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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

Gilbert R, Asselbergs M, Davis D, et al. Healthcare Excellence Canada; 2023.

Patient safety requires a systems approach to identify problems and arrive at lasting solutions that reduce harm. This document encourages discussion amongst a broad base of stakeholders to address all forms of harm, such as discrimination, inequality, and psychological stress, in addition to physical injury. The resource insists these components be incorporated in work to close quality and safety gaps across the health care system.
Multi-use Website
Canadian Institute for Health Information, Health Excellence Canada.
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 reports that assess the results of improvement efforts and provide data analysis.
Plymouth Meeting, PA: Institute for Safe Medication Practices; 2023.
Experience from the sharp end helps to inform safety improvement initiatives. The results from this field survey will inform the revision of a high-alert medication list used to raise awareness about certain drugs that have heightened potential to cause patient harm if used incorrectly. The deadline for submitting comments is October 20, 2023.

Rockville, MD: Agency for Healthcare Research and Quality; July 2023.

Obstetric hemorrhage and severe high blood pressure during pregnancy are leading known causes of preventable maternal harms in the United States. The AHRQ Safety Program for Perinatal Care, Phase 2 developed toolkits consisting of case scenarios, slides, and facilitators guides to work in tandem to address these threats to maternal safety. The materials inform training opportunities to improve the safety culture of labor and delivery units and decrease maternal and neonatal adverse events that result from poor communication and system failures.

All Toolkits (267)

Published Date
PSNet Publication Date
Displaying 81 - 100 of 267 Results
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.
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.
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.
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.
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.
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.