Toolkits

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.

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.

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. 

This fact sheet provides a list of high-alert medications commonly used in ambulatory care and recommends strategies to reduce risk of errors.

The AHRQ Surveys on Patient Safety Culture™ (SOPS®) Medical Office Survey collects information from outpatient providers and staff about the culture of patient safety in their medical offices. The survey is intended for offices with at least three providers, but it also can be used as a tool for smaller offices to stimulate discussion about quality and patient safety issues. The survey is accompanied by a set of resources to support its use. The data submission window for 2022 is now closed.

To protect children and pets from accidental exposure to prescription medications, this consumer alert outlines the dangers of inappropriate storage and disposal of medication skin patches.

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.

This Web site provides information and tools that support an educational campaign to encourage high-quality communication about medication use. The annual observance is in October and the last observance focused on the theme of "Medication Adherence – On track with your meds and your health".

A series of patient safety brochures, videos and infographics directed toward specific areas of care that encourages patients to take an active role by asking questions and addressing problems with their providers. Topics include preventing falls, medication safety, and safe surgery. Available in both English and Spanish.

A handy list for medical personnel to ensure and implement safe prescribing practices by avoiding use of these dangerous shortcuts.

Time pressure can negatively impact critical thinking, information gathering, and communication abilities. This tool builds teamwork and decision-making skills by testing participants as they work through a time-delimited scenario with a sick child to gather clues and determine a diagnosis. 

Communication strategies are important for engaging staff in behaviors that support effective teamwork. This website highlights a process that involves briefings, supportive conversations, and debriefings as a communication structure for use during COVID-19 care episodes and other complex interactions.

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. 

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.

Patient safety organizations (PSOs) collect and analyze protected incident data from across the United States. Expert analysis of PSO data can be utilized to inform design and implementation of local initiatives. This brochure provides guidance for health care organizations regarding benefits of working with a PSO and what to consider when choosing one.

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.

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.