Improving Patient Safety in Nursing Homes: Resource List

This document contains references to Web sites that provide practical resources nursing homes can use to implement changes to improve patient safety culture and patient safety.

Resources by Dimension

The following resources are organized according to the relevant Nursing Home Survey on Patient Safety Culture dimensions they can help improve. Some resources are duplicated and cross-referenced because they may apply to more than one dimension.

Dimension 1. Overall Perceptions of Resident 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 the AHRQ 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
    • Organized assignments for accompanying patient safety plan or program
    • American Society for Healthcare Risk Management: Perspective on disclosure of unanticipated outcome information
    • Checklist for patient safety and Joint Commission on the Accreditation of Healthcare Organizations standards

  2. Making Health Care Safer: A Critical Analysis of Patient Safety Practices, Evidence Report/Technology Assessment
    http://innovations.ahrq.gov/content.aspx?id=399

    This evidence report is featured on the AHRQ 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.

  3. 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. These are 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.

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

    This toolkit is featured on the AHRQ 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.

Dimension 2. Feedback and Communication About Incidents

  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 Institute for Healthcare Improvement Web site 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 frontline staff is a critical component of demonstrating a commitment to safety and ensuring that staff members continue to report safety issues. This Institute for Healthcare Improvement Web site identifies tips and tools for providing feedback.

Dimension 3. Supervisor Expectations and Actions Promoting Resident Safety and Dimension 4. Management Support for Resident 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 Institute for Healthcare Improvement 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 organization by making regular rounds to discuss safety issues with frontline staff. This Institute for Healthcare Improvement Web site discusses the benefits for management making regular rounds and provides links to tools available for download. One specific tool created by Dr. Allan Frankel is highlighted.

  3. 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.

Dimension 5. Organizational Learning

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

    How do you introduce innovations to your organization? How do you encourage others to think "outside the box" and accept new ideas? 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 the Institute for Healthcare Improvement Web site. This decision tree can be used to analyze an error or adverse event that has occurred in an organization to help identify how human factors and systems issues contributed to the event. This decision tree is particularly helpful when working toward a nonpunitive approach.

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

    Errors occur when our actions do not agree with our intentions even though we are capable of carrying out the task. This Web site from the Institute for Healthcare Improvement outlines error proofing. It includes links to the following topics for more specific information and strategies: Use Affordances, Use Constraints, Use Differentiation, and 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), carry out the test (Do), observe and learn from the consequences (Study), and determine what modifications should be made to the test (Act).

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

    This resource is featured on the AHRQ Health Care Innovations Exchange Web site. Mistake-Proofing the Design of Health Care Processes is a synthesis of practical examples from the world of health care on the use of process or 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 in health care-and in many cases relatively inexpensively. In Mistake-Proofing the Design of Health Care Processes, risk managers and chief medical officers will benefit from common-sense approaches to reducing risk and litigation, and organizations will find the groundwork for a successful program that fosters innovation and creativity as they address their patient safety concerns and approaches.

  6. Nursing Home Learning Collaborative Improves Quality of Care, Reduces Staff Turnover
    http://www.innovations.ahrq.gov/content.aspx?id=259

    This featured profile is available on the AHRQ Innovations Exchange Web site. In this approach to improving nursing home care, known as the "Wellspring Model," nursing homes come together in a learning collaborative to exchange performance data and conduct group training for both staff and leadership on quality improvement processes.

  7. 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.

  8. A Systems Approach to Quality Improvement in Long-Term Care: Safe Medication Practices Workbook
    http://psnet.ahrq.gov/resource.aspx?resourceID=5148

    This manual available for download through the AHRQ Patient Safety Network provides nursing home staff with a step-by-step guide for medication management to reduce medication errors in long-term care.

  9. 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 root cause analysis (RCA) investigations. This guide functions as a cognitive aid to help teams develop a chronological event flow diagram (an understanding of what occurred) along with a cause and effect diagram (why the event occurred). RCA teams have found this book an effective aid with these sometimes difficult activities.

  10. Will It Work Here?: A Decisionmaker's Guide to Adopting Innovations
    http://www.innovations.ahrq.gov/resources/guideTOC.aspx

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

Dimension 6. Training and Skills

  1. Try This: Best Practices in Nursing Care to Older Adults
    http://www.innovations.ahrq.gov/content.aspx?id=2105

    "Try This" is a series of assessment tools where each issue focuses on a topic specific to the older adult population. The content is directed to orient and encourage all nurses to understand the special needs of older adults and to use the highest standards of practice in caring for older adults.

Dimension 7. Compliance With Procedures

There are no resources identified at this time.

Dimension 8. Teamwork

  1. 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.

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

    This toolkit is featured on the AHRQ 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 of each of the following tools along with provisions for implementation: Multidisciplinary Rounding, Huddles, Rapid Response and Escalation, and Structured Communication.

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

    Developed jointly by the Department of Defense (DoD) and the Agency for Healthcare Research and Quality (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 Military Health System (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 include.

    • "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/ahrqchecklist.aspx

      Answering these questions can help your institution understand its level of readiness to initiate the TeamSTEPPS program. You may find it helpful to have a colleague review your 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 provides insight into the core concepts of teamwork as they are applied to the rapid response system (RRS). The module contains the Instructor Guide in electronic form plus 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®).

Dimension 9. Handoffs

  1. Cooperative Network Improves Patient Transitions Between Hospitals and Skilled Nursing Facilities, Reducing Readmissions and Length of Hospital Stays
    http://www.innovations.ahrq.gov/content.aspx?id=2162

    This featured profile is available on the AHRQ Health Care Innovations Exchange Web site. Summa Health System's Care Coordination Network strives to ensure smooth transitions between the hospitals and 37 local skilled nursing facilities, leading to fewer readmissions and lower length of stay in the hospital.

  2. Handoff of Care Frequently Asked Questions
    http://www.healthsystem.virginia.edu/internet/e-learning/handoff_faq.pdf

    This resource from the University of Virginia Health System identifies a strategy to improve handoff communication called IDEAL (Identify, Diagnosis, Events, Anticipate, Leave).

  3. Fax Back Sheet
    http://www.innovations.ahrq.gov/content.aspx?id=2508

    This profile is available on the AHRQ Health Care Innovations Exchange Web site. Physicians need to know specific information before writing or changing an order related to pain management. This fax back sheet assists nursing home staff (primarily nursing and pharmacy staff) in assembling the needed information before calling the physician. This sheet makes the information exchange and the decisionmaking process more efficient and effective.

  4. Medications At Transitions and Clinical Handoffs (MATCH) Initiative
    http://innovations.ahrq.gov/content.aspx?id=1979

    This toolkit is featured on the AHRQ Health Care Innovations Exchange Web site. The goal of the 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.

  5. Post-Acute Transfer Form
    http://www.innovations.ahrq.gov/content.aspx?id=186

    This profile is available on the AHRQ Health Care Innovations Exchange Web site. This form is used to standardize information transferred between acute care hospitals and skilled nursing facilities throughout the four-county northeastern Ohio region. It may be adapted for use in other areas. It includes information on medications, activities of daily living, orders, and special care needs.

  6. Planning for Your Discharge: A Checklist for Patients and Caregivers Preparing to Leave a Hospital, Nursing Home, or Other Health Care Setting
    http://www.innovations.ahrq.gov/content.aspx?id=2578

    This profile is available on the AHRQ Health Care Innovations Exchange Web site. This patient handout can help patients, caregivers, and medical staff communicate as patients prepare to leave a hospital, nursing home, or other health care setting. The booklet provides many questions and prompts for patients and caregivers so that they can gather information to ensure a safe discharge.

Dimension 10. 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 be a thorough guide to assist a facility through the implementation and training of SBAR communication. Items included in this toolkit are 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 (Situation-Background-Assessment-Recommendation) technique provides a framework for communication between members of the health care team about a patient's condition. This downloadable tool from the Institute for Healthcare Improvement contains two documents. "SBAR Report to Physician About a Critical Situation" is a worksheet/script that a provider can use to organize information in preparing to communicate with a physician about a critically ill patient. "Guidelines for Communicating With Physicians Using the SBAR Process" explains how to carry out the SBAR technique.

Cross-reference to resource already described:

Dimension 11. Nonpunitive Response to Mistakes

  1. "Nonpunitive Response to Error": The Fair and Just Principles of the Aurora Health Care Culture
    https://cahps.ahrq.gov

    This presentation from the AHRQ Surveys on Patient Safety Culture User Group Meeting describes Aurora Health Care's approach to creating a culture of safety and reviews the action steps taken to address the "Nonpunitive Response to Error" dimension in the survey.

  2. Patient Safety and the "Just Culture": A Primer for Health Care Executives
    http://psnet.ahrq.gov/resource.aspx?resourceID=1582

    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.

  3. 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

    This presentation on "Patient Safety and the Just Culture" by David Marx defines just culture, the safety task, the just culture model, and statewide initiatives in New York.

Cross-references to resources already described:

Dimension 12. Staffing

  1. Workforce Retention in Long-Term Care: "What a Difference Management Makes"
    http://www.riqualitypartners.org/2/Site/CustomFiles/Qlty_DocMgr/Eaton%20Summary.doc Plugin Software Help]

    This article, available for download, discusses workforce retention in long-term care facilities and proposes suggestions for reducing staff.

  2. Workforce Strategies: Introducing Peer Mentoring in Long-Term Care Settings
    http://www.directcareclearinghouse.org/download/WorkforceStrategies2.pdf

    This article identifies the benefits of peer mentoring in long-term care settings for staff retention and provides instructions on how to design a peer mentoring program.

  3. Creation of Households Program in Nursing Home Improves Residents' Health Status, Reduces Staff Turnover, and Boosts Demand for Services
    http://innovations.ahrq.gov/content.aspx?id=2051

    This featured profile is available on the Agency for Healthcare Research and Quality's Innovations Exchange Web site. Meadowlark Hills, a retirement community, renovated one of its facilities so that residents can live together in group households and become more independent. The innovator noted that the change in approach led to improvements in residents' health, a sharp decrease in staff turnover, and a significant increase in demand for facility services, all without raising operating costs.

Cross-reference to resource already described:

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Current as of June 2011
Internet Citation: Improving Patient Safety in Nursing Homes: Resource List. June 2011. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/professionals/quality-patient-safety/patientsafetyculture/nursing-home/resources/nhimpdim.html