Resources by Type of Harm
Contents
- Diagnostic Safety
- Falls
- Hospital-Associated Infections
- Maternal Safety
- Medication Safety
- Never Events
- Opioid Safety
- Pressure Ulcers
- Readmissions
- Sepsis
- Surgical Safety
- Transitions in Care
- Venous Thromboembolism
Diagnostic Safety
AHRQ Improving Your Laboratory Testing Process: A Step-by-Step Guide for Rapid-Cycle Patient Safety and Quality Improvement
The tools in this step-by-step guide can increase the reliability of the testing process in primary care offices by helping office staff examine how tests are managed.
AHRQ Surveys on Patient Safety Culture® (SOPS®) Diagnostic Safety Supplemental Item Set for Medical Office
The SOPS® Diagnostic Safety Supplemental Item Set for medical offices is used in conjunction with the core SOPS® Medical Office Survey to help medical offices assess the extent to which their organization's culture supports the diagnostic process, accurate diagnoses, and communication around diagnoses.
AHRQ Implementation Opportunity: TeamSTEPPS® for Diagnosis Improvement Course
This course uses the TeamSTEPPS principles to explore how healthcare teams can achieve safer, more accurate, and more timely diagnosis in all healthcare settings. Those interested should email TeamSTEPPStraining@ahrq.hhs.gov. A training team member will be in touch to schedule training assistance.
Falls
AHRQ Falls Management Program: A Quality Improvement Initiative for Nursing Facilities
This resource describes an interdisciplinary quality improvement initiative to assist nursing facilities in providing individualized, person-centered care and improving their fall care processes and outcomes through educational and quality improvement tools.
AHRQ Fall TIPS: A Patient-Centered Fall Prevention Toolkit
This resource consists of a formal risk assessment and tailored plan of care for each patient. The toolkit has reduced falls by 25 percent in acute care hospitals and is used in more than 100 hospitals in the United States and internationally.
AHRQ Improving Patient Safety in Long-Term Care Facilities
This training curriculum is for frontline personnel in nursing homes and other long-term care facilities to help them detect and communicate changes in a resident’s condition and prevent and manage falls.
AHRQ National Patient Safety Databases (NPSD) Spotlight: Patterns of Fall Interventions
This report contains an analysis of non-identifiable data derived from Patient Safety Organizations (PSOs) from across the country related to falls. Organizations can use this report to understand, at a national level, current practices such as common interventions and combinations of interventions in place before patient falls. Organizations can evaluate their own data and patterns of interventions to consider how they compare, which may help them to identify opportunities for improvement.
AHRQ NPSD Spotlight: Falls: Associated Factors and Clinical Outcomes
This report of national falls data from PSOs from across the country examines falls across multiple dimensions. The report highlights differences in outcomes from falls across gender and age groups. Organizations can use this report to develop tailored and quality improvement initiatives based on insights into the prevalence and outcomes of falls.
AHRQ Preventing Falls in Hospitals: A Toolkit and Training Program
This toolkit and training program focus on overcoming the challenges associated with developing, implementing, and sustaining a fall prevention program. It consists of a five-module, in-person training curriculum and a series of companion webinars on specific topics related to fall prevention.
VHA Falls Toolkit
Organizations can use this toolkit from the VHA to develop a comprehensive falls prevention program. Toolkit elements include a program self-assessment, falls notebook, post falls huddle documents, and more.
Hospital-Associated Infections
AHRQ Community-Acquired Pneumonia (CAP) Patient Safety Clinical Decision Support Implementation Toolkit
This toolkit is intended to help clinicians and clinical informaticians in primary care and other ambulatory settings implement and adopt the CAP clinical decision support alert for the management of community-acquired pneumonia.
AHRQ's Healthcare-Associated Infections Program
AHRQ's healthcare-associated infections (HAI) program funds work to help frontline clinicians and other healthcare staff prevent HAIs by improving how patient care is delivered. The program website includes links to tools and resources to prevent HAIs.
AHRQ Safety Program for End-Stage Renal Disease Facilities Toolkit
This toolkit helps prevent healthcare-associated infections in dialysis patients receiving care at end-stage renal disease clinics. The toolkit includes four instructional modules that a facilitator can use to teach dialysis center team members specific ways to create a culture of safety.
AHRQ Toolkit for Preventing Central Line-Associated Bloodstream Infections (CLABSI) and Catheter-Associated Urinary Tract infections (CAUTI) in ICUs
The customizable education toolkit includes evidence-based practices centered on use of the Comprehensive Unit-based Safety Program model. The resource guides users through an assessment of current practices, development and implementation of a plan to decrease HAIs, and ways to overcome common challenges ICU teams face in addressing CLABSI and CAUTI.
AHRQ Toolkit for Reducing CAUTI in Hospitals
This resource helps hospitals prevent CAUTI in patients and improve safety culture at the unit level by implementing evidence-based, practical tools from the Core Comprehensive Unit-based Safety Program Toolkit.
AHRQ Toolkit to Reduce CAUTI and Other HAIs in Long-Term Care Facilities
Based on the Comprehensive Unit-based Safety Program, this toolkit includes instructional materials and resources in infection prevention best practices, resident and family engagement, quality improvement, and sustainability to guide facilities through implementing an improvement project to reduce HAIs.
AHRQ Toolkit for Reducing CLABSI
This resource, designed to be used with the Core Comprehensive Unit-based Safety Program Toolkit, can help hospital units implement evidence-based practices to reduce and, in many cases, eliminate CLABSI.
AHRQ Toolkit To Improve Safety for Mechanically Ventilated Patients
ICU staff can use this toolkit to apply the proven principles and methods of AHRQ’s Comprehensive Unit-based Safety Program to reduce complications for patients on ventilators, such as ventilator-associated pneumonia.
CDC Infection Control Guidelines and Guidance
Healthcare organizations from all settings can use this resource, which includes a set of core practices for all settings. Guidelines are organized by specific personnel or setting, antimicrobial resistance, medical devices or procedures, and diseases and organisms.
CDC Infection Control Tools
This library of general resources and tools—organized by setting, pathogen, or quick observational tools—can help healthcare providers implement infection control measures and prevent healthcare-associated infections.
CDC Targeted Assessment for Prevention (TAP) Strategy
The TAP Strategy is a framework of three components (Target, Assess, and Prevent) which healthcare organizations can use to prevent HAIs. Target helps organizations identify where they have the greatest opportunity to reduce HAI rates by generating TAP reports using the National Healthcare Safety Network data. Assess helps organizations appraise infection prevention policies, practices, and areas for improvement. Prevent helps organizations tailor interventions to prevent HAIs based on their results from the other two components. Organizations can email HAIprevention@cdc.gov for questions and assistance; CDC provides free support to healthcare organizations and others who would like to use the TAP strategy.
AHRQ Implementation Opportunity: AHRQ Safety Program for Telemedicine
Urgent care and primary care practices can learn how to improve patient safety and reduce harm associated with antibiotics in a free 18-month AHRQ program that starts in June 2024. Interested practices can learn more via an informational webinar. Those with additional questions can contact the program team at safetyprogram4telemedicine@norc.org.
Maternal Safety
AHRQ Toolkit for Improving Perinatal Safety
This toolkit helps labor and delivery units improve patient safety and quality of care for mothers and their newborns based on teamwork and communication skills, perinatal safety strategies, and in situ simulation training. The tools can be customized to local unit processes and procedures.
Health Resources & Services Administration (HRSA) Alliance for Innovation on Maternal Health (AIM)
This HRSA-funded national collaborative promotes the development and use of maternal care quality improvement bundles. Organizations can use the patient safety bundles to improve care delivery and outcomes for specific conditions in pregnant and postpartum people. Patient safety bundles are collections of evidence-informed best practices and include conditions such as obstetric hemorrhage, severe hypertension in pregnancy, and safe reduction of primary cesarean birth, among others.
Medication Safety
AHRQ Blood Thinner Pills: Your Guide to Using Them Safely
This resource includes a booklet and video about blood thinner medications in both English and Spanish to help patients understand how blood thinner medications work and why it is important to take them correctly.
AHRQ Medications at Transitions and Clinical Handoffs (MATCH)
This resource features strategies from the field that can help hospitals improve medication reconciliation processes for patients as they move through the healthcare system.
AHRQ Nursing Home Antimicrobial Stewardship Guide
This resource provides field-tested, evidence-based modules that can help nursing homes develop antibiotic stewardship programs to help them use and prescribe antibiotics appropriately.
AHRQ Toolkit To Improve Antibiotic Use in Acute Care Hospitals
This toolkit provides guidance for hospitals on developing and improving an antibiotic stewardship program, creating a culture of safety around antibiotic prescribing, and learning and disseminating best practices for the diagnosis and treatment of common infectious disease syndromes.
AHRQ Toolkit To Improve Antibiotic Use in Long-Term Care
This toolkit provides guidance for long-term care facilities on developing and improving an antibiotic stewardship program, creating a culture of safety around antibiotic prescribing, communicating with residents and families about infection concerns, and using best practices for the diagnosis and treatment of common infectious disease syndromes.
CDC Core Elements of Antibiotic Stewardship for Hospitals, Outpatient Care, Nursing Homes, and Resource-Limited Settings
These key principles for providers and facilities can be used to measure and improve antibiotic prescribing in order to protect patients from harms related to unnecessary antibiotic use and combat antibiotic resistance.
FDA MedWatch Program
This voluntary reporting program enables health professionals, patients, and consumers to share information about observed or potential adverse effects from FDA-regulated products such as prescription and over-the-counter medicines, biological products, and medical devices.
Never Events
AHRQ PSNet Primer: Never Events
This article presents the National Quality Forum’s list of serious reportable events, or “Never Events,” based on 2016 data. The 29 events are grouped into seven categories. As noted in the primer, many states have made reporting serious adverse events (including many Never Events) mandatory.
Opioid Safety
AHRQ Six Building Blocks: A Team-Based Approach to Improving Opioid Management in Primary Care How-to-Implement Toolkit
This resource helps support primary care clinics as they independently implement effective, guideline-driven care for their patients with chronic pain who are using opioid therapy.
HRSA Funding Opportunity: Rural Communities Opioid Response Program
Rural organizations can apply for funding to address the rural opioid crisis via 10 grant programs. Funded programs have access to technical assistance, evidence-based programs and best practices, and training programs. For more information email ruralopioidresponse@hrsa.gov.
Pressure Ulcers
AHRQ Preventing Pressure Ulcers in Hospitals: A Toolkit for Improving Quality of Care
This resource assists hospital staff in implementing effective pressure ulcer prevention practices through an interdisciplinary approach to care.
Readmissions
AHRQ Hospital Guide to Reducing Medicaid Readmissions
This resource provides evidence-based strategies to reduce readmissions among the adult Medicaid population.
AHRQ Primary Care-Based Efforts To Reduce Potentially Preventable Readmissions
This resource supports the reduction of preventable readmissions by addressing the role of primary care in improving the quality and safety of care as patients transition from the hospital setting.
AHRQ Project BOOST (Better Outcomes by Optimizing Safe Transitions)
This resource provides hospitals a comprehensive set of interventions to improve the care transition process after discharge in order to reduce readmissions.
AHRQ Re-Engineered Discharge (RED) Toolkit
This toolkit is a research-based tool to assist hospitals in improving their discharge process and reducing avoidable readmissions. The toolkit includes a guide in both English and Spanish to help staff ensure that patients understand their discharge instructions.
CMS Guide to Reducing Disparities in Readmissions
This guide for healthcare practitioners, leaders, and community partners is designed to help them understand root causes of avoidable readmissions and disparities. The guide also includes strategies, resources, and implementation examples that organizations can use as they work to reduce avoidable readmissions.
Sepsis
CDC Hospital Sepsis Program Core Elements
The guide and accompanying webinar series present the structural and procedural components necessary to provide safe, evidence-based care for patients with sepsis in the hospital setting.
Surgical Safety
AHRQ Ambulatory Surgery Centers Toolkit
This toolkit helps ambulatory surgery centers apply AHRQ's Comprehensive Unit-based Safety Program to prevent surgical site infections and other complications and improve safety culture in their facilities.
AHRQ Toolkit for Improving Surgical Care and Recovery
This toolkit helps hospitals improve patients' surgical experience by adopting enhanced recovery practices, which are evidence-based processes that are supported by multidisciplinary perioperative care teams. Hospitals can use the toolkit to prevent complications such as surgical site infections, venous thromboembolism, and urinary tract infection and to improve perioperative safety culture.
AHRQ Toolkit To Promote Safe Surgery
This toolkit helps perioperative and surgical units in hospitals identify opportunities to improve care and safety practices and implement evidence-based interventions to prevent surgical site infections and other complications.
Transitions in Care
AHRQ Questions Are the Answer (English and Spanish versions)
This resource includes materials to improve communication between patients and clinicians to help make healthcare safer, including AHRQ's QuestionBuilder app, brochures and handouts, and videos of patients and clinicians discussing the importance of asking questions.
AHRQ Taking Care of Myself: A Guide for When I Leave the Hospital
This resource presents an easy-to-read guide to help nurses or discharge advocates work with patients to track medication schedules, upcoming medical appointments, and important phone numbers after they leave the hospital.
AHRQ Toolkit To Engage High-Risk Patients in Safe Transitions Across Ambulatory Settings
This toolkit is designed to help staff actively engage patients and their care partners to prevent errors during transitions of care among ambulatory care sites.
AHRQ Transitioning Newborns from NICU to Home: A Resource Toolkit
This toolkit provides customizable resources to help hospitals and families safely transition newborns out of the neonatal intensive care unit to home by creating a Health Coach Program.
Venous Thromboembolism (VTE)
AHRQ Preventing Hospital-Associated Venous Thromboembolism: A Guide for Effective Quality Improvement
This resource outlines the latest evidence on how to lead a quality improvement effort to prevent hospital-acquired venous thromboembolism.
AHRQ Your Guide to Preventing and Treating Blood Clots
This resource discusses ways to prevent, treat, and recognize symptoms of blood clots. It also describes medications used to prevent blood clots and their side effects.
