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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
Measurement Tool/Indicator
Rockville, MD: Agency for Healthcare Research and Quality; October 2020.
Ambulatory surgery centers (ASCs) are increasingly being used to provide surgical care. The AHRQ Surveys on Patient Safety Culture™ (SOPS®) Ambulatory Surgery Center Survey seeks opinions from the field regarding safety culture in the ambulatory surgical center environment. The survey is presented with additional resources to help organizations assess their safety culture, including the results of a pilot program testing the survey and a user's guide. Voluntary data submission will be open June 1-22 for ASCs that have administered the survey.
Measurement Tool/Indicator
Classic
Rockville MD: Agency for Healthcare Research and Quality; 2020.
Culture has been described as a key to establishing high reliability organizations. The National Quality Forum's Safe Practices for Healthcare and the Leapfrog Group both mandate hospitals to regularly assess their safety culture. This AHRQ Web site provides validated safety culture survey tools (Hospital, Medical Office, Nursing Home, Community Pharmacy, Ambulatory Surgery Center), user guides health care organizations can use to implement the surveys and a bibliography of articles discussing the use of SOPS in the field. Organizations can also use the AHRQ database to compare their Surveys on Patient Safety Culture™ (SOPS®) results. In addition, reports are available that summarize the benchmarking data across cohorts nationwide. An AHRQ WebM&M perspective discussed how to establish a safety culture.
Organizational Policy/Guidelines
Horsham, PA; Institute for Safe Medication Practices: April 2023.
Community pharmacies are common providers of medication delivery that harbor process weaknesses affecting safety. This guidance shares evidence-based steps to address problems such as wrong patient errors and lack of consistent barcode system use in the community setting.
Measurement Tool/Indicator
Joint Commission.
This website provides sentinel event data reported to The Joint Commission, which includes information on sentinel events reported from January through December 2022. Falls, unintended retained foreign bodies, and delays in treatment were among the most frequently submitted incidents in this time period which represents a 19% increase over 2021. The data and graphs are updated regularly and include a 5 year trend analysis and specific analysis associated with event type by year from 2018 through 2022.
All Toolkits (266)
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Government Resource
Leeds, UK: Health Education England, Public Health England, NHS England and Community Health and Learning Foundation; December 11, 2017.
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.
Toolkit
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.
Toolkit
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.
Toolkit
Centers for Disease Control and Prevention; CDC.
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.
Measurement Tool/Indicator
Horsham, PA: Institute for Safe Medication Practices; 2017.
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.
Rockville, MD: Agency for Healthcare Research and Quality; 2017.
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.
Measurement Tool/Indicator
Institute for Safe Medication Practices; ISMP.
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.
Rockville, MD: Agency for Healthcare Research and Quality; July 2017.
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.
Institute for Healthcare Improvement, National Patient Safety Foundation. Cambridge, MA: Institute for Healthcare Improvement; 2017.
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.
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
Horsham, PA: Institute for Safe Medication Practices; March 2017.
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.
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.
Book/Report
Incident Analysis Collaborating Parties. Edmonton, AB: Canadian Patient Safety Institute; 2012.
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.
Toolkit
Murthy VH. New England Journal of Medicine. 2016;375.
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.
Lioce L, Lopreiato J, Downing D, et al, eds and the Terminology and Concepts Working Group. Rockville, MD: Agency for Healthcare Research and Quality; January 2020. AHRQ Publication No. 20-0019.
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.
Book/Report
Rockville, MD: Agency for Healthcare Research and Quality; October 2016.
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.
Toolkit
Canadian Institute for Health Information, Canadian Patient Safety Institute.
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.
Philadelphia, PA: Pew Charitable Trusts; September 6, 2016.
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.
