Toolkit and Resource Descriptions
Patient Safety Tools: Improving Safety at the Point of Care
Toolkit and Resource Descriptions
Improving Patient Flow in the Emergency Department
By implementing a patient flow process called "Door to Doc" this project improves the safety of care for patients in the emergency department (ED) by reducing the time patients wait to be seen and by expediting admission to the most appropriate hospital unit. A toolkit contains the necessary resources for implementing operational changes, including:
Toolkit Web Site: http://www.bannerhealthinnovations.org/DoortoDoc/About+D2D.htm.
Improving Patient Safety Through Enhanced Provider Communication
This project focuses on improving the safety and effectiveness of communication between providers and among teams. A standardized situational briefing model is used as a guide to facilitate timely communication about changes in patient status on need. The model is also used to implement daily patient-centered rounds by multi-disciplinary teams and to conduct team huddles each shift to discuss patient care plans. In addition, the project uses other communication tools designed to help clinicians and health care professionals implement effective teamwork and communication strategies in their practice settings to improve patient safety.
The toolkit includes:
Toolkit Web Site: http://www.safecoms.org.
The Emergency Department Pharmacist as a Safety Measure in Emergency Medicine
This project focuses on improving medication safety by implementing an emergency department pharmacist program. A toolkit facilitates the implementation of similar programs into other hospital emergency departments. The toolkit includes:
Toolkit Web Site: http://www.emergencypharmacist.org/index.html.
Using Military Simulation to Improve Rural Obstetric Safety
This project brings together simulation technology and team performance training to improve obstetric care and promote safety for women and children, particularly in rural communities. Project leaders developed and tested a standardized curriculum for simulated obstetric emergency response drills and safety. The project toolkit includes:
Toolkit Web Site: https://www.obsafety.org/content/blogcategory/53/101/.
Testing the Re-Engineered Hospital Discharge
This project re-engineered the process of discharging patients from a hospital back into the community to make the process safer. The discharge workflow was redesigned using a set of 10 discrete, mutually reinforcing components that aim to reduce post-discharge adverse events and subsequent re-hospitalizations. Two features of the re-engineered process are a discharge advocate who works with patients throughout the process, and the real time production of a simple, easy to understand discharge plan. The toolkit includes:
Toolkit Web Site: http://www.bu.edu/familymed/projectred.html.
Presentation: Reducing Avoidable Hospital Readmissions.
Web Conference: http://www.ahrq.gov/news/kt/red/.
Implementing a Program of Patient Safety in Small Rural Hospitals
This project provides tools to improve patient safety by engineering a culture of safety in small rural hospitals. These tools include resources for small rural hospitals to conduct and interpret the AHRQ Hospital Survey on Patient Safety Culture. Another aspect is creating an infrastructure for reporting, collecting, and analyzing data about voluntarily reported medication errors. The toolkit provides resources to engineer the components of a culture of safety in small rural hospitals, including:
Toolkit Web Site: http://www.unmc.edu/rural/patient-safety.
Implementing Reduced Work Hours to Improve Patient Safety
This project implements evidence-based work schedules to help reduce work hours for extended shifts for residents to reduce errors from sleep and fatigue and also from a lack of continuity of care. Toolkit resources include:
Toolkit Web Site: http://workhoursandsafety.org.
Improving Medication Safety in Clinics for Patients 55 and Older
This project improves the safety of care and care processes in outpatient settings through a partnership model involving patients, health care providers, and the community. The project implements a patient safety partnership council that includes both providers and patients and uses focus groups, interviews, and other tools to facilitate patient-centered care, including medication safety for elderly patients. The toolkit includes:
Toolkit Web Site: http://patientsafety.org/page/109587/.
Improving Warfarin Management
This project applied ISO 9001 principles to establish a virtual anticoagulation clinic for two hospitals and two physician practices and resulted in the development of a model for developing safe care delivery systems. The toolkit features:
Toolkit Web Site: http://www.crhealthcarealliance.org.
Preventing Venous Thromboembolisms in the Hospital
This project focuses on eliminating preventable hospital-acquired venous thromboembolism. The safe-practice intervention focuses on improved adherence to proven prophylactic methods that should substantially reduce venous thromboembolism in hospitalized patients. The project toolkit includes:
Toolkit Web Site: http://www.hospitalmedicine.org/ResourceRoomRedesign/RR_VTE/VTE_Home.cfm.
Patient Multidisciplinary Training for Medication Reconciliation
This project implements a single, shared, updated and reconciled medication and allergy list for patients across the continuum of inpatient and outpatient care. A central component of this intervention is the development of objective criteria for use in the hospital inpatient, primary care, or home health outpatient settings to trigger pharmacist review and involvement in taking the patient's medication history. The toolkit includes:
Toolkit Web Site: http://www.legacyhealth.org/body.cfm?id=749.
Reducing Discrepancies in Medication Histories and Orders at Handoffs
This project implements a training intervention to improve medication history interviewing skills and offers a guide to creating a single medication history list within the medical record. The training focuses on identifying patient risk factors frequently responsible for inaccurate medication reconciliation, including limited English proficiency and low health literacy, complex medication histories, or impaired cognitive status. The toolkit contains resources for both health care professionals and patients, including:
Toolkit Web Site: http://www.medrec.nmh.org/nm/for+physicians+match.
A Simulation-Based Safety Curriculum in a Children's Hospital Emergency Department
This project aims to decrease and mitigate the effects of medical errors in a pediatric emergency department through the implementation of a multidisciplinary, multi-clinician, simulation-based safety curriculum that emphasizes team behaviors. The project toolkit provides:
For more information please contact Mary Patterson at: firstname.lastname@example.org.
Improving Medication Adherence
The project implements a multi-modal patient medication education intervention to improve safety hospital-wide by involving clinicians and patients during the hospital stay. Drawing on health behavior change theory, the intervention focuses on reducing 30-day hospital readmissions and on improving patient satisfaction and medication adherence. The toolkit promotes a generalizable and sustainable education program with tools and resources that promote structured medication education, administrative support and staff training, and established quality improvement techniques. The toolkit includes:
Toolkit Web Site: http://www.ccm.upmc.edu/epitome/.
Reducing Central Line Bloodstream Infections and Ventilator-Associated Pneumonia
This project couples two interventions to improve critical care—reduction of catheter-related blood stream infections and ventilator-associated pneumonia. The project used a randomized controlled trial to compare the effectiveness of various strategies for implementing an improvement initiative. The toolkit includes:
Improving Hospital Discharge Through Medication Reconciliation and Education
This project implements a "discharge bundle" consisting of medication reconciliation, patient-centered hospital discharge education, and post discharge continuity checks. This intervention improves the safety of patient discharges from the hospital by increasing patients' understanding of their illness and treatment and fostering continuity of care. The toolkit contains such resources as:
Interactive Venous Thromboembolism Safety Toolkit for Providers and Patients
This project implements safe practice interventions for patients with venous thromboembolism. An interactive safety toolkit contains multiple evidence-based tools for providers and patients to improve the safety of the process for the diagnosis and treatment of venous thromboembolism, including:
Toolkit Web Site: http://vte.son.washington.edu/.