HHS releases new tools with aim to make health care safer

Dec 17 2007

An array of toolkits designed to help doctors, nurses, hospital managers, patients and others reduce medical errors was released by HHS' Agency for Healthcare Research and Quality.

The 17 toolkits, developed by AHRQ-funded experts who specialize in patient safety research, are free, publicly available, and can be adapted to most health care settings. The toolkits range from checklists to help reconcile medications when patients are discharged from the hospital to processes to enhance effective communication among caregivers and with patients to toolkits to help patients taking medications.

"These toolkits build on AHRQ's investment in patient safety research over the past 6 years and support our commitment to research that can be put to use in everyday settings,” said AHRQ Director Carolyn M. Clancy, M.D. “These toolkits are a major advance toward putting knowledge into practice and saving lives."

The toolkits were developed through AHRQ's Partnerships in Implementing Patient Safety (PIPS) program. Researchers who developed the toolkits examined best practices in a variety of health care settings, including small rural facilities, large urban hospitals, health clinics, and hospital emergency departments. They also studied patient safety interventions among diverse populations, including children and older patients.

While some of the toolkits focus on identifying high-risk practices, others are designed to help health professionals reduce medication errors or other patient harms. Examples of the kinds of interventions that the toolkits promote include:

• The Re-Engineered Hospital Discharge “Project RED” toolkit standardizes the hospital discharge process through a set of manuals and software designed to improve communication between patients and clinicians.
• The Medications at Transitions and Clinical Handoffs “MATCH” toolkit focuses on identifying patient risk factors frequently responsible for inaccurate medication reconciliation, including limited English proficiency and low health literacy, complex medication histories, or impaired mental status.
• The Preventing Venous Thromboembolisms in the Hospital and the Interactive Venous Thromboembolism Safety Toolkit for Providers and Patients toolkits focus on multidisciplinary approaches to the elimination of preventable hospital-acquired blood clots.
• The ED Pharmacist as a Safety Measure in Emergency Medicine toolkit focuses on improving medication safety and reconciliation through the implementation of a program that places pharmacists in hospital emergency departments.