Tools and Resources

Patient safety tools and resources

Advancing Patient Safety: A Decade of Evidence, Design, and Implementation

This document highlights some of the Agency's contributions in advancing patient safety during the past decade.

Advances in Patient Safety: From Research to Implementation

This four-volume set from AHRQ and the U.S. Department of Defense describes what federally funded programs have accomplished in new patient safety findings, investigative approaches, process analyses, and practical tools for preventing medical errors and harm.

Advances in Patient Safety: New Directions and Alternative Approaches

This compendium describes what federally funded programs have accomplished in understanding medical errors and implementing programs to improve patient safety over the last 5 years.

Advances in the Prevention and Control of HAIs

This report presents methodological insights from projects in AHRQ’s Healthcare-Associated Infections (HAI) Program. The individual papers presented were prepared by AHRQ-funded HAI project leaders.

AHRQ Patient Safety Tools and Resources

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.

AHRQ Safety Program for End-Stage Renal Disease Facilities

The 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.

Bringing Human Factors into Home Health Care

Many health care technologies that involve information technology (IT) are moving into the home, for use by caregivers who look after the growing number of older adults with chronic illnesses. With funding from the Agency for Healthcare Research and Quality (AHRQ), the Institute of Medicine conducted a study of these health IT-related technologies that looks at the imbalances between the demands of the new home technologies and the capabilities of caregiver-users, with recommendations for designs that ensure greater ease and accuracy of use.

Carbapenem-Resistant Enterobacteriaceae (CRE) Control and Prevention Toolkit

Leaders in infectious disease and infection control, as well as those concerned with patient safety and performance improvement, can use this toolkit to develop interventions to control carbapenem-resistant Enterobacteriaceae (CRE). CRE are the result of a complex family of plasmid-borne resistance factors that circulate among Enterobacteriaceae. In the United States, the overwhelming majority of CRE cases are caused by the plasmid-borne Klebsiella pneumoniae carbapenemase (KPC) gene circulating among Enterobacteriaceae, mostly commonly among Klebsiella pneumoniae isolates. KPC-producing organisms have spread epidemically in the United States and around the world among hospitalized patients.

Central Line Insertion Care Team Checklist

This checklist provides sequential critical steps that have shown to reduce central line-associated infections.

Communication and Optimal Resolution (CANDOR) Toolkit

A traditional approach when unexpected harm occurs often follows a “deny-and-defend” strategy, providing limited information to patients and families, and avoiding admission of fault. In short, the CANDOR process is a more patient-centered approach that emphasizes early disclosure of adverse events and a more proactive method to achieving an amicable and fair resolution for the patient/family and involved health care providers.

Consumer Experience

Information on a project to develop recommendations for ideal reporting systems that consumers would use to report their experiences with patient safety events. Patients and their family members are in a unique position to identify gaps in care that may have contributed to adverse events.

Health Care-Associated Infections

This page features helpful links to information, tools, and resources on healthcare-associated infections (HAIs), which are the most common complication of hospital care and are one of the top 10 leading causes of death in the United States. AHRQ-funded research and initiatives to reduce HAIs are also highlighted.

Improving Hospital Discharge Through Medication Reconciliation and Education

Project focused on improving the hospital discharge process.

MATCH Toolkit for Medication Reconciliation

This toolkit provides a step-by-step guide to improving the medication reconciliation process.

Medical Liability Reform & Patient Safety Initiative

Too many patients experience significant challenges with health care quality and patient safety, and injured patients are not well-served by the current medical liability system. In addition, the medical community reports serious problems with the medical liability system. In response, one component of President Obama's health care reform proposals is launching a new demonstration initiative through the Agency for Healthcare Research and Quality (AHRQ), Department of Health and Human Services (HHS).

Nursing Home Antimicrobial Stewardship Modules

The Nursing Home Antimicrobial Stewardship Modules include four tested, evidence-based toolkits to help optimize antibiotic use in nursing homes. The modules are intended to assist nursing homes develop antimicrobial programs.

Preventing Avoidable Readmissions

The Agency for Healthcare Research and Quality offers information and tools for clinicians and patients to make the hospital discharge process safer and to prevent avoidable readmissions. This page features links to AHRQ's resources for preventing avoidable readmissions or trips to the emergency room.

Preventing Hospital-Acquired Venous Thromboembolism: A Guide for Effective Quality Improvement

Pulmonary embolism resulting from deep vein thrombosis—collectively referred to as venous thromboembolism—is the most common preventable cause of hospital death. Pharmacologic methods to prevent venous thromboembolism are safe, effective, cost-effective, and advocated by authoritative guidelines, yet large prospective studies continue to demonstrate that these preventive methods are significantly underused. Based on quality improvement initiatives undertaken at the University of California, San Diego Medical Center and Emory University Hospitals, 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.

Promoting Safety and Quality Through Human Resource Practices

Executive Summary

Synthesis: Results of AHRQ-Funded HAI Projects

AHRQ has commissioned a 3-year HAI Synthesis Project, which is reviewing and aggregating the findings and results of healthcare-associated infections (HAI) research and implementation projects funded by AHRQ, primarily in the core period from fiscal years 2007 to 2010. The overall project will present important results for dissemination to the field and will report HAI knowledge gaps identified by project teams.

Toolkit for Reduction of Clostridium difficile Infections Through Antimicrobial Stewardship