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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; 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.
Press Release/Announcement
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.
Measurement Tool/Indicator
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.
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.
All Toolkits (82)
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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.
Rockville, MD: Agency for Healthcare Research and Quality; August 2021. AHRQ Publication No. 21-0047-2-EF.
Patient and family engagement is core to effective and safe diagnosis. This new toolkit from the Agency for Healthcare Research and Quality promotes two strategies to promote meaningful engagement and communication with patients to improve diagnostic safety: (1) a patient note sheet to help patients share their story and symptoms and (2) orientation steps to support clinicians listening and “presence” during care encounters.
BeMedWise Program at NeedyMeds, Gloucester, MA.
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".
Fact Sheet/FAQs
Oakbrook Terrace, IL: Joint Commission. 2002-2020.
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.
Horsham, PA; Institute for Safe Medication Practices; February 12, 2021.
A handy list for medical personnel to ensure and implement safe prescribing practices by avoiding use of these dangerous shortcuts.
Tools/Toolkit
Child Health Patient Safety Organization. Washington DC: Children's Hospital Association; May 2020.
Effective communication is an important component of diagnostic accuracy. Shaped with data collected by a patient safety organization, this five section toolkit features tactics to support effective communication across diagnostic process in children’s hospital care, including the use of time outs, case analysis and communication gap assessment.
Multi-use Website
Circle Up for COVID-19 Training. Center for Medical Simulation.
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.
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.
Toolkit
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.
Toolkit
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.
Fact Sheet/FAQs
Agency for Health Research Research and Quality.
The AHRQ Health Literacy Universal Precautions Toolkit, 2nd edition, can help primary care practices reduce the complexity of health care, increase patient understanding of health information, and enhance support for patients of all health literacy levels.
Meeting/Conference Proceedings
Canadian Patient Safety Institute: 2019.
Structured approaches to managing negative psychological consequences of medical errors on health care professionals, patients, and families are important for emotional healing and organizational learning. This webinar series featured discussions on peer support efforts and a toolkit for Canadian health care workers.
Book/Report
Boston, MA: Institute for Healthcare Improvement; 2019.
This toolkit provides access to nine key tools to help organizations improve teamwork, incident analysis, and communication as well as templates to support their use and instructions to begin associated processes. Featured tools include the Situation-Background-Assessment-Recommendation approach, huddle agendas, and failure modes and effects analysis.
Toolkit
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.
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.
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.
Government Resource
Agency for Healthcare Research and Quality; AHRQ.
Health literacy is important for effective care communications and safe medication use. This toolkit provides resources associated with medication therapy management and patient health literacy. Materials include health literacy assessments and guidance for prescription medicine instructions. A past PSNet perspective discussed the role of health literacy in patient safety.
Measurement Tool/Indicator
Institute for Safe Medication Practices; ISMP.
Texting as a communication method in the clinical environment is convenient, but it introduces distraction that can result in error. This survey sought to track the prevalence of medical order texting to better understand its impact on care processes.
Rockville, MD: Agency for Healthcare Research and Quality; December 2014.
Ambulatory surgery centers provide care to growing numbers of patients. This toolkit draws from AHRQ's Comprehensive Unit-based Safety Program to help ambulatory surgical center teams develop communication and teamwork skills to reduce infections and other iatrogenic harms.
Measurement Tool/Indicator
ISMP; Institute for Safe Medication Practices.
Verbal orders are prevalent in all care environments, but they are often complex communications that can place patients at risk for harm. Given the increase of electronic prescribing, this survey explores current verbal medication ordering practices and strategies to ensure their effectiveness.
