Resources by Safety Topic
Contents
- Diagnostic Safety
- Emergency Preparedness
- Falls
- Healthcare-Associated Infections
- Maternal Safety
- Medication Safety
- Never Events
- Opioid Safety
- Pressure Ulcers
- Readmissions
- Sepsis
- Surgical Safety
- Transitions in Care
- Venous Thromboembolism
Diagnostic Safety
AHRQ Diagnostic Stewardship as a Model to Improve the Quality and Safety of Diagnosis
Healthcare organizations can use this issue brief to understand and implement diagnostic stewardship models to enhance diagnostic safety. The brief includes suggestions for structural measures to determine whether diagnostic stewardship is improving diagnosis and safety and reducing diagnostic error.
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 TeamSTEPPS® for Diagnosis Improvement
The TeamSTEPPS for Diagnosis Improvement Course applies the TeamSTEPPS framework to the specific problem of diagnostic error. The course aims to raise diagnostic safety awareness, introduce the concept of a broad multidisciplinary diagnostic team that includes nonclinicians and patients and their families, and provide assessment and training tools to support local efforts to reduce diagnostic harm. The course consists of seven training modules customizable to the needs of the local team and course facilitator.
CDC Core Elements of Hospital Diagnostic Excellence (DxEx)
This resource describes the core elements and actions hospitals can take to improve diagnosis. Actionable practices for improving diagnosis and patient safety include (1) diagnostic stewardship, (2) strengthening systems and processes to improve accurate and timely diagnosis, and (3) surveillance for diagnostic safety events to learn from and improve. Hospitals can use the available companion tools to implement the Core Elements by assessing their diagnostic excellence program against examples of priority activities (PDF, 3 MB) and additional activities (PDF, 2.3 MB). The Medical Test Checklist (PDF, 395 KB) supports hospitalized patients and their caregivers in asking questions about, understanding, and confirming their test results and diagnosis.
Emergency Preparedness
Administration for Strategic Preparedness and Response (ASPR) Technical Resources, Assistance Center, and Information Exchange (TRACIE) Resource Library
The ASPR TRACIE resource library offers healthcare organizations information and resources such as toolkits, checklists, articles, and fact sheets, organized by topic areas, to support health system preparedness.
ASPR Healthcare and Public Health Risk Identification and Site Criticality (RISC) Toolkit 2.0
The RISC Toolkit is a web-based, objective, data-driven risk assessment with self-assessment modules to help healthcare and public health sector organizations to identify threats and hazards; assess vulnerabilities; and determine criticality and consequences. The aggregated data enable healthcare organizations to compare facilities across systems, coalitions, and regions.
ASPR Health Care Preparedness and Response Capabilities for Health Care Coalitions
This resource supports regional healthcare delivery systems, including healthcare coalitions, hospitals, and emergency medical services, to effectively prepare for and respond to emergencies that impact the public’s health. The resource is organized by four capabilities (Foundation for Health Care and Medical Readiness, Health Care and Medical Response Coordination, Continuity of Health Care Service Delivery, and Medical Surge), each with a goal and a set of objectives with associated activities.
Falls
AHRQ Falls Management Program: A Quality Improvement Initiative for Nursing Facilities
This resource is focused on falls reduction using quality improvement tactics to assist nursing facilities in improving their fall care processes and outcomes through a person-centered approach to care.
AHRQ Fall Tailoring Interventions for Patient Safety (TIPS): A Patient-Centered Fall Prevention Toolkit
This evidence-based toolkit has reduced falls by 25 percent in a cohort of over 100 acute care hospitals in the United States and abroad. The toolkit includes a formal risk assessment and tailored plan of care for each patient.
AHRQ Improving Patient Safety in Long-Term Care Facilities
This falls prevention 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 to prevent and manage falls.
AHRQ National Patient Safety Databases (NPSD) Spotlight: Patterns of Fall Interventions
This report contains a national sample of non-identifiable data derived from Patient Safety Organizations (PSOs) for patient falls. Organizations can use this report to understand fall prevention strategies. The report allows organizations to evaluate their own data and patterns of interventions to consider how they compare with the national sample, which may help them identify opportunities for improvement.
AHRQ NPSD Spotlight: Falls: Associated Factors and Clinical Outcomes
This report contains a national sample of non-identifiable data derived from Patient Safety Organizations (PSOs) for patient falls. This 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.
Center for Disease Control and Prevention (CDC) Stopping Elderly Accidents, Deaths & Injuries (STEADI) Initiative: Older Adult Fall Prevention
The STEADI initiative and tools are designed to support healthcare providers treating older adults who are at risk of falling or who may have fallen in the past. Its core elements include Screen, Assess, and Intervene. The resources include information about falls, screening options, medications linked to falls, and standardized gait and balance assessment tests; educational brochures for patients and caregivers; success stories on how to implement and evaluate a STEADI-based fall prevention program; and videos.
Veterans Health Administration (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-fall huddle documents, and more.
Healthcare-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 (HAI) Program
AHRQ’s 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 (ESRD) Facilities Toolkit
This ESRD Toolkit was created to help end-stage renal disease clinics prevent healthcare-associated infections in dialysis patients. The toolkit helps dialysis center clinicians make care safer by following clinical best practices, creating a culture of safety, using checklists and other audit tools, and engaging with patients and their families. The toolkit has science-based, practical resources that reflect the real-world experiences of the frontline providers who participated in the toolkit’s development.
AHRQ Toolkit for Preventing Central Line-Associated Bloodstream Infections (CLABSI) and Catheter-Associated Urinary Tract infections (CAUTI) in Intensive Care Units (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.
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.
AHRQ Toolkit: Labor and Delivery Unit Safety: Obstetric Hemorrhage
This toolkit describes safety elements to help nurses, physicians, midwives, and other labor and delivery unit staff safely manage obstetric hemorrhage. Safety elements are structured around the Comprehensive Unit-based Safety Program (CUSP). Staff can review the elements to determine appropriate implementation approaches in their facilities in the context of existing policies and processes to manage obstetric hemorrhage. A video associated with the toolkit demonstrates the use of the CUSP techniques to address postpartum hemorrhage.
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.
U.S. Food and Drug Administration (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.
Veterans Health Administration (VHA) Opioid Safety Clinical Tools
This webpage presents clinical tools to support opioid safety that were developed by the VA National–Academic Detailing Service for providers and patients. The resources include educational guides and reference guides on the topics of pain management and opioid safety, opioid use disorder, and opioid overdose.
VHA Opioid Safety: Veteran/Patient Education
VHA has compiled educational resources for patients to improve their role in the safe use of opioids for pain management. The resources include those developed by the Department of Veterans Affairs and other agencies, such as the Food and Drug Administration and the Centers for Disease Control and Prevention. The information includes factsheets to inform patients about taking opioids and what to ask their provider before taking opioids.
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 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.
Centers for Medicare & Medicaid Services (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
AHRQ Best Practices in the Diagnosis and Treatment of Sepsis
These slides and associated facilitator guide present specific approaches to diagnosing sepsis, the empiric treatment of sepsis, stopping or narrowing antibiotic therapy in patients with suspected sepsis, and durations of therapy for patients with 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
This resource includes materials to improve communication between patients and clinicians to help make healthcare safer, including AHRQ’s QuestionBuilder app (available in English and Spanish), 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.
