Toolkits

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.

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. 

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. 

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 emergent and primary care settings to minimize patient suicide and self-harm. Areas of focus include post-discharge follow-up, admissions, and family engagement.

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.

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.

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.

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.

Communication and shared decision-making are fundamental tactics to guide clinical team and patient efforts to minimize the potential for prescription opioid misuse. This tool kit includes modules for providers that outline practice and communication strategies to help with postoperative pain. Patient and family materials in the kit focus on safe medication disposal and instructions for tracking pre- and post-surgery pain levels.

This toolkit focuses on identification of, and rapid response to, sepsis in obstetric patients. It includes screening, evaluation and monitoring, and antibiotic use recommendations for maternal sepsis patient.

Structured processes are important strategies for embedding safe care practices. This tool kit shares training modules and tools to support a 4-point practice to improve antibiotic prescribing and reduce hospital-acquired infections. Elements of the process center on diagnosis, testing, reassessment and duration.

The Comprehensive Unit-based Safety Program (CUSP), originally developed at Johns Hopkins Hospital by Dr. Peter Pronovost and colleagues, has been instrumental in driving patient safety improvement in several landmark patient safety initiatives. The CUSP approach emphasizes improving safety culture by through a continuous process of reporting and learning from errors, improving teamwork, and engaging staff at all levels in safety efforts.  Most recently, an AHRQ-funded project using the CUSP model achieved a 40% reduction of central line–associated bloodstream infections in intensive care units nationwide. This toolkit includes modules on how to build the CUSP team, identify recurring safety concerns, and improve teamwork and communication.

Hospitalized patients are at risk for medication errors. This set of tips seeks to help hospitalized patients contribute to the safe use of medications in their care. Recommendations include that patients know the reason they are taking each medication, speak up if any medications look different than previously, and talk with pharmacists when picking up discharge medications.

The AHRQ Health Literacy Universal Precautions Toolkit, 2nd edition, can help primary care practices reduce the complexity of health care, increase patient understanding of health information, and enhance support for patients of all health literacy levels.

Newborns assigned temporary names are at increased risk for patient misidentification and wrong-patient errors. This newsletter article reports on the role of electronic health records in newborn misidentification and the unintended consequences associated with a Joint Commission set of recommendations to reduce risk. 

This resource provides newsletters that target concerns associated with spinal pain interventions and offers safety strategies. The collection focuses on three primary areas: procedural contraindications, procedure-related complications, and injectate-related complications such as the safe use of multi-dose and single-dose vials.

Patient engagement has been promoted as a strategy to enhance safety in health care. This toolkit helps patients organize information about their medical history, current concerns, symptoms, and medications to prepare them for medical appointments.

Inadequate follow-up of test results can contribute to missed and delayed diagnoses. Developing optimal test result management systems is essential for closing the loop so that results can be acted upon in a timely manner. The Partnership for Health IT Patient Safety convened a working group to identify how technology can be used to facilitate improved communication and timely action regarding test results. This report summarizes the methods used by the working group and their findings. Recommendations include improving communication by standardizing the format of test results, including required timing for diagnostic testing responses, automating the notification process in electronic health records, and optimizing alerts to reduce alert fatigue. A past WebM&M commentary discussed a case involving ambulatory test result management.

Data surveillance and transparency are core to measuring and informing improvement efforts. This website provides detailed data that links ambulatory care prescribing activity to National Health Service hospitalizations in an effort to clarify potential adverse medication events. The dashboard launched tracking gastrointestinal bleeding as an indicator of a medication-related adverse result and will expand to other indicators and conditions over time.

Although focusing on system failure has been highlighted as key to improving patient safety, individual behaviors must also be recognized as contributors to risks. This guide provides tactics for managers to address concerns associated with practitioner performance that arise during incident investigations. The guide helps managers initiate constructive conversations with clinical staff when their performance creates conditions for unsafe care delivery.