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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

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.

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 (23)

1 - 20 of 23 Results
Duke Center for Healthcare Safety and Quality.
Improving teamwork and communication is a continued focus in the hospital setting. This toolkit is designed to help organizations create a culture that embeds teamwork into daily practice routines. Topics covered include team leadership, learning and continuous improvement, clarifying roles, structured communication, and support for raising concerns.
Davis K, Collier S, Situ J, et al. Rockville, MD: Agency for Healthcare Research and Quality; December 2017. AHRQ Publication No. 1800051EF.
Transitions are known to be vulnerable to communication errors. This toolkit focuses on patient transitions between ambulatory care environments and encourages staff to engage patients and families in their care to prevent errors during care transitions.
Boutwell A, Bourgoin A , Maxwell J, et al. Rockville, MD: Agency for Healthcare Research and Quality; September 2016. AHRQ Publication No. 16-0047-EF.
This toolkit provides information for hospitals to help reduce preventable readmissions among Medicaid patients. Building on hospital experience with utilizing the materials since 2014, this updated guide explains how to determine root causes for readmissions, evaluate existing interventions, develop a set of improvement strategies, and optimize care transition processes.
Rockville, MD: Agency for Healthcare Research and Quality; December 2013. AHRQ Publication No. 12(14)-0054-EF.
Infants discharged from the neonatal intensive care unit to home are particularly vulnerable to care coordination errors. This four-component toolkit includes materials to help hospitals implement a coach program to educate providers and families about common communication and health concerns that arise during this transition.
Society for Hospital Medicine.
This Web site provides resources to help health systems implement the Multi-Center Medication Reconciliation Quality Improvement Study (MARQUIS) medication reconciliation program. 
Rockville, MD: Agency for Healthcare Research and Quality; June 2013.
Studies have shown that a surprisingly large proportion of hospitalized patients are not aware of their diagnoses or treatment plan and that their preferences are often not taken into account in advanced care planning. This failure to provide patient-centered care indicates a need for increased patient engagement in safety and quality efforts. This toolkit published by the Agency for Healthcare Research and Quality is designed to help hospitals develop partnerships with patients around improving safety. Developed with input from clinicians and patients, the guide emphasizes four strategies—working with patients as advisors, improving bedside communication, integrating patients and families into shift changes, and using patient input to improve the discharge process. An AHRQ WebM&M perspective by Dr. Saul Weingart discusses the practical challenges of engaging patients in improvement efforts.
This Web site offers information about a standardized process for handoffs in emergency care designed to help reduce risks and improve reliability.
Jack B, Paasche-Orlow M, Mitchell S, Forsythe S, Martin J. Rockville, MD: Agency for Healthcare Research and Quality; September 2015. AHRQ Publication No. 12(13)-0084.
This toolkit provides information to help hospitals implement Project RED, including how to determine goals at the outset and measure project outcomes after implementation.
Gleason KM, Brake H, Agramonte V, Perfetti C. Rockville, MD: Agency for Healthcare Research and Quality; 2012. AHRQ Publication No.11(12)-0059.
This toolkit, based on lessons learned from facilities that have implemented the Medications at Transitions and Clinical Handoffs (MATCH) initiative, provides strategies to implement and improve medication reconciliation in health care.

The Royal Pharmaceutical Society. 

This Web site offers a toolkit to improve the safety of handoffs, patient transfers, and post-hospitalization medication use.
Boston University Medical Center.
This Web site includes information on the Re-Engineered Discharge project (Project RED), which has developed strategies to enhance patient safety by improving the hospital discharge process to reduce readmissions.
Little Rock, AR: National Transitions of Care Coalition; April 2008.
This Web site provides tools for providers to improve patient safety during transitions, including a medication card, care transitions checklist, guidebooks, and policy papers.
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. 
Banner Health.
This AHRQ-funded toolkit provides templates and other documentation support to help hospitals implement an initiative to improve patient flow processes by reducing the time emergency department patients wait to be seen and admitted. The model is also designed to gain front-line practitioner acceptance of these changes and to improve both efficiency and patient safety.
Leonhardt K; Bonin K; Pagel P; Aurora Health Care; Consumers Advancing Patient Safety; CAPS.
This AHRQ-funded toolkit outlines how one Midwestern hospital system successfully implemented a patient advisory council. A companion toolkit illustrates how the council worked with the hospital to develop and implement a medication list initiative.