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.
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.
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.
Durham, NC: Duke Center for Healthcare Safety and Quality; June 2019.
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.
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.
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.
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.
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.
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.
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.
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