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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

Multi-use Website
Institute for Healthcare Improvement.
This website provides resources for promoting patient safety during Patient Safety Awareness Week. The 2023 observance will be held March 12-18. 

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.

Rockville, MD: Agency for Healthcare Research and Quality; October 2022.

Inappropriate antibiotic prescribing is associated with increased risk potential. This toolkit assists in simplifying the antibiotic decision-making process. It is organized around a four-point decision aide and contains resources on using a stewardship program, communicating about prescribing and applying best practices for common infectious diseases.

All Toolkits (266)

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Displaying 61 - 80 of 266 Results
Fact Sheet/FAQs
Classic
Horsham, PA; Institute for Safe Medication Practices: February 2019.
Drawing on information gathered from the ISMP Medication Errors Reporting Program, this fact sheet provides a comprehensive list of commonly confused medication names, including look-alike and sound-alike name pairs. Drug name confusion can easily lead to medication errors, and the ISMP has recommended interventions such as the use of tall man lettering in order to prevent such errors. An error due to sound-alike medications is discussed in this AHRQ WebM&M commentary.
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.
Itasca, IL: American Academy of Pediatrics; 2018.
Diagnostic error prevention in primary care is a persistent challenge. This AHRQ-funded toolkit provides guidance for ambulatory care organizations that seek to improve the reliability of diagnosis in children. The material focuses on tactics to enhance how practices recognize, track, and follow up on adolescent depression, pediatric elevated blood pressure, and actionable laboratory results.
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.
Horsham, PA; Institute for Safe Medication Practices: 2018.
This fact sheet lists medications with a high risk of causing significant harm to patients when incorrectly administered. The 2018 publication reflects insights gathered through a survey of current medication use in acute care facilities. The update includes changes such as expanded examples of antithrombotic agents listed and removal of IV radiocontrast media due to lack of errors reported with its use.
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.
Fact Sheet/FAQs
Patient Safety and Risk Management Service Delivery and Safety. Geneva, Switzerland; World Health Organization: August 2019.
This publication highlights statistics that illustrate the global impact of patient harm. The information provided includes the number of hospitalized patients injured during the care process, global costs of medication-related harms, and risks associated with radiation use.
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.
Tools/Toolkit
NHS Improvement. London, UK: National Health Service; March 15, 2018.
Although focusing on system failure has been highlighted as key to improving patient safety, individual behaviors must also be recognized as contributors to risks. This guide provides tactics for managers to address concerns associated with practitioner performance that arise during incident investigations. The guide helps managers initiate constructive conversations with clinical staff when their performance creates conditions for unsafe care delivery.
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.
Rockville, MD: Agency for Healthcare Research and Quality; March 2018.
Organizational culture can affect the use of tools and processes implemented to improve safety. This release of the Health Information Technology Patient Safety Supplemental Item Set to be used in conjunction with the AHRQ Surveys on Patient Safety Culture™ (SOPS®) Hospital Survey can help organizations explore how culture affects the use of health information technology. Included with the data set is a report of initial results regarding its use in the field.
Institute for Safe Medication Practices; ISMP.
Smart infusion pumps help prevent dosage errors and capture metrics on therapy delivery and omissions. This survey sought to gather data on how clinicians use infusion pump data to inform improvement efforts. 
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.
Center for Health Design. Concord, CA: Center for Health Design; 2018.
Behavioral and mental health patients have unique concerns that affect their safety. This toolkit provides strategies, insights, and research to address vulnerabilities to this patient population. Design interventions to improve the service environment are also available.
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.
Rockville, MD: Agency for Healthcare Research and Quality; November 2017.
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.
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.
Society to Improve Diagnosis in Medicine.
Clinical reasoning can be flawed due to bias, fatigue, or knowledge deficits. This tool provides a five-component mechanism to help instructors assess students' diagnostic reasoning abilities and guide feedback (i.e., hypothesis-directed data gathering, articulation of a problem representation, formulation of a prioritized differential diagnosis, diagnostic testing aligned with high-value care principles, and metacognition. Faculty development videos are also provided to guide in use of the tool.