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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

NIHCM Foundation. Washington DC: National Institute for Health Care Management. August 2, 2022.

Preventable maternal morbidity is an ongoing challenge in the United States. This infographic shares general data and statistics that demonstrate the presence of racial disparities in maternal care that are linked to structural racism. The resource highlights several avenues for improvement such as diversification of the perinatal staffing and increased access to telehealth.

Rockville, MD: Agency for Healthcare Research and Quality; July 2022.  AHRQ Publication No. 22-0038.

Diagnostic improvement continues to gain focus as a goal in health care. The Measure Dx tool provides teams with guidance and strategies to detect and learn from diagnostic errors in their organizations. It includes a checklist to gauge readiness for implementation, measurement strategies, and recommendations for analyzing data and translating findings into front line care. 

Rockville, MD: Agency for Health Quality and Research; June 2022.

The potential for workplace violence degrades patient and staff safety. AHRQ is developing a survey item set that will help nursing homes identify and improve factors associated with workplace safety. The Workplace Safety Supplemental Item Set will assess the extent to which nursing homes’ organizational culture supports workplace safety. The new supplemental item set can be administered optionally at the end of the SOPS Nursing Home Survey. AHRQ will build this new measure of workplace safety upon its existing and highly successful SOPS program. This announcement calls for nursing homes to participate in a pilot study to test the application of the supplemental item set in the field.

Agency for Healthcare Research and Quality. 

Effective measurement of diagnostic error is essential for understanding the problem and generating improvements. The Common Formats provide a standard terminology for voluntary reporting of diagnostic errors to patient safety organizations. This website provides access to tools supporting use of the Common Formats that include forms and a users' guide.

All Toolkits (77)

1 - 20 of 77 Results
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. 
Multi-use Website
Institute for Healthcare Improvement.
This website provides resources for promoting patient safety during Patient Safety Awareness Week. The annual observance is held in March.
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. 

American Society of Anesthesiologists, American Academy of Orthopaedic Surgeons. Pain Alleviation Toolkit.  March 12, 2020.

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.

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.
Agency for Healthcare Research and Quality. 2019.
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.
Multi-use Website
Rockville, MD: Agency for Healthcare Research and Quality; August 2019.
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.
Horsham, PA: Institute for Safe Medication Practices; 2019.
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.

ISMP Medication Safety Alert! Acute Care Edition. April 25, 2019.

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. 
Commentary
SIS Patient Safety Committee. Spine Intervention Society.
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.
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.
Chicago, IL: Health Research & Educational Trust; 2018.
Proactive identification of conditions that degrade the diagnostic process can drive improvement. This toolkit provides resources to help organizations seeking to improve diagnosis. The publication includes case studies that illustrate implementation challenges and provides infrastructure enhancement suggestions for hospital teams as they design interventions to reduce diagnostic errors.
SIDM Patient Engagement Committee. Evanston, IL: Society to Improve Diagnosis in Medicine; October 2018.
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.
Partnership for Health IT Patient Safety. Plymouth Meeting, PA: ECRI; August 2018.
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.
Government Resource
National Health Service.
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.
University of Utah Drug Information Service; ASHP; American Society of Health-System Pharmacists.
Efforts to limit the availability of opioids has led to a shortage of needed medications. This fact sheet provides strategies for organizations who seek to improve management of injectable opioids while taking into account both safety and supply availability.
Rockville, MD: Agency for Healthcare Research and Quality. June 2017.
Communication in labor and delivery units can be challenging. This AHRQ-funded program draws from comprehensive unit-based safety program principles to reduce errors in maternal and neonatal care. The toolkit provides guidance and materials focused on enhancing teamwork skills, implementing perinatal safety strategies, and utilizing in situ simulation. Team training modules and care bundles are shared to enable skill development. A previous WebM&M commentary explored a near miss with a neonate.
Toolkit
Choosing Wisely Canada.
Opioid misuse is a concern in both the United States and Canada. This campaign shares 14 specialty-specific recommendations to improve opioid safety in Canadian hospitals. An Annual Perspective discussed the opioid crisis as a patient safety concern.
Government Resource
Health Education England, Public Health England, National Health Service England; NHS England and Community Health and Learning Foundation.
Limits in patients' ability to understand health instructions and information affects the safety of their care. This toolkit provides resources related to health literacy including a business case for interventions, educational materials, and guides for engaging patients in discussions about low health literacy.
Agency for Healthcare Research and Quality; AHRQ.
Preventing surgical complications including surgical site infections are a worldwide target for improvement. This toolkit builds on the success of the Comprehensive Unit-based Safety Program to initiate change. The tools represent practical strategies that helped members of a large-scale collaborative to identify areas of weakness, design improvements, and track the impact of the interventions.