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.

General Resources

  1. 2010 Long Term Care National Patient Safety Goals
    http://www.jointcommission.org/patientsafety/nationalpatientsafetygoals/

    The purpose of The Joint Commission Long Term Care National Patient Safety Goals is to improve patient safety in a long-term care setting by focusing on specific goals. This Web site contains a link to the latest goals, which include improvements emanating from the Standards Improvement Initiative. In addition, the site has information on the new numbering system and minor language changes for consistency.

  2. 30 Safe Practices for Better Health Care Fact Sheet
    http://innovations.ahrq.gov/content.aspx?id=765

    This fact sheet is featured on the Agency for Healthcare Research and Quality's Health Care Innovations Exchange. The National Quality Forum has identified 30 safe practices that evidence shows can work to reduce or prevent adverse events and medication errors. These practices can be universally adopted by all health care settings to reduce the risk of harm to patients. This tool also provides background information about the National Quality Forum, as well as links to a report providing more detailed information about the 30 Safe Practices.

  3. Advancing Excellence in America's Nursing Homes
    http://www.nhqualitycampaign.org/star_index.aspx?controls=welcome

    Advancing Excellence in America's Nursing Homes is an ongoing coalition-based campaign concerned with how we care for older adults, chronically ill and disabled people, and people recuperating in a nursing home environment. This voluntary campaign monitors key indicators of nursing home care quality, both clinical quality and organizational improvement goals; promotes excellence in caregiving; acknowledges the critical role nursing home staff have in providing care; and recognizes the important role of consumers in contributing ideas and suggestions to the campaign.

  4. AHRQ Health Care Innovations Exchange
    http://www.innovations.ahrq.gov/

    The Agency for Healthcare Research and Quality's Health Care Innovations Exchange is a comprehensive program designed to accelerate the development and adoption of innovations in health care delivery. This program supports AHRQ's mission to improve the safety, effectiveness, patient centeredness, timeliness, efficiency, and equity of care, with a particular emphasis on reducing disparities in health care and health among racial, ethnic, and socioeconomic groups. The Innovations Exchange has the following components:

    • Searchable innovations and attempts
    • Searchable QualityTools
    • Learning opportunities
    • Networking opportunities

  5. AHRQ Medical Errors and Patient Safety
    http://www.ahrq.gov/qual/patientsafetyix.htm

    The Agency for Healthcare Research and Quality Medical Errors and Patient Safety Web site provides links to various resources and tools for promoting patient safety in the following categories:

    • Tips for Consumers and Patients
    • Background
    • Communication and Teamwork
    • Design and Working Conditions
    • Implementation and Transformation
    • Patient Safety Organizations
    • Patient Safety Research and Funding Opportunities
    • Tools and Techniques

  6. AHRQ Patient Safety Network
    http://www.psnet.ahrq.gov/

    The Patient Safety Network (PSNet) is a national Web-based resource featuring the latest news and essential resources on patient safety. The site offers weekly updates of patient safety literature, news, tools, and meetings ("What's New"), and a vast set of carefully annotated links to important research and other information on patient safety ("The Collection"). Supported by a robust patient safety taxonomy and Web architecture, AHRQ PSNet provides powerful searching and browsing capability,as well as the ability for diverse users to customize the site around their interests (My PSNet). It also is tightly coupled with AHRQ WebM&M, the popular monthly journal that features user-submitted cases of medical errors, expert commentaries, and perspectives on patient safety.

  7. CAHPS® Nursing Home Surveys
    https://cahps.ahrq.gov

    The Consumer Assessment of Healthcare Providers and Systems (CAHPS®) program is a multiyear AHRQ initiative. This Web site provides information on the CAHPS Nursing Home Surveys, as well as links to three separate instruments: an in-person questionnaire for long-term residents, a mail questionnaire for recently discharged short-stay residents, and a questionnaire for residents' family members.

  8. Centers for Medicare & Medicaid Services (CMS): Nursing Homes
    http://www.cms.hhs.gov/CertificationandComplianc/12_NHs.asp

    This page provides basic information about being certified as a Medicare or Medicaid nursing home provider and includes links to applicable laws, regulations, and compliance information. The site also has related nursing home reports, compendia, and a list of special focus facilities (i.e., nursing homes with a record of poor survey [inspection] performance on which CMS focuses extra attention) available for download.

  9. Chasing Zero: Winning The War On Healthcare Harm
    http://discoveryhealthcme.discovery.com/zero/media/program.html

    A near-fatal medical error almost cost the lives of twins born to actor Dennis Quaid and his wife. This real-life event inspires a new patient education documentary featuring the Quaid family's personal ordeal, along with stories of other families who faced medical errors. It also features experts who are leading efforts to help health care providers reduce medical errors and improve patient safety outcomes.

  10. The Commonwealth Fund
    http://www.commonwealthfund.org/

    The Commonwealth Fund is a private foundation that aims to promote a high-performing health care system that achieves better access, improved quality, and greater efficiency. Efforts are aimed particularly at society's most vulnerable populations, including low-income people, uninsured people, racial and ethnic minority groups, young children, and older adults. The Commonwealth Fund provides information on a variety of health care topics, free publications, and innovations and tools for improving health care.

  11. Consumers Advancing Patient Safety
    http://www.patientsafety.org/

    Consumers Advancing Patient Safety (CAPS) is a consumer-led nonprofit organization aimed at providing a collective voice for individuals, families, and healers who want to prevent harm in health care encounters through partnership and collaboration. CAPS features a transitions toolkit (available at http://www.patientsafety.org/page/142046/) titled "Taking Charge of Your Healthcare: Your Path to Being an Empowered Patient."

  12. Department of Defense Patient Safety Program
    http://health.mil/dodpatientsafety

    The Department of Defense Patient Safety Program is a comprehensive program designed to establish a culture of patient safety and quality within the Military Health System (MHS). The program encourages a systems approach to create a safer patient environment; engages MHS leadership; promotes collaboration across all three Services; and fosters trust, transparency, teamwork, and communication.

  13. Enhanced Toileting Program Reduces Incontinence and Its Comorbidities Among Residents of Long-Term Care Facility
    http://www.innovations.ahrq.gov/content.aspx?id=2245

    This featured profile is available on the AHRQ Health Care Innovations Exchange Web site. A long-term care facility adopted an enhanced toileting program consisting of the following components: individualized toileting plan of care based on periodic resident assessments, revised and new care documentation tools, devices to assist with toileting, and comprehensive education and training for facility staff. The program led to a sharp decline in the prevalence of incontinence (from 76 to 38 percent of residents) and in associated comorbidities and staff injuries.

  14. Facility Assessment: Checklists for Activities of Daily Living

    This 11-page quality tool is featured on the AHRQ Health Care Innovations Exchange Web site. It provides self-assessment checklists for nursing home staff to use in assessing processes related to declines in activities of daily living (ADL) among facility residents, in order to identify areas that need improvement. These checklists focus primarily on issues related to the "late-loss" ADLs of transfers, toilet-use, bed mobility, and eating. This tool includes checklists on the following ADL-related topics: screening for ADL function and decline, assessment, care plans, monitoring and reassessment of ADL function, and staff education and training.

  15. Facility Assessment: Checklists for Delirium
    http://www.innovations.ahrq.gov/content.aspx?id=1665

    This 11-page quality tool is featured on the AHRQ Health Care Innovations Exchange Web site. It provides self-assessment checklists for nursing home staff to use in assessing processes related to delirium in the facility, in order to identify areas that need improvement. This tool includes checklists on the following delirium-related topics: delirium assessment, delirium care plans, delirium screening, and staff education and training.

  16. Home-Like, Self-Directed Environment Provides Superior Quality of Life Than in Traditional Nursing Homes and Assisted Living Facilities
    http://www.innovations.ahrq.gov/content.aspx?id=1857

    This featured profile is available on the AHRQ Health Care Innovations Exchange Web site. THE GREEN HOUSE® model provides older adults with an alternative to nursing homes and traditional assisted living facilities. These communities provide groups of 7 to 10 older adults a comfortable, warm, home environment and staff who provide the highest level of clinical care while nurturing relationships and older adults' autonomy. A 30-month evaluation suggests that THE GREEN HOUSE® adults receive equal or higher quality of care and report better quality of life than residents of nursing homes.

  17. Immunizations Toolkit
    http://www.innovations.ahrq.gov/content.aspx?id=1684

    This toolkit is featured on the AHRQ Health Care Innovations Exchange Web site. It was developed to increase immunization rates among nursing home residents and staff. It offers specific information and education on the benefits of influenza (flu) and pneumonia immunization, as well as sample guidelines and tools needed to run an effective and sustainable resident and staff immunization program.

  18. Institute for Healthcare Improvement
    http://www.ihi.org/ihi Exit Disclaimer

    The Institute for Healthcare Improvement is a reliable source of energy, knowledge, and support for a never-ending campaign to improve health care worldwide. The institute helps accelerate change in health care by cultivating promising concepts for improving patient care and turning those ideas into action.

  19. Institute for Safe Medication Practices
    http://www.ismp.org

    The Institute for Safe Medication Practices offers a wide variety of free educational materials and services on their Web site:

    • Special Medication Hazard Alerts
    • Searchable information on a wide variety of medication safety topics
    • Answers to Frequently Asked Questions about medication safety
    • Food and Drug Administration Patient Safety Videos
    • Pathways for Medication Safety Tools
    • White papers on bar-coding technology and electronic prescribing
    • A monitored Message Board to share questions, answers, and ideas

  20. The Joint Commission: Patient Safety
    http://www.jointcommission.org/PatientSafety/

    The Patient Safety pages on The Joint Commission Web site offer information on patient safety-related standards, the National Patient Safety Goals, the Speak UpT initiatives (a national program urging patients to become active participants on their health care team), and other resources.

  21. National Center for Patient Safety
    http://www.patientsafety.gov

    The National Center for Patient Safety (NCPS) was established in 1999 to develop and nurture a culture of safety throughout the Department of Veterans Affairs. The primary intended audience for the public Web site is health care professionals and health care administrators.

  22. National Patient Safety Foundation®
    http://www.npsf.org/

    The National Patient Safety Foundation® has been pursuing one mission since its founding in 1997 - to improve the safety of the health care system for the patients and families it serves. NPSF is unwavering in its determined and committed focus on uniting disciplines and organizations across the continuum of care, championing a collaborative, inclusive, multistakeholder approach.

  23. National Quality Forum
    http://www.qualityforum.org/Topics/Safety.aspx

    The National Quality Forum (NQF) is a nonprofit organization that aims to improve the quality of health care for all Americans through fulfillment of its three-part mission:

    • Setting national priorities and goals for performance improvement;
    • Endorsing national consensus standards for measuring and publicly reporting on performance; and
    • Promoting the attainment of national goals through education and outreach programs.

  24. Nursing Home "Neighborhoods" Emphasize Dignity and Independence, Leading to Improvements in Resident Health and Quality of Life and Lower Employee Turnover
    http://www.innovations.ahrq.gov/content.aspx?id=1906

    This featured profile is available on the AHRQ Health Care Innovations Exchange Web site. Providence Mount St. Vincent (known as "The Mount") developed and implemented a new model for nursing home care in which most residents live in a "neighborhood" of 20 to 23 residents containing a cluster of private and semiprivate rooms and a large kitchen/dining area that serves as the central gathering spot for meals and activities. The Mount's approach also focuses on giving residents more independence, autonomy, and dignity than in a traditional nursing home, leading to a greater sense of community and a higher quality of life for residents, as well as a better work environment for employees.

  25. Nutrition Care Alerts: Warning Signs and Action Steps for Caregivers in Nursing Facilities

    This featured profile is available on the AHRQ Health Care Innovations Exchange Web site. This guide, developed by nutrition and long-term care experts, can help caregivers of nursing home residents learn more about the warning signs of poor nutrition and practical steps to maintain and improve residents' nutritional health. Warning signs include unintended weight loss, dehydration, pressure ulcers, and complications from tube feeding.

  26. Pennsylvania Patient Safety Authority
    http://www.patientsafetyauthority.org/Pages/Default.aspx

    The Pennsylvania Patient Safety Authority is charged with taking steps to reduce and eliminate medical errors by identifying problems and recommending solutions that promote patient safety in various health care settings. The Web site features current patient safety articles and highlights patient safety initiatives and tools. Users can browse by care setting, event (e.g., falls, medication errors), discipline, audience, and patient safety focus.

  27. WHO Collaborating Centre for Patient Safety Solutions
    http://www.ccforpatientsafety.org/patient-safety-solutions

    The Joint Commission, Joint Commission International, and World Health Organization host a center for patient safety solutions. This Web site provides information about nine solutions for improving patient safety approved by the International Steering Committee. Solutions include: (1) Look-Alike, Sound-Alike Medication Names, (2) Patient Identification, (3) Communication During Patient Hand-Overs, (4) Performance of Correct Procedure at Correct Body Site, (5) Control of Concentrated Electrolyte Solutions, (6) Assuring Medication Accuracy at Transitions in Care, (7) Avoiding Catheter and Tubing Mis-Connections, (8) Single Use of Injection Devices, and (9) Improved Hand Hygiene to Prevent Health Care-Associated Infection.

Falls Management/Prevention

  1. Falls in Nursing Homes Fact Sheet
    http://www.premierinc.com/safety/topics/falls/downloads/E-02-falls-nursing-homes.doc

    This fact sheet identifies the problem of falls in nursing homes and offers strategies for preventing falls.

  2. Falls Management Program
    http://www.qualitynet.org/dcs/ContentServer?cid=1136495771104&pagename=Medqic/MQTools/ToolTemplate&c=MQTools

    This interdisciplinary program available for download from QualityNet. It is designed to assist nursing facilities in improving their fall care processes and outcomes through educational and quality improvement tools.

  3. Interdisciplinary Team Identifies and Addresses Risk Factors for Falls Among Nursing Home Residents, Leading to Fewer Falls and Less Use of Restraints
    http://www.innovations.ahrq.gov/content.aspx?id=1835

    This featured profile is available on the AHRQ Innovations Exchange Web site. Ethica Health and Retirement Communities has developed a falls management program, the cornerstone of which is an interdisciplinary "falls team" at each nursing home that regularly assesses residents for their risk of falling and develops intervention plans for those found to be at high risk. The team also documents and investigates every fall and takes steps to reduce the chance of recurrence. The program led to a slight decline in falls and a large reduction in use of restraints.

  4. Limiting Physical Restraint Use
    http://www.primaris.org/Physical%20Restraints

    Primaris and a group of Missouri nursing homes collaborated on a 3-year project to reduce the use of physical restraints. This Web site provides background information on restraints and free quality improvement resources on this topic, including a variety of checklists and educational materials.

  5. Department of Veteran Affairs National Center for Patient Safety 2004 Falls Toolkit
    http://www.va.gov/ncps/SafetyTopics/fallstoolkit/index.html

    The Department of Veterans Affairs National Center for Patient Safety (NCPS) worked with the Patient Safety Center of Inquiry in Tampa, Florida, and others to develop the NCPS Falls Toolkit. The toolkit is designed to aid facilities in developing a comprehensive falls prevention program. This Web site contains links to the falls notebook, media tools, and additional resources.

  6. Best Practice Intervention Tools for Fall Prevention
    http://www.innovations.ahrq.gov/content.aspx?id=2094

    The Best Practice Intervention Packages (BPIP) are featured on the AHRQ Health Care Innovations Exchange Web site. The packages were designed for use by any home health agency to support efforts to reduce avoidable acute care hospitalizations. The topic of this package is falls prevention.

Reducing Pressure Ulcers

  1. Braden Scale for Predicting Pressure Sore Risk
    http://www.innovations.ahrq.gov/content.aspx?id=2403

    This rating scale for nurses and other health care providers is featured on the AHRQ Health Care Innovations Exchange Web site. It predicts a patient's level of risk for developing pressure ulcers. The scale is composed of six subscales that measure functional capabilities of the patient that contribute to either higher intensity and duration of pressure or lower tissue tolerance for pressure.

  2. Nursing Home Improvement Feedback Tool
    http://www.innovations.ahrq.gov/content.aspx?id=2193

    This tool is featured on the AHRQ Health Care Innovations Exchange Web site. The Nursing Home Improvement Feedback Tool (NHIFT, or "nifty") is a computer-based audit and feedback tool that assists nursing homes in collecting data and viewing process measure scores for four clinical topics: depression, pain, physical restraints, and pressure ulcers.

  3. On-Time Quality Improvement for Long-Term Care
    http://www.ahrq.gov/research/ontime.htm

    AHRQ launched a program to help frontline nursing home staff reduce the occurrence of in-house pressure ulcers, providing residents with more efficient, effective, and patient-centered care. The On-Time Quality Improvement for Long-Term Care program is an innovative program designed to improve day-to-day practice in nursing homes, improve and redesign workflow, enrich work culture, and reduce pressure ulcers. This Web site contains program materials, a video, and readiness and health information technology assessment tools available for download.

  4. Prevention and Treatment Program Integrates Actionable Reports Into Practice, Significantly Reducing Pressure Ulcers in Nursing Home Residents
    http://www.innovations.ahrq.gov/content.aspx?id=2153

    This featured profile is available on the AHRQ Health Care Innovations Exchange Web site. The On-Time Pressure Ulcer Prevention and Treatment Program uses standardized documentation data elements and actionable clinical reports that are integrated into practice at nursing homes; the goal of the program is to help nursing home staff identify and address risk factors for pressure ulcers in residents.

  5. Staff Training and Support, Incentives, and Feedback Fails to Generate Sustainable Reductions in Pressure Ulcers at Nursing Home
    http://www.innovations.ahrq.gov/content.aspx?id=1895

    This profile is available on the AHRQ Health Care Innovations Exchange Web site. Guided by a university research team, a 136-bed, not-for-profit nursing home in Pennsylvania implemented a quality improvement program to reduce the incidence of pressure ulcers (PUs). The program had three components: increasing workers' ability to recognize and prevent PUs, giving them incentives to perform better, and providing management and staff with performance feedback. Although there was a significant reduction in PUs during the program's 3-month implementation period, these gains were not sustained.

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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/nhimpgen.html