The Agency for Healthcare Research and Quality (AHRQ) offers tools for health care organizations, providers, and policymakers to improve patient safety in health care settings. The free tools and resources listed here are available online and in print.
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Tools for Health Care Organizations and Providers
Patient Safety Measurement and Reporting Tools
The Hospital Survey on Patient Safety Culture examines patient safety culture from a hospital staff perspective and allows hospitals to assess their safety culture and track changes over time. Hospitals that administer the patient safety culture survey can voluntarily submit their data to the Comparative Database, a resource for hospitals wishing to compare their survey results to similar types of hospitals.
Print: AHRQ Publication No. 08-0048
Web: http://www.ahrq.gov/qual/patientsafetyculture/hospsurvindex.htm
Hospital Survey on Patient Safety Culture: Comparative Database Reports give benchmark data collected voluntarily from more than 1,000 U.S. hospitals. Survey results from these hospitals are averaged over the entire sample by topical composite or individual survey item. Two appendixes report the average responses, which are broken down by hospital or respondent characteristics.
The Medical Office Survey on Patient Safety Culture measures issues relevant to patient safety in the ambulatory medical office setting. Pilot tested in approximately 100 medical offices, the survey lets providers and staff assess their safety culture, identify areas where improvement is needed, track changes in patient safety, and evaluate the effect of interventions. Researchers can also use the survey to assess patient safety culture improvement initiatives.
Print: AHRQ Publication No. 08(09)-0059
Web: http://www.ahrq.gov/qual/patientsafetyculture/mosurvindex.htm
The Nursing Home Survey on Patient Safety Culture
uses provider and staff perspectives to assess their
nursing home's safety culture, identify areas where
improvement is needed, track changes in patient safety,
and evaluate the impact of interventions. Pilot tested in
40 nursing homes, the survey also lets researchers assess
safety culture improvement initiatives in nursing homes.
Print: AHRQ Publication No. 08(09)-0060
Web: http://www.ahrq.gov/qual/nhsurvey08/nhguide.htm
The Nursing Home Survey on Patient Safety Culture:
User Comparative Database Report is based on
data from 226 nursing homes in the United States and
provides initial results that nursing homes can use to
compare their patient safety culture to other U.S. nursing
homes. The report consists of a narrative description
of the findings and four appendixes presenting data
by nursing home characteristics and respondent
characteristics.
Patient Safety Organizations (PSOs)
were created by the Patient Safety and
Quality Improvement Act to improve
the quality and safety of health care by
encouraging clinicians and health care
organizations to voluntarily report patient
safety events without fear of legal discovery. PSOs offer
a secure environment to identify and reduce the risks
associated with patient care. As independent, external
experts, PSOs collect, analyze, and aggregate patient
safety data locally, regionally, and nationally to develop
insights into the underlying causes of patient safety
events.
Web: http://www.pso.ahrq.gov
Patient safety, quality and risk managers,
clinicians, and others use Common
Formats to collect patient safety
event information in a standard way,
using common language, definitions,
technical requirements for electronic
implementation, and reporting specifications. Common
Formats optimize the opportunity for the public and
private sectors to learn more about trends in patient
safety with the purpose of improving health care quality.
AHRQ has developed Common Formats for hospitals
and nursing homes (including skilled nursing facilities) to collect data for all types of adverse events, near
misses, and unsafe conditions.
Web: http://www.pso.ahrq.gov
Measures of health care quality that make use of readily
available hospital administrative data, the Quality
Indicators™ can be used to highlight potential quality
concerns, identify areas that need further study and
investigation, and track changes over time. AHRQ
distributes the Quality Indicators through free software
programs that can help hospitals identify quality of care
events that might need further study. The current AHRQ
Quality Indicators modules represent various aspects of
quality:
- Patient Safety Indicators reflect quality of care
inside hospitals, as well as geographic areas, to
focus on potentially avoidable complications and
iatrogenic events.
- Prevention Quality Indicators identify hospital
admissions in geographic areas that evidence
suggests may have been avoided through access to
high-quality outpatient care.
- Inpatient Quality Indicators reflect quality of care
inside hospitals, as well as across geographic areas,
including inpatient mortality for medical conditions
and surgical procedures.
- Pediatric Quality Indicators use indicators from
the other three modules with adaptations for use
among children and neonates to reflect quality of
care inside hospitals, as well as geographic areas,
and identify potentially avoidable hospitalizations.
Web: http://www.qualityindicators.ahrq.gov
The Hospital Consumer Assessment of Healthcare
Providers and Systems (HCAHPS) is a survey
instrument for measuring patients' perspectives on
hospital care. The 27-question survey contains patient
perspectives on care and patient rating items that
encompass key topics, including communication with
doctors and nurses, responsiveness of hospital staff,
pain management, communication about medicines,
discharge information, and cleanliness and quietness
of the hospital environment. The survey also includes
screener questions and demographic items that are used
for adjusting the mix of patients across hospitals and for
analytical purposes.
Web: http://www.hcahpsonline.org 
Implementation Guides for Improving Patient Safety
A Toolkit for Hospitals: Improving Performance
on the AHRQ Quality Indicators™ helps hospitals
understand AHRQ's Quality Indicators that use hospital
administrative data to assess the quality of care provided,
identify areas of concern in need of further investigation,
and monitor progress over time. The toolkit is a general
guide to using improvement methods and focuses on the
17 Patient Safety Indicators and the 28 Inpatient Quality
Indicators to improve quality and patient safety.
Web: http://www.ahrq.gov/qual/qitoolkit
The Emergency Severity
Index (ESI): A Triage Tool
for Emergency Department
Care, Version 4 is a five-level
emergency department
triage algorithm that provides
clinically relevant stratification
of patients into five groups
from 1 (most urgent) to 5 (least
urgent) on the basis of acuity
and resource needs. The ESI
helps hospital emergency departments
rapidly identify patients in need of immediate attention,
better identify patients who could safely and more
efficiently be seen in a fast-track or urgent care center
rather than the main emergency department, and
more accurately determine thresholds for diversion of
ambulance patients from the emergency department. The
2012 edition of the Implementation Manual includes a
pediatrics section and many other updates.
- Implementation Manual
Print: AHRQ Publication No. 12-0014
Web: http://www.ahrq.gov/research/esi/esi1.htm
- Emergency Severity Index, Version 4: Everything You Need To Know
DVD: AHRQ Publication No. 05-0046-DVD
Improving Patient Flow
and Reducing Emergency
Department Crowding: A Guide
for Hospitals presents step-by-step
instructions for planning
and implementing patient flow
improvement strategies to
alleviate crowded emergency
departments. It addresses creating
a patient flow team, measuring performance, identifying strategies, preparing to launch,
facilitating change, and sharing results.
Print: AHRQ Publication No. 11(12)-0094
Web: http://www.ahrq.gov/qual/ptflow
Medications at Transitions and
Clinical Handoffs (MATCH)
Toolkit for Medication
Reconciliation, based on the
MATCH Web site, incorporates
the experiences and lessons
learned by health care facilities
that have implemented MATCH
strategies to improve their
medication reconciliation
processes for patients as they
move through health care settings.
Print: AHRQ Publication No. 11(12)-0059
Web: http://www.ahrq.gov/qual/match
The Guide to Patient and Family Engagement
in Hospital Quality and Safety will help hospitals
work as partners with patients and families to improve
quality and safety. It contains four strategies to help
hospitals partner with patients and families, and it has
an implementation handbook and tools for patients,
families, and clinicians for each strategy. The four
strategies are: Helping hospitals recruit and work with
patient and family advisors, communicating with patients
and families throughout their hospital stay to improve
quality, implementing nursing bedside change of shift
report, and engaging patients and families in discharge
planning.
Available in 2013.
The Preventing Pressure Ulcers in Hospitals toolkit
assists hospital staff in implementing effective pressure
ulcer prevention practices through an interdisciplinary
approach to care. The toolkit draws on literature on best
practices in pressure ulcer prevention and includes both
validated and newly developed tools.
Web: http://www.ahrq.gov/research/ltc/pressureulcertoolkit
Preventing Hospital-Acquired Venous
Thromboembolism: A Guide for Effective Quality
Improvement is based on quality improvement
initiatives undertaken at the University of California, San
Diego Medical Center and Emory University Hospitals
in Atlanta. This guide assists quality improvement
practitioners in leading an effort to improve prevention of one of the most serious problems facing hospitalized
patients: Hospital-acquired venous thromboembolism.
Print: AHRQ Publication No. 08-0075
Web: http://www.ahrq.gov/qual/vtguide
The Falls Management Program: A Quality
Improvement Initiative for Nursing Facilities presents
an interdisciplinary quality improvement initiative
designed to assist nursing facilities in providing
individualized, person-centered care and improving their
fall care processes and outcomes through educational and
quality improvement tools.
Web: http://www.ahrq.gov/research/ltc/fallspx/fallspxmanual.htm
Developing a Community-Based
Patient Safety Advisory Council.
provides approaches for hospitals and
other health care organizations to use to
develop a community-based advisory
council that can drive change for patient
safety through education, collaboration,
and consumer engagement.
Print: AHRQ Publication No. 08-0048
Web: http://www.ahrq.gov/qual/advisorycouncil
Mistake-Proofing the Design
of Health Care Processes
is illustrated with numerous
examples and explains how to
apply the industrial engineering
concept of mistake-proofing to
processes in hospitals, clinics,
and physicians' offices.
Print: AHRQ Publication No. 07-0020
CD: AHRQ Publication No. 07-0020-CD
Web: http://ahrq.gov/qual/mistakeproof
Patient Safety Training Tools
Team Strategies and Tools to Enhance Performance
and Patient Safety (TeamSTEPPS®) is a set of tools
to help train clinicians in teamwork and communication
skills to reduce risks to patient safety.
Web: http://www.teamstepps.ahrq.gov
TeamSTEPPS tools include—
AHRQ Web M&M (Morbidity and Mortality Rounds
on the Web) is a free, peer-reviewed online journal
and forum on patient safety and health care quality that
features expert analysis of medical errors that readers
report anonymously, interactive learning modules on
patient safety ("Spotlight Cases"), Perspectives on
Safety, and interactive learning modules on patient safety
("Spotlight Cases"). Continuing medical education and
continuing education unit credits are offered.
Web: http://www.WebMM.ahrq.gov
If chest tubes are inserted incorrectly,
patients can suffer adverse outcomes
and even fatal complications, and
clinicians can be exposed to injury or
infection. Problems and Prevention:
Chest Tube Insertion is an 11-minute
DVD that uses video excerpts of 50 actual chest tube
insertions to illustrate problems that can occur during the
procedure.
DVD: AHRQ Publication No. 06-0069-DVD.
Resources for Health Care Organizations, Providers, and Policymakers
AHRQ Patient Safety Network (AHRQ PSNet) is a
national Web-based resource that features the latest news
and essential resources on patient safety. The site offers
weekly updates of patient safety literature, news, tools,
and meetings ("What's New"); Patient Safety Primers;
and a vast set of carefully annotated links to important
research and other information on patient safety ("The
Collection"). Supported by a robust patient safety
taxonomy and Web architecture, AHRQ PSNet provides
powerful searching and browsing capability, as well as
the ability for diverse users to customize the site around
their interests ("My PSNet").
Web: http://www.psnet.ahrq.gov
The Preventing Avoidable Hospital Readmissions Web
page provides links to AHRQ tools for health care teams
and consumers to make the hospital discharge process
safer and to prevent avoidable readmissions.
Web: http://www.ahrq.gov/qual/impptdis.htm
Using a Comprehensive Unit-based Safety Program
to Prevent Healthcare-Associated Infections is a Web
page that provides an overview of the Comprehensive
Unit-based Safety Program (CUSP) and links to useful
CUSP resources on the Web, including reports and
journal articles. With funding from AHRQ, hospitals in
all 50 States, the District of Columbia, and Puerto Rico
are employing CUSP to reduce healthcare-associated
infections, including central line-associated blood stream
infections, catheter-associated urinary tract infections,
and ventilator-associated pneumonia, in intensive care
units and other health care units and settings.
Web: http://www.ahrq.gov/qual/cusp.htm
Transforming Hospitals: Designing
for Safety and Quality presents the
experiences of three model hospitals
that incorporated evidence-based
design elements into their construction
and renovation projects. This DVD
shows hospital leaders how evidence-based design can
improve the quality and safety of hospital services. It is
an especially useful tool for hospitals that are planning
capital construction projects or renovations.
DVD: AHRQ Publication No. 07-0076-DVD
Resident Duty Hours: Enhancing Sleep, Supervision,
and Safety is an AHRQ-funded study from the Institute
of Medicine that confirms that acute and chronically
fatigued medical residents are more likely to make
mistakes that affect patient care. The Institute of
Medicine recommends several changes to the existing
80-hour-per-week limit on resident work hours,
including:
- Residency programs provide opportunities for sleep
each day and each week during resident training.
- The Accreditation Council for Graduate Medical
Education provide better monitoring of duty-hour
limits.
- Residency review committees set guidelines for
residents' patient caseloads.
Web: http://books.nap.edu/openbook.php?record_id=12508
Patient Safety and Quality:
An Evidence-Based Handbook
for Nurses is a three-volume
handbook in which nurses will
find peer-reviewed discussions
and reviews of issues and
literature regarding patient
safety and quality health care.
Each of the 51 chapters and 3
leadership vignettes presents
an examination of the state
of the science behind quality and safety concepts and
challenges nurses to use evidence to change practices
and engage in developing the evidence base to address
critical knowledge gaps.
CD: AHRQ Publication No. 08-0043-CD
Web: http://www.ahrq.gov/qual/nurseshdbk
Advances in Patient
Safety: New Directions
and Alternative
Approaches is a four-volume
set of 115 articles
that describe patient safety
findings, investigative
approaches, process
analyses, lessons learned,
and practical tools to
prevent patients from
being harmed. It includes
articles by AHRQ-funded patient safety researchers
on topics such as reporting systems, risk assessment,
safety culture, medical simulation, health information
technology, and medication safety.
Print: AHRQ Publication No. 08-0034 (1-4)
CD: 08-0034-CD
Web: http://www.ahrq.gov/qual/advances2
Advances in Patient Safety: From Research to
Implementation is a four-volume set of 140 articles
that describe accomplishments between 1999 and
2004 by federally funded programs in understanding
medical errors and implementing programs to improve
patient safety. Included are articles with a research
and methodological focus, articles that address
implementation issues, and tools to improve patient
safety.
CD: AHRQ Publication No. 05-0021-CD
Web: http://www.ahrq.gov/qual/advances
Advancing Patient Safety:
A Decade of Evidence,
Design, and Implementation
highlights many of AHRQ's
contributions in advancing
patient safety in the 10 years
after Institute of Medicine
released its sentinel report To Err is Human: Building a
Safer Health System.
Print: AHRQ Publication No. 09(10)-0084
Web: http://www.ahrq.gov/qual/advptsafety.htm
Tools for Patients and Families
20 Tips to Help Prevent
Medical Errors tells patients
what they can do to get safer care
and addresses medicines, hospital
stays, surgery, medical tests, and
more.
Be More Involved in Your Health Care: Tips for
Patients gives patients tips to use before, during, and
after a medical appointment to get the best possible care.
Blood Thinner Pills: Your
Guide to Using Them Safely
explains, in both in English
and Spanish, what patients can
expect while taking blood thinner
medication.
Print: AHRQ Publication No. 09-0086-C
Web: http://www.ahrq.gov/consumer/btpills.htm#booklet
Designed for use in medical office waiting rooms, My
Questions for This Visit are 50-sheet notepads that let
patients list the three questions they want to remember to
ask during medical visits.
Staying Active and Healthy with Blood Thinners
is a 10-minute video that features easy-to-understand
explanations, in English and Spanish, of how blood
thinners work and why it is important to take them
correctly. It also introduces BEST, an easy way to
remember how to fit blood thinner medication into daily
life.
DVD: AHRQ Publication No. 09-0086-DVD
Web—English: http://www.healthcare411.ahrq.gov/videocast.aspx?id=555
Web—Spanish: http://www.healthcare411.ahrq.gov/videocast.aspx?id=556
Check Your Medicines: Tips for Taking Medicines
Safely has questions patients should ask their doctors to
help them take the right medicine in the right way at the
right time.
Print—English and Spanish: AHRQ Publication No. 10-M052-C
Web—English: http://www.ahrq.gov/consumer/checkmeds.htm
Web—Spanish: http://www.ahrq.gov/consumer/spcheckmeds.htm
Your Medicine: Be Smart. Be Safe
answers common questions about
getting and taking medicines and has
handy forms that help patients keep
track of their medicines.
Five Steps to Safer Health Care was produced in
collaboration with the American Hospital Association
and the American Medical Association to explain
the questions patients should ask their doctors about
medicines, tests, procedures, surgery, and hospitals.
Having Surgery? What You Need to Know lists
questions patients should ask to better understand an
upcoming surgery.
Taking Care of Myself: A
Guide for When I Leave the
Hospital is an easy-to-read guide
in English and Spanish that
helps patients track medication
schedules, upcoming medical
appointments, and important
phone numbers after they leave
the hospital. Hospital staff can
also complete the information
and use the guide to discuss this
important information during the discharge process.
Print: AHRQ Publication No 10-0059-C
Web—English: http://www.ahrq.gov/qual/goinghomeguide.htm
Web—Spanish: http://www.ahrq.gov/qual/goinghomesp.htm
Your Guide to Preventing
and Treating Blood Clots
discusses ways to prevent, treat,
and recognize symptoms of
blood clots. It also describes
medications used to prevent
blood clots and their side effects.
Print: AHRQ Publication No. 09-0067-C
Web—English: http://www.ahrq.gov/consumer/bloodclots.htm
Web—Spanish: http://www.ahrq.gov/consumer/spblclots.htm
AHRQ's Questions are the Answer initiative is
designed to improve communication between patients
and clinicians to help make health care safer. The Web
site features:
- A 7-minute video featuring patients and clinicians
who stress the importance of asking questions and
sharing information.
- Individual videos from patients and health care
providers who discuss how asking questions
improves patient care.
- An interactive Question Builder that helps patients
to compile and print a list of questions to ask during
their next medical visit.
- Tips, links to AHRQ tools, and a glossary.
Web: http://www.ahrq.gov/questions
Conozca las preguntas (Know the Questions), a
Spanish-language companion site to Questions are the
Answer, encourages Hispanics to go to the doctor and
ask questions to achieve better health outcomes. The
Web site features tips on how to talk with doctors and
questions to ask when receiving medical care.
Web: http://www.ahrq.gov/preguntas
How To Order Resources
All AHRQ publications are available online. Health care
organizations can receive multiple copies of most printed
materials at no cost by calling AHRQ's Publications
Clearinghouse at (800) 358-9295 or by sending an Email
that includes the title and AHRQ Publication Number to
ahrqpubs@ahrq.hhs.gov.
AHRQ Publication No. 12-M008
(Replaces AHRQ Publication No. 09-M024)
Current as of May 2012
Internet Citation:
AHRQ Patient Safety Tools and Resources. AHRQ Publication No. 12-M008, May 2012. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/qual/pstools.htm
540 Gaither Road Rockville, MD 20850 