Toolkits

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.

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.

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.

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.

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.

Traditionally, health systems have disclosed adverse events to patients only through a lengthy process that involves providing limited information to patients and families, avoiding admissions of fault, and emphasizing protection of the clinicians involved. This approach may harm safety culture and has been criticized as not being patient-centered. Some pioneering institutions, such as the University of Michigan Health System, began implementing an alternative approach known as "communication and resolution," which emphasizes early disclosure of adverse events and proactive attempts to reach an amicable solution. Early adopters of this method have achieved notable results, including a decline in malpractice lawsuits. The CANDOR toolkit, developed by AHRQ as part of the Medical Liability Reform and Patient Safety Initiative, provides tools for health care organizations to implement a communication-and-resolution program. The toolkit includes videos, slides, gap analysis assessments and teaching materials. It has been tested in 14 hospitals in several different states. A PSNet interview with the chief risk officer of the University of Michigan Health System discusses the organization's pioneering efforts to implement a communication-and-response system.

Checklists are a recommended method to reduce omissions in care, despite controversies regarding their impact on safety. This toolkit provides a collection of checklists that have been developed and field tested by participants in the Hospital Engagement Network to prevent harm associated with the use of central lines, adverse drug events, and falls.

Patient safety organizations collect data across various systems and states. This site supports review and comment of versions of common formats developed to provide a standardized method to collect and report incident data to patient safety organizations. 

Electronic health records have potential to improve health care, but they may also introduce unanticipated risks. This report describes the results of a group convened to explore strategies to enhance health IT safety. Focusing on copying and pasting health data from one record to another as the first area of concern, the report recommends enabling systems to identify what data has been copied in the electronic health record and where it came from, providing training to ensure the safe use of copy and paste, and regularly track and assess copying and pasting practices. The report includes tools to related to the recommendations. A WebM&M commentary explores the hazards associated with the use of copy and paste.

Root cause analysis offers a structured way to detect and address system weaknesses. This workbook illustrates how root cause analysis can be applied to community pharmacy services to identify problems and design an action plan to implement improvement strategies.

The National Quality Forum (NQF) has been a leader in defining patient safety reporting measures. This website provides information about the third cycle of an NQF patient safety project that solicited new measures and reviewed existing patient safety metrics. A final report is now available.

The NHS Safety Thermometer was a tool developed by the National Health Service to facilitate staff participation in measuring patient harm in various care environments. This report collection explores the data collected on four types of health care–acquired conditions (pressure ulcers, falls, catheter–associated urinary tract infections, and venous thromboembolisms) in NHS patients over a 5-year period. The NHS Safety Thermometer is no longer used as an official data type. 

Catheter–associated urinary tract infections (CAUTIs) are common complications in hospitalized patients. This toolkit was developed as part of a national implementation project to reduce rates of CAUTIs in hospitals and apply principles of the comprehensive unit-based safety program. The toolkit includes modules that focus on implementation, sustainability, and resources to help hospitals design CAUTI prevention efforts at the unit level.

Warfarin is a high-alert drug. This guide provides information for consumers to help take the blood thinner safely.

Leadership commitment to improvement efforts is key to sustain patient safety initiatives. This toolkit consists of a workbook, board engagement self-assessment tool, and video modules to help leadership translate efforts from the board room to the front line to reduce medical errors in their hospitals.

Patient falls are preventable and can be addressed through quality and safety strategies. This toolkit provides a process to help health care organizations determine factors that contribute to falls in their facilities and design interventions to drive improvement.