Toolkits

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.

The opioid crisis is a persisting patient safety problem. One approach to prevent misuse of opioids is to raise awareness of the addictive nature of the medication. This national campaign enlists communities and individual clinicians to provide patient education to address the opioid epidemic. The website offers videos and other resources to assist community-level efforts to reduce risk for opioid addiction.

High-alert medications have the potential to cause substantial patient harm if administration mistakes occur. This assessment tool will enable organizations across a range of care environments to determine opportunities for improvement in 11 high-alert medication categories. In addition, the tool provides an opportunity for organizations to submit their data anonymously to a national data collection effort led by the Institute for Safe Medication Practices to define the current state of high-alert medication practices in health care. The data submission process is now closed.

Both organizational culture and the physical environment affect the safety of care delivery. This toolkit provides resources to help organizations assess hazards related to the design of their facilities. The toolkit focuses on six areas of safety: infections, falls, medication errors, security, injuries of behavioral health, and patient handling.

Drug shortages can contribute to treatment delays and complications that lead to patient harm. This survey sought insights from hospital directors of pharmacy regarding their experiences with drug shortages over the past 6 months. 

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.

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. 

Although patient safety is considered a noble goal in health care, garnering the resources for improvement efforts can be hindered by other demands. This toolkit provides strategies for health care leaders to develop a business case for patient safety efforts to generate support for organizational investments. Materials include assessments and templates for financial documents and presentation materials.

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.

This tool provides institutions with the capacity to assess use of antithrombotic agents, submit data to the Institution for Safe Medication Practices for self-assessment scores, compare practices with other hospitals, and allow the development of an ongoing progress report.

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.

Performing incident analysis can help organizations understand why adverse events occur and how to prevent them. This toolkit provides a framework to help organizations gather insights from staff, patients, and family members regarding what caused the failure and why it happened and to guide efforts to prevent similar incidents.

The terms in the initial collection have been expanded to reflect changes in the field which now inlcudes artificial intelligence  and gamification. The document will continue to be refined and expanded over time.

Large-scale and individualized strategies are needed to address opioid misuse. This website provides resources related to a national initiative to improve opioid prescribing practices by obtaining physician commitment to adhere to guidelines and screening methods.

Antimicrobial stewardship is one strategy to reduce health care–associated infections in a variety of settings. This guide provides detailed instructions and four adaptable toolkits to establish antimicrobial stewardship programs in nursing homes.

Reducing preventable harm associated with health care is a worldwide goal. This Canadian initiative developed a measure to track unintended harm in acute care hospitals, a toolkit to accompany reduction efforts, and a report that explains how the measure can help assess the results of improvement efforts.

The usability of electronic health record (EHR) systems can affect clinicians' ability to provide safe patient care. This fact sheet summarizes the results of a stakeholder meeting that explored usability problems and identified three improvement strategies that focused on effective testing, user assessment of EHR safety, and sharing of lessons learned.

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.

Development of high reliability remains an elusive goal for health care organizations. The Joint Commission has also advocated for achieving high reliability in health care. This website collects evidence and existing tools to help organizations work toward high reliability, including the ORO 2.0 assessment tool to enable hospital leaders evaluate their culture, leadership, and performance.

The experience of Sorrel King and the death of her daughter has motivated health care leaders and the industry to improve patient safety. This curriculum provides a set of materials that incorporates lessons from Josie's Story into existing educational programs.