The Agency for Healthcare Research and Quality (AHRQ) offers practical, research-based tools and resources to help a variety of health care organizations, providers, and others make care safer in all health care settings. These tools help staff in hospitals, emergency departments, long-term care facilities, and ambulatory settings to prevent avoidable complications of care. They also address priority areas that have been identified as part of the U.S. Department of Health and Human Services Partnership for Patients and value-based purchasing programs. The tools and resources in this flier are organized alphabetically for clinicians by health care site, for use with patients, and as general patient safety research and data resources.
All tools can be found on the AHRQ Web site at www.ahrq.gov/tools/index.html
- Tools for Health Care Organizations
- Tools to Engage Patients
- Additional Patient Safety Resources: Research, Data, Measurement
Choosing a Patient Safety Organization (PSO) describes the benefits of working with a PSO. PSOs can help providers develop successful approaches to improving quality and reducing adverse outcomes, and make it possible to have Federal confidentiality and privilege protections apply to certain information (defined as "patient safety work product") developed when a provider works with a PSO. The brochure also discusses questions providers may want to consider when choosing a PSO.
Consumer Assessment of Healthcare Providers and Systems (CAHPS®) is a suite of surveys originally developed by AHRQ and designed to measure patients' experiences of their care, including communication with doctors and nurses, responsiveness of staff, and other indicators of safe, high-quality care. The surveys are developed from the patient's perspective on what's important to measure. They are used by Federal agencies and other organizations for value-based purchasing programs, public reporting, accreditation, quality improvement, and health services research. The surveys are available for different settings and health plans. Some CAHPS surveys can be customized with supplemental item sets, including, for example, patient-centered medical homes; health literacy; interpreter services; health information technology; and children with chronic conditions.
- Clinician and group practices
- Emergency departments
- Home health care
- Hospices (hospice facility, hospital, home)
- Hospital outpatient and ambulatory surgery centers
- In-center hemodialysis facilities
- Nursing homes (long-stay, short-stay, family member surveys)
- Health Plans: Commercial, Medicaid, Medicare
- Experience of Care and Health Outcomes
(ECHO®— for behavioral health)
- Cancer care—inpatient and outpatient treatment for drug therapy, radiation therapy, and surgical therapy
- Home and community-based services programs
Comprehensive Unit-Based Safety Program (CUSP) Toolkit includes customizable training tools that build the capacity to address safety issues by combining clinical best practices, the science of safety, and attention to safety culture. Created for clinicians by clinicians, the toolkit includes training tools to make care safer by improving the foundation of how clinical team members work together. Each module includes teaching tools and resources to support change at the unit level and includes facilitator notes that take you step-by-step through the module, presentation slides, tools, and videos.
Settings and problems addressed include:
- Ambulatory surgery centers
- Central line-associated bloodstream infections (CLABSI)
- Catheter-associated urinary tract infections (CAUTI)--hospitals
- CAUTI--long-term care facilities
- Mechanically ventilated patients
- Perinatal safety
- Safe surgery
Health Care Facility Design Safety Risk Assessment Toolkit helps healthcare design teams proactively identify and mitigate built environment conditions that may impact patient and work safety in the hospital and other healthcare environments. The toolkit addresses approaches to design that target six areas of safety: infections, falls, medication errors, security, injuries of behavioral health, and patient handling.
Surveys on Patient Safety Culture™ (SOPS™) is a suite of staff-administered surveys that help health care organizations assess how their staff perceive various aspects of safety culture in the following settings:
- Medical offices
- Nursing homes
- Community pharmacies
- Ambulatory surgery centers
Team Strategies and Tools to Enhance Performance and Patient Safety 2.0 (TeamSTEPPS®) is a core curriculum initially developed for use in hospitals and adapted to other settings. It is a customizable "train the trainer" program plus specialized tools to reduce risks to patient safety by training clinicians in teamwork and communication skills. Materials include a leader's guide for trainers, a pocket guide of important concepts for trainees (also available as an app through the Apple app store and Google Play store), and a multimedia guide featuring training videos to illustrate various concepts. Online modules also are available. Additional modules address:
- Long-term care
- Office-based care
- Patients with limited English proficiency
- Rapid response systems guide
Carbapenem-Resistant Enterobacteriaceae (CRE) Control and Prevention Toolkit provides a framework for outlining steps needed to design and implement CRE control and prevention of infection transmission, including what staff is responsible for each task and time frame for completing the tasks.
Communication and Optimal Resolution (CANDOR) Toolkit enables health care organizations to implement an AHRQ-developed process. Like similar programs in place in other organizations, CANDOR gives hospitals and health systems the tools to respond immediately when a patient is harmed and to promote candid, empathetic communication and timely resolution for patients and caregivers. Based on expert input and lessons learned from the Agency's $23 million Patient Safety and Medical Liability grant initiative launched in 2009, the CANDOR toolkit was tested and applied in 14 hospitals across three U.S. health systems.
Each of the toolkit's eight modules contains PowerPoint slides with facilitator notes. Some modules also contain tools, resources, or videos.
Fall TIPS: A Patient-Centered Fall Prevention Toolkit consists of a formal risk assessment and tailored plan of care for each patient. The toolkit has reduced falls by 25 percent in acute care hospitals and is used in more than 100 hospitals in the U.S. and internationally.
Family-Centered Rounds (FCR) Toolkit was designed to increase family engagement in rounds for hospitalized children. It is intended for use by health care providers initiating FCR and/or operationalizing optimal practices in the setting of existing FCR, including: physicians, nurses, hospital administrators, and quality improvement personnel.
Guide for Developing a Community-Based Patient Safety Advisory Council provides approaches for hospitals and other health care organizations to use to develop a community-based advisory council that can drive change for patient safety through education, collaboration, and consumer engagement.
Guide to Patient and Family Engagement in Hospital Quality and Safety helps hospitals work as partners with patients and families to improve quality and safety. Includes an implementation handbook and tools for patients, families, and clinicians.
Hospital Guide to Reducing Medicaid Readmissions provides evidence-based strategies to reduce readmissions among the adult Medicaid population.
I-PASS Mentored Implementation Handoff Curriculum is a comprehensive handoff curriculum that has been proven to improve the safety, efficiency, and efficacy of shift-to-shift handoffs during patient handoffs.
Making Informed Consent an Informed Choice: Training Modules for Health Care Leaders and Professionals provides tools to hospital leaders and health professionals to improve informed consent policy and practice.
Medications at Transitions and Clinical Handoffs (MATCH) Toolkit features strategies from the field that can help hospitals improve medication reconciliation processes for patients as they move through the healthcare system.
Multi-Center Medication Reconciliation Quality Improvement Study (MARQUIS) Toolkit includes a set of medication reconciliation tools to reduce medication errors that frequently occur during care transitions when patients enter and leave the hospital.
Preventing Falls in Hospitals: A Toolkit for Improving Quality of Care focuses on overcoming the challenges associated with developing, implementing, and sustaining a fall prevention program. Includes an implementation guide to help put prevention strategies into practice.
- Fall Prevention in Hospitals Training Program supports the training of hospital staff on how to implement AHRQ's Preventing Falls in Hospitals Toolkit. It consists of a five-module, in-person training curriculum and a series of companion Webinars on specific topics related to fall prevention. An Implementation Guide provides additional suggestions for how to use the training program and the toolkit.
Preventing Hospital-Associated Venous Thromboembolism: A Guide for Effective Quality Improvement outlines the latest evidence on how to lead a quality improvement effort to prevent hospital-acquired venous thromboembolism.
Preventing Pressure Ulcers in Hospitals is a toolkit that assists hospital staff in implementing effective pressure ulcer prevention practices through an interdisciplinary approach to care.
- Pressure Injury Prevention in Hospitals Training Program supports the training of hospital staff on how to implement AHRQ's Preventing Pressure Ulcers in Hospitals Toolkit. It consists of a five-module, in-person training curriculum and a series of companion Webinars on specific topics related to pressure injury prevention. An Implementation Guide provides additional suggestions for how to use the training program and the toolkit.
Project BOOST (Better Outcomes by Optimizing Safe Transitions) provides hospitals a comprehensive set of interventions to improve the care transition process after discharge in order to reduce readmissions.
REDUCE MRSA (Methicillin-Resistant Staphylococcus aureus) Enhanced Protocol explains that universal decolonization is the most effective intervention to reduce MRSA infections. This tool provides instructions for implementing decolonization in adult intensive care units.
Re-Engineered Discharge (RED) Toolkit is a research-based tool to assist hospitals, including those that serve diverse populations, in improving their hospital discharge process and reducing avoidable readmissions. An English/Spanish guide to help staff ensure that patients understand their discharge instructions is also available.
Toolkit for Reduction of Clostridum difficile Infections Through Antimicrobial Stewardship assists hospital staff and leadership in developing an effective antimicrobial stewardship program that targets inappropriate use of antibiotics, which has the potential to reduce C. difficile.
Toolkit for Using the AHRQ Quality Indicators: How To Improve Hospital Quality and Safety helps hospitals understand AHRQ's Quality Indicators and how to use them to identify areas of concern in need of further investigation, and monitor progress over time. See Quality Indicators under the section, Additional Patient Safety Resources: Research, Data, and Measurement.
Toolkit to Improve Antibiotic Use in Acute Care Hospitals provides presentations and tools for clinicians to use to improve antibiotic prescribing in the hospital setting. The toolkit explains how you can apply the Four Moments of Antibiotic Decision Making, an innovative approach to antibiotic stewardship that empowers clinicians to be stewards of their own antibiotic prescribing. The toolkit also provides guidance on developing and improving your antibiotic stewardship program, creating a culture of safety around antibiotic prescribing in your hospital, and learning and disseminating best practices for the diagnosis and treatment of common infectious disease syndromes.
Transitioning Newborns from NICU to Home: A Resource Toolkit provides customizable resources to help hospitals and families safely transition newborns out of the neonatal intensive care unit to home using a Health Coach Program.
Emergency Severity Index (ESI): A Triage Tool for Emergency Department Care, Version 4 is a five-level emergency department (ED) triage algorithm that provides clinically relevant stratification of patients into five groups from 1 (most urgent) to 5 (least urgent) on the basis of acuity and resource needs.
Improving Patient Flow and Reducing Emergency Department Crowding: A Guide for Hospitals presents step-by-step instructions for planning and implementing patient flow improvement strategies to alleviate crowded emergency departments.
Sepsis Telehealth Project & Toolkit is a guide to train rural emergency department (ED) clinicians on how to integrate remote intensive care unit (ICU) staff into the workflow for the purpose of treating patients with severe sepsis and septic shock. The toolkit could be used to integrate remote staff into any healthcare setting and applied to other medical conditions.
CAHPS® Nursing Home Survey (see description under Multiple Settings section)
CUSP Toolkit to Reduce CAUTI and Other HAIs In Long-Term Care Facilities (see description under Multiple Settings section)
Falls Management Program: A Quality Improvement Initiative for Nursing Facilities is an interdisciplinary quality improvement initiative to assist nursing facilities in providing individualized, person-centered care and improving their fall care processes and outcomes through educational and quality improvement tools.
Improving Patient Safety in Long-Term Care Facilities is a training curriculum for front-line personnel in nursing home and other long-term care facilities to help them detect and communicate changes in a resident's condition and prevent and manage falls. Includes an Instructor Guide and separate student workbooks.
Nursing Home Antimicrobial Stewardship Guide provides field-tested, evidence-based modules that can help nursing homes develop antibiotic stewardship programs to help them use and prescribe antibiotics appropriately. Appropriate antibiotics use can reduce antimicrobial resistance and help retain the effectiveness of treatments for infection, which are a common threat to resident safety.
Nursing Home Survey on Patient Safety Culture (see description under Multiple Settings section)
Safety Program for Nursing Homes: On-Time Pressure Ulcer Prevention is a team training curriculum to help nursing homes with electronic medical records reduce the occurrence of pressure ulcers.
TeamSTEPPS® Long-Term Care Version (see listing under Multiple Settings)
Toolkit to Educate and Engage Residents and Family Members helps nursing homes encourage an open and respectful dialogue between nurses and prescribing clinicians and residents and family members and helps residents and family members participate in their care.
Understanding Omissions of Care in Nursing Homes helps nursing home staff understand how omissions of care are defined in a way that is meaningful to stakeholders, including residents and caregivers, and actionable for research or improving quality of care.
Ambulatory Surgery Center (ASC) Survey on Patient Safety Culture (see description under Multiple Settings section)
CAHPS® Clinician & Group Survey (see description under Multiple Settings section)
The Community-Acquired Pneumonia (CAP) Patient Safety Clinical Decision Support Implementation Toolkit is a resource to help clinicians and clinical informaticians in primary care and other ambulatory settings implement and adopt the CAP clinical decision support (CDS) alert for the management of community-acquired pneumonia.
Guide to Improving Patient Safety in Primary Care Settings by Engaging Patients and Families is an ongoing project that currently offers four interventions and four case studies designed to improve patient safety by meaningfully engaging patients and families in their care. The full guide is in development.
Health Literacy Universal Precautions Toolkit, 2nd Edition can help primary care practices reduce the complexity of healthcare, increase patient understanding of health information, and enhance support for patients of all literacy levels. It includes tools to improve spoken and written communication, tools to improve self-management and empowerment, and others.
Improving Your Laboratory Testing Process: A Step-by-Step Guide for Rapid-Cycle Patient Safety and Quality Improvement. The tools in this step-by-step guide can increase the reliability of the testing process in your office by helping you examine how tests are managed.
Medical Office Survey on Patient Safety Culture (see description under Multiple Settings section)
Primary Care-Based Efforts to Reduce Potentially Preventable Readmissions addresses the role of primary care in improving the quality and safety of care as patients transition from the hospital setting.
Reducing Diagnostic Errors in Primary Care Pediatrics Toolkit aims to assist primary care practice teams with a systematic approach to reduce diagnostic errors among children in three important areas:
- Elevated blood pressure, which is misdiagnosed in 74 to 87 percent of children.
- Adolescent depression, which affects nearly 10 percent of teenagers, and is misdiagnosed in almost 75 percent of adolescents.
- Actionable pediatric diagnostic tests, which are potentially delayed up to 26 percent of the time.
Safety Program for End-Stage Renal Disease Facilities Toolkit helps end-stage renal disease clinics prevent healthcare-associated infections in dialysis patients by following clinical practices, creating a culture of safety, using checklists and other audit tools, and engaging with patients and their families. The toolkit includes four instructional modules that a facilitator can use to teach dialysis center team members specific ways to create a culture of safety.
Six Building Blocks and Six Building Blocks: A Team-Based Approach to Improving Opioid Management in Primary Care Self-Service How-To Guide help support primary care clinics as they independently implement effective, guideline-driven care for their patients with chronic pain who are using opioid therapy.
TeamSTEPPS® for Office-Based Care (see description under Multiple Settings section)
The Toolkit to Engage High-Risk Patients in Safe Transitions Across Ambulatory Settings is designed to help staff actively engage patients and their care partners to prevent errors during transitions of care.
Be More Engaged in Your Health Care: Tips for Patients, a brochure that gives patients tips to use before, during, and after a medical appointment to get the best possible care.
Blood Thinner Pills: Your Guide to Using Them Safely explains, in both English and Spanish, what patients can expect while taking blood thinner medication.
Getting Ready for Your Ambulatory Surgery. This 2-page patient brochure helps patients and their families prepare for ambulatory surgeries and other procedures performed in outpatient settings.
InfoSAGE, short for "Information Sharing Across Generations," is a free web resource to facilitate care coordination among the patient and family members and their medical team. It includes a medication manager to help older adults and their families keep an accurate medication list, coordinate the list with prescribing clinicians, track the impact of medications on symptoms, view medication precautions and drug-drug interactions, and become more engaged as partners in their care.
My Questions for This Visit are 50-sheet notepads designed for use in physician offices to help patients identify the top three questions they want to remember to ask during medical visits.
Questions Are the Answer materials are designed to improve communication between patients and clinicians to help make healthcare safer.
Research from a wide variety of AHRQ patient safety projects was synthesized into materials featuring AHRQ’s trusted evidence about diagnostic testing and results, medication safety, safe transitions between care settings, and the importance of patient and family engagement in healthcare.
In 2019, AHRQ developed its QuestionBuilder app by fusing the latest mobile technology with longstanding research to put questions to ask at patients’ fingertips.
Notepads, an online Question Builder, and a DVD with a 7-minute video (designed to be played in waiting rooms) of patients and clinicians discussing the importance of asking questions are also available.
- Conozca las preguntas (Know the Questions), a Spanish-language companion site to Questions Are the Answer, encourages Hispanics to go to the doctor and ask questions to achieve better health outcomes. The website features tips on how to talk with doctors and questions to ask when receiving medical care.
Staying Active and Healthy With Blood Thinners is a 10-minute video that features easy-to-understand explanations, in English and Spanish, of how blood thinners work and why it is important to take them correctly. It also introduces BEST, an easy way to remember how to fit blood thinner medication into daily life.
Taking Care of Myself: A Guide for When I Leave the Hospital is an easy-to-read guide to help nurses or discharge advocates work with patients to track medication schedules, upcoming medical appointments, and important phone numbers after they leave the hospital.
Your Guide to Preventing and Treating Blood Clots discusses ways to prevent, treat, and recognize symptoms of blood clots. It also describes medications used to prevent blood clots and their side effects.
Your Medicine: Be Smart. Be Safe answers common questions about getting and taking medicines; includes a handy form to help patients keep track of their medicines.
Advances in Patient Safety and Medical Liability highlights results from a number of AHRQ-funded planning and demonstration grants aimed at improving patient safety and malpractice outcomes, as well as the environment in which those outcomes occur. Some of the topics include the role of patients and families in supporting improved care and patient safety; the impact of institutional silence when patient harm occurs; and the implementation of disclosure, apology, and offer programs.
Common Formats are specifications used to collect patient safety event information in a standard way, using common language, definitions, technical requirements for electronic implementation, and reporting. The Common Formats can be used to collect data on all types of adverse events, near misses, and unsafe conditions in hospitals, nursing homes, and more. Common Formats are currently available for hospitals, nursing homes, and community pharmacies.
Comparative Databases for Safety and Quality
- CAHPS Health Plan Database gathers survey results from Health Plan Survey users across the country and then reports aggregated data in an Online Reporting System that all survey users can use to identify strengths and weaknesses in their own performance.
- CAHPS Clinician & Group Survey (CG-CAHPS) Database has been accepting survey data since 2010. It was developed in response to the growing demand for comparative results for the various versions of the Clinician & Group Survey. Submissions to the database will be suspended starting in 2021. However, the historic data will remain available.
- Hospital Survey on Patient Safety Culture (HSOPS) Comparative Database is a central repository for survey data from hospitals that have administered the AHRQ Patient Safety Culture Survey instrument and can be used by hospitals to compare their results to those of other hospitals.
Diagnostic Safety Series of Issue Briefs
- Operational Measurement of Diagnostic Safety: State of the Science discusses the state of the science of operational measurement of diagnostic safety for the purpose of providing knowledge and suggestions to encourage healthcare organizations to begin to identify and learn from diagnostic errors.
- Telediagnosis for Acute Care: Implications for the Quality and Safety of Diagnosis highlights what we do and don’t know about using telemedicine for diagnosis and the implications for research and practice.
- Evidence on Use of Clinical Reasoning Checklists for Diagnostic Error Reduction summarizes current evidence on use of checklists to improve diagnostic reasoning.
- Health Information Technology for Engaging Patients in Diagnostic Decision Making in Emergency Departments reviews the current state of health IT-based methods for engaging patients in the diagnostic process in the emergency department and outlines opportunities for further development.
Healthcare Comes Home: The Human Factors is an AHRQ-funded report from the National Research Council that offers recommendations for system improvements to address the most prevalent and serious threats to safety and quality of care provided in the home environment.
Healthcare Simulation Dictionary – Second Edition has added 40 new terms to the more than 100 healthcare simulation terms and definitions in the first edition. The dictionary standardizes simulation terminology for healthcare simulation professionals to use in areas such as education, assessment, research, and systems integration.
Hospital-Acquired Conditions National Scorecard provides interim and final data on hospital-acquired conditions (HACs) from national efforts to make health care safer. Results show a 21 percent decline in HACs from 2010 to 2015.
Making Healthcare Safer III Report: A Critical Analysis of Existing and Emerging Patient Safety Practices reviews 47 practices that target patient safety improvement in hospitals, primary care practices, long-term care facilities, and other healthcare
National Scorecard on Hospital-Acquired Conditions is a report that shows progress toward the goal of reducing hospital-acquired conditions (HACs). These are conditions that a patient develops while in the hospital being treated for something else. The National Scorecard on Hospital-Acquired Conditions Updated Baseline Rates and Preliminary Results 2014–2017, the most recent report, shows that from 2014 to 2017, HACs fell by 13 percent, saving about 20,500 lives and about $7.7 billion in healthcare costs.
National Healthcare Quality and Disparities Report, a congressionally mandated annual report that presents trends and disparities in the effectiveness, safety, timeliness, patient-centeredness, and efficiency of care based on more than 250 measures of care.
- Patient Safety Chartbook, a companion report, presents data in easy-to-understand graphic format.
Network of Patient Safety Databases (NPSD) contains nonidentifiable, aggregated patient safety information voluntarily reported by AHRQ-listed Patient Safety Organizations from across the nation. The NPSD data are made available to the public through various informational products. The NPSD Dashboards enable users t o explore and visualize data elements collected and examine associations between different elements over time. The NPSD Chartbooks provides an overview of the patient safety data captured in the NPSD Dashboards and highlights patterns and trends in the data.
NPSD Dashboards page: https://www.ahrq.gov/npsd/data/dashboard/index.html
Patient Safety in Ambulatory Settings Technical Brief explores fundamental questions about patient safety practices in ambulatory care and identifies promising safety initiatives that have not been broadly implemented or studied. The brief finds that significant gaps exist in ambulatory safety research, notably a lack of studies in patient engagement and timely and accurate diagnosis.
Patient Safety Network (AHRQ PSNET) is a national Web-based resource that features the latest news and essential resources on patient safety, including weekly literature updates, news, tools, and meetings; patient safety primers; and annotated links to important research and other information on patient safety. It also includes case reports and safety perspectives from Web M&M (Morbidity and Mortality Rounds on the Web), a peer-reviewed online journal and forum on patient safety and health care quality.
Settings and problems addressed by the Quality Indicators™ include:
- Inpatient Quality Indicators reflect quality of care inside hospitals, including inpatient mortality for medical conditions and surgical procedures.
- Patient Safety Indicators reflect quality of care inside hospitals to focus on potentially avoidable complications and healthcare-associated events.
- Prevention Quality Indicators identify hospital admissions that evidence suggests may have been avoided through access to high-quality outpatient care.
- Pediatric Quality Indicators use indicators from the other three modules with adaptations for use among children and neonates to reflect quality of care inside hospitals and identify potentially avoidable hospitalizations.
Primary Care-Based Efforts To Reduce Readmissions Environmental Scan provides insights on the components and themes that should be part of a re-engineered visit in order to inform the development of effective interventions that can be tested in a diverse set of primary care clinics. The environmental scan examines what is currently known about reducing readmissions from the primary care perspective, with a focus on evidence of successful practices.
Resident Duty Hours: Enhancing Sleep, Supervision, and Safety, an AHRQ-funded report from the Institute of Medicine, recommends changes to resident work hours and training programs to enhance patient safety.
Resident Safety Practices in Nursing Home Settings is a technical brief that describes the state of the science around nursing home safety in order to establish a research agenda for moving the field forward.