Patient Safety

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Improving patient safety has always been the top priority for hospitals and is fundamental to delivering quality health services. Hospitals should assess their processes, identify optimization opportunities, and implement evidence-based practices to create a culture of safety. Please note: on some web browsers, document links may automatically download to your computer rather than open up on your screen.

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Impact of Doxycycline on Clostridioides Difficile Infection in Patients Hospitalized with Community-Acquired Pneumonia
Doxycycline is associated with a lower risk of Clostridioides difficile infection (CDI) compared to azithromycin when used for atypical coverage in community-acquired pneumonia (CAP).
Web link    Date Added: 01/24/2024    Date Last Modified: Jan 24 2024 8:52PM  
The ABCs of ADEs
This webinar by the Great Plains Quality Innovative Network provides an overview of the terms related to drug-related harm, the scope of the problem, risk factors, prevention strategies and available resources.
Video    Date Added: 01/24/2024    Date Last Modified: Jan 24 2024 8:58PM  
Impact of Reducing Time-to-Antibiotics on Sepsis Mortality, Antibiotic Use, and Adverse Events
This study published in the Annals of the American Thoracic Society researched the benefits and harms of shortening time-to-antibiotics for sepsis, concluding that the impacts of faster time-to-antibiotics for sepsis vary markedly across simulated hospital types. However, even in the worst-case scenario, new antibiotic-associated adverse events were rare.
Web link    Date Added: 01/24/2024    Date Last Modified: Jan 24 2024 9:17PM  
Diagnosis and Assessment of Urinary Tract Infections (UTIs)
This webinar provides an overview of the different types of urinary tract infections (UTIs), including risk factors, symptoms, diagnosis and treatment options.
Video    Date Added: 01/24/2024    Date Last Modified: Jan 24 2024 9:32PM  
Strategies and Tactics to Reduce HAIs
The strategies and tactics highlighted in this resource from the American Hospital Association are used by hospitals to reduce healthcare-associated infections and improve their infection prevention and control efforts.
Adobe PDF    Date Added: 11/17/2023    Date Last Modified: Nov 17 2023 12:29PM  
How to Reduce Chronic Obstructive Pulmonary Disease Readmissions
This recorded presentation defines chronic obstructive pulmonary disease (COPD) and shares resources to support patients in managing this disease. Kim Jungkind, a quality improve specialist with the TMF Innovation Network, also provides ideas for reducing COPD readmissions.
Video    Date Added: 11/08/2023    Date Last Modified: Nov 29 2023 11:26AM  
Reducing Adverse Drug Events in Vulnerable Populations
This presentation discusses strategies and solutions for reducing adverse drug events in vulnerable patient populations.
Video    Date Added: 11/06/2023    Date Last Modified: Dec 11 2023 10:38AM  
Project Firstline – Infection Control & COVID-19 Training for Healthcare Workers
This educational video series from the Centers for Disease Control and Prevention teaches the basic ideas behind infection control, how they work to prevent COVID-19 and how using infection control actions can protect health care workers, their co-workers, patients and the community. Learners can earn a certificate of completion for watching episodes and/or earn continuing education credits through Training and Continuing Education Online.
Web link    Date Added: 09/26/2023    Date Last Modified: Sep 26 2023 6:41PM  
Clean Hands Count Fact Sheet
This Clean Hands Count campaign fact sheet from the Centers for Disease Control and Prevention (CDC) aims to improve health care provider adherence to CDC hand hygiene recommendations.
Adobe PDF    Date Added: 09/15/2023    Date Last Modified: Sep 15 2023 1:24PM  
Heat-Related Illnesses
This fact sheet from the Centers for Disease Control and Prevention list symptoms and responses for several common heat-related illnesses, such as heat stroke and heat exhaustion.
Adobe PDF    Date Added: 08/17/2023    Date Last Modified: Aug 17 2023 3:02PM  
Quality Improvement Data Collection Plan
Complete this Data Collection Plan prior to collecting data for a project or monthly measure review in order to identify the data required for the task, identify a goal for each measure, define the source of data, and identify the person(s) responsible for the data collection.
Microsoft Excel    Date Added: 07/14/2023    Date Last Modified: Jul 14 2023 11:28AM  
Podcast: What Happened to Patient Safety?
In this podcast from the Institute for Healthcare Improvement, Sue Sheridan of Patients for Patient Safety US describes how she strives for transparency and champions the patient role in developing solutions.
Podcast    Date Added: 06/13/2023    Date Last Modified: Jun 13 2023 11:54AM  
Connecting your Hospital Culture of Safety to Patient Harm Reduction
Watch this HQIC Community of Practice Call recorded discussion on how successful and sustainable patient safety improvement rests heavily on an organizational culture of attitudes, actions, teamwork and technology centered on reducing the risk of patient harm.
Video    Date Added: 04/24/2023    Date Last Modified: Apr 24 2023 5:31PM  
Best Practice Pocket Cards Spread Knowledge
This series of nearly 20 different infection prevention reference cards from the Health Quality Innovation Network can be downloaded and shared with frontline health care staff. Topics include enhanced barrier precautions, personal protective equipment, cleaning and disinfection, and transmission-based precautions.
Web link    Date Added: 04/17/2023    Date Last Modified: Apr 17 2023 5:12PM  
Implementation of Antibiotic Stewardship Core Elements at Small and Critical Access Hospitals
This document, provided by the Centers for Disease Control and Prevention (CDC), provides guidance on practical strategies to implement antibiotic stewardship programs in small and critical access hospitals.
Adobe PDF    Date Added: 01/10/2023    Date Last Modified: Jan 10 2023 3:00PM  
CAUTI Coaching Package
This tool, prepared by Alliant Health Solutions, a Hospital Quality Improvement Contractor (HQIC), provides evidence-based best practices and resources to create quality improvement action plans for catheter-associated urinary tract infection (CAUTI) prevention.
Adobe PDF    Date Added: 01/10/2023    Date Last Modified: Jan 10 2023 2:37PM  
FAQs About MRSA
This fact sheet, provided by the Centers for Disease Control and Prevention (CDC), includes frequently asked questions about Methicillin-resistant Staphylococcus aureus (MRSA) for health care professionals as well as patients and families.
Adobe PDF    Date Added: 01/10/2023    Date Last Modified: Jan 10 2023 2:55PM  
HSAG HQIC Infection Preventionist Orientation Checklist
This tool, designed by infection preventionists (IPs), provides a comprehensive overview of key areas that all IPs should be familiar with upon entering the field. This list can be used to start an orientation program or serve as a gap analysis for an existing program.
Adobe PDF    Date Added: 01/09/2023    Date Last Modified: Jan 9 2023 11:04PM  
CLABSI Prevention Strategies - Gap Analysis Tool
This tool, prepared by Alliant Health Solutions, a Hospital Quality Improvement Contractor (HQIC), is used to assess the difference between central line associated blood stream infection (CLABSI) prevention actual practice and expected performance. It is important to assess practice through observation and audit rather than relying on if a policy is in place, as practice can vary from policy.
Adobe PDF    Date Added: 01/06/2023    Date Last Modified: Jan 10 2023 2:44PM  
CAUTI Prevention Strategies - Gap Analysis Tool
This tool, prepared by Alliant Health Solutions, a Hospital Quality Improvement Contractor (HQIC), is used to assess the difference between catheter-associated urinary tract infection (CAUTI) prevention actual practice and expected performance. It is important to assess practice through observation and audit rather than relying on if a policy is in place, as practice can vary from policy.
Adobe PDF    Date Added: 01/06/2023    Date Last Modified: Jan 10 2023 2:44PM  
Strategies to Prevent Clostridioides Difficile Infection in Acute Care Facilities
This document, provided by the Centers for Disease Control and Prevention (CDC), provides information on the basic principles and interventions recommended for the prevention of Clostridioides difficile infection (CDI) in acute care facilities. The strategies are intended to facilitate implementation of CDI prevention efforts by state and local health departments, quality improvement organizations, hospital associations and health care facilities.
Web link    Date Added: 01/03/2023    Date Last Modified: Jan 10 2023 2:42PM  
Core Elements of Hospital Antibiotic Stewardship Programs
This document, provided by the Centers for Disease Control and Prevention (CDC), updates the 2014 Core Elements for Hospital Antibiotic Stewardship Programs and incorporates new evidence and lessons learned from experience with the Core Elements.
Web link    Date Added: 01/03/2023    Date Last Modified: Jan 10 2023 2:43PM  
Clostridioides Difficile Infection (CDI): Process Improvement Discovery Tool
This tool, prepared by Alliant Health Solutions, a Hospital Quality Improvement Contractor (HQIC), helps hospitals provide safer patient care by completing an assessment to identify process improvement opportunities. Hospitals can use the results to develop specific strategies to address gaps and identify resource needs.
Adobe PDF    Date Added: 12/30/2022    Date Last Modified: Jan 10 2023 2:42PM  
Central Venous Catheter: Observation Tool
This observation tool, provided by the Centers for Disease Control and Prevention (CDC), can be used to observe patients with central lines in place.
Adobe PDF    Date Added: 12/29/2022    Date Last Modified: Jan 10 2023 2:40PM  
Compendium of Strategies to Prevent HAIs in Acute Care Hospitals
The document, provided by The Society for Healthcare Epidemiology of America (SHEA), highlights practical recommendations in a concise format designed to assist acute care hospitals in implementing and prioritizing their infection prevention efforts.
Web link    Date Added: 12/29/2022    Date Last Modified: Jan 10 2023 2:41PM  
Limestone Medical Improves Hand Hygiene Rates with Electronic Monitoring System
According to the Centers for Disease Control and Prevention, health care providers on average clean their hands less than half of the times they should. Limestone Medical Center in Groesbeck, Texas, sought to improve its employee hand hygiene compliance rate, and did, by 96.01 percent.
Web link    Date Added: 07/20/2022    Date Last Modified: Jul 20 2022 5:11PM  
National Action Plan to Advance Patient Safety
Preventable harm in health care remains a major concern in the United States, despite substantial effort to improve over the past 20 years. This report from the Institute for Healthcare Improvement provides clear direction for health care leaders, delivery organizations, and associations to make significant advances toward increased safety and reduced harm across the continuum of care.
Web link    Date Added: 07/06/2022    Date Last Modified: Jul 6 2022 1:04PM  
What Kind of Quality Department Best Supports Whole System Quality?
Research by the Institute for Healthcare Improvement Innovation Team has identified some of the keys to successfully organizing quality departments. By bringing the right people together, building connections across different functions, and distinguishing among different types of quality activities, health care systems can build strong and balanced teams.
Web link    Date Added: 07/06/2022    Date Last Modified: Jul 6 2022 12:57PM  
2022 NHSN Training – Videos and Slides
View presentations from the 2022 annual National Healthcare Safety Network (NHSN) live training on how to identify, report, and analyze VAE, PedVAE, CAUTI, CLABSI, Secondary Bloodstream Infection (BSI) and Site-Specific Infections, SSI, MRSA Bacteremia and C. difficile LabID events, as well as presentations on validation of healthcare-associated infection data, and reporting and analysis of antibiotic use and resistance data.
Web link    Date Added: 07/05/2022    Date Last Modified: Jul 5 2022 6:32PM  
Hand Hygiene Observation Tool
Hospitals can use this guide to the effective and consistent monitoring and reporting of hand hygiene compliance for the purposes of improving patient safety.
Adobe PDF    Date Added: 04/08/2022    Date Last Modified: Apr 8 2022 12:43PM  
Hand Hygiene Data Collection Tool
This tool allows health care providers to document and monitor hand hygiene before and after patient contact and after removal of gloves.
Web link    Date Added: 04/05/2022    Date Last Modified: Apr 5 2022 2:05PM  
StAT Learning Series for Hospital Clinical Staff and Leaders
The new StAT (Standards, Approaches and Tactics for Infection Control & Prevention) Learning Series includes a variety of interactive, self-paced learning modules on infection prevention and control in the hospital setting. The series of 15-minute learning modules is produced by the Centers for Medicare & Medicaid Services (CMS) and is tailored to teams leading hospital infection prevention programs and care teams.
Web link    Date Added: 08/19/2021    Date Last Modified: Aug 19 2021 9:54PM  
Update on Short Stay and HWDRG Reviews
Livanta was recently awarded a national contract for Short Stay and Higher Weighted Diagnosis-Related Group (HWDRG) reviews. They will perform these reviews for all 50 states, five U.S. territories, and Washington, DC. Please note that this national contract does not change your state Beneficiary and Family Centered Care Quality Improvement Organization for quality of care reviews and appeals.
Web link    Date Added: 08/18/2021    Date Last Modified: Aug 18 2021 10:04PM  
Ventilator-Associated Events Tracer Tool
Hospitals can use this Tracer Tool to survey and evaluate their processes for reducing ventilator-associate events, with the goal of providing safe, high-quality patient care.
Microsoft Word    Date Added: 07/09/2021    Date Last Modified: Jul 9 2021 2:44PM  
Tracer Tool Action Plan
Hospitals can use this Tracer Tool companion document to track quality improvement progress.
Microsoft Word    Date Added: 06/21/2021    Date Last Modified: Jun 21 2021 2:02PM  
Quality Improvement Worksheet for Testing Change
Hospitals can use this worksheet to track organizational improvement changes through the Plan, Do, Study, Act cycle.
Adobe PDF    Date Added: 05/27/2021    Date Last Modified: May 27 2021 5:52PM  
Surgical Site Infection Reduction Tracer
Hospitals can use this tracer tool to survey and evaluate their processes for surgical site infections (SSI), with the goal of providing safe, high-quality patient care.
Microsoft Word    Date Added: 05/17/2021    Date Last Modified: Jun 7 2021 3:21PM  
Central Line-Associated Bloodstream Infection (CLABSI) Tracer
Hospitals can use this tracer tool to survey and evaluate their processes for central line-associated bloodstream infections (CLABSI).
Microsoft Word    Date Added: 05/14/2021    Date Last Modified: Jun 7 2021 2:11PM  
Catheter-Associated Urinary Tract Infection Tracer
Hospitals can use this Tracer Tool to survey and evaluate their processes for catheter-associated urinary tract infections, with the goal of providing safe, high-quality patient care.
Microsoft Word    Date Added: 05/14/2021    Date Last Modified: May 18 2021 5:22PM  
Hospital Readmissions Tracer Tool
Hospitals can use this Tracer Tool to survey and evaluate their processes for reducing patient readmissions, with the goal of providing safe, high-quality patient care.
Microsoft Word    Date Added: 05/12/2021    Date Last Modified: Apr 14 2022 4:12PM  
Adverse Drug Event Tracer: Hypoglycemic Agents
Hospitals can use this Tracer Tool to survey and evaluate their processes for adverse drug events regarding hypoglycemic agents, with the goal of providing safe, high-quality patient care.
Microsoft Word    Date Added: 05/10/2021    Date Last Modified: May 18 2021 5:12PM  
Practice Guidelines for Administration of Buprenorphine for Treating Opioid Use Disorder
In an effort to get evidenced-based treatment to more Americans with opioid use disorder, the Department of Health and Human Services (HHS) is releasing new buprenorphine practice guidelines that remove a requirement tied to certain training certification, which some practitioners have cited as a barrier to treating more people.
Web link    Date Added: 05/10/2021    Date Last Modified: May 10 2021 8:30PM  
Adverse Drug Event Tracer: Opioids
Hospitals and other health care facilities can download this tool from TMF Health Quality Institute to help them assess their readiness to prevent or react to an adverse drug event.
Microsoft Word    Date Added: 04/14/2021    Date Last Modified: May 18 2022 8:39AM  
Ventilator-associated Events (VAE) Process Improvement Discovery Tool
The Process Improvement Discovery Tool helps hospitals provide safer patient care by identifying process improvement opportunities for ventilator-associated events.
Adobe PDF    Date Added: 03/24/2021    Date Last Modified: Jun 7 2021 3:07PM  
Ventilator-Associated Events (VAE) Top Ten Checklist
A checklist for hospitals to review current interventions, or initiate new ones, for VAE reduction in your facility.
Adobe PDF    Date Added: 03/09/2021    Date Last Modified: Jun 21 2021 1:06PM  
Venous Thromboembolism (VTE) Top Ten Checklist
A checklist for hospitals to assess current practices to prevent harm from VTE-associated events in your facility.
Adobe PDF    Date Added: 03/09/2021    Date Last Modified: Jun 21 2021 1:11PM  
Venous Thromboembolism (VTE) Process Improvement Discovery Tool
The Process Improvement Discovery Tool helps hospitals provide safer patient care by identifying improvement opportunities to reduce harm from venous thromboembolism.
Adobe PDF    Date Added: 03/09/2021    Date Last Modified: Jun 7 2021 3:10PM  
Hospital Quality Improvement Program Updates
QualityNet, from the Centers for Medicare & Medicaid Services (CMS), provides health care quality improvement news, resources, and data reporting tools and applications for providers and others.
Web link    Date Added: 02/22/2021    Date Last Modified: Feb 22 2021 11:09AM  
Tips and Tools for Reporting CY 2020 eCQMs: On-demand Webinar
This event will provide information for successful submission of CY 2020 electronic clinical quality measure (eCQM) data to the Hospital Inpatient Quality Reporting (IQR) Program and Promoting Interoperability Program.
Web link    Date Added: 12/23/2020    Date Last Modified: Dec 23 2020 10:12AM  
Quarter 3 (Q3) 2020 Hospital Inpatient Quality Reporting (IQR) Program Checklist
The Q3 2020 Hospital IQR Program Checklist, available on the Quality Reporting Center website, will assist you in meeting your Q3 2020 Hospital IQR Program requirements.
Adobe PDF    Date Added: 12/23/2020    Date Last Modified: Dec 23 2020 12:35PM  
Engaging Patients and Families as Safety Champions and Change Leaders
Improving safety culture in any health care setting involves engaging all team members. This webinar helps established team leaders from the bedside to the board room and across the care continuum discover how to use evidence-based teamwork tools to engage patients and family member as safety champions.
Video    Date Added: 12/16/2020    Date Last Modified: Dec 16 2020 8:02PM  
AHRQ 10 Patient Safety Tips for Hospitals
The Agency for Healthcare Research and Quality (AHRQ) shares 10 patient safety tips hospital staff can implement to prevent medical errors and adverse events.
Adobe PDF    Date Added: 12/16/2020    Date Last Modified: Dec 16 2020 8:23PM  
Pneumococcal Vaccine Timing for Adults
Make sure your patients are up-to-date with pneumococcal vaccination with this CDC guidance on pneumococcal vaccine timing for adults.
Adobe PDF    Date Added: 12/16/2020    Date Last Modified: Dec 16 2020 8:13PM  
What is Patient Safety?
Watch this brief video from the Leapfrog Hospital Group that highlights the two most common harms patients experience in a hospital setting and how to prevent them.
Video    Date Added: 12/16/2020    Date Last Modified: Dec 16 2020 8:29PM  
National Action Plan for Combating Antibiotic-Resistant Bacteria
The National Action Plan for Combating Antibiotic-Resistant Bacteria (CARB), 2020-2025, presents actions that the United States Government will take in the next five years to improve the health and wellbeing of all Americans by changing the course of antibiotic resistance.
Web link    Date Added: 12/16/2020    Date Last Modified: Dec 16 2020 7:00PM