Toolkit and Resource Descriptions

Patient Safety Tools: Improving Safety at the Point of Care

Patient Safety Tools: Improving Safety at the Point of Care--Toolkit and Resource Descriptions

Toolkit and Resource Descriptions

Contents

Improving Patient Flow in the Emergency Department (Twila Burdick)
Improving Patient Safety Through Enhanced Provider Communication (Kay Daugherty)
The Emergency Department Pharmacist as a Safety Measure (Rollin (Terry) Fairbanks)
Using Simulation to Improve Rural Obstetric Safety (Jeanne-Marie Guise)
Testing the Re-engineered Hospital Discharge (Brian Jack)
Improving Patient Safety in Small, Rural Hospitals (Katherine Jones)
Implementing Reduced Work Hours to Improve Patient Safety (Christopher Landrigan)
Improving Medication Safety in Clinics for Patients 55 and Older (Kathryn Leonhardt)
Improving Warfarin Management (James Levett)
Preventing Venous Thromboembolism in the Hospital (Greg Maynard)
Patient Multidisciplinary Training for Medication Reconciliation (Melinda J. Muller)
Reducing Discrepancies in Medication Histories and Orders at Handoffs (Gary Noskin)
A Simulation-Based Safety Curriculum in a Children's Hospital Emergency Department (Mary Patterson)
Improving Medication Adherence (Carl Sirio)
Reducing Central Line Bloodstream Infections and Ventilator-Associated Pneumonia (Theodore Speroff)
Improving Hospital Discharge Through Medication Reconciliation and Education (Mark Williams)
Interactive Venous Thromboembolism Safety Toolkit for Providers and Patients (Brenda Zierler)


Projects

Improving Patient Flow in the Emergency Department
Twila Burdick, MBA; Banner Health/Arizona State University, Phoenix
AHRQ Grant No. HS015921-01

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:

  • Strategies for "Door to Doc" re-design principles.
  • Multidisciplinary training aids and methods.
  • An actionable communication plan.
  • Other tools aimed at project management and patient safety culture.

Toolkit Web Site: http://www.bannerhealthinnovations.org/DoortoDoc/About+D2D.htm.

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Improving Patient Safety Through Enhanced Provider Communication
Kay Daugherty, Ph.D., R.N.; Denver Health and Hospital Authority, CO
AHRQ Grant No. HS015846-01

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:

  • A framework for specific communication strategies.
  • Educational materials.
  • Evaluation and analysis tools.

Toolkit Web Site: http://www.safecoms.org.

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The Emergency Department Pharmacist as a Safety Measure in Emergency Medicine
Rollin (Terry) Fairbanks, M.D., MS; University of Rochester, NY
AHRQ Grant No. HS015921-01

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:

  • A description of the formal, optimized role of the emergency department pharmacist.
  • Challenges and accompanying solutions to implementing emergency department pharmacist programs.
  • Evidence to support the efficacy of such a program.

Toolkit Web Site: http://www.emergencypharmacist.org/index.html.

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Using Military Simulation to Improve Rural Obstetric Safety
Jeanne-Marie Guise, M.D.; Oregon Health & Science University, Portland
AHRQ Grant No. HS015800-01

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:

  • The standardized curriculum that consists of simulations and team debriefings.
  • Team training modules.
  • Two clinical didactics specific to obstetric emergencies.
  • A labor and delivery safety attitudes survey.
  • A complete electronic obstetric charting tool.

Toolkit Web Site: https://www.obsafety.org/content/blogcategory/53/101/.

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Testing the Re-Engineered Hospital Discharge
Brian Jack, M.D.; Boston Medical Center, MA
AHRQ Grant No. HS015905-01

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:

  • A discharge manual and software program.
  • A discharge advocate training manual and instructions.
  • Patient education materials.
  • Guidelines for medication reconciliation and for developing a discharge plan for patients.
  • Instructions for telephone re-enforcement of the discharge plan.

Toolkit Web Site: http://www.bu.edu/familymed/projectred.html.

Publication: Taking Care of Myself: A Guide for When I Leave the Hospital

Presentation: Reducing Avoidable Hospital Readmissions.

Web Conference: http://www.ahrq.gov/news/kt/red/.

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Implementing a Program of Patient Safety in Small Rural Hospitals
Katherine Jones, Ph.D.; University of Nebraska Medical Center, Omaha
AHRQ Grant No. HS015822-01

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:

  • Rural-adapted version of the Hospital Survey on Patient Safety Culture (HSOPS) and Premier Customized Excel™ Data Tool.
  • Tools for small rural hospitals to benchmark and interpret HSOPS findings.
  • Staff training modules to implement MEDMARX™, a systematic medication error reporting program in small rural hospitals.
  • Tools to implement a just culture and a learning culture including root cause analysis in small rural hospitals.

Toolkit Web Site: http://www.unmc.edu/rural/patient-safety.

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Implementing Reduced Work Hours to Improve Patient Safety
Christopher Landrigan, M.D. MPH; Brigham and Women's Hospital, Boston, MA
AHRQ Grant No. HS015906-01

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:

  • Ready-to-implement circadian-based work schedules.
  • Evidence-based guidelines for successful shift changes and safe handovers.

Toolkit Web Site: http://workhoursandsafety.org.

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Improving Medication Safety in Clinics for Patients 55 and Older
Kathryn Leonhardt, M.D.; Aurora Health Care, Milwaukee, WI
AHRQ Grant No. HS015915-01

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:

  • A how-to guide for developing and implementing an outpatient patient-provider council.
  • A how-to guide for improving medication list accuracy in the clinic setting

Toolkit Web Site: http://patientsafety.org/page/109587/.

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Improving Warfarin Management
James Levett, M.D.; Kirkwood Community College, Cedar Rapids, IA
AHRQ Grant No. HS015830-01

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:

  • Tools for implementing a virtual anticoagulation clinic by other communities of providers.
  • Training materials on teaching ISO 9001 quality concepts.
  • Anticoagulation care guidelines.
  • Techniques for simplifying and controlling documents across multiple institutions and sites of care.
  • Guidelines for utilizing auditing, and corrective and preventive action plans to monitor clinical outcomes.
  • Patient education materials.

Toolkit Web Site: http://www.crhealthcarealliance.org.

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Preventing Venous Thromboembolisms in the Hospital
Greg Maynard, M.D. University of California, San Diego
AHRQ Grant No. HS015826-01

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:

  • Materials to assess venous thromboembolism risk at admission and a prophylaxis protocol that includes recommended options for patients at various risk levels.
  • Software-based protocols that others can use to create and modify venous thromboembolism prophylaxis order sets based on their own evidence-based conclusions.

Toolkit Web Site: http://www.hospitalmedicine.org/ResourceRoomRedesign/RR_VTE/VTE_Home.cfm.

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Patient Multidisciplinary Training for Medication Reconciliation
Melinda J. Muller, M.D.; Legacy Health System, Portland, OR
AHRQ Grant No. HS015904-01

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:

  • Clinician training tools in medication reconciliation.
  • Medication and allergy lists for reconciliation.
  • Criteria for pharmacist consultation and review of medication history.
  • Patient education tools.
  • Resources geared toward successful implementation, such as institutional review board forms and scripts for patient and staff focus groups.

Toolkit Web Site: http://www.legacyhealth.org/body.cfm?id=749.

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Reducing Discrepancies in Medication Histories and Orders at Handoffs
Gary Noskin, M.D.; Northwestern University, Evanston, IL
AHRQ Grant No. HS015886-01

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:

  • Resources for measuring error and associated harm.
  • Guidelines on safe process design principles.
  • Evaluation, education, and training tools.
  • Lessons learned on implementation and sustainability of medication reconciliation, among others.

Toolkit Web Site: http://www.medrec.nmh.org/nm/for+physicians+match.

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A Simulation-Based Safety Curriculum in a Children's Hospital Emergency Department
Mary Patterson, M.D.; Cincinnati Children's Hospital Medical Center, OH
AHRQ Grant No. HS015841-01

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:

  • A simulation-based curriculum.
  • A re-evaluation and reinforcement plan involving all ED personnel and house staff.
  • An abbreviated teamwork training course for multidisciplinary and interdisciplinary trauma teams.
  • Instructional materials necessary to implement the 1.5-day safety course including a training agenda.
  • Knowledge pre and post-test questionnaires.
  • Lectures, including a section on crew resource management concepts and video presentations.
  • A link to a Safety Attitude and Safety Climate Survey.

For more information please contact Mary Patterson at: mary.patterson@cchmc.org.

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Improving Medication Adherence
Carl Sirio, M.D.; University of Pittsburgh, Pittsburgh, PA
AHRQ Grant No. HS015851-01

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:

  • Training CD-ROMs.
  • Pocket/wallet-sized cards to promote health behavior change guidelines.
  • Classroom training materials.

Toolkit Web Site: http://www.ccm.upmc.edu/epitome/.

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Reducing Central Line Bloodstream Infections and Ventilator-Associated Pneumonia
Theodore Speroff, Ph.D.; Vanderbilt University School of Medicine and HCA, Nashville, TN
AHRQ Grant No. HS015934-01

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:

  • Educational materials.
  • Surveys for infection control and safety.
  • Information on collaborative improvement strategies.
  • Checklists to monitor the bundled processes of care.
  • Guide and template worksheets for initiating a quality improvement team and maintaining continuous action plans.

Toolkit Web Site: http://www.hcapatientsafety.org/custompage.asp?guidcustomcontentid=
{30E376EA-1232-4B78-9AF3-95B6E565A847}
.

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Improving Hospital Discharge Through Medication Reconciliation and Education
Mark Williams, M.D.; Emory University, Atlanta, GA
AHRQ Grant No. HS015882-01

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:

  • Medication reconciliation forms.
  • A checklist for discharge patient education.
  • A checklist for a post-discharge continuity check as well as suggestions for successful implementation.

Toolkit Web Site: http://www.hospitalmedicine.org/Content/NavigationMenu/
QualityImprovement/QIClinicalTools/Quality_Improvement.htm
.

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Interactive Venous Thromboembolism Safety Toolkit for Providers and Patients
Brenda Zierler, Ph.D., R.N.; University of Washington, Seattle
AHRQ Grant No. HS015898-01

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:

  • Patient education materials.
  • Prevention guidelines.
  • Screening and assessment materials.
  • Treatment pathways.

Toolkit Web Site: http://vte.son.washington.edu/.

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Current as of August 2012
Internet Citation: Toolkit and Resource Descriptions: Patient Safety Tools: Improving Safety at the Point of Care. August 2012. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/professionals/quality-patient-safety/patient-safety-resources/resources/pips/grants.html