Perioperative Patient Handoff Tool Kit

The tool kit, developed by the Association of Perioperative Registered Nurses (AORN) and the US Department of Defense Patient Safety Program, provides web-based resources to guide perioperative professionals in standardizing handoff communications among caregivers. The tool kit includes supporting research for evidence-based recommendations, sample checklists and forms, PowerPoint presentations on standardizing communication and information exchanges in perioperative practice, and an annotated guide to additional resources.

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TeamSTEPPS: Strategies and Tools to Enhance Performance and Patient Safety

The Department of Health and Human Services Agency for Healthcare Research and Quality (AHRQ) and the Department of Defense's military health system developed TeamSTEPPS, an evidence-based team training and implementation toolkit that demonstrates techniques of effective communication and other teamwork skills. The toolkit, which responds to the Institute of Medicine's call for "interdisciplinary team training programs that incorporate proven methods for team management" to prevent medical errors, is designed to optimize team performance and outcomes across the health care delivery system.

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Removing Insult from Injury: Disclosing Adverse Events

Researchers at the Johns Hopkins Bloomberg School of Public Health are working to help educate physicians in how to disclose medical errors to patients and their families. They've developed a 25-minute training video, “Removing Insult from Injury: Disclosing Adverse Events,” available for purchase on their website. The video features short vignettes of doctors talking with patients to illustrate the best methods for disclosing medical errors. The video can be a helpful tool for practicing physicians and physicians in training, risk managers, and health care organizations.

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Pursuing an Optimal Culture of Safety

The Controlled Risk Insurance Company/Risk Management Foundation (CRICO/RMF) website features a "Pursuing an Optimal Culture of Safety" section that discusses how organizational culture underpins all patient interactions within the health care system and the importance of culture in fostering patient safety. In order to establish more highly reliable systems in health care, organizations will need to simultaneously design for reliability and address culture in more explicit ways.

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American Academy of Neurology Patient Safety Tips

The American Academy of Neurology (AAN) is an international association of neurologists and neuroscience professionals dedicated to providing the best possible care for patients with neurological disorders. The Patient Safety Tips on the AAN website are designed to increase awareness of patient safety issues and provide neurologists with tools and programs to enhance patient safety, improve patient care, create more efficient office practices, and improve practice risk management strategies. A number of tips focus on how to assist patients with health literacy issues.

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Medically Induced Trauma Support Services (MITSS)

Medically Induced Trauma Support Services (MITSS) offers resources for both patients and clinicians to support, educate, train and offer assistance to individuals affected by medically induced trauma. The MITSS mission is to promote open and honest communication and to provide support services to ALL individuals who have been affected by unexpected complications due to medical and/or surgical procedures, medical errors or systems error, for example.

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NPSF Patient Safety Bibliography

The National Patient Safety Foundation (NPSF) offers a comprehensive bibliography of patient safety materials from medical, legal, news, and other sources. The bibliography represents a list of substantive works on issues in patient safety and encompasses the broad range of topics affecting this concept. Currently, the bibliography includes over 5,500 items in both the HTML and data (drop-down menu) sections.

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Incident Decision Tree

The Incident Decision Tree (IDT) has been created to provide a framework for human resource and National Health Service (NHS) managers determining the course of action to take with staff who have been involved in a patient safety incident. The objective of the tool is to encourage a consistent and fair approach to staff issues across the NHS. Ultimately, using the IDT will allow NHS organisations to avoid unnecessary and costly suspensions and alleviate the anxiety suffered by the staff involved.

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Agency for Healthcare Research and Quality (AHRQ) Hospital Survey on Patient Safety Culture

A new survey for assessing patient safety culture in hospitals was released in November 2004 by the Agency for Healthcare Research and Quality (AHRQ). Available to the public at no charge, the survey includes a comprehensive set of tools, such as recommendations and guidance on sampling, setting up the survey for web-based completion, and analyzing the data. The survey is specifically designed for use in the hospital setting and was thoroughly tested for reliability prior to its release.

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National Guideline Clearinghouse

The National Guideline Clearinghouse (NGC), an initiative of the Agency for Healthcare Research and Quality (AHRQ), is a public resource for evidence-based clinical practice guidelines. The NGC site contains abstracts and full-text clinical practice guidelines, guideline comparisons, a searchable bibliography database for literature citations, and a discussion forum for exchanging ideas about guidelines.

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Storywork Institute

An excellent resource to develop your storytelling skills and the use of story to change culture, develop leadership, and spread quality improvement efforts. [USA] User submitted: Susan Edgman-Levitan

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Second Global Patient Safety Challenge: Safer Surgery Saves Lives

The World Alliance for Patient Safety initiated work on the second Global Patient Safety Challenge in January 2007. The initiative, "Safe Surgery Saves Lives," aims to improve the safety of surgical care around the world. By focusing attention on surgery as a public health issue, the World Health Organization is recognizing the importance of improving the safety of surgical care.

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International Society for Quality in Health Care (ISQua)

This resource provides services to guide health professionals, providers, researchers, agencies, policy makers and consumers, to achieve excellence in healthcare delivery to all people, and to continuously improve the quality and safety of care. [AUSTRALIA]

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Clinical Safety Research Unit (CSRU)

The Clinical Safety Research Unit (CSRU), established in September 2002 with an initial grant from Smith and Nephew Foundation, provides resources on risk management and patient safety as well as tools for root cause analysis.

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World Health Organization

The World Health Organization (WHO), the United Nations specialized agency for health, is governed by 192 states. WHO’s objective is the attainment by all peoples of the highest possible level of health. Health, defined under the WHO constitution, is a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity. [SWITZERLAND]

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Australian Council for Safety and Quality in Health Care

The Australian Council for Safety and Quality in Health Care was established in January 2000 by Australian Health Ministers to lead national efforts to improve the safety and quality of health care provision in Australia. [AUSTRALIA]

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National Patient Safety Agency

The National Patient Safety Agency (NPSA) is a Special Health Authority created in July 2001 to coordinate the efforts of the entire United Kingdom to report, and more importantly to learn from, patient safety incidents occurring in the National Health Service.

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Australian Patient Safety Foundation

The Australian Patient Safety Foundation Inc. (APSF) is a non-profit independent organisation dedicated to the advancement of patient safety. The APSF provides leadership in the reduction of harm to patients in all health care environments, through its incident management system. [AUSTRALIA]

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National Patient Safety Foundation

The mission of the National Patient Safety Foundation (NPSF) is to improve measurably patient safety in the delivery of health care by its efforts to: Identify and create a core body of knowledge; Identify pathways to apply the knowledge; Develop and enhance the culture of receptivity to patient safety; Raise public awareness and foster communications about patient safety; and Improve the status of the Foundation and its ability to meet its goals.

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Partnership for Patient Safety

Partnership for Patient Safety (p4ps) is a patient-centered initiative to advance the reliability of healthcare systems worldwide. p4ps initiates focused partnerships and joint ventures with organizations and individuals that share our core values and objectives. [USA]

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Department of Veterans Affairs (VA) National Center for Patient Safety

The National Center for Patient Safety (NCPS) embodies the Department of Veterans Affairs' (VA) uncompromising commitment to reducing and preventing adverse medical events and close calls while enhancing the care given to patients. The NCPS represents a unified and cohesive patient safety program, with active participation by all of the 163 VA facilities supported by dedicated patient safety managers. The program focuses on prevention not punishment, applying human factor analysis, and the safety research of high reliability organizations (e.g., aviation and nuclear power) targeted at identifying and eliminating system vulnerabilities in order to prevent harm to patients.

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Premier Safety Institute

The Safety Institute provides key documents, tools and resources on safety for workers, patients, and the environment through its public access website, free online newsletter, and online safety store. The Institute is part of Premier Inc, a leading healthcare alliance affiliated with more than 1600 not-for-profit hospitals offering comparative databases and tools for JCAHO, CMS and quality/safety performance measurement. [USA]

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Anesthesia Patient Safety Foundation

The mission of Anesthesia Patient Safety Foundation is to ensure that no patient shall be harmed by anesthesia. The purposes of this corporation are: to foster investigations that will provide a better understanding of preventable anesthetic injuries, encourage programs that will reduce the number of anesthetic injuries, and promote national and international communication of information and ideas about the causes and prevention of anesthetic injuries. [USA]

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Quality Check and Quality Reports

Quality Check links consumers and providers to the nearly 16,000 Joint Commission-accredited health care organizations and programs throughout the United States. New functionality allows consumers to search for sites of care and compare up to six Joint Commission-accredited organizations at the same time. Quality Reports will soon be available to provide information about the quality and safety of Joint Commission-accredited organizations.

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Institute for Family-Centered Care

The Institute for Family-Centered Care, a non-profit organization, provides leadership to advance the understanding and practice of patient- and family-centered care. By promoting collaborative, empowering relationships between providers and consumers, the Institute facilitates patient- and family-centered change in all settings where individuals and families receive care and support. Guidance for creating patient and family advisory councils, supporting family participation on committees and task forces (e.g., patient safety, pain management, quality improvement, and patient and family education), collaborative design planning, and involving patients and families in staff orientation and the education of students and trainees is available from the Institute.

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Josie King Patient Safety Program

Through the creation of a patient safety program, the King's hope to help prevent this from ever happening to another child. The Josie King Pediatric Patient Safety Program at the Johns Hopkins Children's Center will identify safety concerns, revise medical education to sharpen focus on proactive safety measures, and empower families to assume equal partnership in their child's care. [USA]

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PULSE (Persons United Limiting Substandards and Errors in Healthcare)

PULSE is a nonprofit, support group and organization working to improve patient safety and reduce the rate of medical errors in the United States using real life stories and experiences. Members and participants are encouraged to use their experience to educate the community and advocate for a safer health care system. [USA]

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Research Randomizer

This website generates lists of random numbers for those who want an easy way to identify a random sample (i.e., a set of patient records to review). The random number set can also be downloaded in Excel format for ease of use.

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Joint Commission National Patient Safety Goals

The Joint Commission evaluates and accredits nearly 15,000 health care organizations and programs in the United States and is the nation's predominant standards-setting and accrediting body in health care. The National Patient Safety Goals, required to be implemented by all accredited organizations to improve the safety and quality of care, are updated annually.

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Joint Commission on Accreditation of Healthcare Organizations

The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) evaluates and accredits nearly 17,000 health care organizations and programs in the United States. An independent, not-for-profit organization, JCAHO is the nation's predominant standards-setting and accrediting body in health care. Since 1951, JCAHO has developed state-of-the-art, professionally based standards and evaluated the compliance of health care organizations against these benchmarks. Its mission is to continuously improve the safety and quality of care provided to the public through the provision of health care accreditation and related services that support performance improvement in health care organizations. In support of this mission, in 2002, JCAHO introduced Shared Visions-New Pathways, an initiative that focuses accreditation on operational systems that are critical to the safety and quality of patient care.

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Harvard Health Policy Review

This semi-annual journal strives to publish high-quality articles covering the entire spectrum of health policy issues and is designed to appeal to audiences with different degrees of familiarity with the subjects of health care and health policy. [USA]

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The Leapfrog Group for Patient Safety

The Leapfrog Group was formed by The Business Roundtable and comprises over 100 private and public purchasers of health care benefits. The organization promotes quality in health care from a consumer perspective by setting standards, the first of which relate to patient safety. Hospitals in the United States have been asked to voluntarily report on their efforts to meet these standards. [USA]

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Agency for Healthcare Research and Quality

The Agency for Healthcare Research and Quality (AHRQ) research provides evidence-based information on health care outcomes; quality; and cost, use, and access. Information from AHRQ’s research helps people make more informed decisions and improve the quality of health care services. AHRQ was formerly known as the Agency for Health Care Policy and Research. [USA]

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MITSS Story DVD: Documentary of an Adverse Event

The MITSS Story DVD, produced by the Medically Induced Trauma Support Services, tells the story of a physician and a patient who share an adverse event and presents their journey toward healing. The 16-minute DVD is intended to stimulate discussion in any health care organization about the cultural and institutional barriers that exist following adverse medical events around disclosure, apology, and support. A facilitator's guide, discussion questions, and suggested readings are also featured. [A suggested donation is requested to order the DVD.]

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American College of Medical Quality

This website aims to provide leadership and education in healthcare quality management. [USA]

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AHRQ WebM&M (Morbidity & Mortality)

The Agency for Healthcare Research and Quality (AHRQ) developed this web-based journal, Morbidity & Mortality, and resource about patient safety and health care quality. Users can anonymously submit actual cases of patient safety events and five will be posted on the site each month, with commentary from expert faculty. One "spotlight case" each month also includes interactive components including education and opportunities for CME credits. [USA]

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FMEA Information Centre

The FMEA Info Centre is a non-commercial web-based inventory dedicated to the promotion of Failure Mode and Effect Analysis. Resources listed on the site include books, publications and downloads, plus updates on research and news related to FMEA in all industries. [USA]

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Advances in Patient Safety: From Research to Implementation

Advances in Patient Safety: From Research to Implementation describes what federally funded programs have accomplished in understanding medical errors and implementing programs to improve patient safety over the last five years. This compendium of articles is sponsored jointly by the Agency for Healthcare Research and Quality (AHRQ) and the Department of Defense (DoD)-Health Affairs.

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Patient Safety Indicators (PSIs)

The Patient Safety Indicators (PSIs) are a new tool to help health system leaders identify potential adverse events occurring during hospitalization. The AHRQ Quality Indicators (QIs) measure health care quality by using readily available hospital inpatient administrative data. Patient Safety Indicators are a set of indicators providing information on potential inhospital complications and adverse events following surgeries, procedures, and childbirth. The PSIs were developed after a comprehensive literature review, analysis of ICD-9-CM codes, review by a clinician panel, implementation of risk adjustment, and empirical analyses. [USA]

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Maryland Patient Safety Center

The Maryland Patient Safety Center brings together health care providers to study the causes of unsafe practices and put practical improvements in place to prevent errors. The Center's approach combines a voluntary, statewide approach to reporting serious adverse events with improvement activities coordinated by a statewide patient safety center. Resources for both practitioners and consumers are available on the website.

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Massachusetts Coalition for the Prevention of Medical Errors

The Massachusetts Coalition for the Prevention of Medical Errors was established to improve patient safety and minimize medical errors. The goals of the coalition are to: Establish a mechanism to identify and implement best practices to minimize medical errors; Increase awareness of error prevention strategies through public and professional education; and Identify areas of mutual interest and minimize duplication of regulatory and Joint Commission on Accreditation of Healthcare Organizations (JCAHO) requirements so that efforts are focused on initiatives that can best improve patient care.

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Minnesota Health Information

This website offers a wide range of information about the cost and quality of health care in Minnesota. It is designed to be a clearinghouse of health care information which provides links to a wide range of health-related websites.

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Utah Department of Health Patient Safety Initiatives

Infomation about patient safety initiatives in the State of Utah and other resources in the region.

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Wisconsin Patient Safety Institute

The Wisconsin Patient Safety Institute is a private not-for-profit coalition of health care consumers, purchasers (private employers, public purchasers, and health plans), provider organizations and professionals, researchers, regulators and policy makers committed to improving patient safety in Wisconsin's health care system. This website contains a great booklet on best practices which can be downloaded as a .PDF file. [USA]

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No Thing Left Behind

No Thing Left Behind, a surgical safety project, focuses on helping hospitals, surgeons, perioperative care nurses, and patients work together to ensure that surgical instruments used in an operation (such as sponges and needles) are not left behind in the patient. They developed an easy 1-2-3 prevention method: 1) use radio-opaque items and perform a methodical inspection before closing the wound; 2) allow time for counting surgical tools; and 3) x-ray when there is a discrepancy.

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