Patient safety projects funded by the Agency for Healthcare Research and Quality (AHRQ) range from system-wide event reporting methods to specific measures to minimize medical errors. The information here summarizes AHRQ patient safety tools and resources designed for health systems, providers, and consumers.
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Research Findings and Summaries
Advances in Patient Safety: New Directions and Alternative Approaches. This 4-volume set of 115 articles describes new patient safety findings, investigative approaches, process analyses, lessons learned, and practical tools to prevent harming patients. It complements AHRQ's Advances in Patient Safety: From Research to Implementation and represents years of study by AHRQ-funded patient safety researchers and others. It includes articles on reporting systems, risk assessment, safety culture, medical simulation, health information technology, medication safety, and other important topics. Available at http://www.ahrq.gov/qual/advances2/ or as AHRQ Publication No. 08-0034 (print copy) or 08-0034-CD (Searchable CD-ROM).
Advances in Patient Safety: From Research to Implementation. This 4-volume set of 140 articles describes accomplishments by federally funded programs in understanding medical errors and implementing programs to improve patient safety between 1999 and 2004. Included are articles with a research and methodological focus, articles that address implementation issues, and tools to improve patient safety. Available at http://www.ahrq.gov/qual/advances/ or as AHRQ Publication No. 05-0021-CD.
Patient Safety and Quality: An Evidence-Based Handbook for Nurses. In this 3-volume handbook, nurses will find peer-reviewed discussions and reviews of a wide range 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. Available at http://www.ahrq.gov/qual/nurseshdbk/ or as AHRQ Publication No. 08-0043 (print copy) or 08-0043-CD (CD-ROM).
Patient Safety Research Highlights. This 20-page program brief describes more than 100 AHRQ-supported studies in patient safety that have produced new findings, tools, and products that the health care system, health care providers, and researchers can use to improve patient safety. Available at http://www.ahrq.gov/qual/psresearch.htm or as AHRQ Publication No. 06-P023.
Training Tools
Problems and Prevention: Chest Tube Insertion. If chest tubes are inserted incorrectly, patients can suffer adverse outcomes and even fatal complications, and clinicians can be exposed to injury or infection. This 11-minute DVD uses video excerpts of 50 actual chest tube insertions to illustrate problems that can occur during the procedure. A summary of the recommendations and ordering information for the DVD are available at http://www.ahrq.gov/qual/chesttubes.htm or as AHRQ Publication No. 06-0069-DVD.
Team Strategies and Tools to Enhance Performance and Patient Safety (TeamSTEPPS™). TeamSTEPPS is a set of tools to help train clinicians in teamwork and communication skills to reduce risks to patient safety. Available at http://teamstepps.ahrq.gov/index.htm or as AHRQ Publication No. 06-0020. The tools include:
- A leader's guide that provides materials for leader training.
- A learner's guide for participants.
- A pocket-sized guide of important team concepts for participants to use in their everyday work.
- A CD for trainers and leaders that includes reproducible materials for local needs.
- A DVD with nine video vignettes that illustrate examples of successful and unsuccessful teamwork.
- A module on Rapid Response Systems, in which hospitals use groups of clinicians to bring critical care expertise to patients requiring immediate treatment. The module includes PowerPoint presentations, teaching modules, and video vignettes that can be used to train hospital staff. Available as AHRQ Publication No. 08(09)-0074-CD.
Tools for Health Care Providers and Policymakers
Developing a Community-Based Patient Safety Advisory Council. This guide provides approaches for hospitals and other health care organizations to use to develop a community-based advisory council of patients, consumers, practitioners, and professionals from health care and community organizations to drive change for patient safety through education, collaboration, and consumer engagement. Available at http://www.ahrq.gov/qual/advisorycouncil/ or as AHRQ Publication No. 08-0048.
Mistake-Proofing the Design of Health Care Processes. This guide, illustrated with numerous examples, explains how to apply the industrial engineering concept of mistake-proofing to processes in hospitals, clinics, and physicians' offices. Available at http://www.ahrq.gov/qual/mistakeproof/ or as AHRQ Publication No. 07-0020 (print copy) or 07-0020-CD (CD-ROM).
Resident Duty Hours: Enhancing Sleep, Supervision, and Safety. This AHRQ-funded study from the Institute of Medicine (IOM) confirms that acute and chronically fatigued medical residents are more likely to make mistakes that affect patient care. The IOM recommends several changes to the existing 80-hour-per-week limit on resident work hours. For example, the IOM recommends that: 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, and residency review committees set guidelines for residents' patient caseloads. The December 2008 report brief is available at http://www.iom.edu/CMS/3809/48553/60449/60469.aspx.
Patient Safety Organizations. Patient Safety Organizations (PSOs) are designed to improve the quality and safety of health care by encouraging clinicians and health care organizations to voluntarily report and share data on patient safety events without fear of legal discovery. Dozens of organizations are listed as PSOs. Organizations eligible to become PSOs include public or private entities; profit or not-for-profit entities; provider entities, such as hospital chains; and other entities that establish special components to serve as PSOs. By providing both privilege and confidentiality, PSOs create a secure environment where clinicians and health care organizations can collect, aggregate, and analyze data that enable the identification and reduction of the risks and hazards associated with patient care. Available at http://www.pso.ahrq.gov.
Common Formats. 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, 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 released an initial set of Common Formats for hospitals to collect data for all types of adverse events, near misses, and unsafe conditions. Common Formats and information for users are accessible online through AHRQ's PSO Web site at http://www.pso.ahrq.gov.
Preventing Hospital-Acquired Venous Thromboembolism: A Guide for Effective Quality Improvement. 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 important problems facing hospitalized patients: hospital-acquired venous thromboembolism. Available at http://www.ahrq.gov/qual/vtguide/ or as AHRQ Publication No. 08-0075.
Transforming Hospitals: Designing for Safety and Quality. By presenting 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. This DVD is an especially useful tool for hospitals that are planning capital construction projects or renovations. Available as AHRQ Publication No. 07-0076-DVD.
Surveys to Measure Patient Safety Culture
AHRQ offers a suite of tools that measure patient safety culture in hospitals, medical offices, and nursing homes. Tools include survey instruments, report templates, and a User's Guide that provides information on getting started, selecting a sample, determining data collection methods, establishing data collection procedures, conducting a Web-based survey, preparing and analyzing data, and producing reports.
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 to track changes over time. Hospitals that administer the AHRQ patient safety culture survey can voluntarily submit their data into the Comparative Database, a resource for hospitals wishing to compare their patient safety culture survey results to similar types of hospitals. Available at http://www.ahrq.gov/qual/patientsafetyculture/hospsurvindex.htm or as AHRQ Publication No. 08-0048.
Hospital Survey on Patient Safety Culture: Comparative Database Reports are available for 2007, 2008, and 2009. These reports give benchmark data collected voluntarily from nearly 400 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 97 medical offices, this 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. Available at http://www.ahrq.gov/qual/patientsafetyculture/mosurvindex.htm or as AHRQ Publication No. 08-0059.
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. Available at http://www.ahrq.gov/qual/nhsurvey08/nhguide.htm or as AHRQ Publication No. 08-0060.
Tools to Share Information
AHRQ Web M&M (Morbidity and Mortality Rounds on the Web). This free, peer-reviewed online journal and forum on patient safety and health care quality features expert analysis of medical errors that readers report anonymously, interactive learning modules on patient safety ("Spotlight Cases"), perspectives on safety, and forums for online discussion. Continuing medical education and continuing education unit credits are offered. Available at http://www.WebMM.ahrq.gov.
AHRQ Patient Safety Network. This national Web-based resource features the latest news and essential resources on patient safety. Items in the AHRQ PSNet collection support a multidisciplinary, systems approach to minimizing errors in health care and come from a range of disciplines and sources, including clinical medicine, health care administration, engineering, general sciences, psychology, equipment and facility design, policy, law, and the media. Its Patient Safety Primers guide users through key concepts in patient safety and provide background and context and highlighting relevant content from AHRQ PSNet and AHRQ WebM&M. Available at http://psnet.ahrq.gov/about.aspx and http://psnet.ahrq.gov/primerHome.aspx.
Patient Safety and Health Information Technology E-Newsletter. AHRQ's monthly e-newsletter provides timely patient safety and health information technology (IT) news and information. It features concise descriptions of recent findings from AHRQ-supported research and information about new initiatives, upcoming meetings, and other patient safety and health IT activities. A free subscription requires only a computer and an E-mail address. Available by going to http://www.ahrq.gov, selecting "E-mail Updates," and providing the requested information. On the "Quick Subscribe" page, select "Patient Safety and Health Information Technology ENewsletter." Current and past issues of the newsletter are available at http://www.ahrq.gov/news/ptsnews.htm.
Tools for Consumers
AHRQ materials help health care consumers work as partners with their doctors, pharmacists, and nurses.
Blood Thinner Pills: Your Guide to Using Them Safely. This guide for patients explains what to expect while taking blood thinner medication. Available as AHRQ Publication No. 09-0086-C in English and Spanish.
Check Your Medicines: Tips for Taking Medicines Safely. This checklist has questions patients should ask their doctors to help them take the right medicine in the right way at the right time. Available at http://www.ahrq.gov/consumer/checkmeds.htm or as AHRQ Publication No. 08-M044-A.
Five Steps to Safer Health Care. This flyer explains what questions patients should ask their doctors about medicines, tests, procedures, surgery, and hospitals. Available at http://www.ahrq.gov/consumer/5steps.htm or as AHRQ Publication No. 04-M005.
Having Surgery? What You Need to Know. This brochure lists questions patients should ask their doctors or nurses to better understand an upcoming surgery. Available at http://www.ahrq.gov/consumer/surgery/surgery.htm or as AHRQ Publication No. 05(06)-0074-A.
Your Guide to Preventing and Treating Blood Clots. This guide for patients discusses ways to prevent, treat, and recognize symptoms of blood clots. It also describes medications used to prevent blood clots and their side effects. Available at http://www.ahrq.gov/consumer/bloodclots.htm or as AHRQ Publication No. 09-0067-C in English and Spanish.
Questions Are the Answer
Questions are the Answer:
This Web-based set of tools gets patients more engaged and involved in their health care by addressing topics and linking to AHRQ publications for consumers on:
- Reducing medical mistakes.
- Talking with clinicians.
- Getting medical tests.
- Planning for surgery.
- Getting a prescription.
An interactive Question Builder helps patients to compile and print a list of questions to ask their health care provider or pharmacist during their next visit. Questions are grouped by topic areas to make it easy to create a personalized list.
A printed version of the question list tool with space for answers, called Be Prepared for Medical Appointments—Build Your Question List, is available from AHRQ as AHRQ Publication No. 07-0039-A or 07-0039-B (Spanish).
The Questions are the Answer site also provides non-AHRQ resources, a glossary, and 30- and 60-second
videos that were used in a national public service advertising campaign. Available at http://www.ahrq.gov/questionsaretheanswer.
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How to Get These Free Resources
These and other AHRQ resources are available at http://www.ahrq.gov. Single copies of most printed materials are available at no cost by calling AHRQ's Publications Clearinghouse at (800) 358-9295 or by sending an W-mail request with the title and publication number to ahrqpubs@ahrq.hhs.gov.
AHRQ Publication No. 09-M024
(Replaces AHRQ Publication No. 08-M070)
Current as of July 2009
Internet Citation:
AHRQ Patient Safety Tools and Resources. AHRQ Publication No. 09-M024. July 2009. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/qual/pstools.htm
540 Gaither Road Rockville, MD 20850