Resources by Dimension

Improving Patient Safety in Hospitals

The following resources are organized according to the relevant HSOPS dimensions they can help improve. Some resources are duplicated and cross-referenced because they may apply to more than one dimension. 

Dimension 1. Teamwork Within Units

  1. Crisis Management Simulation Course
    http://www.innovations.ahrq.gov/content.aspx?id=265

    This featured profile is available on AHRQ's Health Care Innovations Exchange Web site. Crisis Resource Management (CRM) is a 7-hour course for labor and delivery (L&D) practitioners. It uses various strategies of crew resource management, a safety program developed by the aviation industry, to create realistic simulations designed to facilitate improvement of teamwork and communication skills in a real L&D crisis. According to postimplementation surveys, the course is highly regarded by the vast majority of participants. Surveys conducted 1 or more years after the course suggest that it produces lasting benefits, including improvements in communication, team leadership, and team performance during crises. 

  2. Curricula for Simulated Obstetric Emergency Response Drills & Safety (CORDS™)
    http://www.innovations.ahrq.gov/content.aspx?id=1937

    The CORDS toolkit is featured on AHRQ's Health Care Innovations Exchange Web site. It was designed to use military and aviation style simulation experiences to prepare labor and delivery staff for an obstetric emergency. The toolkit also includes information about the importance of communication and teamwork. 

  3. Patient Safety Primer: Teamwork Training
    http://psnet.ahrq.gov/primer.aspx?primerID=8

    Providing safe health care depends on highly trained individuals with disparate roles and responsibilities acting together in the best interests of the patient. The AHRQ Patient Safety Network explains this topic further and provides links for more information on what is new in teamwork training. 

  4. Patient Safety Through Teamwork and Communication Toolkit
    http://innovations.ahrq.gov/content.aspx?id=1947

    This toolkit is featured on AHRQ's Health Care Innovations Exchange Web site. It consists of an education guide and communication tools. The education guide provides a plan for the education and integration of communication and teamwork factors into clinical practice. The communication tools section provides a description for each of the following tools, along with provisions for implementation:

    • Multidisciplinary Rounding.
    • Huddles.
    • Rapid Response and Escalation.
    • Structured Communication.
  5. Pennsylvania Patient Safety Advisory (Vol.7, Suppl. 2)
    http://psnet.ahrq.gov/resource.aspx?resourceID=18509&sourceID=1&emailID=6

    This supplement from the Pennsylvania Patient Safety Authority is available for download from the AHRQ Patient Safety Network. It outlines tactics to improve communication, including crew resource management, chain-of-command policies, and teamwork training. 

  6. TeamSTEPPS™—Team Strategies and Tools to Enhance Performance and Patient Safety
    http://teamstepps.ahrq.gov/

    Developed jointly by the Department of Defense (DoD) and AHRQ, TeamSTEPPS™ is a resource for training health care providers in better teamwork practices. The training package capitalizes on DoD's years of experience in medical and nonmedical team performance and AHRQ's extensive research in the fields of patient safety and health care quality. Following extensive field testing in the MHS and several civilian organizations, a multimedia TeamSTEPPS™ toolkit is now available in the public domain to civilian health care facilities and medical practices. Additional TeamSTEPPS™ tools are in development.

    • "TeamSTEPPS: Integrating Teamwork Principles into Healthcare Practice": An article in the November/December 2006 issue of Patient Safety and Quality Healthcare. http://www.psqh.com/novdec06/ahrq.html
    • TeamSTEPPS Readiness Assessment Tool
      http://teamstepps.ahrq.gov/readiness/

      Answering these questions can help an institution understand its level of readiness to initiate the TeamSTEPPS™ program. Users may find it helpful to have a colleague review their responses or to answer the questions with a larger group (e.g., senior leaders).

    • TeamSTEPPS Rapid Response Systems (RRS) Training Module
      http://teamstepps.ahrq.gov/abouttoolsmaterials.htm (order information available on this Web site)

      This evidence-based module will provide insight into the core concepts of teamwork as they are applied to the rapid response system. The module contains the Instructor Guide in electronic form and training slides that include a high-quality video vignette of teamwork as it relates to RRS. This comes as a CD-ROM with the printable files (Word®, PDF, and PowerPoint®).

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Dimension 2. Supervisor/Manager Expectations and Actions Promoting Patient Safety and Dimension 3. Management Support for Patient Safety

  1. Appoint a Safety Champion for Every Unit
    http://www.ihi.org/IHI/Topics/PatientSafety/SafetyGeneral/Changes/IndividualChanges/Appoint+a+Safety+Champion+for+Every+Unit.htm

    Having a designated safety champion in every department and patient care unit demonstrates the organization's commitment to safety and may make other staff members feel more comfortable about sharing information and asking questions. This IHI Web site identifies tips for appointing a safety champion. 

  2. Conduct Patient Safety Leadership WalkRounds™
    http://www.ihi.org/IHI/Topics/PatientSafety/SafetyGeneral/Changes/IndividualChanges/Conduct+Patient+Safety+Leadership+WalkRounds.htm

    Senior leaders can demonstrate their commitment to safety and learn about the safety issues in their own organization by making regular rounds to discuss safety issues with the frontline staff. This IHI Web site discusses the benefits of management making regular rounds and provides links to tools available for download. One specific tool created by Dr. Allan Frankel is highlighted: http://www.wsha.org/files/82/WalkRounds1.pdf. PDF file [PDF File]  

  3. A Framework for Leadership Improvement
    http://www.ihi.org/IHI/Topics/LeadingSystemImprovement/Leadership/EmergingContent/AFrameworkforLeadershipofImprovement.htm

    This framework, developed by IHI, was built on the concepts of "will, ideas, and execution." It organizes leadership processes that focus the organization and senior leaders on improvement. 

  4. Get Boards on Board
    http://www.ihi.org/IHI/Programs/Campaign/BoardsonBoard.htm

    This resource from IHI offers a how-to guide, presentation, tools, and resources for obtaining board support for patient safety. 

  5. Leadership Guide to Patient Safety
    http://www.patientsafetyboard.org/DesktopModules/Documents/DocumentsView.aspx?tabID=0&ItemID=31896&MId=5204&wversion=Staging

    This guide is part of IHI's Innovation series. It shares the experience of senior leaders who have decided to address patient safety and quality as a strategic imperative within their organizations. It presents what can be done to make the dramatic changes that are needed to ensure that patients are not harmed by the care systems they trust will heal them. 

  6. Patient Safety Rounding Toolkit
    http://www.dana-farber.org/pat/patient-safety/patient-safety-resources/patient-rounding-toolkit.html

    The Patient Safety Rounding Toolkit is available to download from the Dana-Farber Cancer Institute. It provides resources for assessing whether an organization will benefit from patient safety rounds and for designing and implementing a patient safety rounds program. 

  7. Strategies for Leadership: Patient- and Family-Centered Care
    http://www.aha.org/aha/issues/Quality-and-Patient-Safety/strategies-patientcentered.html

    This Strategies for Leadership toolkit from the American Hospital Association (AHA) complements previous toolkits and other AHA activities that have focused on safety, effectiveness, efficiency, timeliness, and equity in care. It features a video, discussion guide, and resource guide.

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Dimension 4. Organizational Learning—Continuous Improvement

  1. AHRQ Health Care Innovations Exchange Learn & Network
    http://www.innovations.ahrq.gov/learn_network/listall.aspx

    How do staff introduce innovations to their organization? How do they encourage others to think "outside the box" and accept new ideas? Users can browse the Learn & Network part of this site to find advice and ideas from experts and practitioners, insights from the literature, and opportunities to participate in discussions and learning networks on specific topics. 

  2. Decision Tree for Unsafe Acts Culpability
    http://www.ihi.org/IHI/Topics/PatientSafety/SafetyGeneral/Tools/Decision+Tree+for+Unsafe+Acts+Culpability.htm

    The decision tree for unsafe acts culpability is a tool available for download from IHI's Web site. Users can consult this decision tree when analyzing an error or adverse event that has occurred in their organization. It can help identify how human factors and system issues contributed to the event. This decision tree is particularly helpful when working toward a nonpunitive approach in an organization. 

  3. Error Proofing
    http://www.ihi.org/IHI/Topics/Improvement/ImprovementMethods/Changes/Error+Proofing.htm

    Errors occur when actions do not agree with intentions even though people are capable of carrying out the task. This Web site from IHI outlines error proofing. It includes links to the following topics, which contain more specific information and strategies:

    • Use Affordances.
    • Use Constraints.
    • Use Differentiation.
    • Use Reminders.
  4. Institute for Healthcare Improvement: Plan-Do-Study-Act (PDSA) Worksheet (IHI Tool)
    http://www.ihi.org/IHI/Topics/Improvement/ImprovementMethods/Tools/Plan-Do-Study-Act+(PDSA)+Worksheet.htm

    The Plan-Do-Study-Act (PDSA) Worksheet is a useful tool for documenting a test of change. The PDSA cycle is shorthand for testing a change by developing a plan to test the change (Plan), carrying out the test (Do), observing and learning from the results (Study), and determining what modifications should be made to the test (Act). 

  5. Mistake Proofing the Design of Health Care Processes
    http://www.innovations.ahrq.gov/content.aspx?id=482

    This resource is featured on AHRQ's Health Care Innovations Exchange. It includes practical examples on the use of process and design features to prevent medical errors or the negative impact of errors. It contains more than 150 examples of mistake proofing that can be applied to health care, in many cases relatively inexpensively. Risk managers and chief medical officers can benefit from commonsense approaches to reducing risk and litigation. Organizations will find the groundwork for a successful program that fosters innovation and creativity as they address their patient safety concerns and approaches. 

  6. Patient Safety Primer: Root Cause Analysis
    http://www.psnet.ahrq.gov/primer.aspx?primerID=10

    Root cause analysis (RCA) is a structured method used to analyze adverse events. Initially developed to analyze industrial accidents, RCA is now widely deployed as an error analysis tool in health care. The AHRQ Patient Safety Network explains this topic further and provides links for more information on what is new in RCA. 

  7. VA National Center for Patient Safety: NCPS Root Cause Analysis Tools
    http://www.va.gov/ncps/CogAids/RCA/index.html

    Since 1999, NCPS has developed tools, training, and software to facilitate patient safety and RCA investigations. This guide functions as a cognitive aid to help teams in developing a chronological event flow diagram (an understanding of what occurred) and a cause and effect diagram (why the event occurred). RCA teams have found this book an effective aid with these challenging activities.

  8. Voluntary System To Report and Analyze Nursing Errors Leads to Patient Safety Improvements
    http://www.innovations.ahrq.gov/content.aspx?id=2246

    This featured profile is available on AHRQ's Health Care Innovations Exchange Web site. The Healthcare Alliance Safety Partnership is a 3-year quality improvement pilot project involving a board of nursing and three hospital systems. They are developing a voluntary, nonpunitive system for reporting, investigating, and analyzing nursing errors. During the 3 years of reporting, nurses reported incidents to the partnership. Then, nurse analysts performed an extensive investigation and worked with a multidisciplinary committee to make prescriptive recommendations to the nurse and the institution. These recommendations covered organizational, individual, and technical improvements that could be made to reduce the chance of recurrence. Although the number of participating nurses was limited, the changes the hospital systems made helped to address a wide variety of safety problems that were directly under the control of these organizations and led to the adoption of many quality improvements. 

  9. Will It Work Here?: A Decisionmaker's Guide to Adopting Innovations
    http://www.innovations.ahrq.gov/resources/InnovationAdoptionGuide.pdf PDF file [PDF File]

    The goal of this guide is to promote evidence-based decisionmaking and help decisionmakers determine whether an innovation would be a good fit—or an appropriate stretch—for their health care organization.

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Dimension 5. Overall Perceptions of Patient Safety

  1. Basic Patient Safety Program Resource Guide for "Getting Started"
    http://www.innovations.ahrq.gov/content.aspx?id=383

    This resource guide is featured on AHRQ's Health Care Innovations Exchange Web site. It provides tools to assist health care facilities in implementing a patient safety program. This toolkit includes the following program tools, all of which may be customized as needed:

    • Generic safety plan: template.
    • Comprehensive medical safety program.
    • Quality and safety officer job description: template.
    • A sample grid for listing committee assignments to document and demonstrate the interdisciplinary aspects of the organization's safety program.
    • A document shared by the American Society of Healthcare Risk Management that may be helpful for developing a process for disclosing medical errors to patients and family.
    • Checklist for patient safety and Joint Commission on the Accreditation of Healthcare Organizations standards.
  2. Improving Patient Safety in Hospitals: Turning Ideas Into Action
    http://www.med.umich.edu/patientsafetytoolkit/index.htm

    The University of Michigan Health System developed a resource for clinicians and administrative leaders responsible for strategic initiatives aimed at creating and sustaining quality of care and patient safety in hospitals. This patient safety toolkit presents ways of turning patient safety ideals into practical and achievable strategies. It includes information on the following topics: overview, safety plan, adverse events, infection prevention and control, safety culture, safety curriculum, medication safety, and disclosure. 

  3. Making Health Care Safer: A Critical Analysis of Patient Safety Practices
    http://www.innovations.ahrq.gov/content.aspx?id=399

    This evidence report is featured on AHRQ's Health Care Innovations Exchange Web site. It presents practices relevant to improving patient safety, focusing on hospital care, nursing homes, ambulatory care, and patient self-management. It defines patient safety practices, provides a critical appraisal of the evidence, rates the practices, and identifies opportunities for future research. 

  4. Patient Safety Primer: Safety Culture
    http://psnet.ahrq.gov/primer.aspx?primerID=5

    The concept of safety culture originated outside health care, in studies of high reliability organizations, organizations that consistently minimize adverse events despite carrying out intrinsically complex and hazardous work. High reliability organizations maintain a commitment to safety at all levels, from frontline providers to managers and executives. This commitment establishes a "culture of safety." The AHRQ Patient Safety Network explains this topic further and provides links for more information on what is new in safety culture. 

  5. Studer Group Toolkit: Patient Safety
    http://www.innovations.ahrq.gov/content.aspx?id=2592

    This toolkit is featured on AHRQ's Health Care Innovations Exchange Web site. It provides health care leaders and frontline staff specific tactics they can immediately put into action to improve patient safety outcomes. By routinizing specific behaviors, organizations can improve patient safety without purchasing new equipment, adding staff, or spending additional time to put them into practice. The actions are divided into eight sections, each of which has been identified as a priority area for health care organizations to address as they seek to provide safer care. 

  6. The Transforming Care at the Bedside Toolkit
    http://innovations.ahrq.gov/content.aspx?id=2327

    This toolkit is featured on AHRQ's Health Care Innovations Exchange Web site. It provides information for hospital units interested in adopting the "Transforming Care at the Bedside" (TCAB) model of nurse-initiated quality improvements. TCAB is a national program developed and managed by the Robert Wood Johnson Foundation and IHI.

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Dimension 6. Feedback and Communication About Error

  1. Conduct Safety Briefings
    http://www.ihi.org/IHI/Topics/PatientSafety/SafetyGeneral/Changes/IndividualChanges/Conduct+Safety+Briefings.htm

    Safety briefings in patient care units are tools to increase safety awareness among frontline staff and foster a culture of safety. This IHI Web site (IHI) identifies tips and tools for conducting safety briefings.

  2. Provide Feedback to Frontline Staff
    http://www.ihi.org/IHI/Topics/PatientSafety/SafetyGeneral/Changes/IndividualChanges/Provide+Feedback+to+Front-Line+Staff.htm

    Feedback to the frontline staff is a critical component of demonstrating a commitment to safety and ensuring that staff members continue to report safety issues. This IHI Web site identifies tips and tools for how to communicate feedback.

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Dimension 7. Communication Openness

  1. Arizona Hospital and Healthcare Association SBAR Communication
    http://www.azhha.org/patient_safety/sbar.aspx

    This SBAR (Situation-Background-Assessment-Recommendation) Communication toolkit, available for download through the Arizona Hospital and Healthcare Association, is designed to assist facilities through the implementation and training of SBAR communication. This toolkit includes samples of SBAR documents; staff education, including practice scenarios to use SBAR; and policy recommendations. 

  2. SBAR Technique for Communication: A Situational Briefing Model
    http://www.ihi.org/IHI/Topics/PatientSafety/SafetyGeneral/Tools/SBARTechniqueforCommunicationASituationalBriefingModel.htm

    The SBAR technique provides a framework for communication between members of the health care team about a patient's condition. This downloadable tool from IHI includes two documents. The document "SBAR Report to Physician About a Critical Situation" is a worksheet/script that a provider can use to organize information when preparing to communicate with a physician about a critically ill patient. The document "Guidelines for Communicating With Physicians Using the SBAR Process" explains how to carry out the SBAR technique in detail.

Cross-references to resources already described:

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Page last reviewed August 2010
Internet Citation: Resources by Dimension: Improving Patient Safety in Hospitals. August 2010. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/professionals/quality-patient-safety/patientsafetyculture/hospital/resourcelist/hospimpdim.html