Email Updates
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
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.
Houston TX; Baylor College of Medicine: 2022.
Assessment can identify the current state of a process or program to reveal areas of weakness and inform improvement implementation efforts. This scenario-based tool focuses on 10 areas of an organization’s journey to support diagnostic safety.
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.
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.
All Toolkits (17)
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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.
Horsham, PA: Institute of Safe Medication Practices; 2021
Long-term care patients often have concurrent conditions that increase their risk of medication error. This fact sheet provides a list of potential high-alert medications prevalent in long-term care settings that should be administered with particular care due to the heightened potential for harm. A past PSNet perspective discussed medication safety in nursing homes.
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.
Krukas A, Franklin ES, Bonk C, et al. Patient Safety. 2020;2.
Intravenous vancomycin is an antibiotic with known medication safety risk factors. This assessment is designed to assist organizations to review clinician and organizational knowledge, medication administration activities and health information technology as a risk management strategy to minimize hazards associated with vancomycin use.
Stanford, CA; California Maternal Quality Care Collaborative: January 22, 2020.
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.
Horsham, PA: Institute for Safe Medication Practices; 2018.
Standardized practices have not been uniformly adopted to support safe IV medication therapy. This risk assessment tool will help organizations proactively identify process weaknesses that could contribute to patient harm. Users of the guide can also contribute to a national effort to collect data on current IV push practices. The data collection process is now closed.
Fact Sheet/FAQs
Horsham, PA; Institute for Safe Medication Practices: 2018.
This fact sheet lists medications with a high risk of causing significant harm to patients when incorrectly administered. The 2018 publication reflects insights gathered through a survey of current medication use in acute care facilities. The update includes changes such as expanded examples of antithrombotic agents listed and removal of IV radiocontrast media due to lack of errors reported with its use.
Kaprielian VS; Sullivan DT; Josie King Foundation.
The experience of Sorrel King and the death of her daughter has motivated health care leaders and the industry to improve patient safety. This curriculum provides a set of materials that incorporates lessons from Josie's Story into existing educational programs.
Book/Report
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.
Multi-use Website
Silver Spring, MD: American Nurses Association; 2015.
Nurses play an important role in reducing catheter–associated urinary tract infections (CAUTIs). This toolkit, developed as a Partnership for Patients strategy, focuses on promoting nursing behaviors to prevent CAUTIs including decreasing catheter use and improving catheter maintenance.
Toolkit
National Association of Clinical Nurse Specialists; NACNS.
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.
Fact Sheet/FAQs
Consumer Updates. Silver Spring, MD: US Food and Drug Administration; December 12, 2012.
Highlighting concerns associated with patients' use of medical devices at home, such as difficulty understanding instructions, this article offers tips for consumers to help reduce risks.
Toolkit
Association of periOperative Registered Nurses; AORN
This Web site includes information and resources for National Time Out Day, an initiative to raise awareness on the importance of surgical team time outs. The annual observation is in June.
Massachusetts Coalition for the Prevention of Medical Errors, MassPRO, Massachusetts Extended Care Foundation. Boston, MA: Commonwealth of Massachusetts; 2007.
This manual provides nursing home staff with a step-by-step guide for medication management to reduce medication errors in long-term care.
Measurement Tool/Indicator
ISMP
This article lists common risks associated with opiates, a high-alert medication, as well as recommended safety improvements to reduce these risks.
