Resources and Tools on Patient and Healthcare Workforce Safety

Safety Resources from the Agency for Healthcare Research and Quality
Additional HHS and Other Federal Resources and Programs

Safety Resources from the Agency for Healthcare Research and Quality

These curated lists of resources align with the four foundational areas identified by the National Action Plan and with types of harms that occur in healthcare settings. These resources will help you address many of the issues you identify in your safety assessment.

These survey tools ask healthcare providers and other staff in hospitals, medical offices, nursing homes, community pharmacies, and ambulatory surgery centers about their organizational culture's support for patient safety. Available supporting resources include data entry and analysis tools, improvement resource lists, impact case studies on SOPS surveys, and an action planning tool.

The Comprehensive Unit-based Safety Program (CUSP) Method

The CUSP method can help clinical teams make care safer by combining improved teamwork, clinical best practices, and the science of safety. The Core CUSP toolkit includes training resources and tools to apply the CUSP methods and build capacity to address safety issues.

Patient Safety Primer: Safety Culture

This resource provides an overview of patient safety culture and covers key concepts.

Patient and Family Engagement

Guide to Improving Patient Safety in Primary Care Settings by Engaging Patients and Families

This resource offers four interventions and case studies designed to improve patient safety by meaningfully engaging patients and families in their care.

Guide to Patient and Family Engagement in Hospital Quality and Safety

This guide helps hospitals work as partners with patients and families to improve quality and safety. It includes an implementation handbook and tools for patients, families, and clinicians.

TeamSTEPPS 3.0 (Team Strategies and Tools to Enhance Performance and Patient Safety)

This evidence-based resource provides exercises, videos, and other resources relevant to four fundamentals of teamwork: leadership, situation monitoring, mutual support, and communication. TeamSTEPPS is applicable to many clinical settings (long-term care, office practices, etc.) and team participants (patients, support staff, administrators, etc.).

CANDOR (Communication and Optimal Resolution) Toolkit

This resource provides healthcare organizations the tools to respond immediately when a patient is harmed and to promote candid, empathetic communication and timely resolution for patients and caregivers.

Toolkit for Engaging Patients to Improve Diagnostic Safety

This resource contains two strategies, Be The Expert On You and 60 Seconds To Improve Diagnostic Safety, that enhance communication and information sharing within the patient-provider encounter to improve diagnostic safety. Each strategy contains practical materials to support adoption within office-based practices.

Improving Healthcare Safety by Engaging Patients and Families

This resource summarizes 53 AHRQ-funded projects to improve patient safety by supporting increased patient and family engagement.

CAHPS Ambulatory Care Improvement Guide

This comprehensive resource is for health plans, medical groups, and other providers seeking to improve their performance in the domains of patient experience measured by the Consumer Assessment of Healthcare Providers and Systems (CAHPS) surveys of ambulatory care.

Implementation Opportunity: TeamSTEPPS 3.0 Trainings

From March through November 2024, AHRQ will offer virtual and limited in-person TeamSTEPPS 3.0 trainings led by experienced facilitators at no charge to participating healthcare teams and individuals. These trainings will prepare participants to improve team communication, manage challenges more collaboratively, and successfully implement TeamSTEPPS to improve patient care at their organization. Those interested should email TeamSTEPPStraining@ahrq.hhs.gov. A training team member will be in touch to help you and your team identify your organization’s goals and needs, complete pretraining activities, and schedule a training session based on your availability.

Workforce Safety

Burnout: A PSNet Primer

This article provides an overview of burnout in healthcare and covers key definitions and concepts. Authors discuss current efforts to prevent and reduce burnout, including a guide for implementing organizational strategies to prevent and reduce burnout.

Burnout in Primary Care: Assessing and Addressing It In Your Practice

This resource, designed to support primary care practice administrators in learning about and addressing staff burnout, includes information about burnout, tools and strategies to help practices address burnout and improve staff well-being, and links to additional resources.

Funding Opportunity: New AHRQ R01: Systems-Based Approaches to Improve Patient Safety by Improving Healthcare Worker Safety and Well-Being

AHRQ is seeking applications for funding support up to $2M over 4 years that propose approaches to improve the interrelated systems and processes embedded in healthcare delivery to support healthcare worker safety and well-being in various health settings.

Learning Systems

Measure Dx: A Resource to Identify, Analyze, and Learn from Diagnostic Safety Events

This resource helps clinicians, quality, safety and risk management professionals, and other health system leaders detect, analyze, and learn from diagnostic safety events.

Calibrate Dx: A Resource to Improve Diagnostic Decisions

This self-evaluation tool helps clinicians improve their diagnostic decision making. It provides structured exercises and tools to help clinicians learn from reviewing their clinical practice.

Quality Indicators

AHRQ’s quality indicators are standardized, evidence-based measures of healthcare quality that can be used to measure and track clinical performance and outcomes. They include measures for prevention, inpatient hospital care, patient safety, pediatric hospital care, and emergency department care.

Funding Opportunity: New LHS E-StaR Program

Through a joint initiative funded over a 5-year period, AHRQ and the Patient-Centered Outcomes Research Institute are supporting scientist training and research centers to create new models of learning health systems that generate evidence to optimize care as quickly, broadly, and equitably as possible.

Diagnostic Safety

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.

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

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.

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.

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.

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.

Hospital-Acquired Infections

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.

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.

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.

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.

The 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.

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.

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.

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.

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

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.

Medication Safety

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.

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.

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.

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.

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.

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.

Opioid Safety

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.

Pressure Ulcers

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

Hospital Guide to Reducing Medicaid Readmissions

This resource provides evidence-based strategies to reduce readmissions among the adult Medicaid population.

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.

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.

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.

Surgical Safety

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 improve perioperative safety culture.

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.

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.

Transitions

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.

The 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.

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.

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.

Venous Thromboembolism

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.

Additional HHS and Other Federal Resources and Programs

The federal partners in the National Action Alliance share these tools, materials, implementation and funding opportunities, and resources developed by their agencies to enhance and improve safety efforts.

Centers for Disease Control and Prevention

Healthcare Infection Prevention Guidelines
Core Elements of Antibiotic Stewardship Programs for Hospitals, Outpatient Care, Nursing Homes, and Resource-Limited Settings
Hospital Sepsis Program Core Elements
National Institute for Occupational Safety and Health (NIOSH) National Occupational Research Agenda Healthcare and Social Assistance Sector Council
NIOSH Impact Wellbeing^TM Campaign

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Resources and Tools on Patient and Healthcare Workforce Safety

Safety Resources from the Agency for Healthcare Research and Quality

AHRQ Resources by National Action Plan Foundational Area

AHRQ Resources by Type of Harm

Culture, Leadership, and Governance