Guidelines
Horsham, PA: Institute for Safe Medication Practices; 2022.
This updated report outlines 19 consensus-based best practices to ensure safe medication administration, such as diluted solutions of vincristine in minibags and standardized metrics for patient weight. The set of recommended practices has been reviewed and updated every two years since it was first developed in 2014 to include actions related to eliminating the prescribing of fentanyl patches for acute pain and use of information about medication safety risks from other organizations to motivate improvement efforts. The 2022 update includes new practices that are associated with oxytocin, barcode verification in vaccine administration, and high-alert medications.
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.
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 emergency and primary care settings to minimize patient suicide and self-harm. Areas of focus include post-discharge follow-up, admissions, and family engagement.
Horsham, PA: Institute for Safe Medication Practices; 2021.
This fact sheet provides a list of high-alert medications commonly used in ambulatory care and recommends strategies to reduce risk of errors.
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.
Measurement Tool/Indicator
Rockville, MD: Agency for Healthcare Research and Quality; June 2022.
The AHRQ Surveys on Patient Safety Culture™ (SOPS®) Medical Office 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 data submission window for 2022 is now closed.
Rockville, MD: US Food and Drug Administration; 2021.
To protect children and pets from accidental exposure to prescription medications, this consumer alert outlines the dangers of inappropriate storage and disposal of medication skin patches.
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.
Measurement Tool/Indicator
Agency for Healthcare Research and Quality. April 2021.
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.
Multi-use Website
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 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.
Horsham, PA; Institute for Safe Medication Practices; February 12, 2021.
A handy list for medical personnel to ensure and implement safe prescribing practices by avoiding use of these dangerous shortcuts.
Tools/Toolkit
Harrisburg, PA: Pennsylvania Safety Authority; 2020.
Time pressure can negatively impact critical thinking, information gathering, and communication abilities. This tool builds teamwork and decision-making skills by testing participants as they work through a time-delimited scenario with a sick child to gather clues and determine a diagnosis.
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.
Rockville, MD; Agency for Healthcare Research and Quality: 2020.
The COVID-19 pandemic is placing surge demand and strain on health organizational, department, and unit-level capacity and personnel. This announcement features a prototype tool as a model for health systems to evaluate hospital-specific demand for medical and intensive care unit beds and the needed equipment to equip staff to keep patients safe during shifting conditions associated with providing care during an emerging crisis.
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.
