Patient Safety Tool Kit

Tool/Resource Category	Tool/Resource
General Patient Safety	Compendium of Best Solutions by National Patient Safety Foundation (www.npsf.org) Reducing Medical Errors and Improving Patient Safety: Success Stories from the Front Lines of Medicine by the National Coalition on Healthcare (NCHC) and the Institute for Healthcare Improvement (IHI) (www.nchc.org) ABC's of Patient Safety by National Patient Safety Foundation (www.npsf.org) Checklist of Elements that Contribute to a Patient-Safe Environment (Spath P. Patient Safety Improvement Guidebook) (www.brownspath.com) JCAHO Sentinel Event Alerts (www.jcaho.org) IHI (www.ihi.org) FHA Helpful Hints on Preventing Transfusion Reactions FHA Helpful Hints on Preventing Injury Related to Restraints FHA Helpful Hints on Preventing Inpatient Suicide FHA Helpful Hints on Preventing Infant Abduction Agency for Health Care Research and Quality (www.ahrq.org) Interagency Quality Coordinating Task Force (www.quic.gov) Institute of Medicine Reports (www.national-academies.org) The Leapfrog Group (www.leapfroggroup.org) Audio tape series "How safe is our health care system? What can states do to improve patient safety and reduce medical errors?" www.ahrq.gov/news/ulp/ulptapes.htm or 800-358-9295 Anatomy of an error (continuing ed program) Bridge Medical www.mederrors.com Video "First do no harm" (www.p4ps.org) Making Health Care Safer: A Critical Analysis of Patient Safety Practices (www.ahrq.gov) VISN 8 Patient Safety Center (www.patientsafetycenter.com) Ohio Hospital Association (www.ohiopatientsafety.org) Lessons in Patient Safety (compendium www.npsf.org) The Michigan Health and Safety Coalition (MH&SC) www.mihealthandsafety.org/) Patient Safety Handbook www.patientsafety.gov) Patient Safety Reporting System (www.psrs.arc.nasa.gov) Partnership for Safety (www.partnershipforsafety.org)
Culture and Leadership	AHA Strategies for Leadership: Hospital Executives and Their Role in Patient Safety (800-242-2626 #166924) AHA/VHA Strategies for Leadership: An Organizational Approach to Patient Safety (www.aha.org/medicationsafety) AHA Strategies for Leadership Video Series (800-242-2626 #166921; #166922; #166923) Beyond Blame Video by Bridge Medical (www.mederrors.com) MHHP Redefining the Culture for Patient Safety (www.mhhp.com/ptsafety/psbrochure.htm) NPSF "Talking to Patients About Health Care Injury" (www.npsf.org/statement.htm) Elements of a Culture of Safety. Pennsylvania Patient Safety Collaborative (717-564-6606) Elements of a Culture of Safety www.gha.org AHA Quality Advisory: A "Culture of Safety"-- Disclosure of Unanticipated Outcome Information (www.aha.org) ASHRM: Perspective on Disclosure of Unanticipated Outcome Information (www.ashrm.org) Sample survey from Allina Hospitals and Clinics (www.ismp.org/Tools/AllinaAssessment.html) Sample survey from CareGroup (Contact Dr. Weingart for permission sweingar@caregroup.harvard.edu) Department of Veterans Affairs - Close call pilot culture assessment instrument (Bagian and Weick) Patient safety and the "Just Culture": A primer for health care executives (www.mers-tm.net/files/Marx_Primer.pdf) MHHP Communicating outcomes to patients www.mhhp.com//images/pdfs/outcomes.pdf
Medication Safety	Florida Patient Safety Steering Committee Practice Models for Medication Safety (www.fha.org/quality.html) AHA Quality Advisory: Improving Medication Safety (www.aha.org/medicationsafety) Institute for Safe Medication Practices (ISMP) Hospital Medication Self-Assessment Tool (www.ismp.org) Institute for Safe Medication Practices (ISMP) Medication Safety Self-Assessment for Community/Ambulatory Pharmacy (www.ismp.org) Medication Errors edited by Michael Cohen (1999) available from ISMP Recommendations to Reduce Medication Errors Associated with Verbal Medication Orders and Prescriptions (www.nccmerp.org) FHA Helpful Hints on Preventing Medication Errors American Society of Hospital Pharmacists (www.ashp.org) Medication Safety Issue Briefs (www.hhnmag.com/asp/downloads.asp) Addressing Medication Errors in Hospitals: A Practical Tool Kit (quality.chcf.org) Safe Medication Principles from CMA (www.cmanet.org/publicdoc.cfm/578/207/GENER/735) Medication-Use System Safety Strategy (www.ashp.org/patient_safety/ms3-1.pdf)
Surgical Safety	Florida Patient Safety Steering Committee Practice Model for Marking the Correct Surgery/Procedure Site (www.fha.org/quality.html) VHA Correct Site Surgery Verification Seven Absolutes (www.vha.com) FHA Helpful Hints on Preventing Surgery on the Wrong Sidewww.fha.org/members-only/surgery.html JCAHO Sentinel Event Alert - Lessons learned: Wrong site surgery (www.jcaho.org/about+us/news+letters/sentinel+event+alert/index.htm) AORN Position Statement on Correct Site Surgery (www.aorn.org) Anesthesia Patient Safety Foundation (www.gasnet.org/societies/apsf/) American Academy of Opthalmologywww.aao.org/aaoweb1/library/2001_1181.cfm AHRQ Making Health Care Safer www.ahcpr.gov/clinic/ptsafety/chap43b.htm Spine Surgery - Prevention of Wrong-Site Surgery www.spine.org/smax.cfm American Academy of Orthopaedic Surgeons www.aaos.org/wordhtml/2000news/c9-16.htm AORN Position Statementon Correct Site Surgery www.aorn.org/about/positions/correctsite.htm NY State Department of Health Pre-Operative Protocols Panel(www.health.state.ny.us/nysdoh/commish/2001/preopletter.htm VHA Incorporated www.vha.com/releases/020114.asp Oregon Ass. Of Hospitals Fact Sheet www.aracnet.com/~oahhs/issues/safety/surgery.htm Policy on handling Meds in OR www.mmhs.com/online_documents/medical_errors.htm
Patient Involvement	Florida Patient Safety Steering Committee sample medication model from UCH. AHA Quality Advisory: Partnering with Patients (www.aha.org/medicationsafety) AHRQ 20 Tips (www.ahrq.gov) SFHHA Questions to Ask Prior to Receiving Medical Treatment (800-624-3365). SFHHA Some Tips and Suggestions for your Safety and Security (800-624-3365). Five Steps to Safer Health Care (www.jcaho.org/patient_safety.html) Preventing Medication Errors (www.safemedication.com/meds/prevention.html) HAP Partners in Quality: Taking an Active Role in Your Health Care (www.hap2000.org/hhap)(717-564-9200) Your Role in Safe Medication Use (www.mhalink.org/publications/docs/consumerguide.pdf) NIA Medicines: Use them safely (www.nih.gov/nia/health/agepages/medicine.htm) Speak Up Campaign (www.jcaho.org/)
Computerized Physician Order Entry	AHA Quality Advisory: Computerized Physician Order-Entry Systems (www.aha.org/medicationsafety) Primer on CPOE- California Health Care Foundation (http://quality.chcf.org/view.cfm?itemID=3315) The effect of barcode-enabled point of care technology on medication administration errors by Bridge Medical (www.mederrors.com/pdf/whitepaper_barcode.pdf)
Devices/Equipment	Medical Devices Safety Reports (mdsr.ecri.org/index.asp) MRI Harzards (www.patientsafety.gov)
Falls	Florida Patient Safety Steering Committee Practice Models for Falls Prevention Pdf Format, Word Format VISN 8 Safety Center (www.patientsafetycenter.com) JCAHO Sentinel Event Alert: Fatal falls: Lessons for the future (www.jcaho.org/edu_pub/sealert/se_alert.html)
Bed Safety/Entrapment	A Guide to Bed Safety (www.fda.gov/cdrh/beds/) VISN 8 Patient Safety Center (www.patientsafetycenter.com)
Teams/Training/Tools	MedTeams Products (www.drc.com/TrainingAnalysis/medteams.htm) RCA (www.jcaho.org/accredited+organizations/ambulatory+care/sentinel+events/forms+and+tools/root+cause+analysis+matrix.htm) FMEA (www.patientsafety.gov/HFMEA.html), (www.jcaho.org/sentinel/fmeca_chart.pdf), (Instructional Materials to Accompany the HFMEA™ Videotape), (Using Health Care Failure Mode and Effect Analysis™: The VA National Center for Patient Safety’s Prospective Risk Analysis System) Evolution of CRM Strategies for Leadership, A toolkit for improving Patient Safety (includes HFMEA and RCA tools), to order contact AHA at 800/242-2626, for triage cards only contact dcannon@chepinc.org
Sample Safety Plans/Job Description	Patient Safety Officer Society (www.psos.org) Medication Safety Practitioner (www.ismp.org/Tools/covenantjobdesc.html) Sample Safety Policy (www.wlm-web.com/hcnet/ECFiles/ecframe.htm) Safety Officer Description/Plan www.ismp.org/tools/covenantjobdesc.html Safety Resources www.premierinc.com/frames/index.jsp
Medical Gases	www.fda.gov/dcer/guidance/4341fnl.htm www.ecri.org/documents/misconnflowmeter.asp
Needle Stick Safety	NIOSH (www.cdc.gov/niosh/2000-108.html) www.nappsl.org EPINET (www.med.virginia.edu/medcntr/centers/epinet/subpage2.html) Sharps Safety (www.premierinc.com)