Resources by Dimension (continued)
Improving Patient Safety in Hospitals: Resource List
Dimension 8. Frequency of Events Reported
Multifaceted Program Increases Reporting of Potential Errors, Leads to Action Plans to Enhance Safety
This featured profile is available on AHRQ's Health Care Innovations Exchange Web site. The University of Texas M.D. Anderson Cancer Center implemented a multifaceted initiative known as "The Good Catch" Program. The program was designed to increase the reporting of potential errors related to medication, equipment, and patient care. Key elements of the program include (1) a change in use of terminology from negative to positive terms and phrases (e.g., from "close call" or "near miss" to "good catch"); (2) friendly, team-based competition to promote reporting; (3) development of an end-of-shift safety report; (4) executive leadership-sponsored rounds and incentives; and (5) a multidisciplinary workgroup to promote reporting. The program increased the reporting of potential errors dramatically, by 1,468 percent, in the 6-month pilot phase of the program and spurred the development of action plans designed to address the common causes of potential errors.
Patient Safety Toolbox for States
This electronic toolbox is featured on AHRQ's Health Care Innovations Exchange Web site. It is intended to provide States with tools they can use or modify as they develop or improve adverse event reporting systems. The toolbox includes information (policies, practices, forms, reports, methods, and contracts) related to State reporting systems, links to other Web resources, and fast facts and issues related to patient safety.
Reducing Errors in Health Care: Translating Research Into Practice
This fact sheet is featured on AHRQ's Health Care Innovations Exchange Web site. It provides research-based information on medical errors and how to reduce them. It addresses patients at risk, how errors occur, ways to improve patient safety, and ways to promote safety.
Cross-reference to resource already described:
- Dimension 4. Organizational Learning Continuous Learning, #3 Error Proofing.
Dimension 9. Teamwork Across Units
Cross-references to resources already described:
- Dimension 1. Teamwork Within Units, #3 Patient Safety Primer: Teamwork Training.
- Dimension 1. Teamwork Within Units, #4 Patient Safety Through Teamwork and Communication Toolkit.
- Dimension 1. Teamwork Within Units, #5 Pennsylvania Patient Safety Advisory.
- Dimension 1. Teamwork Within Units, #6 TeamSTEPPS™—Team Strategies and Tools to Enhance Performance and Patient Safety.
Dimension 10. Staffing
Hospital Nurse Staffing and Quality of Care
This report summarizes the findings of AHRQ-funded and other research on the relationship of nurse staffing levels to adverse patient outcomes. This information can be used by decisionmakers to make more informed choices in terms of adjusting nurse staffing levels and increasing nurse recruitment while optimizing quality of care and improving nurse satisfaction.
Resident Duty Hours: Enhancing Sleep, Supervision, and Safety
This December 2008 report brief for an AHRQ-funded study from the Institute of Medicine (IOM) confirms that acute and chronically fatigued medical residents are more likely to make mistakes that affect patient care. The IOM recommends several changes to the existing limit on resident work hours of 80 hours per week. For example, the IOM recommends that residency programs provide opportunities for sleep each day and each week during resident training, the Accreditation Council for Graduate Medical Education provide better monitoring of duty hour limits, and residency review committees set guidelines for residents' patient caseloads.
Dimension 11. Handoffs and Transitions
Door-to-Doc Patient Safety Toolkit
This toolkit is featured on AHRQ's Health Care Innovations Exchange Web site. "Door to Doc" is a patient flow redesign process that improves the safety of care for patients in the emergency department by reducing the time patients wait to be seen and by expediting admission to the most appropriate hospital unit.
Handoff of Care Frequently Asked Questions
http://www.healthsystem.virginia.edu/internet/e-learning/handoff_faq.pdf [PDF File]
This resource from the University of Virginia Health System identifies a strategy to improve handoff communication called IDEAL (Identify patient, Diagnosis, recent Events, Anticipated changes, Leave time for questions).
Handoffs and Signouts
The process of transferring responsibility for care is referred to as the "handoff," with the term "signout" used to refer to the act of transmitting information about the patient. The AHRQ Patient Safety Network explains this topic further and provides links for more information on what is new in handoffs and signouts in the context of care during hospitalization.
Handoffs and Transitions in the Emergency Department Setting
http://www.marylandpatientsafety.org/html/collaboratives/ed/documents/HandoffsTransitionCallDigest.pdf [PDF File]
In order to provide collaborative teams with an opportunity to learn from their faculty and other collaborative teams, the Maryland Patient Safety Center hosted a call in September 2006 to discuss strategies that lead to more effective handoffs among staff and units in the hospital. This summary is intended to share this discussion and lessons learned from that call.
Medication Safety Reconciliation Toolkit
This medication safety reconciliation toolkit is featured on AHRQ's Health Care Innovations Exchange Web site. It helps hospitals establish and implement a standardized medication reconciliation process. The toolkit provides guidance, sample forms, and tips.
Medications At Transitions and Clinical Handoffs (MATCH) Initiative
This resource is featured on AHRQ's Health Care Innovations Exchange Web site. The goal of the Medications At Transitions and Clinical Handoffs (MATCH) Initiative is to measurably decrease the number of discrepant medication orders and the associated potential and actual patient harm. This toolkit is designed to assist all types of organizations, whether caring for inpatients or outpatients or using an electronic medical record, a paper-based system, or both.
Perioperative Patient "Hand-Off" Toolkit
The Association of periOperative Registered Nurses and the DoD Patient Safety Program collaboratively developed this new Web-based toolkit that provides resources to guide perioperative professionals in standardizing handoff communications among caregivers. The toolkit, based on the TeamSTEPPS initative, will help develop consistency in communications needed for effective patient care. The toolkit includes supporting research for evidence-based recommendations on perioperative patient handoffs, sample checklists and forms, PowerPoint presentations on standardizing communication and information exchanges in perioperative practice, and an annotated guide to additional resources.
Project RED (Re-Engineered Discharge) Toolkit
This toolkit is featured on AHRQ's Health Care Innovations Exchange Web site. These tools were developed to facilitate the Project RED (Re-Engineered Hospital Discharge) intervention. Project RED is a randomized controlled trial at Boston Medical Center. This project reengineers the workflow process and improves patient safety for patients from a network of community health centers discharged from a general medical service at an urban hospital serving a low-income, ethnically diverse population. The toolkit includes:
- After Hospital Care Plan (AHCP) sample form.
- Training manual.
- A description of the computerized workstation and process used to create and print the AHCP.
Strategies and Tools To Improve Healthcare Handoffs and Transitions
This DoD resource provides an overview on the importance of structured handoff processes and provides information on the Joint Commission requirement. The resource illustrates a handoff communication tool that can be recalled through the mnemonic device, "I PASS the BATON."
Strategies To Improve Handoffs
This tool is featured on AHRQ's Health Care Innovations Exchange Web site. From the Maryland Patient Safety Center, it provides an outline of recommended strategies to improve the handoff process in hospitals (i.e., patient transitions in care from one provider to another).
Transitions of Care Checklist
http://www.ntocc.org/Portals/0/TOC_Checklist.pdf [PDF File]
The National Transitions of Care Coalition Advisory Task Force has released a transitions of care list that provides a detailed description of effective patient transfer between practice settings. This process can help to ensure that patients and their critical medical information are transferred in a safe, timely, and efficient manner.
Dimension 12. Nonpunitive Response to Error
Nonpunitive Response to Error: The Fair and Just Principles of the Aurora Health Care Culture
This presentation from the AHRQ Surveys on Patient Safety Culture User Group Meeting describes Aurora Health Care's approach to creating of a culture of safety and reviews the action steps taken to address the "Nonpunitive Response to Error" dimension in the SOPS survey.
Patient Safety and the "Just Culture": A Primer for Health Care Executives
Accountability is a concept that many leaders wrestle with as they steer their organizations and patients toward understanding and accepting the idea of a blameless culture within the context of medical injury. This report by David Marx is available for download through the AHRQ Patient Safety Network and outlines the complex nature of deciding how best to hold individuals accountable for mistakes.
Patient Safety and the "Just Culture": A Presentation by David Marx, J.D.
http://www.health.state.ny.us/professionals/patients/patient_safety/conference/2007/docs/patient_safety_and_the_just_culture.pdf [PDF File]
This presentation defines just culture, the safety task, the just culture model, and statewide initiatives in New York.
Cross-references to resources already described:
- Dimension 4. Organizational Learning—Continuous Improvement, #2 Decision Tree for Unsafe Acts Culpability.
- Dimension 4. Organizational Learning—Continuous Learning, #8 Voluntary System To Report and Analyze Nursing Errors Leads to Patient Safety Improvements.
- Dimension 7. Communication Openness, #1 Arizona Hospital and Healthcare Association SBAR Communication.
- Dimension 7. Communication Openness, #2 SBAR Technique for Communication: A Situational Briefing Model.
- Dimension 8. Frequency of Events Reported, #1 Multifaceted Program Increases Reporting of Potential Errors, Leads to Action Plans to Enhance Safety.