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Premier Safety Share
Each issue of Safety Share Newsletter contains four to five
popular and frequently used safety tools and resources on
patient, worker and environmental safety. This safety tool
archive is a compiliation of all the safety tools and resources
from Premiers Safety Share issue January 2002 to the
IHI
Month Year Topic by Tab Tool Description Tool Location
Changes in four key elements of the service delivery system are
described in the IHI white paper. The changes include the care team,
patient activation, clinical information system, and leadership. IHI
identifies the challenges faced in the current system, introduces a new http://www.premierinc.com/quality-
IHI white paper – design for the delivery of primary care, and encourages office practices safety/tools-services/safety/safety-
Planning a primary and clinics to move ahead with their own efforts to strive for better share/06-06-downloads/14-planned-
IHI Patient Safety care delivery system patient outcomes. √ care-white-paper-2006.pdf
A tool for conducting brief, ad hoc staff meetings focused on sharing Word;Patient Safety/Medication
Device Use – Safety observations and concerns about safety hazards related to the use of Systems/Tools; Under: Culture of
IHI Patient Safety Briefing Model medical devices and equipment √ Safety
Executive Review of A guide for executives on how to channel senior management attention Word;Improvement Methods/Tools;
IHI Patient Safety Projects (IHI Tool) to quality projects √ Under: Information Gathering Tools
Sampling is used to simplify the gathering of data for improvement and Excel;Improvement Methods/Tools;
IHI Patient Safety Sampling (IHI Tool) to prevent unnecessary data collection. √ Under: Information Gathering Tools
Checklist for
Assessing Word;Patient Safety/Medication
Institutional A short self-assessment survey for use by any health care organization Systems/Tools; Under: Culture of
IHI Patient Safety Resilience wishing to gauge its patient safety climate √ Safety
Decision Tree for Patient Safety/Medication
Unsafe Acts A decision tree that can be followed when analyzing an error or adverse Systems/Tools; Under: Culture of
IHI Patient Safety Culpability event; developed by Partners HealthSystem √ Safety
Patient Safety/Medication
Patient Safety Systems/Tools; Under: Culture of
IHI Patient Safety Tracking Database Example of a database for tracking patient safety issues √ Safety
The tool was developed by safety administrators at Iowa Health System
(IHS) to help front-line staff initiate Device Use – Safety Briefings, which Word;Patient Safety/Medication
Device Use – Safety provide a forum for shared observations and concerns related to the use Systems/Tools; Under: Culture of
IHI Patient Safety Briefing Model of medical devices, equipment, and complex software in the institution. √ Safety
A simple, easy-to-use tool that front-line staff can use to share Adobe;Patient Safety/Medication
Safety Briefings (IHI information about potential safety problems and concerns on a daily Systems/Tools; Under: Culture of
IHI Patient Safety Tool) basis, to promote safety consciousness and learning √ Safety
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Premier Safety Share
IHI
Month Year Topic by Tab Tool Description Tool Location
Safety Huddle The tool enumerates data elements to collect during a test of Safety Word;Patient Safety/Medication
Results Collection Briefings, including medication safety issues and "near miss" medication Systems/Tools; Under: Culture of
IHI Patient Safety Tool errors that are identified before they cause harm. √ Safety
The RFID Resource Center includes an implementation guide
describing the use of HIBC (Health Industry Bar Code) Standards with
RFID – Web-based RFID, an overview of RFID technology (including its potential
resource center applications and costs), a white paper, "RFID In Healthcare: Benefits, http://www.hibcc.org/AUTOIDUPN/
May 2007 Bar Coding available Limitations & Recommendations," and other related articles. RFID.htm
Catheter-related blood stream infections (BSI) are a significant source of
morbidity and mortality associated with a variety of devices used to
access the vascular system. Meticulous aseptic technique is both
required and effective to prevent BSI. Faculty share their observations,
Webcast – Best best practices, and outcome data as they discuss this important topic.
practices to reduce This free webcast is a replay from the original August 17, 2007, webcast
catheter-related provided by Cardinal Health's Center for Safety and Clinical Excellence
blood stream and will remain available for one full year. Continuing education credit is http://www.cardinal.com/clinicalcent
September 2007 Bundling - evidence based practice infections also provided. er/materials/webcasts/index.asp
A recent AHRQ audio newscast series featured an interview with Peter
Pronovost, M.D., Ph.D., of The Johns Hopkins University School of
Medicine. Dr. Pronovost discussed his research about interventions to
reduce bloodstream infections in hospital ICUs caused by central
venous catheters. Patients in the United States spend about 18 million
days in the intensive care unit per year and in more than 50 percent of
the cases, an ICU patient will have a central venous catheter inserted.
AHRQ tools – Unfortunately, approximately 80,000 patients each year develop AHRQ podcast:
Podcast on reducing catheter-related bloodstream infections, and about 28,000 of them will http://www.healthcare411.org/podc
May 2007 Bundling - evidence based practice BSI die from the infection. ast.aspx?id=197
The recommendations include the assessment of the electromagnetic
Recommendations environment of the facility, identification of areas where critical medical http://my.premierinc.com/all/safety/
for Electromagnetic devices are used, coordination of the purchase and management of all publications/01-
Compatibility in electronic equipment, and the reporting of problems to FDA MedWatch 02_downloads/CDRH-%20EMC-12-
January 2002 Cell Phones and EMC Healthcare Facilities program. 01.doc
Excel: Premier / Modules / b24d7277-3ce3-4a13-baeb-3f4ffe9a8b03.xls / Patient Safety Share
Premier Safety Share
IHI
Month Year Topic by Tab Tool Description Tool Location
A free interactive video module that will help identify and treat C. difficile
is available from the British Medical Journal (BMJ) and the Department
of Health. Titled "How you can reduce C. difficile infections," the video
demonstrates how a major UK hospital successfully managed an
outbreak and introduced measures that can be applied to prevent
infections. The module discusses how to diagnose and treat patients
with C. diffcile infections, the importance of hand hygiene in preventing
infection, the cautious use of prescribing antibiotics, and understanding
Online learning the patient experience. To begin the module, go to
September 2007 C. difficile associated disease module – C. difficile http://bmjlearning.com/cdifficile. http://bmjlearning.com/cdifficile
Community hospitals implementing computerized physician order entry http://my.premierinc.com/all/safety/
are succeeding in gaining physician participation and addressing the publications/07-
gaps in safety and quality they were targeting, according to a new report 03_downloads/10_CPOE_comm_h
July 2003 Computerized physician order entry CPOE Report & Tips by the California HealthCare Foundation and First Consulting Group. osp.pdf
http://www.hospitalconnect.com/ah
CPOE evaluation and The report explores CPOE implementation, costs, challenges, benefits, a/key_issues/patient_safety/resour
March 2003 Computerized physician order entry case studies and lessons learned. ces/index.html#patientsafety
Advances in technology are making it easier to improve patient safety.
The September/October issue of Patient Safety and Quality Healthcare
focuses on recent technology designed to reduce the risk of medical
On-line resources – errors. Among the topics featured in this issue are bar coding to reduce
Computers and electronics in bar coding, RFID and medication errors, electronic medical records (EMR) and radio http://www.psqh.com/sepoct05/tocc
November 2005 healthcare patient safety frequency identification (RFID) systems. .html
Premier, the first GPO to win Hospitals for a Healthy Environment's
Web-based resource (H2E) Champions of Change Award (in 2003) and again in 2004, has
to assist healthcare launched a new Web-based resource to assist healthcare organizations
organizations with with environmentally friendly selection, recycling and disposal of
environmentally computers and electronics. These resources are also being used to
friendly selection, guide the selection of electronic device manufacturers for Premier
recycling and members and for recycling of electronics in Premier's corporate offices.
disposal of The Web-based resource was produced by Premier's Safety Institute
Computers and electronics in computers and with assistance and support from Health Care Without Harm and the http://www.premierinc.com/all/safet
March 2005 healthcare electronics. Computer Take Back Campaign. y/resources/computers/index.jsp
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Premier Safety Share
IHI
Month Year Topic by Tab Tool Description Tool Location
This manual was written to assist hospitals in developing strategies for
temporary negative pressure isolation and provides instruction on the
use of equipment used for airborne infectious disease management. In Download the manual from the
addition to graphic "how to" portrayals, the guide includes tools such as Safety Institute's Construction,
Minnesota manual – preventative maintenance schedules and a sample log for measuring ICRA, risk assessment web site, or
Methods for particle counts for performance improvement planning. Additional go to:
temporary negative information, including education/training slides, are located at the Web http://www.health.state.mn.us/oep/t
Mar 2007 Construction - ICRA pressure isolation site below. raining/bhpp/isolation.html
Created by the University of Minnesota, InformeDesign®
www.informedesign.umn.edu brings research and practice aspects of
the design professions together. Designers face a multitude of complex
challenges that are environmental, behavioral, and design in nature.
This Web site focuses on providing the design community with
reputable research sources that address those challenges. A monthly
publication, Implications, addresses the issues facing practitioners and
researchers who focus on design and human behavior. Under the links,
Inform eDesign – "SPACE," then "Healthcare," there is a wide variety of healthcare related
Healthcare design articles and research summaries on topics from ambulatory care to http://www.informedesign.umn.edu/
Feb 2007 Construction - ICRA implications wellness centers. Rs.aspx?s=space&tId=664
The construction and ICRA concept and matrix as described and For more information on and
promoted by the Association for Professionals in Infection Control and resources about construction on
Epidemiology (APIC) and the American Society for Healthcare Premiers Web site:
Engineering (ASHE) are available in two training videos. One is directed www.premierinc.com/quality-
to healthcare professionals (20 minutes) and one to construction safety/tools-
Construction; ICRA personnel (eight minutes), with availability in English and Spanish. Go to services/safety//resources/construc
Sept 2006 Construction - ICRA training www.EnvisionInc.net. tion/.
This model program engages nurses and leaders at all levels of the
organization to improve the quality and safety of patient care on medical
and surgical units. Ten hospitals graduated from the third phase of the
five-year program in May. TCAB is not a traditional quality improvement
program; one primary characteristic that sets it apart is its focus on
engaging frontline staff and unit managers. Ideas for transforming the
way care is delivered on medical/surgical units come from the nurses
Transforming Care at and other care team members who spend the most time with patients http://www.rwjf.org/pr/product.jsp?i
September 2008 Culture - Safety - Tool the Bedside and their families. d=30051&c=EMC-CA137
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Premier Safety Share
IHI
Month Year Topic by Tab Tool Description Tool Location
To assist institutions in making the business case for quality programs,
the Institute for Healthcare Improvement (IHI) is unveiling the Adverse
Events Prevented Calculator. This tool helps model the financial
implications of reductions in adverse event rates in an organization and
assists in translating actual and potential improvement results into
projected lives and dollars saved. The tool allows one to track the
change in rate of any one type of adverse event over time and, when
appropriate additional data are added, the consequent change in
unnecessary deaths ("lives saved"), real and additional potential cost
IHI tool – Adverse savings ("dark green dollar" savings and "light green dollar" savings, http://www.ihi.org/IHI/Topics/Patien
Events Prevented respectively), and the return on investment of quality improvement work tSafety/SafetyGeneral/Tools/advers
September 2008 Culture - Safety - Tool Calculator targeting those adverse events. √ eeventspreventedcalculator.htm
The Joint Commission offers an Internet-based collaborative forum to
help frontline workers; healthcare administrators, researchers and other
healthcare professionals collaborate on developing performance
improvement solutions. One feature currently being test piloted allows
registered users to discuss solutions, edit existing solutions and create
new solutions that will then be available to the entire healthcare The site, titled WikiHealthCareTM,
community. The first quality improvement topics posted to the site can be accessed through a link on
address smoking cessation counseling programs and smoke-free The Joint Commission's home
hospital campuses. Development of the site was funded, in part, through page, or directly at
a research grant from the Smoking Cessation Leadership Center at the http://wikihealthcare.jointcommissio
October 2007 Culture - Safety - Tool WikiHealthCareTM University of California, San Francisco. n.org.
Now AHRQ is providing a new tool developed for small and critical
access hospitals to benchmark and compare their results from the
AHRQ Hospital Survey on Patient Safety Culture. However, the tool can
be used by any size hospital because it allows the addition of any
benchmarking data. The tool is from Statis Health and the Oklahoma
Small hospital Foundation for Medical Quality and the Hospital Interventions Quality http://www.premierinc.com/quality-
benchmarking tool Improvement Organization Support Center (HIQIOSC) and is adapted safety/tools-
for AHRQ hospital with permission for a benchmarking tool developed by the Nebraska services/safety/topics/culture/benc
July 2007 Culture - Safety - Tool survey Center for Rural Health Research. hmarking-data.jsp#cah-tool
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Premier Safety Share
IHI
Month Year Topic by Tab Tool Description Tool Location
The Premier Performance Suite is a comprehensive offering of hospital For more information on the
performance tools to integrate quality and safety, labor management, Premier Performance Suite, visit
and supply chain channels for a global approach to improving overall the home page at:
quality and cost. The Performance Suite provides Web-based http://www.premierinc.com/quality-
Premier – New performance measurement and benchmarking, real time surveillance, safety/tools-services/performance-
Mar 2007 Culture - Safety - Tool Performance Suite™ and best practices to allow hospitals to make better decisions. suite/.
The first monograph, "Are You Rolling the Dice on CEO Succession?" is
designed to help trustees navigate the CEO selection process. The
monograph contains a Leadership Continuity Risk Management Model To order any of the monographs,
to help trustees understand how to effectively define the requirements contact the Center at 888.540.6111
for a new CEO, assess candidates and approach the final selection or e-mail at:
process. The second, "The Board's Fiduciary Role: Legal info@americangovernance.com.
Responsibilities of Health Care Governing Boards," describes the basic Access the tool at:
legal duties and obligations of the boards of not-for-profit hospitals. This http://www.americangovernance.co
CEO assessment guidance can be used to support trustee recruitment and orientation, m/americangovernance/ctool/welco
Feb 2007 Culture - Safety - Tool tool for leadership and as a reference tool for existing board members. me.html.
The Center for Healthcare Governance has provided the first tool in a
series of Collaborative Leadership Tools. "Collaborative Leadership: A
New Model for Developing Truly Effective Relationships Between CEOs
and Trustees" explores the board/CEO relationship in the context of
governance reform, which calls for boards in all sectors to raise the bar
on their performance and accountability. This CEO resource discusses
what governance reform means in terms of how boards and CEOs work
together to lead their healthcare organizations. It also provides an
assessment tool and process that CEOs can use to take the lead in
diagnosing their current relationship with their board, and to work Access the tool at:
together with board leaders to re-energize and strengthen the http://www.americangovernance.co
CEO assessment relationship to achieve maximum effectiveness and value. If completed m/americangovernance/ctool/welco
Jan 2007 Culture - Safety - Tool tool for leadership online, all responses are confidential. me.html
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IHI
Month Year Topic by Tab Tool Description Tool Location
The tool is for physician practices to use to enhance awareness of
patient safety issues, heighten awareness of characteristics that make a
practice safer, and create a new reference point and baseline for There is a $200 per practice fee to
practices to enhance and support patient safety. The tool can be complete the assessment online
completed electronically so users can receive a feedback report and access the comparative report
comparing themselves to other practices (percentile rankings on each site. Download the file or use online
Assessing physician question). Users also can receive a workbook with information and at
Nov 2006 Culture - Safety - Tool practices resources on how the practice can improve their performance. http://www.physiciansafetytool.org.
The tool is designed to help hospital CEOs and their boards forge a
Collaborative stronger relationship. This CEO resource discusses what governance
Leadership: A New reform means in terms of how boards and CEOs work together to lead
Model for Developing their healthcare organizations. It also provides an assessment tool and
Truly Effective process that CEOs can use to take the lead in diagnosing their current
Relationships relationship with their board, and to work together with board leaders to Access the tool at:
Between CEOs and re-energize and strengthen the relationship to achieve maximum http://www.americangovernance.co
Nov 2006 Culture - Safety - Tool Trustees effectiveness and value. m/americangovernance/
The consensus statement is intended to provide a deeper understanding
of preventable adverse events, their impact on patients, families, and
providers, and how to manage such events. The report provides detailed
guidelines based on the premise that all care should be safe and patient-
centered and proposes a full disclosure when adverse events or medical
errors occur, including an apology to the patient. The report is divided
into three major sections: the patient and family experience, the
caregiver experience, and the management of the event. Each section
contains a summary of the expert consensus of the issue, including the
reasoning and evidence behind the consensus, and recommendations.
The report also offers appendices that include recommendations, a case Go to:
When Things Go study on communicating with patients and families, elements of http://www.premierinc.com/all/safet
Wrong: Responding emotional support of caregivers, and a bibliography on medical y/publications/04-06-downloads/07-
April 2006 Culture - Safety - Tool to Adverse Events disclosure. responding-adverse-events.pdf
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Premier Safety Share
IHI
Month Year Topic by Tab Tool Description Tool Location
A recent directive from the U.S. Veterans Health Administration provides
background information on the disclosure of adverse events related to
clinical care to patients or their representatives. VA Directive 2005-049
(.pdf) (163 KB), "Disclosure of Adverse Events to Patients," is
consistent with the Joint Commission on Accreditation of Healthcare
Directive on Organizations requirements, and includes key definitions and a policy http://www.premierinc.com/all/safet
disclosure of adverse statement on disclosure for all VA hospitals. y/publications/12-05-downloads/09-
December 2005 PSS News events va-adverse-events.pdf
A leadership guide offering eight steps for senior health care leaders to
help their organizations achieve patient safety and high reliability is
available from the Institute for Healthcare Improvement (IHI). "The
The Leadership Leadership Guide to Patient Safety: Resources and Tools for
Guide to Patient Establishing and Maintaining Patient Safety" introduces the concept of
Safety: Resources "reliability," defined as patients getting the intended tests, medications,
and Tools for information, and procedures at the appropriate time and in accordance
Establishing and with their values and preferences. Strategies for redesign of healthcare http://www.premierinc.com/all/safet
Maintaining Patient systems are presented using examples that IHI has gleaned from its y/publications/11-05-full-
November 2005 PSS News Safety experience in guiding organizations in improving patient safety. √ txt.jsp#story-06-downloads
Premier's Safety Institute has developed a Spanish version of the
Agency for Healthcare Research and Quality's (AHRQ) Hospital Survey
Hospital Survey on on Patient Safety Culture survey tool, as well as a customized The survey tool can be accessed at
Patient Safety Microsoft® Excel data tool for easy entry and rapid display of survey http://www.premierinc.com/all/safet
August 2005 Culture - Safety - Tool Culture results. y/culture/
The long awaited Patient Safety and Quality Improvement Act (P.L.109-
41) was signed into law on July 29, 2005, to encourage a culture of
safety in healthcare organizations by providing legal protection of
Patient Safety and information on medical errors and adverse events voluntarily reported to http://thomas.loc.gov/cgi-
Quality Improvement patient safety organizations (PSOs). Lawmakers intend the information bin/bdquery/z?d109:SN00544:|TO
August 2005 PSS News Act (P.L.109-41) to be used to improve patient safety and reduce medical errors. M:/bss/d109query.html
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Premier Safety Share
IHI
Month Year Topic by Tab Tool Description Tool Location
Reconciling medications across the continuum of care is a new 2005
JCAHO safety goal. Experience has shown that poor communication of
medical information at transition points is responsible for as many as 50
percent of all medication errors in the hospital and up to 20 percent of
adverse drug events. A Massachusetts Coalition Web site describes Go to http://www.macoalition.org
how a group of hospitals in Massachusetts implemented a medication and look under “Coalition
Medication strategy reconciliation strategy and provides various tools and forms for others to Initiatives,” then “Reconciling
July 2005 Culture - Safety - Tool tools adopt or adapt. Medications.”
Copies of "5 Steps to Safer Health
A campaign designed to help distribute valuable information about Care" and the public service
improving patient safety to healthcare providers and patients across the announcement are available on the
country has been initiated by the Agency for Healthcare Research and AHRQ's Web site: English version:
Quality (AHRQ), the American Hospital Association (AHA). The http://www.ahrq.gov/consumer/5ste
campaign, called "5 Steps to Safer Health Care," includes posters and ps.htm
fact sheets that offer evidence-based, practical tips on the role patients Spanish version:
5 Steps to Safer can play to help avoid errors related to prescription medicines, http://www.ahrq.gov/consumer/cinc
June 2005 Culture - Safety - Tool Health Care laboratory tests, procedures, and surgery. orec.htm
The Agency for Healthcare Research and Quality (AHRQ) has published View entire document at
a new fact sheet entitled "30 Safe Practices for Better Health Care" http://www.premierinc.com/all/safet
(.doc) (42 KB). These are AHRQ-supported, evidence-based practices y/publications/05-05-downloads/07-
from the National Quality Forum (NQF) that demonstrate they can work fact-sheet-30-practices.doc; An
to reduce or prevent adverse events and medical errors. The safe executive summary (.pdf) (495 KB)
practices were endorsed by the NQF member organizations, which of the report is available from
30 safe practices in strongly urge that these 30 safe practices be universally adopted in all AHRQ and contains information on
May 2005 Culture - Safety - Tool healthcare applicable healthcare settings to reduce the risk of harm to patients. how to obtain copies of the com
Most hospital leaders are concerned that mandatory, non-confidential
public reporting would discourage internal reporting of patient incidents http://www.premierinc.com/all/safet
and encourage lawsuits while failing to provide substantial benefits to y/publications/05-05-downloads/04-
Error Reporting and patient safety, according to a recent survey of hospital executives in the abst-error-report-disclosure-
May 2005 PSS News Disclosure Systems Journal of the American Medical Association. systems.doc
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Month Year Topic by Tab Tool Description Tool Location
Premier has developed a customized data collection and analysis tool
that provides immediate feedback on the results of the hospital culture
survey tool released by the Agency for Healthcare Research and Quality
Premier - customized (AHRQ). The customized Excel™ data tool was developed for easy http://www.premierinc.com/all/safet
data collection and entry and rapid display of the results from the surveys to provide y/publications/03-05-full-
March 2005 PSS News analysis tool immediate internal review and feedback. txt.jsp#story-08-downloads
A new tool to assess the safety culture of a hospital as a whole, or in
specific units within hospitals, as well as to track changes in patient
safety over time and evaluate the impact of patient safety interventions.
Premier's Safety Institute is providing the complete tool kit, which All components may be
Hospital Survey on includes the survey, detailed user's guide for administration of paper or downloaded at
Patient Safety web-based methods, data collection and analysis, customizable www.premierinc.com/all/safety/cult
November 2004 Culture - Safety - Tool Culture templates for reporting results, references, and results of the pilot study. ure.
The video discusses how best to inform patients and their families in the
Discussing event of a medical error that causes harm. The video includes clinical
Unanticipated scenarios and comments from a medical ethicist, a hospital risk For information on how to obtain
Outcomes and manager, and two healthcare attorneys. The comments offer the videotape, go to:
Disclosing Medical suggestions on how to effectively disclose adverse events to patients http://www.gha.org/pha/video/index
October 2004 Culture - Safety - Tool Errors and their families. .asp.
http://www.ihi.org/IHI/Topics/Patien
Patient Safety tSafety/MedicationSystems/Tools/P
Leadership Collects data and then keeps track of how the information is used, what atientSafetyLeadershipWalkRound
July 2004 Culture - Safety - Tool WalkRounds actions are taken, and generate feedback and reports. √ sDatabase.htm
http://www.premierinc.com/safety/r
The majority of hospitals responding to a Premier survey have formal, esources/disclosure/downloads/Pre
board approved policies to disclose medical errors to patients, according mier-disclosure-survey-results.pdf;
to a survey conducted by Premier, Inc. The survey uncovered some survey discussion:
Premier Patient promising trends in medical error disclosure practices. A full discussion http://www.premierinc.com/all/safet
Safety Culture of the survey may be downloaded. y/publications/08-04-downloads/02-
June 2004 PSS News Survey results disclosure-release.doc
Michigan Hospital Association toolkit is a series of recommendations
based on current research and best practices. It was developed by a http://my.premierinc.com/all/safety/
nine-member volunteer workgroup of health professionals experienced publications/06-04-downloads/09-
June 2004 Culture - Safety - Tool ICU toolkit in leading ICUs and improving patient safety and quality of care. icu-toolkit.pdf
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IHI
Month Year Topic by Tab Tool Description Tool Location
An institution-wide policy regarding non-punitive reporting, this brochure
reinforces the non-punitive reporting policy and encourages all co- http://www.premierinc.com/all/safet
Living a Culture of workers to report errors, it was signed by the hospital president and y/publications/02-04-downloads/10-
February 2004 Culture - Safety - Tool Patient Safety mailed to all co-worker homes. √ st-john-nonpunitive-brochure.pdf
Improvements in medication list accuracy, allergy list accuracy, and safe
prescription writing practices that were observed by Gundersen
Ambulatory Patient Lutheran Medical Center.
December 2003 Culture - Safety - Tool Safety - Toolkit http://www.gundluth.org/SCOPE
“Disclosure of unanticipated events: Creating an effective patient
communication policy," the monograph covers considerations for
developing policies and procedures in specific settings such as acute http://my.premierinc.com/all/safety/
Disclosure policy care, long-term care and pediatric care. It also examines the effect of publications/12-03-downloads/09-
December 2003 Culture - Safety - Tool guide disclosure policies on litigation. disclosure-part2-1-policy.pdf
In a report released by the Institute of Medicine, a panel recommends
work hour limits and other changes to the work environment for nurses
Keeping Patients to strengthen patient safety. The panel also noted that regulators and
Safe: Transforming healthcare leaders should work to reduce workplace inefficiencies, such
the Work as excessive paperwork and documentation, which reduce the time Purchase the report online at
Environment of nurses have to spend with patients. http://books.nap.edu/catalog/10851
November 2003 PSS News Nurses .html?onpi_newsdoc110403
http://www.qualityhealthcare.org/Q
HC/Topics/PatientSafety/Medicatio
Safety Climate Organizations working to develop or improve a culture of safety need a nSystems/Tools/Safety+Climate+S
July 2003 Culture - Safety - Tool Survey Tool reliable measure to monitor the success of their initiatives. √ urvey+(IHI+Tool).htm
Disclosure of
Unanticipated Focus on three aspects of the disclosure process: 1.The initial impact of
Events: The Next the Joint Commission for Accreditation of Healthcare Organizations http://my.premierinc.com/all/safety/
Step in Better (JCAHO) Patient Safety Standards 2.Psychological and legal barriers publications/06-
Communication with that can impede disclosure, and 3.Successful models used by 03_downloads/07_disclosure_ASH
June 2003 Culture - Safety - Tool Patients organizations to manage the disclosure process. RM_part1of3.pdf
The Agency for Healthcare Research and Quality (AHRQ) PSIs are a
tool to help health system leaders identify potential adverse events
occurring during hospitalization. They are a set of indicators providing
AHRQ Patient Safety information on potential in-hospital complications and adverse events http://www.qualityindicators.ahrq.go
April 2003 PSS News Indicators following surgeries, procedures, and childbirth. v/psi_download.htm
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IHI
Month Year Topic by Tab Tool Description Tool Location
Senior leaders conduct weekly WalkRounds™ in different areas of the
Creating a Culture of hospital, to have informal conversations with front-line staff about safety
Safety Through issues and to demonstrate their support of an organizational culture that http://www.premierinc.com/safety/p
Executive promotes nonpunitive reporting of errors, adverse events, near misses, ublications/03-
March 2003 Culture - Safety - Tool WalkRoundsTM and unsafe conditions 03_downloads/01_b.pdf
http://www.premierinc.com/all/safet
Medication System A sample medication error reporting form designed to collect and y/publications/03-
March 2003 Culture - Safety - Tool Analyze-ERRTM analyze actual and potential medication errors. 03_downloads/01_d.pdf
Checklist/Action Plan
for the Management http://www.premierinc.com/all/safet
of High-Alert y/publications/03-
March 2003 Culture - Safety - Tool Medications A checklist/action plan for the safe use of high-alert medications. 03_downloads/01_g.pdf
Policy for Non-
punitive, System-
based Adverse Drug http://www.premierinc.com/all/safet
Event Reporting A sample policy detailing a blame-free adverse drug event reporting y/publications/03-
March 2003 Culture - Safety - Tool Program program. 03_downloads/01_h.pdf
http://www.premierinc.com/all/safet
Medication Safety A patient safety tool helping patients understand their rights and y/publications/03-
March 2003 Culture - Safety - Tool Pledge for Patients responsibilities regarding safe medication use. 03_downloads/01_j.pdf
The video provides step-by-step instructions on how to disclose medical
errors, why disclosure is important, and how open communication can
February 2003 Culture - Safety - Tool Let's Talk strengthen the patient-provider relationship. http://www.npsf.org/
Participating organizations will work to create a system of safety,
Breakthrough Series including changing organizational culture and attitudes of leadership and
Collaborative on front line staff, improving critical core processes, encouraging http://www.ihi.org/collaboratives/bre
Improving Patient appropriate use of technology, and establishing an effective system for akthroughseries/PatientSafety/inde
August 2002 Culture - Safety - Tool Safety measuring harm. √ x.asp
Patient Safety A job description for a safety officer, an organization-wide safety plan,
Program Resource Power Point slides of program elements and key committees, sample
June 2002 Culture - Safety - Tool Guide grids for documenting interdisciplinary components, and other tools. Download at Safety Store.
http://my.premierinc.com/all/safety/
Patient Safety Topics - Patient safety - Patient Safety The intent of the sample Patient Safety Program is to provide tools to resources/patient_safety/patient_sa
HSOPSC downloads (*.doc) Program assist organizations in implementation of a patient safety program. fety_downloads.htm
Excel: Premier / Modules / b24d7277-3ce3-4a13-baeb-3f4ffe9a8b03.xls / Patient Safety Share
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The ED is part of a larger, complex system. Given the complexity of the
system, for the thousands of patients treated each day, there are many
opportunities for medical errors, as well as opportunities to reduce such http://www.premierinc.com/all/safet
errors. This document includes the recommendations of the Patient y/resources/patient_safety/downloa
Patient Safety Topics - Patient safety - ACEP Patient Safety Safety Task Force and the Principles of Patient Care in the Emergency ds/24_ACEP_patient_safety_progr
HSOPSC downloads (*.doc) Program Care Environment. am.doc
ECRI Disclosure of Reviews the JCAHO's disclosure standard, discusses how to develop a http://www.premierinc.com/all/safet
Patient Safety Topics - Patient safety - unanticipated disclosure policy and what the policy should address, and analyzes the y/resources/patient_safety/downloa
HSOPSC downloads (*.pdf) outcomes impact of the standard on medical malpractice claims. ds/disclosure_ecri.pdf
ASHRM: Perspective
on Disclosure of A perspective paper on the disclosure of information involving http://www.premierinc.com/all/safet
Patient Safety Topics - Patient safety - Unanticipated unanticipated outcomes of diagnostic tests, medical treatments, and y/resources/patient_safety/downloa
HSOPSC downloads (*.pdf) Outcome Information surgical interventions. ds/ASHRM_disclosure_05-01.pdf
http://www.premierinc.com/all/safet
Provides guidance for minimizing the chance of the occurance of y/resources/patient_safety/downloa
Patient Safety Topics - Patient safety - VA Patient Safety untoward outcomes consequent to medical care. This handbook ds/25_VA_patient_safety_handboo
HSOPSC downloads (*.pdf) Handbook incorporates Root Cause Analysis. k.pdf
Disclosure: What
works now & what
can work even better
of unanticipated
events: the next step ASHRM Monograh addresses the components of effective
Patient Safety Topics - Patient safety - in better communication of unanticipated outcome, considerations for each of the http://www.premierinc.com/all/safet
sample policies - disclosure resources communication with components and the unique perspectives to be taken in various clinical y/resources/patient_safety/downloa
HSOPSC and policies patients settings. ds/disclosure-part3-02-04.pdf
ASHRM American Society of Healthcare Risk Management: Disclosure
Disclosure of Medical of Medical Errors: Demonstrated Strategy to Enhance Communication,
Errors: Demonstrated a one-hour video produced by ASHRM, focuses on practical risk http://www.ahaonlinestore.com/Pro
Patient Safety Topics - Patient safety - Strategy to Enhance management strategies to approach disclosure. The video is available ductDisplay.asp?ProductID=555&c
HSOPSC Education & training - ASHRM Communication for $50 to ASHRM members, $60 to non-members. Catalog #169520. artID=163827&PCatID=25
Strategies for http://www.ihi.org/IHI/Topics/Patien
Leadership: Hospital tSafety/MedicationSystems/Tools/S
Culture - Safety -Tool Adobe;Patient Executives and Their trategiesforLeadershipHospitalExec
Safety/Medication Systems/Tools; Role in Patient utivesandTheirRoleinPatientSafety.
HSOPSC Under: Culture of Safety Safety A compilation of leadership strategies for enhancing patient safety √ htm
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Walk-throughs enable providers to better understand the experience of http://www.ihi.org/IHI/Topics/Improv
Walk-through (IHI care from the patient’s and family’s points of view — by going through ement/ImprovementMethods/Tools/
HSOPSC Patient Safety Tool) the experience themselves √ Walk-through.htm
The Emergency Preparedness Atlas includes maps showing the
location of hospitals and nursing homes in each state, and case studies
for six states that show bed capacity and the emergency management
and bioterrorism preparedness regions for each facility. The Atlas is
intended to help nursing homes plan how they may be used to handle a
surge of patients in response to emergency situations; it is not a review
of the quality or adequacy of preparedness efforts in any area. The Atlas
can help explain the state-specific regulatory environment of nursing
homes with respect to surge capacity and illustrate nursing home
geographic distribution in the United States. A separate report, "Nursing
AHRQ – Emergency Homes in Public Health Emergencies – Special Needs and Potential
prep guide to locate Roles," addresses the role that nursing homes could play in regional
healthcare sites preparedness, and is based on focus groups with nursing homes in the http://www.ahrq.gov/prep/nursingho
August 2007 Emergency Preparedness during disaster case study states. mes/atlas.htm
The Department of Health & Human Services' (HHS) Agency for
Healthcare Research and Quality (AHRQ) has released a DVD titled,
"Cross Training Respiratory Extenders for Medical Emergencies (Project
XTREME)," that trains healthcare professionals who are not respiratory
care specialists to provide basic respiratory care and ventilator
management to adult patients in any mass casualty event. The DVD
includes six training modules with interactive quizzes to test viewers'
knowledge. Meant for physicians, physician assistants, nurses and
others, the modules cover topics such as infection control, respiratory
care terms and definitions, manual ventilation (using hand-held bags), A free, single copy of the DVD and
AHRQ DVD – mechanical ventilation (using the two types of ventilators included in the a CD-ROM with the report may be
Training for federal government's Strategic National Stockpile of medicines and ordered by calling 800.358.9295 or
respiratory care/vents medical supplies for emergencies), airway maintenance, and airway by sending an e-mail to
June 2007 Emergency Preparedness in disasters suctioning. ahrqpubs@ahrq.hhs.gov.
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AHRQ has released a questionnaire that hospitals and other healthcare
facilities can use to plan and evaluate their readiness for a public health
emergency involving a chemical, biological, radiological, nuclear or
explosive event. The 43-question document is divided into eight
categories: administration and planning; education and training;
communication and notification; patient (surge) capacity; staffing and
Emergency response support; isolation and decontamination; supplies, pharmaceuticals, and
May 2007 Emergency Preparedness planning tool laboratory support; and surveillance. http://www.ahrq.gov/prep/cbrne/
The CDC has provided advance data from vital and health statistics
demonstrating wide variations in terrorism preparedness training. A The report and many updates on
CDC – QuickStats on study by Niska et al., "Training for terrorism-related conditions in Emergency Preparedness may be
training ER staff for hospitals: United States, 2003-04; No. 380," used data to determine downloaded from the Safety
emergency which hospital characteristics are associated with providing terrorism Institute's Emergency
May 2007 Emergency Preparedness preparedness preparedness training to clinical staff. Preparedness Web site.
Two courses designed to help hospital personnel implement the
National Incident Management System (NIMS) are available from the
Federal Emergency Management Agency (FEMA). NIMS was
developed so responders from different jurisdictions and disciplines can
better collaborate to respond to natural disasters and other
emergencies. Course IS-100. HC, "Introduction to the Incident
Command System for Healthcare/Hospitals," describes the history,
features, principles and organizational structure of ICS. FEMA notes
that the course is for hospital personnel who would have a direct role in
emergency preparedness, incident management, and/or emergency
preparedness. Course IS-200. HC, "Applying ICS to Healthcare http://www.training.fema.gov/EMIW
Organizations," is designed to enable healthcare personnel to operate eb/IS/is100HC.asp;
FEMA – efficiently during an incident or event within the ICS and is for personnel http://www.training.fema.gov/EMIW
Implementing the whose primary responsibility is emergency management. FEMA's Web eb/IS/is200HC.asp;
National Incident site has additional information on NIMS implementation activities for http://www.fema.gov/emergency/ni
Management System hospitals. Other professional groups such as the American Society for ms/compliance/assist_non_govt.sh
Feb 2007 Emergency Preparedness (NIMS) Healthcare Engineering also offer similar training courses for ICS. tm
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Month Year Topic by Tab Tool Description Tool Location
Providing Mass Medical Care with Scarce Resources: A Community
Planning Guide (.pdf) (1.1 MB) is the product of a collaborative effort
between AHRQ and the Office of Public Health Emergency
Preparedness. Experts in the areas of mass casualty care, including pre-
hospital care, hospital and acute care, alternative care sites, palliative
care, ethical issues, and legal considerations, contributed to this guide.
It describes shortages (such as of hospital beds and ambulances)
healthcare workers may face and gives planners specific
recommendations, such as providing off-site care and using taxis, http://www.premierinc.com/quality-
AHRQ emergency buses, and private cars to transport sick or injured patients. The report safety/tools-services/safety/safety-
planning – Mass provides planning checklists and tips for making wise use of limited share/12-06-downloads/08-ahrq-
Dec 2006 Emergency Preparedness casualty care guide medical resources. mce-guide.pdf
A Web-based interactive decision tool designed to assist emergency
preparedness and recovery planners is available from the Department of
Health and Human Services. The new tool helps determine how to
access and use health information about various populations such as
HIPAA Privacy Rule: the elderly and those with disabilities, and is consistent with the Health
Disclosures for Insurance Portability and Accountability Act's privacy rule in emergency
Emergency preparedness situations. The tool should help planners organize their Go to:
Preparedness - A activities, and provide useful information to a range of potential http://www.hhs.gov/ocr/hipaa/decisi
July 2006 Emergency Preparedness Decision Tool programs. ontool/.
The 27-minute training video teaches hospital personnel how to
decontaminate children after being exposed to hazardous chemicals
during a bioterrorist attack or other type of disaster. It reviews strategies,
tools and key preparedness planning issues. The training video is
intended for hospitals and emergency and pediatric professionals
because it explains the unique needs of children versus adults during
The Decontamination public health emergencies. The video also covers three main areas: a
of Children: step-by-step presentation of the decontamination process; a real-time
Preparedness and demonstration of the decontamination of children from infancy to To obtain a free single copy,
Response for adolescence, and; a section for administrators that outlines the steps contact the AHRQ Publications
Hospital Emergency involved in establishing and maintaining a pediatric decontamination Clearinghouse at 800.358.9295, or
April 2006 Emergency Preparedness Departments facility in any emergency department. via email at ahrqpubs@ahrq.gov.
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The Joint Commission on Accreditation of Healthcare Organizations
(JCAHO) has issued a guide, "Surge Hospitals: Providing Safe Care in
Emergencies". A "surge hospital" is designed to treat a surge in the
number of patients needing care, triage, treatment, and even surgical
interventions. They are temporary facilities, such as shuttered hospitals,
closed wards in existing hospitals, and mobile facilities designed to Go to:
serve as a stopgap measure to provide medical care until an area's http://www.premierinc.com/all/safet
Surge Hospitals: healthcare organizations can reopen. The guide also includes case y/resources/disaster_readiness/do
Providing Safe Care studies that describe how surge hospitals were established during the wnloads/surge-hospitals-jcr-12-08-
January 2006 Emergency Preparedness in Emergencies recent hurricanes on the Gulf Coast. 05.pdf
The Centers for Disease Control and Prevention's (CDC) National
Institute for Occupational Safety and Health (NIOSH) has released its
2005 NIOSH Pocket Guide to Chemical Hazards. Key general industrial
hygiene information is included on several hundred chemicals and
substances groups such as cyanides, fluorides, and manganese
compounds. The information includes a physical description, exposure
limits, substances with which the chemical is incompatible or will react,
and recommended personal protection equipment. The booklet also
provides information on sanitation measures, first aid procedures,
NIOSH pocket guide - respirator recommendations, exposure routes and symptoms, target http://www.cdc.gov/niosh/npg/defau
December 2005 Emergency Preparedness Chemical hazards organs, and cancer sites. lt.html
Mold: Prevention Mold: Prevention Strategies and Possible Health Effects in the
Strategies and Aftermath of Hurricanes Katrina and Rita and a mold table includes
Possible Health population specific recommendations for protection from exposure to
Effects in the mold in buildings flooded after hurricanes by specific activity and risk
Aftermath of factors, as well as information on how to identify and prevent mold- http://www.premierinc.com/all/safet
Hurricanes Katrina related health effects. The documents include recommendations for y/resources/disaster_readiness/do
November 2005 Emergency Preparedness and Rita control of mold exposure. wnloads/2005-mold-report.pdf
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http://www.premierinc.com/all/safet
y/public-health/downloads/03-
reoccupancy-post-hurricane-10-18-
A fact sheet and checklist were recently developed by the Centers for 05.pdf,
Disease Control and Prevention to assist healthcare facilities with the http://www.premierinc.com/all/safet
tasks involved during clean-up and reopening following extensive water y/public-health/downloads/02-ic-
damage. "Remediation and Infection Control Considerations for checklist-reoccupancy-post-
Reopening Healthcare Facilities Closed due to Extensive Water and hurricane-10-18-05.doc, and
Wind Damage" notes that implementation of these measures is meant http://www.premierinc.com/all/safet
to be followed in accordance with state and local certification y/public-health/downloads/01-ic-
requirements, completion of building and fire inspections, and other checklist-reoccupancy-post-
November 2005 Emergency Preparedness Reopening a facility relevant state or local regulations. hurricane-10-18-05.pdf
The Joint Commission on Accreditation of Healthcare Organizations
(JCAHO) has issued a step-by-step guide, "Standing Together: An
Emergency Planning Guide for America's Communities," for small, rural
and suburban communities to both prepare for and successfully respond
to major local and regional emergencies such as hurricanes, floods,
Standing Together: terrorist attacks, major infectious outbreaks, hazardous materials spills,
An Emergency or other catastrophic occurrences. This comprehensive planning guide
Planning Guide for provides 13 essential steps that local government and public health http://www.premierinc.com/all/safet
America's leaders can use to establish an effective community-based emergency y/publications/10-05-downloads/10-
October 2005 Emergency Preparedness Communities management planning and response process. emergency-planning-guide.pdf
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A recently released Archives of Internal Medicine article describes
improvements in a physician's ability to diagnose and manage diseases
caused by bioterrorism agents. Such improvements were documented
after the completion of an online pre-test that assessed physicians'
baseline knowledge and ability to diagnose and manage potential cases
of smallpox, anthrax, botulism, and plague. An educational module
following the pre-test reviewed diagnosis and decision-making for
patients presenting with anthrax, botulism, plague, smallpox, or a
common disorder that has clinical overlap with these diseases. The
educational module was followed by a post-test, which measured the
module's effectiveness. Extra cases were presented to the physicians The bioterrorism-education module
between the pre- and post-tests on each of the four potential is available for registered users on
Educational module bioterrorism agents. Improvement in results led the study's authors to the Johns Hopkins Medicine's
for physicians – conclude that the online education module may improve physician's Internet Learning Center at:
October 2005 Emergency Preparedness Bioterrorism agents diagnosis and management of diseases caused by these agents. http://www.hopkinsilc.org.
Premier Safety
Institute's Emergency The Premier Safety Institute's Emergency and Public Health
and Public Health Preparedness page also contains relevant and timely news and http://www.premierinc.com/all/safet
September 2005 Emergency Preparedness Preparedness resources related to the disaster. y/public-health/
During clean up and recovery operations following hurricanes, OSHA
issues alerts on the dangers associated with cleanup and recovery from http://www.osha.gov/OshDoc/hurric
September 2005 Emergency Preparedness Keeping workers safe hurricanes. aneRecovery.html
Increased incidence of acute diarrhea may occur in post-disaster
Acute diarrhea - situations where access to electricity, clean water, and sanitary facilities http://www.premierinc.com/all/safet
guidelines for are limited. In addition, usual hygiene practices may be disrupted and y/publications/09-05-downloads/14-
September 2005 Emergency Preparedness management healthcare seeking behaviors may be altered. guide-acute-diarrhea.pdf
Food may not be safe to eat during and after a natural disaster or power http://www.premierinc.com/all/safet
outage. Safe water guidelines provide guidance for using bottled, boiled, y/publications/09-05-downloads/13-
September 2005 Emergency Preparedness Safe food and water or treated water for drinking, cooking, and personal hygiene. food-water-safety.pdf
Information on water supply disruptions excerpted from the CDC
Guidelines for Environmental Infection Control in Health-Care Facilities, http://www.premierinc.com/all/safet
2003 - Recommendations of CDC and the Healthcare Infection Control y/publications/09-05-downloads/12-
September 2005 Emergency Preparedness Water system repair Advisory Committee (HICPAC). water-system-repair.pdf
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Community shelters provide housing for persons displaced from their
homes following natural disasters such as hurricanes, floods, and
earthquakes. In these settings, individuals share living space. Some
individuals may have health problems, including acute or chronic
Community shelter infectious diseases. These recommendations provide basic infection http://www.premierinc.com/all/safet
guidance following control information that will help to prevent exposure to or transmission y/publications/09-05-downloads/11-
September 2005 Emergency Preparedness disasters of infectious agents. community-shelters.pdf
Immunization recommendations (.pdf) (85 KB) are available for
individuals displaced by Hurricane Katrina. Although measles and
rubella are no longer endemic to the United States, introductions do
occur, and crowded conditions may facilitate their spread. Although
Hepatitis A incidence is low in the affected areas, post-exposure
prophylaxis in these settings would be logistically difficult. Consequently,
vaccination is recommended. In addition, the influenza season will begin http://www.premierinc.com/all/safet
Interim immunization soon and influenza can spread easily under crowded conditions. Interim y/publications/09-05-downloads/09-
September 2005 Emergency Preparedness after hurricane recommendations are provided. cdc-advisory-interim-immun.pdf
http://www.premierinc.com/all/safet
After an emergency, it can be difficult to find running water. However, it y/publications/09-05-downloads/06-
is still important to wash your hands (.pdf) (75 KB) to avoid illness. It is handwashing-emergencies.pdf and
best to wash your hands with soap and water but when water isn't http://www.premierinc.com/all/safet
Hand hygiene in available, you can use alcohol-based products (.pdf) (34 KB) made for y/publications/09-05-downloads/21-
September 2005 Emergency Preparedness emergency situations washing hands. clean-hands-cards.pdf
This summary addresses preventing electrocutions associated with
generators plugged into household circuits. Homeowners should not
attempt to install any generator that requires hard-wiring into an existing http://www.premierinc.com/all/safet
Electrical safety and electrical circuit or that requires a trained, qualified electrician to hard- y/publications/09-05-downloads/05-
September 2005 Emergency Preparedness generators wire any generator into a household circuit. electrical-safety.pdf
After a natural disaster, snakes may have been forced from their natural
habitats and move into areas where they would not normally be seen or
expected. When you return to your home, be cautious of snakes that http://www.premierinc.com/all/safet
Snake bite - How to may have sought shelter in your home. If you see a snake in your home, y/publications/09-05-downloads/08-
September 2005 Emergency Preparedness prevent or respond immediately call the animal control agency in your county. snake-bite.pdf
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Animal disposal Most states have guidelines on disposal of dead animals so people with http://www.premierinc.com/all/safet
following an questions regarding the specific situation in their state are encouraged y/publications/09-05-downloads/07-
September 2005 Emergency Preparedness emergency to contact local or state health and agricultural officials for clarification. animal-disposal.pdf
ASHE's Hurricane Relief Resources provides a link to the University of
Minnesota, "Managing Water Infiltration into Buildings: A Systematized See also CDC's "Healthcare Water
Approach for Remediating Water Problems in Buildings due to Floods, System Repair" at
Roof Leaks, Potable Water Leaks, Sewage Backup, Steam Leaks and http://www.dehs.umn.edu/iaq/flood.
September 2005 Emergency Preparedness Flood remediation Groundwater Infiltration." html.
The information is available at
http://www.ahrq.gov/research/shutt
The new report from the Agency for Healthcare Research and Quality ered/. Related: Use of shuttered
(AHRQ) entitled "Use of Former (Shuttered) Hospitals to Expand Surge hospitals report
Capacity" that gives emergency responders and public health officials http://www.premierinc.com/all/safet
useful, practical tools for opening shuttered hospitals when an y/publications/09-05-downloads/02-
emergency is underway. The information is available at ahrq-shutreport.pdf, Tool kit to
http://www.ahrq.gov/research/shuttered/. The report gives surrounding open a facility
communities that aren't immediately affected by the hurricane a way to http://www.premierinc.com/all/safet
assess their existing facilities to meet future needs. It includes lists of y/publications/09-05-downloads/03-
supplies and medications needed by stable medical/surgical patients ahrq-toolkit.pdf, and Checklist to
Use of Former and checklists to assess facility readiness, staffing needs and levels, open a facility found at
(Shuttered) Hospitals and patient transport readiness. The report also contains a tool kit with a http://www.premierinc.com/all/safet
to Expand Surge list of supplies and equipment needed for operation of a reopened y/publications/09-05-downloads/04-
September 2005 Emergency Preparedness Capacity facility. ahrq-checklist.pdf.
Although terrorists use a variety of methods to inflict harm and create
fear, bombs are used most frequently. According to the FBI, bombings
accounted for nearly 70 percent of all terrorist attacks in the United
States and its territories between 1980 and 2001. This practical
summary focuses on common sense principles that will be useful in a
bombing event. It describes how every person, family or organization
should prepare for an emergency or disaster, including knowledge of
work, school and community disaster plans. If you are not familiar with
the plans, contact your supervisor, school administrators, or your local
Preparing for a fire department for more information. This document details what
August 2005 Emergency Preparedness terrorist bombing should be done if a bomber is suspected. This CDC document can be downloaded at http:
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Month Year Topic by Tab Tool Description Tool Location
The Occupational Safety and Health Administration (OSHA) has
released a best practices document (.pdf) (1.9 MB) for hospital-based
first receivers of victims of chemical, biological, and radiological events.
The "Hospital-Based First Receivers of Victims from Mass Casualty
Incidents Involving the Release of Hazardous Substances" document
will assist hospitals in developing and implementing emergency
management plans that address the protection of emergency
department personnel, while receiving contaminated victims from mass
OSHA 'best practice' casualty incidents. It also includes information on victim http://www.premierinc.com/all/safet
guidance for hospital- decontamination, personal protective equipment (PPE), and employee y/publications/01-05-downloads/08-
January 2005 Emergency Preparedness based first receivers training first-receivers-hosp.pdf
The Department of Homeland Security has released a new National
Response Plan. The Department of Health and Human Services will
lead the federal government in providing public health and medical
services during major disasters and emergencies. The National The Plan can be downloaded at:
National Response Response Plan establishes a comprehensive all-hazards approach to http://www.dhs.gov/dhspublic/intera
January 2005 Emergency Preparedness Plan enhance the ability of the United States to manage domestic incidents. pp/
To register: Go to:
Clinician Registry for www.bt.cdc.gov/coca and follow the
Terrorism and links to “Clinician Resources” and
Emergency The registry provides real-time information to help healthcare providers “Registry.” The direct registration
Response Updates prepare for (and possibly respond to) emerging diseases and terrorism link is:
and Training events. CDC also uses the registry to announce new clinician training http://www.bt.cdc.gov/clinregistry/in
October 2004 Emergency Preparedness Opportunities opportunities related to terrorism and emergency response topics. dex.asp.
http://my.premierinc.com/all/safety/
Minnesota's surge publications/08-04-downloads/08-
August 2004 Emergency Preparedness capacity plan Minnesota's surge capacity plan surge-amacdc-email.ppt
Healthcare Facility A study conducted by several disaster medicine experts on strategies to The plan is available from the
and Community manage patient surges in healthcare facilities following a biological or Annals of Emergency Medicine
Strategies for Patient chemical terrorist attack, provides sample response plans for (contact Colleen Hughes at
August 2004 Emergency Preparedness Care Surge Capacity communities in Colorado, Massachusetts, Minnesota, and Virginia. 202.728.0610, Ext. 3010).
The tool helps regional planners locate and rank potential alternative To view the full report and tool, go
sites such as stadiums, schools and recreation centers based on to:
Surge capacity whether they have adequate ventilation, plumbing, food supply, kitchen http://www.ahrq.gov/research/altsit
August 2004 Emergency Preparedness planning facilities and other factors. es.htm.
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Month Year Topic by Tab Tool Description Tool Location
The Centers for Disease Control and Prevention (CDC) has established
partnerships with national clinician organizations for the purpose of
disseminating timely information on disease outbreaks and terrorism
events. COCA's Web site was successfully launched July 20. The site
Clinician Outreach offers many resources for COCA members, including past COCA
and Communication conference call summaries and slides, listings of COCA members, Visit the COCA Web site at
August 2004 Emergency Preparedness Activity (COCA) information on future conference calls and training updates. www.bt.cdc.gov/coca/index.asp.
The Centers for Disease Control and Prevention has a Web-based The module can be completed at
Plague training module designed to teach the natural epidemiology of plague and how http://www.bt.cdc.gov/agent/plague
July 2004 Emergency Preparedness module to manage it as both a natural disease and an intentional attack. /trainingmodule/.
The full report, Evidence
Report/Technology Assessment
No. 95, Training of Hospital Staff to
Training of Clinicians This evidence report updates the evidence report "Training of Clinicians Respond to a Mass Casualty
for Public Health for Public Health Events Relevant to Bioterrorism Preparedness" and Incident, may be obtained free from
Events Relevant to focuses on the effectiveness of hospital disaster drills, computer the AHRQ Publications
Bioterrorism simulations, and tabletop or other exercises used in training hospital Clearinghouse by calling
June 2004 Emergency Preparedness Preparedness staff to respond to a mass casualty incident. 800.358.9295.
The tool, developed by the Evidence-based Practice Center at the
Johns Hopkins University, helps hospitals identify their strengths and
weaknesses during a disaster drill and improve their ability to meet
required emergency management plans. Areas assessed include pre-
drill planning, incident command, decontamination, triage and treatment.
Evaluation of The tool also includes checklists to help hospitals tailor drills to specific
Hospital Disaster health threats, such as a biological or radiation incidents, and a
Drills: A Module- spreadsheet to track and compare drill performance among hospital
June 2004 Emergency Preparedness Based Approach units or hospitals.
The plan calls for specialized response teams, an emergency
preparedness executive steering committee, and regional emergency
response plans during a national emergency. The agency recently
published its National Emergency Management Plan that details the
agency's roles and responsibilities during responses to national
National Emergency emergencies and outlines procedures to ensure assistance is in place http://www.osha.gov/SLTC/emerge
March 2004 Emergency Preparedness Management Plan for responder and recovery workers' health and safety. ncypreparedness/index.html
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Month Year Topic by Tab Tool Description Tool Location
The report, HHS bioterrorism preparedness programs: States reported
progress but fell short of program goals for 2002, examines the extent to
which states completed 2002 cooperative agreement requirements and
whether they identified any factors that hindered implementation of the http://www.premierinc.com/all/safet
Centers for Control and Prevention (CDC) and Health Resources and y/publications/03-04-downloads/04-
March 2004 Emergency Preparedness Services programs: States reported progress agreement of program
HHS bioterrorism preparedness Administration’s (HRSA) cooperativebut fell shortprograms. goals for 2002
d04360r.pdf
An Excel program version (1.4 MB)
Computer staffing A new computer model is available to help hospitals and health systems may be downloaded from:
model - Bioterrorism plan antibiotic dispensing and vaccination campaigns to respond to http://www.ahrq.gov/research/biom
July 2003 Emergency Preparedness Response bioterrorism or large-scale natural disease outbreaks. odel.htm.
The Evacuation Planning Matrix,
available at
Evacuation Planning http://www.osha.gov/dep/evacmatri
June 2003 Emergency Preparedness Matrix Online tool to help employers with emergency planning. x/index.html
Guidance for
Protecting Building
Environments from A new federal guidance is now available to help facility specialists in http://my.premierinc.com/all/safety/
Airborne Chemical, business and government strategically select and use air-filtration and publications/06-
Biological, or air-cleaning systems for protecting occupants in buildings from 03_downloads/08_NIOSH_2003-
June 2003 Emergency Preparedness Radiological Attacks chemical, biological, or radiological attacks. 136.pdf
Disaster
Preparedness and
Response in Texas http://www.healthpolicyinstitute.org/
Hospitals: Part I, projects/disaster_response/dis_res
May 2003 Emergency Preparedness Bioterrorism A bioterrorism disaster preparedness guide for hospitals. p.asp
Information on agents likely to be used in a chemical terrorist attack.
This resource highlights agent-specific identification, medical symptoms,
Emergency personal protective equipment, and decontamination considerations for http://www.cdc.gov/niosh/topics/em
May 2003 Emergency Preparedness Response Resources responding to events involving cyanide, sarin, and nitrogen mustard. res/chemagent.html
Disaster drills are most effective when designed by an interdisciplinary
team that clearly establishes goals before the drill begins. A
Planning and teleconference on disaster drills and readiness assessment asserts that http://www.hsrnet.net/ahrq-
executing disaster the drills should also include a plan to evaluate whether the goals were ulp/bioterrorism/events/0415/materi
May 2003 Emergency Preparedness drills reached. als.htm
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Month Year Topic by Tab Tool Description Tool Location
Addressing the
Smallpox Threat: http://www.hsrnet.net/ahrq-
Issues, Strategies, Copies of a 90-minute audiotape may be purchased for $10 from the ulp/bioterrorism/events/0218/materi
May 2003 Emergency Preparedness and Tools AHRQ Publications Clearinghouse als.htm
Clinician Registry for
E-mail Updates on Clinician's registry to provide real-time information to help prepare for
Terrorism and and respond to terrorism and emergency situations. As participants,
Emergency physicians will receive regular updates on terrorism and emergency
April 2003 Emergency Preparedness Response response issues targeted to clinicians. http://www.bt.cdc.gov/
Smallpox Vaccine A guide addressing legal and risk management issues for hospitals http://biotech.law.lsu.edu/blaw/bt/s
March 2003 Emergency Preparedness Injury and Law Guide related to the smallpox vaccine. mallpox/svlaw.htm
Risk Management
Guidance for Health,
Safety and
Environmental The report covers several issues related to infrastructure and
Security under environmental risks during disaster events, including food, mail, and http://my.premierinc.com/all/safety/
Extraordinary personnel security and safety; transportation; childcare; and building publications/03-
March 2003 Emergency Preparedness Incidents access 03_downloads/11_extraordinary.pdf
The chart presents a concise summary of signs and symptoms to assist
Chemical terrorism with early recognition, as well as to alert healthcare workers about the
February 2003 Emergency Preparedness agents potential for chemical terrorism agents. http://www.unc.edu/depts/spice/
The program provides basic information required to implement a
Bioterrorism Update: smallpox vaccination preparedness program. Presented in a series of
Smallpox modules, it is directed at state and local health department and clinical http://bookstore.phf.org/prod250.ht
February 2003 Emergency Preparedness Preparedness personnel. m
http://my.premierinc.com/all/safety/
Vaccine Information The smallpox VIS must be used with a separate consent form that publications/01-
January 2003 Emergency Preparedness Statement (VIS) requires a signature. 03_downloads/11_small02.pdf
This comprehensive module addresses the vaccine, methods of
Smallpox training inoculation, prevention of contact transmission, laboratory testing and
December 2002 Emergency Preparedness module use of vaccinia immunoglobulins (VIGs). http://www.bt.cdc.gov/
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More than 70 metropolitan hospital executives heard how hospitals near
"Ground Zero" in lower Manhattan and the Pentagon responded to the
National Symposium immediate tragedies of September 11, 2001, as well as strategies http://www.hospitalconnect.com/ah
on Hospital Disaster related to ongoing disaster readiness preparations against possible a/key_issues/disaster_readiness/E
December 2002 Emergency Preparedness Readiness future biological, and chemical, and natural disasters. mWhatsNew.html
Go to
Emergency http://www.premierinc.com/all/safet
preparedness On-line catalogs provide emergency preparedness supplies available y/resources/disaster_readiness/pro
November 2002 Emergency Preparedness materials from several companies d_equip.htm.
AHRQ's Bioterrorism
Emergency Planning http://my.premierinc.com/all/safety/
and Preparedness Biological weapons training for personnel, procedures to permit rapid publications/09-
Questionnaire for recognition of credentialed staff from other facilities, on-call nursing 02_downloads/11_AHRQ_bioterror
October 2002 Emergency Preparedness Healthcare Facilities policies, and designated areas of emergency overflow for patients _checklist.pdf
Disaster kit — Tools
to meet children’s To aid pediatricians, community leaders, parents, and others in
October 2002 Emergency Preparedness needs preparing for and meeting children's needs during a disaster. http://www.aap.org/terrorism/
Preparing for
Terrorism: Tools for
Evaluating the A set of measurement tools and a process for evaluating the extent to
Metropolitan Medical which communities have implemented the disaster preparedness plans
Response System required by the Department of Health and Human Services’ Metropolitan http://www.nap.edu/catalog/10412.
August 2002 Emergency Preparedness Program Medical Response System program. html
Guidance for
Protecting Building
Environments from http://my.premierinc.com/all/safety/
Airborne Chemical, The guidelines address the physical security of ventilation systems, publications/06-
Biological, or airflow and filtration, systems maintenance, program administration, and 02_downloads/05_36_2002_niosh_
June 2002 Emergency Preparedness Radiological Attacks maintenance staff training. ventilation_139.pdf
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Month Year Topic by Tab Tool Description Tool Location
Resources on bioterrorism – including an evidence report on training
Training of Clinicians clinicians, a summary of a workshop on strengthening the nation's
for Public Health response capabilities, the results of a survey noting the gaps and
Events Relevant to resources needed by local public health agencies to respond effectively
Bioterrorism to bioterrorism, and a report from ECRI on personal protective
May 2002 Emergency Preparedness Preparedness equipment. http://www.ahrq.gov/
A training course originally developed by the World Health Organization
and Centers for Disease Control and Prevention for training smallpox Order at
response teams, these presentations help planners and first responders http://www.bt.cdc.gov/agent/smallp
January 2004 Emergency Preparedness CDC Training Slides prepare for the possibility of the use of smallpox as a terrorist weapon. ox/training/overview/index.asp
OSHA has a Web-based training tool on implementing an incident
command system as part of emergency response preparedness. The
Incident command toolprovides guidance on planning for an incident command system and http://www.osha.gov/SLTC/etools/ic
December 2003 Emergency Preparedness syatem addresses applicable OSHA standards. s/index.html
http://www.premierinc.com/all/safet
y/publications/11-03-downloads/09-
Recognizing illness-associated-exposure-chem-
chemical agent agents.doc
November 2003 Emergency Preparedness exposure
A health information bulletin, provides recommendations on preventing http://www.osha.gov/dts/shib/shib1
Brief Guide to Mold in mold growth, proper use of personal protective equipment, and safe 01003.html
November 2003 Emergency Preparedness the Workplace cleanup methods.
A matrix tool, provides information on how facilities can reduce
Fire and Explosion vulnerability to and consequences of a terrorist attack that involves fire http://www.osha.gov/dep/fire-
November 2003 Emergency Preparedness Planning Matrix or an explosive device. expmatrix/index.html.
The Pink Book – “Epidemiology and Prevention of Vaccine Preventable
Epidemiology and Diseases,” the 7th edition from 2002, is now in its second printing. The book is available for download
Prevention of or purchase at
Vaccine Preventable http://www.cdc.gov/nip/publications
October 2003 Emergency Preparedness Diseases /pink/default.htm
Provides employers with information on helping to protect workers from
injuries and illnesses resulting from possible terrorist incidents related to
Chemical, Biological, chemical, biological, radiological, or nuclear attacks.
Radiological, and
Nuclear (CBRN) http://www.osha.gov/dts/shib/revCB
Warfare Agents RN_EscapeRespirators_8-29-
October 2003 Emergency Preparedness Escape Respirators 03.html
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Month Year Topic by Tab Tool Description Tool Location
The Food and Drug Administration joined with the CDC, the EPA and
OSHA in releasing guidelines on how to prevent hazards due to
inappropriate use of cleaners and disinfectants on electronic medical
equipment. Such solutions can cause the equipment to malfunction.
Many stakeholders, including AHA, APIC, and ASHE, provided input to
the guidelines for handling and cleaning of electronic medical devices.
Minimizing the potential for cross contamination and patient and worker http://www.premierinc.com/quality-
FDA guidance – injuries is critical, but of equal importance is the emphasis on the safety/tools-services/safety/safety-
Electronic equipment process of proper cleaning and disinfecting in accordance with share/12-07-downloads/5_FDA-
December 2007 Environmental and Safety Products cleaning hazards manufacturers’ guidelines in the interest of safety Equipment-10_31_07.doc
The newsletter provides news and success stories about topics such as
reduction of medical waste, computer recycling, green cleaning
programs, conversion to reusable products, laboratory chemical
recycling, energy efficient lighting and light bulb recycling. Premier's
EPP program is a collaboration of the Premier Safety Institute and
Premier's group purchasing services. The program is part of Premier's
commitment to helping healthcare facilities with their environmental
efforts, including waste minimization and the elimination of the use of Go to:
March 2006 Environmental and Safety Products Green Link mercury. http://www.premierinc.com/safety
The Clinician Outreach and Communication Activity (COCA) offered a
program in Medical Waste Management on August 23, 2005. Lynne
Sehulster, Ph.D, M(ASCP), of the Centers for Disease Control and
Prevention (CDC) Division of Healthcare Quality Promotion presented
materials addressing: identification of general categories of medical
waste; regulations governing the management of medical waste; insight
Medical waste into how the recent influenza A (H2N2) situation revealed weaknesses in http://www.premierinc.com/all/safet
management the current system of waste management; and understanding the y/publications/10-05-downloads/09-
October 2005 Environmental and Safety Products teleconference importance of reinstating on-site capacity for medical waste treatment. waste-management-slides.ppt
The American Society for Healthcare Environmental Services has
partnered with Orkin, Inc. to promote more effective and environmentally
friendly pest-control practices in healthcare settings, including the
release of a guide on integrated pest management. The partners also See Premier Safety Institute's
plan to publish educational articles and host two educational sessions Environmental and Safety Product
Environmentally on the recommended practice at ASHES' annual conference in list at:
friendly pest control September. The partnership was launched in response to a growing http://www.premierinc.com/all/safet
May 2005 Environmental and Safety Products practices movement in healthcare toward hazardous-chemical reduction. y/resources/lists/
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Month Year Topic by Tab Tool Description Tool Location
Two new handbooks are available online from Occupational Safety and
Health Administration (OSHA): "Best Practices for the Safe Use of
Glutaraldehyde in Health Care," which helps employers and employees
understand and control exposures to glutaraldehyde, a chemical used to Go to:
disinfect and clean heat-sensitive medical, surgical and dental http://www.osha.gov/Publications/gl
equipment, and "Preventing Mold-Related Problems in the Indoor utaraldehyde.pdf and
OSHA online Workplace," which offers recommendations to owners, managers, and http://www.osha.gov/Publications/p
May 2006 Environmentally Preferred Purchasing handbooks occupants on how to fix mold problems in buildings reventing_mold.pdf
nvironmentally A four-CD set containing all the presentations from "Environmentally Order free copies of the book and
Preferable Preferable Purchasing and Healthcare Practices Conference" held in CDs from the Premier Safety Store
Purchasing and Boston, April 29, 2004. Topics include green buildings, mercury at:
Healthcare Practices elimination, recycling medical waste processing, solvent recovery, and http://www.premierinc.com/all/safet
December 2004 Environmentally Preferred Purchasing Conference more. y/store/.
An online resource that aids employers in addressing air quality http://www.cdc.gov/niosh/topics/ind
concerns. The Indoor Environmental Quality topic page provides links to oorenv
a variety of air quality topics, including how to identify, correct, and
prevent indoor air problems; how to implement an effective air quality
Indoor Environmental plan; and resources on mold, asbestos, asthma and allergies, and
November 2003 Environmentally Preferred Purchasing Quality topic page chemical safety.
Premier's Safety Institute has added one more important section to the
Environmental Preferable Purchasing (EPP) module addressing
Environmental chemical cleaners and pesticides. The EPP "Topic summary" describes
Preferable a number of important and useful resources. "Key documents" includes
Purchasing (EPP) a case study of a safer, successful integrated pest management http://www.premierinc.com/all/safet
September 2004 Environmentally Preferred Purchasing module program. y/resources/EPP/index.htm
Cleaning for Health: http://my.premierinc.com/all/safety/
Products and One-stop guide to environmentally preferable cleaning products and publications/04-
Practices for a Safer methods that have been effectively used in office buildings, schools, 03_downloads/04_cleaning_for_he
April 2003 Environmentally Preferred Purchasing Indoor Environment hospitals and other facilities in the United States and Canada. alth.pdf
Environmentally A checklist is available which can be used by healthcare organizations
preferred purchasing to guide purchasing decisions or by manufacturers to assess the http://www.ahrmm.org/info/HCEPT/
October 2002 Environmentally Preferred Purchasing checklist environmental friendliness of products. tool.html
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Month Year Topic by Tab Tool Description Tool Location
The handbook is available for a
The most current knowledge on concepts and methods of human discounted price of $95 at
factors and ergonomics and their applications to help improve quality, http://www.erlbaum.com/ME2/dirm
safety, efficiency, and effectiveness in patient care. The handbook od.asp?sid=28807ECF50FE49F08
provides specific information on how to analyze medical errors with the 37125BE640E681F&nm=&type=eC
Handbook of Human fundamental goal of reducing errors and the potential harm that results. ommerce&mod=CommerceProduct
Factors and Contributors discuss the design of work environment and working Catalog&mid=CD22EA0F118949C
Ergonomics in conditions to improve satisfaction and well being, and the reduction of 09A932248C040F650&tier=3&id=1
Healthcare and burnout and other ailments often experienced by healthcare providers 19DCAD843B64A54BC20DE1F72
Nov 2006 Fall Prevention Patient Safety and professionals. 531996&itemid=0-8058-4885-1
The draft document titled "Safe Patient Handling and Movement
Principles," a collaboration between NIOSH, the American Nurses Available at the NIOSH Web site
Safe Patient Association and the Veterans Affairs Patient Safety Center, is a new at:
Handling and Safe Patient Handling and Movement curriculum module to be used in http://www.cdc.gov/niosh/review/pu
June 2006 Fall Prevention Movement Principles schools of nursing. blic/safe-patient
Minimizing the risk of falls and falls injuries: Guidelines for acute, sub-
acute and residential care settings from the Victorian Quality Council of
Australia provides a framework and supporting resources to support falls
prevention activities in hospital and residential care settings. This falls available for download from the
Minimizing the risk of reduction guideline packet, or tool kit, contains research, tools, and Premier Safety Institute's Falls
falls and falls injuries: education materials, including a sample Microsoft® Excel spreadsheet module
Guidelines for acute, report to track falls data and trends, as well as algorithms for assessing http://www.premierinc.com/all/safet
sub-acute and and reassessing an individual's fall risk. The packet includes numerous y/resources/falls/procedures-
residential care tips for screening, assessing risk, reducing personal and environmental tools.jsp#Tool (under "Sample
January 2006 Fall Prevention settings risk factors, and properly responding to falls. Procedures").
http://www.osha.gov/SLTC/hospital
May 2002 Fall Prevention Ergonomic eTools OSHA ergonomic plan and eTools _etool/mainpage.html
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Month Year Topic by Tab Tool Description Tool Location
The ALFA Institute of Biomedical Sciences Educational Portal contains
medical education material on topics that include pediatric infections,
zoonoses, infectious diseases, internal medicine, dermatology, upper
and lower respiratory infections, surgical infections, antimicrobial
resistance, clinical research tools, biomedical databases, critical care
and sepsis, cardiovascular infections, nosocomial infections, hepatitis B
virus, orthopedic infections, OB/GYN infections and urogenital
infections. A selection of case studies that can be used as interactive
case-based learning tools from the Academy of Infection Management
Web-based are also available. The case studies include the specialties of surgery,
educational tools – pediatrics, ICU, and pneumonia. Specific topics include patient
Infection prevention outcomes related to antibiotic usage and healthcare associated Go to http://www.e-meducation.org/
February 2008 Guidelines case studies infections and http://infectionacademy.org/
Diseases are spread by poor coughing and sneezing techniques. Most
people put their hands in front of their mouths and noses to stop germs
from getting into the air. Unfortunately, this technique puts the germs on
their hands. The germs are then spread to telephones and doorknobs
and many other surfaces, where the next user then acquires. This five-
minute video was designed by three Maine hospitals to encourage
people to cough and sneeze according to the infection control guidelines
put forth by the Centers for Disease Control and Prevention (CDC). It is
aimed at the common citizen. The message is serious, but it is
presented with humor in such a way that it engages the viewer's
Why Don’t We Do It attention for a full five minutes while the message is repeated in
February 2008 Guidelines in Our Sleeves? interesting new ways. and Educational Trust (HRET) has developed a
The Health Research http://coughsafe.com/
comprehensive guide for clinicians and administrators to help
AHA/HRET – incorporate routine HIV testing in their emergency departments (EDs).
Comprehensive tool This practical guide describes different approaches, considerations, and
July 2007 Guidelines for HIV testing in ED resources for making HIV testing routine in ED care. It is based on http://www.edhivtestguide.org/
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Nine presentations from Premier's conference on "Healthcare-
associated infections – What everyone needs to know," held June 19,
2007, in Orlando, FL, are available online for download. Featured faculty
include: Graeme Forrest, M.D., University Maryland Medical Center;
Peter Gross, M.D., Hackensack University Medical Center; Carol
Haraden, Ph.D., IHI; Eli Perencevich, M.D., M.S., VA Maryland
Premier – Healthcare Healthcare System; Chesley Richards, M.D., M.P.H, FACP,
associated infection CDC/DHQP; Richard Van Enk, Ph.D., Bronson Methodist Hospital; Download from:
presentations Daniel Varga, M.D., SSM Healthcare; and Premier's Dan Peterson, M.D, http://www.premierinc.com/advisorli
July 2007 Guidelines available online M.P.H.; Gina Pugliese, R.N., M.S.; and Scott Pope, Pharm.D. ve/
The Association for Professional in Infection Control and Epidemiology
(APIC) has released a white paper on healthcare associated infections
(HAI) titled "Dispelling the Myths: The True Cost of Healthcare-
Associated Infections." Featured in the March issue of Healthcare
Financial Management magazine, the white paper presents the
business case for reducing HAIs from the perspective of the healthcare
executive. Case studies of cost saving are detailed, along with a
methodology for determining the cost of different categories of HAIs.
APIC – A business APIC's goal with the white paper is to help healthcare executives http://www.premierinc.com/quality-
case for preventing understand the costs involved with these infections, evaluate HAIs in safety/tools-
healthcare- their own institutions and take a more aggressive approach to infection services/safety/topics/guidelines/an
Mar 2007 Guidelines associated infections prevention. timicrobials.jsp#business-case
Patients undergoing MRI exams while wearing ECG electrodes and
cables have experienced second and third degree burns sometimes
FDA – Avoiding requiring plastic surgery to repair. After a FDA investigation into reports
burns from received regarding these burns, precautions that can be taken to http://www.premierinc.com/quality-
electrodes and prevent these types of burns were released. The problem is the safety/tools-services/safety/safety-
cables during MRI radiofrequency fields created during an MRI exam can heat ECG cables share/03-07-downloads/07-burns-
Mar 2007 Guidelines exams and electrodes, seriously burning the underlying skin. during-mri.doc
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Month Year Topic by Tab Tool Description Tool Location
AHRQ released a new Evidence Report/Technology Assessment
(Number 9), which concludes that several approaches and practices
implemented to prevent healthcare-associated infections (HAI) are
promising and warrant additional research. The objective of the report
was to determine the effects of quality improvement strategies on HAI
and on HAI rates. The selected infections (.pdf) (785 KB) included
surgical site infections (SSI), central line-associated bloodstream
infections (CLABSI), ventilator-associated pneumonia (VAP), and
catheter-associated urinary tract infections (CAUTI) The AHRQ
Evidence Report concludes that there is insufficient evidence to
recommend quality improvement strategies that will improve adherence
to preventive interventions for healthcare-associated infections. The
evidence is generally of suboptimal quality, consisting primarily of single-
center, simple before-after studies of limited internal and external
validity. Results from the limited data suggest that certain strategies
require additional study and potential wider implementation. Those
AHRQ – Report on strategies include reducing unnecessary catheter use by using "stop http://www.premierinc.com/quality-
strategies to prevent orders" (which require that a catheter be removed after a certain period safety/tools-services/safety/safety-
healthcare- of time if it is no longer needed), reminders to improve surgical antibiotic share/02-07-downloads/12-
Feb 2007 Guidelines associated infections prophylaxis, the use of checklists to improve adherence to central line hainfgap.pdf
A new toolkit designed to provide guidance on issues that should be
considered when designing measures for public reporting of healthcare-
associated infections (HAI) is available from the Centers for Disease
Control and Prevention (CDC). The kit was designed in conjunction with Access the CDC Web site for the
the Association of Professionals in Infection Control and Epidemiology Public Reporting of Healthcare-
(APIC), the Society for Healthcare Epidemiology of America (SHEA) and Associated Infections
other professional groups. Many states are considering making HAI (http://www.cdc.gov/ncidod/dhqp/P
reporting mandatory. "Essentials of Public Reporting of Healthcare- ublicReportingHAIs.html) for the
Associated Infections: A Tool Kit" (.pdf) (199 KB) details recommended toolkit, as well as the February
steps, including the identification or creation of a responsible agency at 2005 American Journal of Infection
CDC – Tools for the state level, personnel for data collection and quality improvement, Control article, Guidance on Public
reporting healthcare- strategies to prevent unintended consequences of public reporting, and Reporting of Healthcare-Associated
Feb 2007 Guidelines associated infections recommended outcome measures. Infections (.pdf) (150 KB).
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Month Year Topic by Tab Tool Description Tool Location
Several new tools have recently been added to the Surgical Care
Improvement Project (SCIP) Web site. The first, "Preventive Antibiotics
in Colon and Rectal Surgery: Discontinuation Within 24 Hours After
Operation," is a presentation that discusses the importance of giving
recommended antibiotics in colorectal surgery with the equally important VTE guidelines are available from
factor of discontinuing the antibiotics within 24 hours. Other tools related the Premier Safety Institute
to venous thromboembolism include: Deep Vein Thrombosis Infection Prevention and Safety
SCIP – New surgical, Prophylaxis Risk Factor Assessment, and Thrombosis Screen and Module under "Other guidelines,
Dec 2006 Guidelines VTE tools Prophylaxis Recommendations. selected resources."
Cough hygiene video, NSF Scrub Club provides an interactive Web-
based educational program with music, games and cartoons that aims
Humor in infection to help protect children from dangerous food borne illnesses as well as
control – Online infectious diseases, and MARR has useful antibiotic information http://www.coughsafe.com/;
educational downloads on fighting antibiotic resistance, a parent's guide for colds, http://www.scrubclub.org/;
resources for adults runny noses, and otitis media. Posters on handwashing include a http://www.mi-
Sept 2006 Guidelines and children reminder for children on when to wash their hands. marr.org/cons_materials.html
The Advisory Committee on Immunization Practices (ACIP) has issued
recommendations for preventing rotavirus gastroenteritis in infants and
children. The recommendations call for American infants to be
immunized with the recently licensed rotavirus vaccine. Infants should
receive three doses of the vaccine, administered orally at two, four and
six months. It is the most common cause of severe gastroenteritis in
infants and young children worldwide. Although rotavirus causes few
deaths among U.S. children, almost all children will become infected http://www.premierinc.com/quality-
with rotavirus by age five. Most of them will develop gastroenteritis, safety/tools-services/safety/safety-
ACIP – New rotavirus resulting in up to 272,000 emergency department visits and 70,000 share/09-06-downloads/12-mmwr-
Sept 2006 Guidelines vaccine hospitalizations each year. rotavirus.pdf
Antibiotic Prophylaxis
in Cardiac Surgery – Go to:
Duration of This guideline provides for one recently CMS approved exception for http://www.premierinc.com/all/safet
March 2006 Guidelines prophylaxis discontinuance of antibiotic prophylaxis. y/resources/guidelines/other.jsp
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Antimicrobial
Prophylaxis for
Surgery: An Advisory
Statement from the This advisory statement provides an overview of issues related to
National Surgical antimicrobial prophylaxis, including specific suggestions regarding Go to:
Infection Prevention antimicrobial selection, initiation and discontinuance of prophylactic http://www.premierinc.com/all/safet
March 2006 Guidelines Project antimicrobials. y/resources/guidelines/other.jsp
New guidelines are designed specifically for the cardiovascular
catheterization laboratory and provide information on such issues as the
selection of antibacterial soaps, the circumstances under which patients Go to:
CV Cath Lab: should receive an antibiotic, protective masks and other garb to be worn http://www.premierinc.com/all/safet
Infection control by catheterization lab staff, and the acceptable level of air circulation in y/resources/guidelines/other.jsp#ca
January 2006 Guidelines guidelines the catheterization lab. rd-cath
New resources on community-acquired MRSA CA-MRSA and a
Template for Gene Vector Guidance have been made available from the
Association for Professionals in Infection Control and Epidemiology
(APIC) Practice Guidance Council. These resources were developed in
collaboration with APIC's Emerging Issues Committee. The CA-MRSA Go to :
resource identifies key resources available via national, state, and local http://www.premierinc.com/all/safet
Community-acquired public health agencies. The Template for Gene Vector Guidance is y/publications/01-06-downloads/11-
MRSA CA-MRSA intended to assist facilities in developing infection control policies to ca-mrsa.pdf and
and a Template for regulate gene vector therapy. APIC recommends any study be reviewed http://www.premierinc.com/all/safet
Gene Vector and approved by their Institutional Review Board (IRB) but also include y/publications/01-06-downloads/12-
January 2006 Guidelines Guidance the involvement of an affiliated Biosafety Committee. gene-vector-therapy.pdf
The U.S. Public Health Service has updated the recommendations for
the management of healthcare personnel (HCP) with occupational
exposure to blood and other body fluids that might contain human
immunodeficiency virus (HIV). Published in the September 30, 2005
Morbidity and Mortality Weekly Report (MMWR) , the recommendations
(.pdf) (267 KB) emphasize adherence to postexposure prophylaxis
(PEP) regimens when indicated, expert consultation in managing http://www.premierinc.com/all/safet
HIV post-exposure exposures, follow-up to improve HCP adherence to PEP, and monitoring y/publications/10-05-downloads/11-
October 2005 Guidelines prophylaxis for adverse events, including seroconversion. hiv-rr5409.pdf
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A "Profile of the Healthcare Industry" that includes hospitals, physician
offices, dental offices, nursing homes, and more as part of its Sector
Notebook Project. The project helps various industry sectors in pollution
prevention, waste minimization, and regulatory compliance efforts. The
EPA Notebook - EPA document contains information on waste and emissions profiles, The Notebook can be accessed at:
Healthcare waste pollution prevention opportunities, a summary of federal statutes and http://www.epa.gov/compliance/res
management regulations, compliance and enforcement history, and compliance ources/publications/assistance/sect
June 2005 Guidelines profiles, resources activities and initiatives. ors/notebooks/health.html
A guide to assist with compliance with the JCAHO Environmental of
Care Standards. Hospitals for a Healthy Environment (H2E) is working
on a clipboard version for JCAHO surveyors. This guide relates each
JCAHO Element of Performance (EP) to specific federal regulations, to
help facilities be in compliance with both. The guide also suggests steps
JCAHO/H2E guide - that facilities can take to encourage environmental performance
Environment-of-care improvements. A comprehensive environmental program, including To view this guide, go to:
compliance and waste minimization and pollution prevention initiatives, can help ensure http://ecm.ncms.org/herc/jcaho3.10
June 2005 Guidelines improvement compliance and reduce costs. .3.html.
Two new guidance documents from the Association for the
Advancement of Medical Instrumentation (AAMI) are designed to assist
manufacturers in assessing the device reprocessing information they
provide. These documents help address concerns that manufacturer's
instructions are often inadequate or don't consider the common
reprocessing methods facilities use. The first document, entitled
"Designing, testing, and labeling reusable medical devices for
reprocessing in healthcare facilities: A guide for device manufacturers"
(TIR12: 2004), is intended to help manufacturers validate the
reprocessing procedures they recommend and guide them in choosing
AAMI guidance facility protocols. The second, "Sterilization of medical devices -
documents - Information to be provided by the manufacturer for the processing of re-
Cleaning and sterilizable medical devices" (ANSI/AAMI/ISO ST81: 2004), sets forth To order, call 800.332.2264, Ext.
May 2005 Guidelines sterilization requirements for labeling and reprocessing instructions. 217, or visit www.aami.org.
The comprehensive lists published by the Food and Drug Administration
(FDA) are available on the FDA Web site. The FDA Guidance
FDA Guidance Documents for Regulated Industry - Annual Comprehensive List of http://www.fda.gov/opacom/morech
March 2005 Guidelines Documents Guidance Documents - and the corrections to that list oices/industry/guidedc.htm
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A presentation titled, From SIP to SCIP (referring to the National
Surgical Infection Prevention Project and the current Surgical Care
Improvement Project) is available from the Surgical Care Improvement
From SIP to SCIP Project. Dale W. Bratzler, M.D., provides a background summary of the
(referring to the Surgical Infection Prevention Project (SIP) and shows some of the
National Surgical national data that has been collected, as well as findings in the clinical
Infection Prevention literature. The presentation also highlights the transition of the SIP into View a PowerPoint® summary
Project and the the Surgical Care Improvement Project (SCIP), which goes beyond just (.ppt) (1.6 MB) or watch a full
current Surgical Care preventing surgical infection and focuses on improving the outcomes for presentation with sound in a video
January 2005 Guidelines Improvement Project) surgery patients. clip at:
A new telephone hotline that provides clinicians with immediate access
to expert advice on treating HIV-infected pregnant women and their
children is available through the federal Health Resources and Services
Administration's National HIV/AIDS Clinicians' Consultation Center at
San Francisco (CA) General Hospital. The Perinatal Hotline
(888.448.8765) provides 24-hour consultation from HIV experts, More information is available from:
including advice on interpreting HIV testing in pregnancy and http://www.ucsf.edu/hivcntr/Hotline
December 2004 Guidelines The Perinatal Hotline implementing the U.S. Public Health Service's clinical care guidelines. s/Perinatal.html
http://my.premierinc.com/all/safety/
CDC also provides PowerPoint presentations that describe West Nile publications/07-04-downloads/12-
July 2004 Guidelines West Nile Virus Virus and methods of treatment and prevention. wnv-coca-talk.ppt
New practice guidelines are available to assist with the administration of
outpatient antimicrobial therapy (OPAT). Due to the lack of evidence-
based studies, these guidelines were formulated from the collective
experience of the Infectious Diseases Society of America Guidelines
Committee and advisors from related organizations. The Practical
Guidelines for Outpatient Parenteral Antimicrobial Therapy updates the
1997 guidelines and are intended to aid in the successful
Practical Guidelines implementation of parenteral antimicrobial services for patients in a
for Outpatient variety of outpatient settings including the home, physician offices, and
Parenteral skilled nursing facilities. The guidelines are general and need to be http://my.premierinc.com/all/safety/
Antimicrobial adapted for each specific setting. publications/07-04-downloads/11-
July 2004 Guidelines Therapy opat-cid-06-04.pdf
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The poster provides clinical guideline reminders for surgical infection
prevention, acute myocardial infarction, congestive heart failure, and http://my.premierinc.com/all/safety/
community-acquired pneumonia. The tool is intended to be displayed in publications/07-04-downloads/10-
CMS clinical areas where staff document the care provided, such as in nurses' clinical-guideline-poster-ar-02-
July 2004 Guidelines guideline reminder stations, doctors' dictation areas, and medical record areas, among 04.pdf
A printed copy of the Centers for Disease Control and Prevention’s
(CDC) "Guidelines for Environmental Infection Control in Health-Care
Facilities - 2003" has been published by the American Society of
Healthcare Engineering (ASHE). Topics covered in this publication
Guidelines for include indoor air quality, construction, ventilation in specialized care
Environmental areas, water quality, water quality in hemodialysis settings, cleaning and
Infection Control in disinfection of environmental surfaces, pest control, principles of
Health-Care Facilities environmental sampling, laundry and bedding, animals in health care, http://www.premierinc.com/all/safet
May 2004 Guidelines - 2003 and regulated medical waste. y/resources/guidelines/index.htm
Guidelines for
Environmental
Infection Control in
Health-Care Facilities http://www.premierinc.com/all/safet
May 2004 Guidelines - 2003 y/resources/guidelines/index.htm
New guidelines for preventing healthcare-associated pneumonia and
other severe lower respiratory infections. These guidelines update and
replace the 1981 guideline. In addition to the latest pneumonia and
respiratory infection recommendations, the guidelines expand the list of
Guidelines for recommended antiviral treatments for influenza patients and
Preventing Health- recommends that potable water be kept at temperatures above 124 http://www.premierinc.com/all/safet
Care-Associated degrees Fahrenheit or below 68 degrees Fahrenheit to reduce the risk of y/resources/guidelines/cdc_guidelin
April 2004 Guidelines Pneumonia, 2003 Legionnaire's disease. es.htm#Pneumonia2003
National Surgical
Infection Prevention New web site for accessing current information on the National Surgical
January 2004 Guidelines (SIP) Infection Prevention (SIP) www.MedQIC.org/sip
Pneumonia Medicare New web site for accessing current information on the Pneumonia
January 2004 Guidelines National Project Medicare National Project www.MedQIC.org/pneumonia
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The CDC Hand Hygiene Resource Web page provides an interactive
training course on hand hygiene and other standard precautions to
prevent healthcare associated infections. The course reviews key
concepts of both hand hygiene and standard precautions. The learner is
The CDC Hand asked a series of hand hygiene questions as they work through the
Hygiene Resource module and again at the end. The course also contains a short 60- http://www.cdc.gov/handhygiene/tra
September 2008 Hand Hygiene Guideline Web page second video on hand hygiene. ining/interactiveEducation/
Diseases are spread by poor coughing and sneezing techniques. Most
people put their hands in front of their mouths and noses to stop germs
from getting into the air. Unfortunately, this technique puts the germs on
their hands. The germs are then spread to telephones and doorknobs
and many other surfaces, where the next user then acquires. This five-
minute video was designed by three Maine hospitals to encourage
people to cough and sneeze according to the infection control guidelines
put forth by the Centers for Disease Control and Prevention (CDC). It is
aimed at the common citizen. The message is serious, but it is
presented with humor in such a way that it engages the viewer's
Why Don’t We Do It attention for a full five minutes while the message is repeated in
February 2008 Hand Hygiene Guideline in Our Sleeves? interesting new ways. Order at: http://coughsafe.com/
The World Health Organization's (WHO) first global patient safety
challenge, "Clean Care is Safer Care," acknowledges the importance of
addressing the global challenge of healthcare-associated infections
(.pdf) ( 2 MB). Low-cost WHO strategies that help reduce infection risks
in areas such as blood products and their use, injection practices and
immunization, safe water, basic sanitation and waste management, and The draft is available for download
clinical procedures, particularly in first-level emergency care, are already at:
WHO – Testing hand available. These strategies are combined with efforts to implement the http://www.who.int/gpsc/resources/
Mar 2007 Hand Hygiene Guideline hygiene guidelines WHO Guidelines on Hand Hygiene in Healthcare (Advanced Draft). newsalert/jan2007/en/
An eight-minute video on proper handwashing technique titled "Last
Clean Chance" has been produced by the Mecklenburg (NC) County
Health Department. The science fantasy thriller is set in a bio-research
lab. The video involves a doomsday scenario in which a virus is leaked Access the video and information
into the lab space. Tailored for the young viewer, the video teaches a online at
valuable skill and reminds us that handwashing is the number one way http://www.charmeck.org/Departme
May 2006 Hand Hygiene Guideline Last Clean Chance to prevent the spread of disease. nts/Health+Department/
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http://www.premierinc.com/all/safet
After an emergency, it can be difficult to find running water. However, it y/publications/09-05-downloads/06-
is still important to wash your hands (.pdf) (75 KB) to avoid illness. It is handwashing-emergencies.pdf and
best to wash your hands with soap and water but when water isn't http://www.premierinc.com/all/safet
Hand hygiene in available, you can use alcohol-based products (.pdf) (34 KB) made for y/publications/09-05-downloads/21-
September 2005 Hand Hygiene Guideline emergency situations washing hands. clean-hands-cards.pdf
The CDC slide sets are available
Slides - Hand at:
hygiene educational The educational slide sets are available as both core and supplemental http://www.cdc.gov/handhygiene/m
July 2003 Hand Hygiene Guideline resource slides, with or without speaker notes and in different formats. aterials.htm.
Hand Hygiene Provides updated educational materials dealing with hand hygiene
November 2002 Hand Hygiene Guideline Resource Center practices. http://www.handhygiene.org/
Word:
Premier's Safety Institute is now offering a checklist to save on your http://www.premierinc.com/quality-
computer and complete or update at your own pace. The Word safety/tools-
document (.doc) (463 KB) retains the HTML format and features services/safety/topics/influenza/ind
developed by the Centers for Disease Control and Prevention (CDC), ex.jsp#checklist; also offers this as
with input from other federal partners. It is intended to help hospitals an Adobe® PDF (2 MB) or online
assess and improve their preparedness for responding to pandemic at:
Comprehensive influenza. Because of differences among hospitals (e.g., characteristics http://www.pandemicflu.gov/plan/he
hospital checklist – of the patient population, size of the hospital/community and scope of althcare/
pandemic influenza services), each hospital will need to adapt this checklist to meet its hospitalchecklist.html.
July 2007 Influenza - pandemic preparation unique needs and circumstances.
New York City has released a pandemic flu preparedness and response
plan (.pdf) (2.3 MB). The plan is a blueprint for identifying an outbreak,
containing its spread and distributing scarce resources like ventilators
and antiviral medications. It also emphasizes that the city must rely on
itself, not Washington, to plan for and react to potential disasters. The
plan describes the importance of early detection to help contain the http://www.premierinc.com/quality-
New York City spread of the illness and includes disease monitoring, laboratory safety/tools-services/safety/safety-
pandemic influenza capacity, vaccine and medicine delivery, hospital preparedness, mental share/07-06-downloads/12-ny-
July 2006 Influenza - pandemic plan health and communications. pandemic-flu-plan.pdf
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checklist that describes steps that long-term care and other residential
facilities can take to prepare for influenza pandemic is available from the
Department of Health and Human Services (HHS) and the Centers for
Disease Control and Prevention (CDC). The checklist was developed to
help long-term care and other residential facilities assess and improve
their preparedness for responding to pandemic influenza. Based on
differences among facilities (e.g., patient/resident characteristics, facility
size, scope of services, hospital affiliation), each facility will need to
adapt this checklist to meet its unique needs and circumstances. The
checklist states that facilities should have a structure for planning and
decision-making, overseen by a multidisciplinary group focused on
pandemic flu planning, and to develop a written influenza plan. The
written influenza plan should include flu surveillance and detection
measures; communications; education and training in basic prevention
and control measures for personnel, residents, and residents' family
members; and an infection control plan for managing residents and
Pandemic flu visitors with pandemic influenza; an occupational health plan to address The checklist is available at:
checklist – Long-term staff absences and related issues; and plans for vaccine and antiviral http://www.pandemicflu.gov/plan/
June 2006 Influenza - pandemic care use and surge capacity. LongTermCareChecklist.html.
The new handbook provides information to help Americans understand
the threat of pandemic influenza and specific actions they can take to
protect themselves and their families and explains topics such as the
differences between seasonal and pandemic flu and what to expect in a
pandemic. The handbook includes an emergency health sheet for
recording personal health information on each family member. A
checklist divides actions into three categories: planning for a pandemic,
limiting the spread of germs and preventing infection, and items to
gather for an extended stay at home. Other important issues include
Pandemic Influenza plans for having nonprescription drugs and other health supplies on Go to:
Planning: A Guide for hand, discussing within a family how care will be given if a member http://www.premierinc.com/all/safet
Individuals and becomes ill, teaching proper hand washing and cough etiquette to y/publications/01-06-downloads/16-
January 2006 Influenza - pandemic Families children, and having supplies of food and water on hand. pandemic-flu-guide.pdf
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A home care influenza toolkit, published by Montgomery County's
Advanced Practice Center, is designed to help people manage influenza
at home. This simple toolkit, "Stay At Home Toolkit for Influenza,"
includes checklists on what to keep in the home, tips on how to
recognize flu signs and symptoms, instructions on using thermometers,
isolating the sick, making disinfectant with bleach, and cleaning
potentially contaminated areas, a personal care log to help caregivers http://www.premierinc.com/quality-
track observations and action, guidelines for those returning to work safety/tools-services/safety/safety-
Stay At Home Toolkit after recovering from flu, and items to keep on hand for pets for disaster share/02-08_downloads/13_Stay-at-
February 2008 Influenza - seasonal for Influenza preparedness. home-toolkit.pdf
For the beginning of the new influenza season, the Centers for Disease
Control and Prevention (CDC) is releasing updates of a few new flu
resources. The CDC's flu Web site at www.cdc.gov/flu has been revised
and is easy to navigate as a resource. This year, the CDC is Downloads are available for
CDC updates emphasizing high-risk children (such as those with asthma or diabetes) printing at:
influenza tools for the and their caregivers, as well as focusing on protecting infants and the http://www.cdc.gov/flu/professional
October 2007 Influenza - seasonal new season elderly through family and community vaccination. s/flugallery/.
A Web site sponsored by the National Influenza Vaccine Summit called
"Prevent Influenza Now!" provides information updates on the current
influenza vaccination season. The site contains vaccine information for
the public about influenza, the benefits of vaccination, who should be
vaccinated, how to find a clinic, media such as public service
announcements and press releases issued for this season's influenza
vaccination campaign, clinic procedures, patient materials, and other
useful tools to help prevent influenza. Information for healthcare
professionals includes a section on the vaccination of healthcare
New Web site workers. This section has many resources on how to increase
provides influenza healthcare worker vaccination, including many toolkits that can be used
Dec 2006 Influenza - seasonal vaccination updates to implement or expand healthcare worker immunization programs. http://www.preventinfluenza.org/
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Online resources and information from the California Distance Learning
Health Network (CDLHN), a non-profit organization of the Graduate
School of Public Health at San Diego State University. The section on
pandemic influenza resources includes the U.S. national strategy for
pandemic influenza and World Health Organization avian influenza
updates. A summit designed to inform California leaders in business,
education, local government, healthcare, social services and other
sectors to better prepare California for influenza pandemic is available Go to:
California Distance as a Webcast. The summit presents the current threat of avian influenza http://cdlhn.com/create_frameset.cf
Learning Health and the risk of a human influenza pandemic and several training videos m?id=32&CFID=523799&CFTOKE
May 2006 Influenza -seasonal Network (CDLHN) related to mass vaccinations and disease investigation. N=19783253
The Department of Health and Human Services (HHS) has developed a Go to: English -
checklist to help home healthcare providers care for the sick during an http://www.premierinc.com/all/safet
influenza pandemic. The checklist will help organizations assess their y/publications/04-06-downloads/06-
readiness to respond by identifying strengths and weaknesses. It also healthcare-checklist.pdf; Spanish -
Home Healthcare explains that building community contacts will provide a strategic http://www.premierinc.com/all/safet
Services Pandemic advantage if a pandemic influenza strikes. The checklist was designed y/publications/04-06-
Influenza Planning with a pandemic influenza in mind, although it may be used in other downloads/06a-spanish-healthcare-
April 2006 Influenza -seasonal Checklist types of emergencies. checklist.pdf
The U.S. Food and Drug Administration (FDA) has published "Questions
and Answers about Using Personal Protective Equipment (PPE) during
Influenza Outbreaks, including Bird Flu (Avian Influenza)"(.doc) (50 KB). http://www.premierinc.com/all/safet
Consistent with the Centers for Disease Control and Prevention (CDC), y/publications/12-05-downloads/10-
Use of personal the document discusses PPE, how the use of PPE prevents the spread questions-answers-ppe-during-flu-
protective equipment of infection, and how PPE for healthcare workers is different from those outbreaks.doc and
during influenza in other industries. The document shows how to search for items http://www.premierinc.com/all/safet
December 2005 Influenza - seasonal outbreaks cleared by the FDA. y/resources/influenza/index.jsp
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The National Foundation for Infectious Diseases' "Kids Need Flu
Vaccine" initiative now includes a new patient education resource for
physicians and healthcare providers. The new patient education
resource kit includes a parental brochure, fact sheet and poster in both
English and Spanish. The kit provides useful strategies to help
physicians and providers improve pediatric influenza vaccination rates
among high-risk children with chronic medical conditions, such as
asthma or diabetes. It also facilitates the implementation of
recommendations by the CDC, AAP and other leading organizations to
vaccinate all infants and toddlers 6 through 23 months of age as well as
Children's vaccine household contacts and out-of-home caregivers of children between
October 2005 Influenza - seasonal education kit birth and 2 years. http://64.242.251.230/index1.html
The purpose of the guide is to provide frontline healthcare personnel
with information about indications and contraindications for the two Last year's National Influenza
types of influenza vaccines, as well as groups to be vaccinated and how Vaccine Summit guide is available
to administer the vaccines. The draft of the guide for the 2005-06 online at
influenza vaccination season contains product-specific information for http://www.immunize.org/influenza/
Influenza Vaccination three injectable influenza vaccines. This information has been included pocketguide.htm, and this site
Pocket Information even though their licensure and availability may not be known before the should be checked periodically for
August 2005 Influenza - seasonal Guide start of the influenza vaccination season. the 2005-2006 version.
As reports of influenza increase during the current season, the Centers
for Disease Control and Prevention (CDC) continues to offer new
resources in the fight to prevent the illness. The "Cover Your Cough"
campaign has new language-specific flyers and posters for healthcare
settings, as well as community settings such as schools and child care
settings. In addition to English, the materials are available in Spanish,
New posters in five Vietnamese, Chinese and Tagalog. Links are also provided to influenza
languages for vaccination information statements (VIS) and materials at the "Be a http://www.cdc.gov/flu/protect/cover
January 2005 Influenza - seasonal healthcare, schools Germ Stopper" site. cough.htm
Summary of
resources to prevent http://www.premierinc.com/all/safet
spread of flu in the This latest tool from the CDC provides various resources, including y/publications/11-04-downloads/08-
November 2004 Influenza - seasonal workplace important telephone numbers, Web pages, and poster/flyer links. flu-tools.pdf
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A free online resource to help health care providers conduct influenza
immunization programs for children is available from The National
Foundation for Infectious Diseases (NFID). The "Kids Need Flu Vaccine,
Too!" program aims to increase immunization rates among children 6-
23 months of age and those with chronic medical conditions; facilitate
implementation of pediatric influenza immunization recommendations
issued by the Centers for Disease Control and Prevention, American tool is supported by the National
Academy of Pediatrics and American Academy of Family Physicians; Influenza Vaccine Summit and can
Kids Need Flu and help educate parents and healthcare providers about the be accessed through the NFID
August 2004 Influenza - seasonal Vaccine, Too! importance of preventing influenza among children. Web site at http://64.242.251.230/.
The newsletter provides news and success stories about topics such as
reduction of medical waste, computer recycling, green cleaning
programs, conversion to reusable products, laboratory chemical
recycling, energy efficient lighting and light bulb recycling. Premier's
EPP program is a collaboration of the Premier Safety Institute and
Premier's group purchasing services. The program is part of Premier's
commitment to helping healthcare facilities with their environmental
efforts, including waste minimization and the elimination of the use of Go to:
March 2006 Mercury Pollution Prevention Green Link mercury. http://www.premierinc.com/safety
Pollution prevention reduces some of the regulatory compliance issues,
such as the hazardous waste rules, by encouraging the use of less toxic
materials. The fact sheets are: Mercury in Healthcare
Lab Reagents
Mercury in Labs and Pharmacies
Mercury in Patient Care Areas
Mercury in Non-Patient Care Areas The fact sheets may be obtained
Formalin Recovery in Health Care Labs from the MnTAP Web site at
Suction Canister Waste Reduction http://www.mntap.umn.edu (click
Ten Tools To Get Below the Regulatory Radar on "Industries" and "Healthcare" for
August 2004 Mercury Pollution Prevention Mercury fact sheets MnTAP Profile, a general fact sheet on MnTAP's services more information).
This resource provides information on such topics as the health effects
Healthcare Hazard of mercury exposure; reducing occupational exposures, including
Control System thorough training and personal protective equipment; and applicable http://www.osha.gov/SLTC/mercury
September 2003 Mercury Pollution Prevention Volume 2 OSHA standards and guidelines. /index.html
September 2008 Patient Safety Patient Safety and This three-volume, 1,400-page handbook for nurses on patient safety http://www.ahrq.gov/qual/nurseshd
Quality: An Evidence- and quality resources contains 89 contributions that represent the work bk/
Based Handbook for of a broad range of nurses and other patient safety researchers
Nurses throughout the nation. The handbook is grouped into six sections:
Patient Safety and Quality; Evidence-based Practice; Patient-centered
Care; Working Conditions and the Work Environment for Nurses;
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February 2008 Patient Safety AHRQ toolkits – 17 The Agency for Healthcare Research and Quality (AHRQ) has http://www.ahrq.gov/qual/pips
patient safety developed a series of toolkits designed to help reduce medical errors.
resources These 17 toolkits, "Patient Safety at the Point of Care," 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, and can be adapted to most healthcare settings.
February 2008 Patient Safety FDA – Downloadable The latest FDA medication safety-related videos, including some http://www.ismp.org/Tools/fdavideo
medication safety developed in cooperation with ISMP, are now available free for viewing s.asp
videos or downloading on the ISMP Web site.The videos added from October
include warnings about Vincristine errors, luer misconnection, and how
the use of a disposable straw with Exactacain, a local anesthetic spray,
may pose a safety risk to patients. November videos highlight side
effects of codeine in nursing mothers, avoiding mix-ups with
Amphotericin B formulations, and warnings for Rocephin use with any IV
product that contains calcium.
February 2008 Patient Safety NIH tool kit – Online http://nihseniorhealth.gov/toolkit/too
health information for lkit.html
seniors
February 2008 Patient Safety Free tool for A free DVD from the Agency for Healthcare Research and Quality, Order at:
designing hospitals "Transforming Hospitals: Designing for Safety and Quality," reviews http://www.ahrq.gov/qual/transform.
for patient safety evidence-based hospital design and how it increases patient and staff htm
satisfaction and safety, quality of care, employee retention, and results
in a positive return on investment. Key concepts of evidence-based
design in a hospital include single-patient rooms, the use of noise
reducing construction materials, easily accessible workstations, and
improved layout for patients and staff. Patient safety issues addressed
are falls, hospital-associated infections and medical errors. The DVD
also presents cases of three hospitals that have incorporated evidence-
based design elements in their construction and renovation.
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December 2007 Patient Safety AHRQ free DVD – A new free DVD addressing patient safety consists of eight modules Order at:
Patient safety involving one to five separate lessons, and provides processes and tools http://www.ahrq.gov/qual/psicdvd.ht
that can be used to develop a systems-based approach to patient m
safety. The modules include the investigation of medical errors and their
root causes; identification, implementation and evaluation of system-
level interventions to address patient safety concerns; and steps
necessary to promote a culture of safety within a hospital or other
healthcare facility.
December 2007 Patient Safety Advancing the √ http://www.premierinc.com/quality-
Practice of Patient- safety/tools-services/safety/safety-
and Family-Centered The Institute for Healthcare Improvement (IHI) recently released a report share/12-07-downloads/6_Patient-
Care titled “Advancing the Practice of Patient- and Family-Centered Care” Family-Centered-Care-2007.pdf
that includes assessment tools to help hospitals determine the degree
to which patient- and family-centered approaches exist in their current
organizational culture; IHI also released a tool that helps gather
information about the perceptions and attitudes of staff and
administrative leaders. The report describes how hospitals can get
started with understanding how quality and safety are advanced by
bringing patients and families directly into the planning, delivery and
evaluation processes. This 25-page report provides rationale for a
patient- and family-centered approach to care and defines its core
concepts and outlines steps that a hospital can take to create
partnerships with patients and families.
October 2007 Patient Safety Drug safety The FDA has released the first issue of its new Drug Safety newsletter. A fact sheet and the inaugural
newsletter from FDA The online newsletter will be published quarterly and provide information issue of the newsletter can be
for healthcare professionals, such as physicians, physician assistants, found at
nurse practitioners, nurses, pharmacists, dentists, other allied http://www.fda.gov/cder/dsn/.
healthcare professionals, health professional associations and drug
information centers. The newsletter will feature findings of selected post-
marketing drug safety reviews from the agency's Center for Drug
Evaluation and Research (CDER), important emerging drug safety
issues, and recently approved new drugs. The newsletter provides post-
marketing information to healthcare professionals to enhance
communication of new drug safety information, raise awareness of
reported adverse events, and stimulate additional adverse event
reporting.
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Month Year Topic by Tab Tool Description Tool Location
September 2007 Patient Safety NCI – End-of-life care The National Cancer Institute (NCI) has published a free palliative-care The CD can be ordered or a
tool training program for health professionals caring for cancer patients. The brochure downloaded online. For
"Education in Palliative and End-of-Life Care for Oncology" CD-ROM more information, go to the NCI
and DVD teaches palliative care competencies and interventions for Web site at
cancer patients. The curriculum is designed to provide the practicing http://www.nci.nih.gov/aboutnci/epe
clinician with information and strategies necessary to provide palliative co
interventions to his or her patients and to provide educational tools and
materials to use in teaching the core competencies of palliative care to
trainees. This curriculum is eligible for continuing education credit for
physicians and nurses.
September 2007 Patient Safety Webcast – Best Catheter-related blood stream infections (BSI) are a significant source of http://www.cardinal.com/clinicalcent
practices to reduce morbidity and mortality associated with a variety of devices used to er/materials/webcasts/index.asp
catheter-related access the vascular system. Meticulous aseptic technique is both
blood stream required and effective to prevent BSI. Faculty share their observations,
infections best practices, and outcome data as they discuss this important topic.
This free webcast is a replay from the original August 17, 2007, webcast
provided by Cardinal Health's Center for Safety and Clinical Excellence
and will remain available for one full year. Continuing education credit is
also provided.
September 2007 Patient Safety FDA – Free patient The latest medication safety-related videos, developed by the FDA in http://www.ismp.org/Tools/fdavideo
safety videos cooperation with ISMP, are now available free for viewing or s.asp
downloading on the ISMP Web site
(http://www.ismp.org/Tools/fdavideos.asp).
The National Cancer Institute (NCI) has published a free palliative-care The CD can be ordered or a
NCI – End-of-life care training program for health professionals caring for cancer patients. The brochure downloaded online. For
September 2007 Patient Safety tool "Education in Palliative and End-of-Life Care for Oncology" CD-ROM more information, go to the NCI
Catheter-related blood stream infections (BSI) are a significant source of
morbidity and mortality associated with a variety of devices used to
access the vascular system. Meticulous aseptic technique is both
required and effective to prevent BSI. Faculty share their observations,
Webcast – Best best practices, and outcome data as they discuss this important topic.
practices to reduce This free webcast is a replay from the original August 17, 2007, webcast
catheter-related provided by Cardinal Health's Center for Safety and Clinical Excellence
blood stream and will remain available for one full year. Continuing education credit is http://www.cardinal.com/clinicalcent
September 2007 Patient Safety infections also provided. er/materials/webcasts/index.asp
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Month Year Topic by Tab Tool Description Tool Location
The latest medication safety-related videos, developed by the FDA in
cooperation with ISMP, are now available free for viewing or
FDA – Free patient downloading on the ISMP Web site http://www.ismp.org/Tools/fdavideo
September 2007 Patient Safety safety videos (http://www.ismp.org/Tools/fdavideos.asp).
The new Healthcare Industry Quick Start module is directed primarily to s.asp
OSHA – New small employers in the healthcare field. The module is designed to help
healthcare "Quick users find free resources on the OSHA Web site related to the
Start" compliance healthcare industry. The eight-step module includes information on http://www.osha.gov/dcsp/complian
August 2007 Patient Safety tool OSHA requirements that apply to many healthcare employers; ce_assistance/quickstarts/
ACR – Updated The white paper titled "ACR Guidance Document for Safe MR Practices" http://www.premierinc.com/quality-
guidance on (.pdf) (335 KB) details MR safety, from the design of the MR suite and safety/tools-services/safety/safety-
magnetic resonance the qualifications of personnel to screening patients and what to do in an share/07-07-downloads/08-safe-
July 2007 Patient Safety safety emergency. mr07.pdf
English:
http://www.premierinc.com/quality-
safety/tools-services/safety/safety-
share/07-07-downloads/04-
meninge-survivor-story-
CDC – New One young man's experience with meningococcal meningitis and his english.doc; Spanish:
meningococcal subsequent recovery is available in both English (.doc) ( KB) and http://www.premierinc.com/quality-
vaccine information Spanish (.doc) (59 KB) to be shared with patients and staff (.doc) (1.9 safety/tools-services/safety/safety-
available in Spanish MB). His story emphasizes the importance of receiving the available share/07-07-downloads/05-
July 2007 Patient Safety and English vaccine. meninge-survivor-story-spanish.rtf
The new Health Care Report Card Compendium is a searchable
directory of more than 200 samples of report cards produced by a
variety of organizations. The samples show formats and approaches for
providing comparative information on the quality of health plans,
hospitals, medical groups, individual physicians, nursing homes, and
other providers of care. The purpose of the AHRQ Report Card
Compendium is to inform and support the various organizations that
AHRQ – Sample develop healthcare quality reports, to provide easy access to examples
healthcare quality of different approaches to content and presentation, and to meet the http://www.talkingquality.gov/comp
June 2007 Patient Safety report cards needs of health services researchers. endium/
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Month Year Topic by Tab Tool Description Tool Location
A new guide available from the Agency for Healthcare Research and
Quality (AHRQ) titled "Mistake-Proofing the Design of Health Care
Processes" describes simple, low-cost interventions that organizations
can undertake to improve patient safety that includes more than 150
real world examples of process or design features that have been
AHRQ toolkit – implemented as a result of root-cause analyses and other interventions http://www.premierinc.com/quality-
"Mistake-proofing" to help ensure that processes help prevent errors or the negative impact safety/tools-services/safety/safety-
healthcare process of an error. share/06-07-downloads/07-
June 2007 Patient Safety design mistakeproofing.pdf
The AORN "Patient Hand-Off Toolkit" helps caregivers effectively
communicate key information such as the patient’s current and past
AORN Patient Hand- condition, ongoing treatments, and possible changes or complications The toolkit can be downloaded free
Off toolkit – Free that should be monitored closely. The kit includes sample checklists and of charge at:
Web-based surgical forms, slide presentations on standardizing communication and http://www.aorn.org/PracticeResour
June 2007 Patient Safety patient transfer information exchanges, and a guide to additional resources. ces/ToolKits/
The CDC has published a national estimate of the number of healthcare-
associated infections (HAI) and HAI-related deaths in the United States http://www.premierinc.com/quality-
in a March-April issue of Public Health article, "Estimating Health Care- safety/tools-
Associated Infections and Deaths in U.S. Hospitals, 2002." The authors services/safety/topics/guidelines/an
concluded that the method they used for estimating the number of HAIs timicrobials.jsp#hc-assoc-
made the best use of existing national data. Data were obtained from infections;
the National Nosocomial Infections Surveillance (NNIS) System (1990- http://www.premierinc.com/quality-
2002), the National Discharge Survey (2002), and the American Hospital safety/tools-
CDC – HAI summary Association Survey (2000). Study findings are summarized in a services/safety/topics/guidelines/an
May 2007 Patient Safety and slide set PowerPoint presentation. timicrobials.jsp#hc-assoc-infections
The new information explains what the Joint Commission is looking for
in adverse tissue reaction policies, such as the reporting of potential
disease transmission to the recipient when notified by the donor source
facility and reporting adverse patient reactions to the donor source
facility. These actions must be carried out and the tissue's unique
identifier must also allow the organization to easily trace the records
when notified of a problem by either the donor facility or the patient's http://www.premierinc.com/quality-
The Joint physician. Tracing the tissue records includes the complete chain of safety/tools-
Commission – FAQs events, including who handled the tissue, how it was transported, stored services/safety/topics/patient_safet
May 2007 Patient Safety on tissue storage and processed, dates and times such activities occurred. y/downloads/jc-standards-faqs.doc
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Month Year Topic by Tab Tool Description Tool Location
The second in a series of collaborative leadership tools for CEOs,
"Clarifying Expectations: A First Step in Developing Truly Effective
Relationships Between CEOs and Trustees," focuses on clarifying
trustees' and CEOs' mutual expectations. It includes a simple exercise
for helping trustees and CEOs refine the way they work together. It also
includes information on the sources of misunderstandings and typical Tool 2 is available at
expectations and describes the roles of and relationships between the http://www.americangovernance.co
AHA – CEO CEO and the board. m/americangovernance/resources/
May 2007 Patient Safety leadership tools CLT/CLTtool2.html
This site provides the agency's latest healthcare research findings,
news, and information. This site enables viewers to also hear the This link is available from the
AHRQ – Audio newscasts through a computer or permit a download to a portable digital Safety Institute's Patient safety web
Mar 2007 Patient Safety newscast series player such as an iPod. site under "Resources."
An online tool created by the Foundation for Healthy Communities in
New Hampshire has a directory that enables healthcare workers working
with culturally and linguistically diverse communities to easily find
translated health forms and documents. The directory provides access
to documents created and translated by New Hampshire health
agencies and organizations. The documents are intended for use by any
healthcare organization. Translated documents include consent forms,
patient bills of rights, financial assistance applications, and information
about cholesterol, asthma and child immunizations. Part of the
New Hampshire – Foundation's Cultural Effectiveness and Quality Health Care Project, the
Health forms in tool will be updated with documents and language translations. Access http://www.healthynh.com/fhc/reso
Feb 2007 Patient Safety multiple languages the tool on the Foundation Web site. urces/translateddocuments.php
The FDA Hospital Bed Safety Workgroup's (HBSW), final guidance on
hospital bed design, "Guidance for Industry and FDA Staff; Hospital Bed http://www.premierinc.com/quality-
System Dimensional and Assessment Guidance to Reduce safety/tools-services/safety/safety-
Entrapment", identifies special issues associated with hospital bed share/01-07-full-txt.jsp#tool-01. The
systems and provides design recommendations for manufacturers of HBSW also has a Bed Safety
new hospital beds and suggestions for healthcare facilities on ways to Entrapment Kit containing
assess existing beds. "A Guide for Modifying Bed Systems and Using information and tools that can be
Accessories to Reduce the Risk of Entrapment", released by the HBSW used to assess the risk of
FDA – Updates on in June 2006, focuses on modifying bed systems and using add-on or entrapment in hospital beds
hospital bed safety replacement equipment and accessories to reduce the entrapment risks http://www.fda.gov/cdrh/beds/entra
Jan 2007 Patient Safety guidance posed by openings in existing bed systems. pmentkit.html.
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Month Year Topic by Tab Tool Description Tool Location
Beginning in June 2007, all hospitals, including Critical Access Hospitals
(CAH), will have 30-day (risk adjusted) mortality rates for acute
myocardial infarction (AMI) and heart failure (HF) published on the
Hospital Compare Web site through an initiative led by the Hospital
Quality Alliance (HQA) . The data reported in June will cover the period
July 1, 2005, to June 30, 2006; reported data will also soon include
pneumonia patients. So that hospitals may become familiar with the
background of the measures and their own mortality rates, Centers for Hospital Compare Web site
Medicare and Medicaid Services (CMS) will provide a mock report (http://www.hospitalcompare.hhs.g
based on 2003 Medicare claims. The rates contained in these initial ov/). Information and updates about
reports will not be posted publicly on the Hospital Compare Web site. this initiative will be posted
IThe CMS timeline from November 2006 contains additional information, periodically to
Hospital Compare - including the important dates for public reporting. More information is http://www.qualitynet.org/ under the
Jan 2007 Patient Safety Mock data available at QNet exchange. "Hospitals" section.
Hospitals for a Healthy Environment (H2E) has developed an
"Environmental Compliance and Improvement Guide" that matches
each JCAHO Element of Performance to specific federal regulations.
This guide helps facilities identify how to be in compliance with both.
The guide also suggests steps that facilities can take to encourage
environmental performance improvements. A comprehensive
environmental program, including waste minimization and pollution
prevention initiatives, not only ensures compliance, but can also help
reduce the costs of compliance. The guide provides links, tips and tools
H2E – New that enumerate specific management practices, materials, regulatory
environmental requirements, and facility infrastructure relevant to the specific JCAHO http://www.h2e-
compliance and Element of Performance (EP). online.org/regsandstandards/jcahoi
Dec 2006 Patient Safety improvement guide The first tool is a "Global Trigger Tool" designed to help get started in ntro.html Trigger Tools
Access IHI
IHI – Patient safety the approach; the other tools focus on specific areas such as measuring at:http://www.ihi.org/IHI/Topics/Pati
Dec 2006 Patient Safety trigger tools adverse drug events,Medical Center, Omaha, NE, intensive a tool and
Creighton University perioperative care, neonatal provides care, to entSafety/SafetyGeneral/Tools/Intr
http://www.premierinc.com/quality-
Medication safety guide considerations of resource requirements when evaluating the safety/tools-services/safety/safety-
guide – Ambulatory ambulatory care environment for medication safety. The guide is titled share/12-06-downloads/07-chrp-
Dec 2006 Patient Safety care "Medication Safety Best Practices Guide for Ambulatory Care Use" best-practices.pdf
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Month Year Topic by Tab Tool Description Tool Location
Several new tools have recently been added to the Surgical Care
Improvement Project (SCIP) Web site. The first, "Preventive Antibiotics
in Colon and Rectal Surgery: Discontinuation Within 24 Hours After
Operation," is a presentation that discusses the importance of giving
recommended antibiotics in colorectal surgery with the equally important VTE guidelines are available from
factor of discontinuing the antibiotics within 24 hours. Other tools related the Premier Safety Institute
to venous thromboembolism include: Deep Vein Thrombosis Infection Prevention and Safety
SCIP – New surgical, Prophylaxis Risk Factor Assessment, and Thrombosis Screen and Module under "Other guidelines,
Dec 2006 Patient Safety VTE tools Prophylaxis Recommendations. selected resources."
Information in the report includes discussions of the scope of WPV,
barriers to violence prevention, prevention programs and strategies, and
research needs. The report discusses information on barriers and gaps
that impede the development and implementation of WPV prevention
programs, and summarizes the best workplace violence http://www.premierinc.com/quality-
Workplace Violence strategy/program practices presented by conference participants, safety/tools-services/safety/safety-
Prevention Strategies general research needs and the importance of linking research findings share/11-06-downloads/10-
November 2006 Patient Safety and Research Needs to practical prevention efforts. workplace-violence-prevention.pdf
The Med Form tool helps patients maintain a single, updated record of
their medications, vitamins, immunizations and allergies to share with
their healthcare providers. The Arizona Hospital and Healthcare
Association's Safe & Sound Patient Safety Initiative, Arizona Medical
Association, and Arizona Partnership for Implementing Patient Safety The Med Form is available in
sponsored the form and it is available statewide in physician offices and Spanish and English at
November 2006 Patient Safety The Med Form tool hospitals. http://www.themedform.com/.
Meeting the Joint Commission's 2007 National Patient Safety Goals, is
available as a tool for all accredited organizations preparing to
implement the 2007 National Patient Safety Goals. The publication
explains how to comply with the 2007 goals and requirements of the
New JCAHO goals, through a compilation of articles, book excerpts and tips. Detailed To order, call JCR Customer
resource – 2007 topics such as identifying safety risks inherent in patient populations, Service toll-free at 877.223.6866, 8
National Patient and encouraging the involvement of patients and families in patient care a.m. to 8 p.m. CT, weekdays, or
Oct 2006 Patient Safety Safety Goals are among those covered in the book. visit www.jcrinc.com
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The Joint Commission on Accreditation of Healthcare Organizations has
a secure extranet Web site that offers new automated tools for reporting
sentinel events and complaints. Full transition to the online tools is
required by January 1, 2007. Locate the tool on the extranet home page
under "Self Report Sentinel Event" in the "Continuous Compliance
Tools" section. Root cause analyses (RCA), action plans, and sentinel The automated complaint tool is
event measures of success may be submitted to the Joint Commission also available on the Joint
using an online RCA collection tool, also accessible from the Commission Web site at:
Sentinel event and "Continuous Compliance Tools" section under the "Sentinel Event http://www.jointcommission.org/Ge
Sept 2006 Patient Safety complaint reporting Activities" link. neralPublic/Complaint/
A new consensus report from the American Medical Association Ethical
Force Program offers guidelines to help healthcare organizations ensure
effective, patient-centered communications with patients of diverse
backgrounds. This report lists a number of specific, measurable
expectations for performance that organizations can use as a framework http://www.premierinc.com/quality-
AMA – Guidelines for for evaluating performance, as well as a guide for improving safety/tools-services/safety/safety-
improving patient communication quality. An organizational self-assessment toolkit based share/07-06-downloads/06-
July 2006 Patient Safety communications on the report is being field-tested. improving-communication.pdf
The Surgical Care Improvement Project (SCIP) Web site has added http://www.premierinc.com/quality-
practical tools for the four SCIP areas: cardiac, infections, venous safety/tools-services/safety/safety-
thromboembolism, and respiratory. Tools include help with antibiotic share/07-06-downloads/13-scip-
timing, glucose management, and prevention of deep vein thrombosis. antibiotics-pocket-card.pdf,
SCIP – Surgical care Visitors can download a DVT order set, an antibiotic recommendations additional tools at
July 2006 Patient Safety improvement tools chart, and a glucose management protocol order set. http://www.medqic.org/scip
The Joint Commission International Center for Patient Safety has a new
online resource that links to resources related to sentinel events and
Joint Commission on Accreditation of Healthcare Organizations
(JCAHO) National Patient Safety Goals. The site, "Patient Safety
Practices," contains tools and resources addressing issues related to
the causes and types of adverse events, U.S. and International Patient
Patient Safety Safety Goals and free access to many of their articles from a variety of
Practices - JCAHO journals, including the "Environment of Care." Go to:
May 2006 Patient Safety web site http://www.jcipatientsafety.org/psp http://www.jcipatientsafety.org/psp
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The National Institute for Occupational Safety and Health (NIOSH) draft,
"Evaluation of Safe Patient Handling and Movement Principles",
available for comment until May 30, 2006. The presentation was
developed for use in nursing schools to improve work practices for
patient care workers. It covers the definition of ergonomics, risk factors
for musculoskeletal injury during patient handling and movement,
Evaluation of Safe recognizing high-risk patient care activities and conditions that result in Go to:
Patient Handling and high-risk patient-care environments, and identifying the best solutions http://www.cdc.gov/niosh/review/pu
April 2006 Patient Safety Movement Principles for patient handling. blic/safe-patient/
The toolkit presents strategies for comprehensively redesigning and
transforming processes of care in a hospital. It details how healthcare
systems can redesign (including the planning steps needed for such
transformation) and presents strategies for translating information
gathered into proposed projects for implementation. Many of the Go to:
AHRQ toolkit – techniques included in the toolkit can be used to guide process http://www.premierinc.com/all/safet
Hospital process improvements without embarking on comprehensive system y/publications/03-06-downloads/09-
March 2006 Patient Safety redesign strategies transformation. hospital-redesign-toolkit.pdf
guide is designed to help outpatient physician practices incorporate
safer systems for medication sample prescribing and dispensing. The
checklist format helps users rate their current medication use processes
(prescribing, dispensing, administering, counseling, and monitoring) so
plans for improvements can be prioritized and implemented. The guide Go to:
Medication safety also addresses processes in technology and safety, office environment, http://www.premierinc.com/all/safet
tool – ambulatory error management, workplace conditions, safety education, and safety y/publications/03-06-downloads/08-
March 2006 Patient Safety care perceptions. best-practices-ambulatory-care.pdf
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Having Surgery? What You Need to Know is designed to help patients
make informed decisions when planning for surgery. The brochure
suggests questions to help patients obtain needed information including
how and where their operation will be performed, what kind of
anesthesia will be used, whether non-surgical medical treatment and Go to
watchful waiting are options, possible risks of not having the surgery, :http://www.premierinc.com/all/safe
potential risks and expected benefits if they have the surgery, and how ty/publications/01-06-downloads/13-
long recovery is expected to take. Additional questions include cost, surgery.pdf. A Spanish language
insurance and whether a second opinion is required and/or covered. The version,
Having Surgery? publication is part of a series of healthcare resources from AHRQ to http://www.premierinc.com/all/safet
What You Need to help people be more active in making informed decisions that can help y/publications/01-06-downloads/14-
January 2006 Patient Safety Know" them obtain high-quality Anesthesiologists (ASA) has approved a
The American Society ofhealthcare. sp-surgery.pdf, is available.
ASA Practice practice advisory on anesthesia awareness intended to help
Advisory – reduce anesthesiologists reduce the risk of unintended patient awareness under http://www.premierinc.com/all/safet
awareness under general anesthesia. The ASA reports that one to two out of every 1,000 y/publications/11-05-downloads/09-
December 2005 Patient Safety anesthesia patients receiving general anesthesia regains consciousness and may aware-advisory-10-05.pdf
This module applies the AHRQ QI to improve population health using
the AHRQ QI as a catalyst for quality improvement, implications of ICD-
9-CM coding practices, the use of the AHRQ QI in the National
Healthcare Quality Reports, methods for creating aggregate
Pediatric Indicator performance indices, and considerations in using the AHRQ QI for http://qualityindicators.ahrq.gov/use
November 2005 Patient Safety Module comparative reporting and pay-for-performance. rmeeting_presentations_2005.htm
A free multimedia safety tool kit is available and contains a five-minute,
Web based version of the patient safety Emmi TM tool that explains the
patient's role in preventing mistakes and infections in hospitals. The tool
kit is sponsored by the American Society of Hospital Risk Management
(ASHRM), Rightfield Solutions, the creators of Emmi patient education
system, and the Health Research and Educational Trust (HRET) of the
Multimedia safety American Hospital Association. Hospitals can post this program on their
tool kit for patient Web sites for patients to view prior to coming to the hospital, or
November 2005 Patient Safety education broadcast the two-minute version on an in-house television network. http://www.emmisafety.com/ashrm
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Month Year Topic by Tab Tool Description Tool Location
The South Carolina Hospital Association (SCHA) Patient Safety
Committee has developed three tools to help consumers, healthcare
facilities, and healthcare workers keep track of all personal medications.
These tools can help consumers, hospital inpatients and outpatients,
hospitals, nursing homes, physician offices, emergency medical
workers, and pharmacists "stay on the same page" so that everyone
knows all of the medications a person takes. The tools are: Universal
Toolkit – Medication Medication Form (UMF), Patient Medication Brochure, and Medication http://scha.org/document.asp?docu
October 2005 Patient Safety safety Reconciliation Form (MRF) ment_id=2,3,32,3491
The agenda at the regional forums and networking meetings includes For more information about these
Regional results from the CMS-Premier Hospital Quality Improvement programs and a schedule and
Performance Demonstration project (how-to's and success stories from top decile registration, visit:
Improvement forums, performers), patient safety, managing length of stay, physician http://www.premierinc.com/all/confe
Rapid Improvement engagement, interactive working groups, and live demonstrations of the rences/ceo/index.jsp?ref=october-
October 2005 Patient Safety Web tool Rapid Improvement Program and Web portal). safety-share
The Joint Commission's August issue of Perspectives on Patient Safety
offers suggestions on meeting the 2006 National Patient Safety Goals
(.pdf) (345 KB). The special issue, provided free for a limited time,
describes each goal and accompanying requirements and offers
compliance tips. For example, JCAHO describes measures
implemented by some organizations to increase compliance with hand
hygiene guidelines from the Centers for Disease Control and Prevention
Suggestions on (CDC), which is required under the goal for reducing the risk of Access the suggestions at
meeting the 2006 healthcare-associated infections. Tips for non-hospital settings, such as http://www.premierinc.com/all/safet
National Patient home care or long-term care, are also included where compliance needs y/publications/08-05-downloads/11-
August 2005 Patient Safety Safety Goals could differ from acute care settings. perspectives-07-05.pdf
A new Institute for Healthcare Improvement (IHI) Innovation Series white
paper expands on a previous paper, "Move Your Dot: Measuring,
Evaluating, and Reducing Hospital Mortality Rates," that introduced a
novel perspective and methodology for understanding and reducing
Move Your Dot: inpatient deaths. "Reducing Hospital Mortality Rates (Part 2)"
Measuring, summarizes preliminary results from a three-year pilot project in which White papers are free and available
Evaluating, and eight hospitals, working with IHI, are testing the theory that hospital online at:
Reducing Hospital mortality can be consistently reduced through a combination of evidence- http://www.ihi.org/IHI/Products/Whit
August 2005 Patient Safety Mortality Rates based interventions. √ ePapers/
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Premier's Safety Institute has developed a Spanish version of the
Agency for Healthcare Research and Quality's (AHRQ) Hospital Survey
Hospital Survey on on Patient Safety Culture survey tool, as well as a customized The survey tool can be accessed at
Patient Safety Microsoft® Excel data tool for easy entry and rapid display of survey http://www.premierinc.com/all/safet
August 2005 Patient Safety Culture results. y/culture/
“Self-Study Modules on Tuberculosis,” a new education tool specifically
designed for healthcare workers and other professionals involved in the
identification, treatment, and care of individuals with tuberculosis and
latent tuberculosis infection is now available. The tool is the result of a
partnership between the Centers for Disease Control and Prevention’s
(CDC) Division of Tuberculosis Elimination and the Division of Media
and Training Services. These courses are also appropriate for staff of
correctional facilities, drug treatment centers, migrant clinics, nursing
homes, homeless shelters, or other facilities serving persons with or at
risk for tuberculosis. Each course has a separate set of modules,
registration process, exam, and credits. The modules can also be
worked through without registering. Content from both the print-based
Self-Study Modules on Tuberculosis and the video-based "A Satellite The modules can be accessed at
Self-Study Modules Primer on Tuberculosis" was used to create Self-Study Modules on http://www.phppo.cdc.gov/phtn/tbm
July 2005 Patient Safety on Tuberculosis Tuberculosis that can be delivered via the World Wide Web. odules/Default.htm.
Alternatives to using medical waste incinerators for treating regulated
medical waste were the focus of a free teleconference July 8, 2005, and Additional information is available
hosted by Hospitals for a Healthy Environment (H2E). Teleconference from H2E at www.h2e-
speaker Sally M. Patterson, regulated medical waste program online.org/events/teleconf/index.cf
coordinator, New York State Department of Health, discussed the m. The slide presentation, (Append
advantages and disadvantages of using alternative treatment 8_RMW_NY.ppt) as well as a chart
technologies approved in the state of New York, including low-heat of alternative technologies can be
Alternative medical treating systems, high-heat treating systems, and chemical treatment downloaded. (Append
July 2005 Patient Safety waste treatment systems. 9_alttechchart.pdf
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A checklist that can aid safety and environmental managers managing
obese patients is now available on the Healthcare Hazard Control (HHC) To review the checklist and
Members' Web site. The list can help staff ensure that a healthcare assessment tool, login at
facility's physical structures and equipment safely accommodates http://www.ecri.org, click "HHC
extremely obese patients and visitors. An assessment tool to guide Homepage," and click the "Sample
caregivers on the safe handling of extremely obese patients has also Policies" link on the left-hand side
been added. An analysis on the safe accommodation of extremely of the screen. The tools can be
Tools for managing obese patients and visitors will be published in the August 2005 HHC found under the "Miscellaneous"
July 2005 Patient Safety obese patients mailing. heading.
The American Medical Association (AMA) has released a new primer
designed to help physicians improve immunization rates, particularly in
minority populations. The primer, “Roadmaps for Clinical Practice,
Improving Immunization: Addressing Racial and Ethnic Populations,”
addresses the leading health indicator of immunization and infectious
diseases, with a special focus on reducing racial and ethnic disparities
in immunizations. In addition to resources, the primer provides tools to
Roadmaps for help physicians ensure that patients are up-to-date with their
Clinical Practice, vaccinations and includes immunization schedules for both children and
Improving adults. The primer is the latest volume in the AMA’s “Roadmaps for The project is supported by an
Immunization: Clinical Practice: Case Studies in Disease Prevention and Health unrestricted educational grant from
Addressing Racial Promotion” series, which provides physicians and other health Sanofi Pasteur and is available
and Ethnic professionals with clinical strategies and tools to address the leading online at www.ama-
July 2005 Patient Safety Populations causes of preventable morbidity and premature mortality. assn.org/go/roadmaps.
A new pocket guide recently released by Health and Human Services
(HHS), "Helping Smokers Quit: A Guide for Nurses," was developed by
AHRQ in collaboration with "Tobacco Free Nurses," a national initiative
funded by The Robert Wood Johnson Foundation. This new tool is
designed to give nurses evidence-based information that they can use
to help their patients quit smoking. The free guide gives nurses' easy Download the guide at
access to information based on the "5 A's" approach to cessation http://www.premierinc.com/all/safet
HHS pocket guide intervention: Ask, Advise, Assess, Assist, and Arrange. It also includes y/publications/06-05-downloads/13-
offers resources to a current listing of smoking cessation medications approved by Food hlpsmksqt.pdf or go to
assist patients with and Drug Administration (FDA) and a referral to HHS' National Quitline, http://www.ahrq.gov/about/nursing/
June 2005 Patient Safety smoking cessation 1-800-QUIT NOW. hlpsmksqt.htm
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The Commonwealth Fund's chart book assesses the quality of care
provided to elderly and disabled Medicare beneficiaries. This is just one
of several chart books available from the Commonwealth Fund on
health policy matters. The chart books are available in either Adobe or
PowerPoint Other topics available include insurance, access, and
quality of care among Hispanic populations, the state of child health
Quality of Care for care in the United States, adults' primary care experiences in five
Medicare industrialized countries, the health of women in New York City, and the All chart books are available at:
June 2005 Patient Safety Beneficiaries value of state pharmacy assistance programs. http://www.cmwf.org/index.htm.
The 5th annual collection of charts and graphs depicts key trends
affecting hospitals and health systems. Sections include trends in the Go to:
overall health care market, organizational trends, utilization and volume, http://www.ahapolicyforum.org/aha
TrendWatch trends in hospital financing, workforce, and the economic contribution of policyforum/trendwatch/chartbook2
June 2005 Patient Safety Chartbook 2005 hospitals. 005.html
A compendium of 140 peer-reviewed articles on patient safety studies
by government-sponsored researchers. These studies include findings
on medication safety, technology, and investigative approaches to better
treatment, process analyses, human factors and practical tools for
preventing medical errors. The 140 articles in the four-volume set cover
a wide range of research paradigms, clinical settings, and patient
populations. Where the research is complete, the findings are
AHRQ-DOD presented; where the research is still in process, the articles report on
compendium - Four- its progress. In addition to articles with a research and methodological
volume set of patient focus, the compendium includes articles that address implementation Go to:
safety research issues or present useful tools and products that can be used to improve http://www.ahrq.gov/qual/advances/
June 2005 Patient Safety studies patient safety. .
The Institute for Safe Medication Practices (ISMP) announced it has
developed a new tool (.doc) (33 KB) designed to assist hospitals in
evaluating antithrombotic therapy. The survey has been mailed to
hospitals with a submission deadline of September 1, 2005. The self- Find the tool at
assessment will help organizations examine medication safety practices http://www.premierinc.com/all/safet
New self-assessment associated with the use of antithrombotic drugs in their facilities. y/publications/05-05-downloads/11-
survey for Hospitals may submit data through a secure Web-based form, which will ismp-self-assessment-launch.doc.
antithrombotic allow them to compare their weighted scores with aggregate data from Further information is available at
May 2005 Patient Safety therapy similar hospitals. http://www.ismp.org.
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The American Society for Healthcare Environmental Services has
partnered with Orkin, Inc. to promote more effective and environmentally
friendly pest-control practices in healthcare settings, including the
release of a guide on integrated pest management. The partners also See Premier Safety Institute's
plan to publish educational articles and host two educational sessions Environmental and Safety Product
Environmentally on the recommended practice at ASHES' annual conference in list at:
friendly pest control September. The partnership was launched in response to a growing http://www.premierinc.com/all/safet
May 2005 Patient Safety practices movement in healthcare toward hazardous-chemical reduction. y/resources/lists/
The Health Research & Educational Trust, an affiliate of the American
Hospital Association (HRET/AHA), has developed two charts to help
hospitals select the best rapid HIV test for their needs. The charts,
developed with input from the Centers for Disease Control and
Prevention (CDC), are designed to help hospitals as they implement the
CDC's recommendation that the test be offered to all women presenting
to labor and delivery with undocumented HIV status. One chart
compares information on test price, external controls, numbers of tests
per case, catalog number, storage temperature, operating temperature,
shelf lives of tests and controls, time required to conduct test, and
validity window periods; the other chart compares information on FDA-
approval date, specimen type, CLIA-status, specificity, sensitivity, To view the charts go to:
Rapid HIV antibody manufacturer, HIV-2 detection capabilities, list price, and external http://www.hret.org/hret/programs/h
May 2005 Patient Safety screening tests controls. ivtransmrpd.html
Advance directives, the legal documents that allow individuals to make
their personal healthcare wishes known before a serious illness or
injury, can be confusing and difficult to understand. The Institute for The forms are available in both
Healthcare Advancement has an advance directive form designed for English
American adults who read below a fifth-grade level. The forms are http://www.premierinc.com/all/safet
available in both English (.pdf) (906 KB) and Spanish (.pdf) (911 KB). y/publications/05-05-downloads/09-
The form is designed in a simple fill-in-the-blank format with illustrations advance-directive-english.pdf (.pdf)
and easy-to-read bullet points. Low-literacy Americans will be able to (906 KB) and Spanish
choose an agent to make medical decisions for them, make their http://www.premierinc.com/all/safet
healthcare wishes known so that their loved ones don't have to guess y/publications/05-05-downloads/10-
Simplifying advanced for them, and provide the necessary signatures to make the document advance-directive-spanish.pdf
May 2005 Patient Safety directives legally binding. √ (.pdf) (911 KB).
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The February issue of the Joint Commission Journal on Quality and
Patient Safety has been made available for a free download now online, http://www.jcrinc.com/subscribers/j
Communicating the issue focuses on communicating critical test results and includes ournal.asp?durki=8739&site=14&re
March 2005 Patient Safety critical test results numerous important topics. turn=455#FEBRUARY%202005
The American Hospital Association's (AHA) Health Research and
Educational Trust (HRET) Web site has a section with information on
studies that describe the use of clinical simulations to train physicians
and other healthcare workers in the latest medical developments. An
advantage of clinical simulations training is that skills are learned
without risking harm to real patients. Simulation-based training also
provides trainees with a broad range of learning experiences, including
the treatment of uncommon conditions unlikely to be encountered in
Clinical Simulation traditional patient-based training. The Clinical Simulation Tools site links http://www.hret.org/hret/programs/s
March 2005 Patient Safety Tools to AHA simulation resources. imulations.html
The Joint Commission on Accreditation of Healthcare Organizations has
released a white paper (.pdf) (643 KB) recommending demonstration
projects to test alternatives to the nation's medical liability system. A
commission of medical liability and patient safety experts states that the
current liability system does not do enough to reduce negligence and
compensate victims of medical errors. The paper recommends
encouraging the adoption of information and simulation technology by
considering plans to offset implementation costs and by expanding
evidence-based reporting. The white paper states that any medical
liability changes need to ensure that the greatest number of injured
patients is fairly compensated, while allowing practitioners and providers http://www.premierinc.com/all/safet
Medical liability White the opportunity to report errors, learn from them, and ensure that those y/publications/03-05-downloads/08-
March 2005 Patient Safety parper errors are not repeated. medical-liability.pdf
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The recently passed Consolidated Appropriations Act for fiscal year
2005 includes an appropriations restriction. This restriction states that
during FY 2005, employers may not be inspected or cited for the
requirement to do annual fit testing of respirators for occupational
exposure to tuberculosis. OSHA can still cite for the non-annual fit
testing requirements of 29 CFR 1910.134 as it relates to tuberculosis,
including the provisions of 29 CFR 1910.134(f)(2) for the lack of initial fit
testing or whenever a different respirator face piece is used. The
standard interpretation is described in an OSHA memo (.doc) (33 KB)
and also states that only annual fit testing of respirators used for
protection against tuberculosis are exempt from citations All other
requirements of the respiratory protection standard, including annual fit
testing, may continue to be cited for respirator use against other http://www.premierinc.com/all/safet
hazards, such as Severe Acute Respiratory Syndrome (SARS) or other y/publications/02-05-downloads/14-
February 2005 Patient Safety OSHA Memo bioaerosols. standard-interpretations.doc
The American Society for Healthcare Risk Management (ASHRM) has a
CD-ROM tool kit created for the various healthcare professionals who
work in the physician practice area. Risk managers can use it to conduct
an on-site survey of a practice for auditing purposes and also as a A sample tool kit has been made
baseline tool to develop additional checklist items. Key areas covered in available,
the tool kit include principles of documentation; what to report to the http://www.premierinc.com/all/safet
insurance claims representative; medical practice office systems risk y/publications/02-05-downloads/13-
prevention strategies; qualities of effective patient relations for office physician-office-toolkit-sample.pdf,
staff; and risks and strategies related to effective telephone and the complete kit can be
communication. The tool kit also can be used as a pre-assessment tool purchased at
Tool kit for physician to identify potential risk areas. The tool kit contains Adobe Acrobat® and http://www.ashrm.org/ashrm/resour
February 2005 Patient Safety office risk managers PowerPoint® files. ces/products.html#toolkits.
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Health information managers are directly involved in clinical quality
issues and outcomes through quality management programs, according
to the January practice brief titled, "The HIM Role in Patient Safety and
Quality of Care." Issued by the American Health Information
Management Association, the document discusses the legal and
regulatory environment, data standards, and return on investment in
technology. Health Information Managers also affect quality through
improved medical record documentation, accurate coding, and index
integrity. The author concludes that the health information managers'
Health information ability to affect patient safety is great, particularly through data reporting. To read the complete article, go to:
manager role in As the coordinators of data quality, the health information managers are http://library.ahima.org/xpedio/grou
February 2005 Patient Safety patient safety the "overseers" of consistent and accurate quality data. ps/public/
One of the special resources developed from past issues of Safety
Share is an archive of all safety tools published in the monthly
newsletter. The resources are organized in an Excel® spreadsheet, with
descriptions of each tool and where they can be accessed. The
spreadsheet is categorized by topic and includes many tools that are http://www.premierinc.com/all/safet
available from the Institute for Healthcare Improvement. These are listed y/publications/tool-list-by-
January 2005 Patient Safety Safety Share toolkit separately as well as included under each pertinent topic. category.xls
A free copy of the book, "Preventing Occupational Exposures to
Preventing Bloodborne Pathogens," a collection of articles from Advances in
Occupational Exposure Prevention (1994 to 2003), is available from the Premier Order free copies of the book from
Exposures to Safety Store. This 235-page book is edited by Jeannie Jagger and Jane the Premier Safety Store at:
Bloodborne Perry from the International Healthcare Worker Safety Center at the http://www.premierinc.com/all/safet
December 2004 Patient Safety Pathogens University of Virginia. y/store/
First, Do No Harm™,
Part 3: Healing Lives, For ordering and more information,
December 2004 Patient Safety Changing Cultures go to: www.p4ps.org.
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Obtain the booklets at the following
The National Diabetes Education Program (NDEP) has two new addresses:
evidence-based publications for healthcare providers and patients. The http://www.premierinc.com/all/safet
first helps providers identify people with pre-diabetes and undiagnosed y/publications/11-04-downloads/06-
Guiding Principles for diabetes, and provide patient-centered care. The second booklet guide-prin-hc-eng.pdf;
Diabetes Care; 4 complements the first and is for people with diabetes. It helps http://www.premierinc.com/all/safet
Steps to Control Your healthcare providers educate patients about self-care principles and y/publications/11-04-downloads/07-
November 2004 Patient Safety Diabetes for Life how to be active partners in their own care. 4-steps.pdf
This conference brought together a diverse group of medication safety
leaders from nursing, pharmacy and technology to explore the newest To learn more about this or past
generation of medication safety technology – designed to help prevent conferences,
Measuring Safety infusion programming errors and to collect data on IV delivery practices. http://my.premierinc.com/all/safety/
with Smart IV The specific focus of this conference was using the data the technology publications/08-04-downloads/09-
August 2004 Patient Safety systems yields as a road map for process improvement at hospitals alaris-conf-grid4.doc
The database is intended to raise awareness among healthcare
purchasers, providers and plans to improve care quality. The Leapfrog
Compendium documents and categorizes financial and non-financial
programs, such as those that reward providers with quality bonuses,
and those that reward providers with public recognition. Incorporated are
the Leapfrog standards of computerized physician order entry, evidence-
based hospital referrals and hospital intensivist programs. The site can The Leapfrog Compendium can be
be searched by state for programs targeting hospitals, physicians, freely accessed at
Pay-for-performance consumers and health plans, or it can be searched from a nationwide http://www.leapfroggroup.org/ircom
July 2004 Patient Safety programs list. pendium.htm.
Hospital flow can be measured at five levels: patient and community;
hospital throughput; hospital activity; hospital performance; and unit
Measurement guide performance. Each level provides a portion of the total measurement http://www.ihi.org/IHI/Topics/Flow/P
for hospital flow picture. Use this guide to learn how to measure data in these key areas atientFlow/EmergingContent/Hospit
July 2004 Patient Safety patterns to help you improve patient flow. √ alFlowMeasurementGuide.htm
Guidance for Using Using the AHRQ Inpatient Quality Indicators or Patient Safety Indicators
the AHRQ Quality to report on hospital quality or make payment decisions are discussed in
Indicators for a new guide. AHRQ's Quality Indicators are measurement tools that
Hospital-Level Public were developed by AHRQ and researchers to help individual hospitals
Reporting or use their own discharge data to better understand and improve the care
October 2004 Patient Safety Payment they provide.
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http://www.jcaho.org/accredited+or
Look alike/Sound The JCAHO has updated its frequently asked questions (FAQs) on the ganizations/patient+safety/05+npsg
October 2004 Patient Safety alike drug list 2005 NPSGs and included a new look-alike/sound alike drug list. /05_npsg_faqs.htm
Rationale and
Interpretive
Guidelines" for the http://www.premierinc.com/all/safet
2005 National Patient This document provides insight into how surveyors will be interpreting y/publications/10-04-downloads/11-
October 2004 Patient Safety Safety Goals the goals next year. npsg-guidelines-09-04.pdf
The National Patient Safety Foundation (NPSF) has a brochure and
companion video entitled "Patient Safety: Your Role in Making
Healthcare Safer." It was created to help patients become more involved
in their healthcare safety. The companion video will help supplement
and reinforce the safety message with patients. The brochure and video Purchase information at:
Patient Safety: Your are part of the National Patient Safety Foundation's Stand up for Patient http://www.mederrors.org/Merchant
Role in Making Safety campaign, which is designed to help patients learn practical ways 2/merchant.mv?Screen=SFNT&Sto
June 2004 Patient Safety Healthcare Safer to help ensure their safety in both inpatient and outpatient settings. re_Code=NO
http://my.premierinc.com/all/safety/
Five steps to patient The poster, available in English and Spanish, succinctly describes the publications/06-
June 2004 Patient Safety safety five steps patients can take to ensure safer care. 04_full_txt.htm#Safety_tools
The webcast features researchers, design professionals, and hospital
leaders presenting and discussing how hospitals of the future should be
built, organized, and managed to maximize patient safety and outcomes
and improve staff performance and satisfaction. Featured are up-to-the-
minute evidence-based design concepts for healthcare buildings. With
an anticipated $20 billion in new hospital construction and major
Designing the 21st renovations projected annually for the next decade, the central question
Century Hospital: of the conference was how hospitals' physical design, operating
Serving Patients and systems, and "corporate culture" affect patients, staff, and hospitals' http://www.rwjf.org/news/hospitalde
June 2004 Patient Safety Staff bottom line. sign
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A new NIOSH Alert is meant to increase healthcare worker awareness
about the health risks when working with hazardous drugs. The alert
Preventing also is intended to educate workers on the steps they can take to
Occupational protect their health. “Preventing Occupational Exposures to
Exposures to Antineoplastic and other Hazardous Drugs in healthcare Settings” may
Antineoplastic and be downloaded in prepublication form. Pharmaceutical agents are
other Hazardous classified as hazardous drugs if research indicates that they may cause http://www.premierinc.com/all/safet
Drugs in healthcare cancer, have developmental or reproductive toxicity, or harm organs in y/publications/05-04-downloads/11-
May 2004 Patient Safety Settings exposure at low doses. 2004-hazdrug-alert.pdf
JCAHO tips -
Compliance with http://www.premierinc.com/all/safet
prohibited Suggestions on how to comply with the National Patient Safety Goal y/publications/05-04-downloads/10-
May 2004 Patient Safety abbreviations related to dangerous abbreviations are now available from the JCAHO. implementation-tips.doc
The Ohio Hospital Association and Patient Safety Institute have
developed a surgical protocol (232 KB) to help Ohio providers prevent
Prevention of wrong- the incidence of wrong-site; wrong-patient and wrong-procedure surgery.
site, wrong-patient, The protocol outlines three steps for caregivers to follow prior to surgery: http://www.premierinc.com/all/safet
wrong-procedure patient verification, marking of the surgical site and a "time-out" before y/publications/05-04-downloads/08-
May 2004 Patient Safety errors incision to conduct a final checklist. ohio-surgical-protocol.pdf
The Tools and A new Web site, "The Tools and Techniques of Improved Medication
Techniques of Use," is intended for those in the healthcare community who design
Improved Medication medication safety programs and/or seek information to enhance existing http://www.aahp.org/content/naviga
April 2004 Patient Safety Use patient safety efforts. tionmenu/medcollab/medcollab.htm
A new easy-to-use Web site to help consumers and health professionals
find information about FDA-approved drug products more quickly and
efficiently. The new interface, Drugs @ FDA, is a searchable database
that includes information on approved prescription drugs, some over-the- http://www.accessdata.fda.gov/scri
April 2004 Patient Safety Drugs @ FDA counter drugs, and discontinued drugs. pts/cder/drugsatfda/
A peer-reviewed newsletter published by the Institute for Safe
Medication Practices (ISMP), Nurse Advise-ERR (February, 2004),
addresses issues such as mixing up IV lines while setting up or
programming a multiple-channel IV pump, the risks of leaving an
unnecessary intra-arterial line in place, a list of high-alert medications,
and questions to use when evaluating infusion pumps. Nurse Advise- Register at
ERR, a medication safety newsletter written especially for nurses by www.ismp.org/NursingArticles/inde
April 2004 Patient Safety Nurse Advise-ERR nurses, is offered free for the remainder of 2004. x.htm
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The Institute for Family Centered Care has produced a number of useful
resources to support the involvement of patients on hospital/healthcare
advisory committees and boards. These resources have been
Patient developed from the experiences of many hospitals/healthcare facilities
representative on and the patients, family members and community representatives who
April 2004 Patient Safety safety committee have worked with them. http://www.familycenteredcare.org/
OSHA’s Hospital e-tool is a Web-based training tool for safety and http://www.premierinc.com/all/safet
health hazard assessments in hospitals that provides a virtual hospital y/resources/needlestick/resources.
March 2004 Patient Safety Hospital e-tool using graphics and visual assists for learning. html#OSHA
http://www.premierinc.com/all/safet
A free electronic bi-monthly newsletter produced by OSHA to inform the y/resources/needlestick/resources.
March 2004 Patient Safety Quick Takes public about recent OSHA activities. html#OSHA
This book includes stories of all types of medical errors such as wrong
Internal Bleeding: patient cases, judgment calls gone awry, and retained sponges. The
The Truth Behind analysis of the causes of errors leads to their suggestions of what
America's Terrifying providers, patients, policymakers, and healthcare leaders need to do to The book can be purchased from
Epidemic of Medical cure this epidemic. The 320-page hardcover book includes an extensive Rugged Land at
February 2004 Patient Safety Mistakes bibliography and 40 pages of footnotes. http://www.ruggedland.com.
Tips for conducting a self-evaluation of compressed gas and cylinder
safety. The article includes a checklist of 10 questions addressing
Checklist - proper storage, use, and handling of compressed gas cylinders to http://www.premierinc.com/all/safet
Compressed gas prevent associated hazards such as oxygen displacement, fires, y/publications/02-04-downloads/09-
February 2004 Patient Safety safety explosions, and toxic exposure. oregon-OSHA-checklist.doc
The National Fire Protection Association (NFPA) provides information
on how to interface elevators and fire alarm systems. The information http://www.premierinc.com/all/safet
ensures safe emergency operation of modern elevators that meet y/publications/01-04-downloads/08-
requirements under NFPA and American Society of Mechanical interfacing-elevators-fire-
January 2004 Patient Safety Fire safety tips Engineers codes. alarms.doc
Safety tips for preventing hospital bed fires, the safety recommendations
apply to both electrically powered and manual healthcare beds, as well http://www.premierinc.com/all/safet
as adjustable medical beds. Some of the initial safety-check y/publications/01-04-downloads/07-
January 2004 Patient Safety Fire safety tips suggestions involve simple observations. FDA-bedfires-12-18-03.pdf
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Through interviews, narration and a viewer's guide, the program
highlights actions that trustees can take to improve patient safety within
The video can be purchased for
their organizations. This video can also aid orientation efforts for new
$275 using order code V02/03AAH.
trustees while reinforcing current trustees' understanding of their role in
Governance, Quality To order, call Joint Commission
creating an organizational culture that focuses on patient safety.
and Safety: The Resources (JCR) Customer
Impact of Joint Service at 877.223.6866 weekdays
Commission from 8 a.m. to 8 p.m. CT, or visit
Accreditation on Infomart on the JCR Web site at:
January 2004 Patient Safety Health Care Delivery www.jcrinc.com.
Healthy Hospitals: The report offers tips and resources for how hospitals can manage
Controlling Pests pests while also protecting the health of people and the environment. http://my.premierinc.com/all/safety/
Without Harmful publications/12-03-downloads/11-
December 2003 Patient Safety Pesticides pesticides.pdf
The paper is an educational tool designed to provide consensus-based, http://my.premierinc.com/all/safety/
Magnetic resonance valid and medically credible information and features detailed, useful publications/12-03-
December 2003 Patient Safety safety checklists. downloads/12_MR-safety.pdf
A resource guide designed to help the elderly and their children start http://www.premierinc.com/all/safet
discussions about end-of-life wishes before an unexpected illness y/publications/11-03-downloads/08-
arises. The booklet is geared toward the elderly and children of the crisis-convo.pdf
aging, and includes a resources list with helpful books and Web sites.
Conversations Before
November 2003 Patient Safety the Crisis
A resource folder designed to help hospitals communicate with patients
Strategies for and families.
Leadership:
Improving http://www.premierinc.com/all/safet
Communications with y/publications/11-03-downloads/10-
November 2003 Patient Safety Patients and Families pcp-english.pdf
The Pink Book – “Epidemiology and Prevention of Vaccine Preventable
Epidemiology and Diseases,” the 7th edition from 2002, is now in its second printing. The book is available for download
Prevention of or purchase at
Vaccine Preventable http://www.cdc.gov/nip/publications
October 2003 Patient Safety Diseases /pink/default.htm
This guide is intended to remind providers to deliver appropriate The guide is available in English at
preventive services while involving patients directly in their preventive http://www.ahrq.gov/ppip/adguide/
The Pocket Guide to care. It includes recommendations on screening tests and
Good Health for immunizations, questions for patients to ask health care providers, and
October 2003 Patient Safety Adults resources for additional information.
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The Failure Modes and Effects Analysis (FMEA) tool is a method for
analyzing any process to see where it is likely to fail; to see how
The Failure Modes changes you are considering might affect the safety of the process; and
and Effects Analysis to track changes in the Risk Priority Number (or RPN) of the process
September 2003 Patient Safety (FMEA) over time. √ http://www.qualityhealthcare.org/.
The Trigger Tool for Measuring Adverse Drug Events (ADEs),
developed with Premier, is a simple yet powerful method of identifying
The Trigger Tool for and tracking the number of medication errors in your hospital – using a
Measuring Adverse retrospective review of patient records to look for sentinel clues or
September 2003 Patient Safety Drug Events (ADEs) "triggers" that indicate a medication error has occurred. √ http://www.qualityhealthcare.org/.
Learning from Each
Other: Success
Stories and Ideas for
Reducing http://www.premierinc.com/all/safet
Restraint/Seclusion The award recognizes excellence in graphic design, editorial content, y/publications/09-03_downloads/08-
September 2003 Patient Safety in Behavioral Health and the ability to achieve overall communications excellence. learning-from-each-other.pdf
Sessions on patient safety officer training, along with general
Quality Colloquium conference sessions on error reduction and quality enhancements; the The CD-ROMs can be purchased
conference at role of technology; informatics; competition for quality and six sigma at
September 2003 Patient Safety Harvard University process improvement. http://www.qualitycolloquium.com/.
This season's flu campaign emphasizes protecting yourself and the
ones you love by getting a flu vaccine. You'll find materials for parents,
Spanish speakers, those at high risk for flu complications, and
immunization providers. Materials are free and can be downloaded http://www.cdc.gov/nip/flu/gallery.ht
September 2003 Patient Safety Flu Gallery easily. m
The fourth installment of the Joint Commission's free video information
series, "The Priority Focus Process and Tracer Methodology". The five
The Priority Focus to seven-minute videos highlight the key components of the new To view this video, go to:
Process and Tracer accreditation process. http://www.jcaho.org/accredited+or
August 2003 Patient Safety Methodology ganizations/svnp/svnp_video.htm
http://www.premierinc.com/all/safet
y/publications/08-
Resource for PCA 03_downloads/09_ISMP_PCA_pu
August 2003 Patient Safety pumps The ISMP Medication Safety Alert's a two-part series on PCA pumps. mpsafety_07-03.doc
Posters and fact sheets providing tips to help patients avoid errors http://www.premierinc.com/all/safet
5 Steps to Safer related to prescription medicines, laboratory tests, procedures and y/publications/08-
August 2003 Patient Safety Healthcare surgery 03_downloads/10_5-steps.pdf
Excel: Premier / Modules / b24d7277-3ce3-4a13-baeb-3f4ffe9a8b03.xls / Patient Safety Share
Premier Safety Share
IHI
Month Year Topic by Tab Tool Description Tool Location
All materials are available at:
http://www.qualityhealthcare.org/Q
QHC requires free registration to access all tools. The site will include HC/
Surgical Site results from teams that participated in the collaborative, as well as tools, Topics/PatientSafety/SurgicalSiteIn
July 2003 Patient Safety Infection Tools such as forms, policies and order sets. √ fections/
The Effect of Health http://my.premierinc.com/all/safety/
Care Working publications/07-
Conditions on Patient Evidence in the scientific literature to make specific recommendations 03_downloads/11_AHRQ_worksum
July 2003 Patient Safety Safety Report about these strategies for improving patient safety. .pdf
http://www.ahrq.gov/consumer/safe
meds/safemeds.htm for the English
version,
http://www.ahrq.gov/consumer/safe
Your Medicine: Play medsp/safemedsp.htm for the
June 2003 Patient Safety It Safe To help consumers use prescription medicines safely. Spanish version.
IHI’s global online
improvement
June 2003 Patient Safety resource Improving access in the office practice √ http://www.QualityHealthCare.org
http://www.ama-
assn.org/ama/pub/article/2403-
June 2003 Patient Safety Standing Orders A collaborative effort to improve influenza vaccination rates 7702.html
These algorithms and a “stop” sign
that can be printed and used in
these settings – if this becomes
necessary – are available on
Tools for rapid assessment of a patient who may present with one or Premier’s Emergency and Public
May 2003 Patient Safety SARS Triage Tools more symptoms suggestive of SARS Health Preparedness site.
http://www.qualityhealthcare.org/Q
HC/Topics/PatientSafety/Medicatio
Trigger Tool for The trigger tool measures adverse drug events and provides instructions nSystems/Tools/Trigger+Tool+for+
Measuring Adverse for conducting a retrospective review of patient records using triggers to Measuring+Adverse+Drug+Events
May 2003 Patient Safety Drug Events (ADEs) identify possible ADEs. √ +(IHI+Tool).htm
http://my.premierinc.com/all/safety/
April 2003 Patient Safety First, Do No Harm Case studies and safety responses store/P4PS_video_form.doc
Excel: Premier / Modules / b24d7277-3ce3-4a13-baeb-3f4ffe9a8b03.xls / Patient Safety Share
Premier Safety Share
IHI
Month Year Topic by Tab Tool Description Tool Location
The site enables searching for measures by specific disease, treatment,
National Quality age range, gender, and a variety of other topics. The clearinghouse also
Measures permits side-by-side comparative measurements that identify which will http://www.qualitymeasures.ahrq.g
April 2003 Patient Safety Clearinghouse™ best work for a given organization. ov/
1.
A set of tools designed to reduce medication errors and help hospitals http://www.premierinc.com/all/safet
take a system-based approach to address such errors. the three main y/publications/03-
Pathways components help hospital leaders and professionals 03_downloads/01_b.pdf 2.
incorporate medication safety into an organization's strategic plan; http://www.premierinc.com/all/safet
identify specific error-prone processes and devise safe alternatives y/publications/03-
using a process flow diagram; learn from case scenarios and the ISMP's 03_downloads/01_d.pdf 3.
10 Key Elements of Medication Use System; and prepare to implement http://www.premierinc.com/all/safet
a bedside bar-coding system for administering medications. 1. An y/publications/03-
executive rounds tool describing how a culture of safety can be fostered 03_downloads/01_g.pdf 4.
2. A sample medication error reporting form designed to collect and http://www.premierinc.com/all/safet
analyze actual and potential medication errors 3. A checklist/action plan y/publications/03-
for the safe use of high-alert medications 4. A sample policy detailing a 03_downloads/01_h.pdf 5.
Medication safety blame-free adverse drug event reporting program 5. A patient safety tool http://www.premierinc.com/all/safet
strategic plan, case helping patients understand their rights and responsibilities regarding y/publications/03-
March 2003 Patient Safety studies, resources safe medication use. 03_downloads/01_j.pdf
http://my.premierinc.com/all/safety/
Pathways for A set of tools designed to reduce medication errors and help hospitals publications/03-
March 2003 Patient Safety Medication Safety take a system-based approach to address such errors. 03_downloads/11_extraordinary.pdf
http://my.premierinc.com/all/safety/
Wrong-site surgery Recommendations for eliminating as well as managing the discovery of publications/03-
March 2003 Patient Safety checklist a wrong-site surgery. 03_downloads/11_extraordinary.pdf
http://my.premierinc.com/all/safety/
Perspectives on The report is devoted entirely to JCAHO'S 2003 National Patient Safety publications/02-
February 2003 Patient Safety Patient Safety Goals and provides practical advice and tips for meeting those goals. 03_downloads/13_ps_01-03.pdf
A new online peer-reviewed journal to showcase patient safety lessons
Web M & M (Web drawn from actual cases of medical errors. The journal is designed to
Morbidity and educate healthcare providers about medical errors in an engaging,
February 2003 Patient Safety Mortality), blame-free environment. http://www.webmm.ahrq.gov/
Excel: Premier / Modules / b24d7277-3ce3-4a13-baeb-3f4ffe9a8b03.xls / Patient Safety Share
Premier Safety Share
IHI
Month Year Topic by Tab Tool Description Tool Location
Pathways for A set of tools designed to reduce medication errors and help hospitals
January 2003 Patient Safety Medication Safety take a system-based approach to address such errors http://www.medpathways.info/
The site provides safety resources, injury and exposure data, industry
www.orprecautions.c information, information about the Needlestick Safety Act, and
January 2003 Patient Safety om convenient links to much more OR safety information. http://www.orprecautions.com/
http://my.premierinc.com/all/safety/
Veterans’ publications/01-
Administration guide Tools to help reduce the potential for entrapment in hospital bed 03_downloads/12_VHA_bed_entra
January 2003 Patient Safety on bed safety zones systems. pment.pdf
http://my.premierinc.com/all/safety/
publications/01-
03_downloads/12_VHA_bed_entra
pment.pdf,
http://my.premierinc.com/all/safety/
publications/01-
03_downloads/14_CorrSurgPt.pdf,
Sample OR guides - Increased attention to medical errors and patient safety as they relate to http://my.premierinc.com/all/safety/
Veterans' correct surgery sites is leading institutions to develop guides and other publications/01-
January 2003 Patient Safety Administration instructional materials to help reduce such errors. 03_downloads/14_CorrSurgPt.pdf
First, Do No Harm
Part 2: Taking the
December 2002 Patient Safety Lead Takes the dialog within the patient safety movement to new levels http://www.fdnh.com/
AHRQ WebM&M
(Morbidity and
Mortality Rounds on Peer-reviewed, Web-based medical journal to showcase patient safety
December 2002 Patient Safety the Web) lessons drawn from actual cases of medical errors. http://www.webmm.ahrq.gov/
It organizes the technology into four categories based on function: (1) http://my.premierinc.com/all/safety/
electronic drug references, (2) e-prescribing solutions, (3) integrated publications/12-
Physician drug e- drug references and formulary tools, and (4) integrated electronic 02_downloads/07_improv_drug_pr
December 2002 Patient Safety prescribing medical records and e-prescribing systems. escrib.pdf
http://my.premierinc.com/all/safety/
Role of the Patient Valuable tips on how patients can choose "advocates" to look out for publications/11-
November 2002 Patient Safety Advocate their best healthcare interests 02_downloads/08_nspf.pdf
This site includes details of the design process, infection control and http://www.ordesignandconstruction
November 2002 Patient Safety OR design tools case studies. .com/
Excel: Premier / Modules / b24d7277-3ce3-4a13-baeb-3f4ffe9a8b03.xls / Patient Safety Share
Premier Safety Share
IHI
Month Year Topic by Tab Tool Description Tool Location
Preventing Infections
in the Hospital — Provides patients with helpful principles for managing their healthcare
What You as a and becoming an active partner with their healthcare team through http://www.npsf.org/download/Prev
October 2002 Patient Safety Patient Can Do infection prevention entingInfections.pdf
Step-by-step instructions on how to disclose medical errors, why
disclosure is important, and how open communication can strengthen http://www.npsf.org/htm/prevent_inf
October 2002 Patient Safety Let's Talk the patient-provider relationship are some of the subjects on the video. ections.html
Videotapes: Patient,
worker, environment Case studies of successful safety
and medication programs –Order from Premier
October 2002 Patient Safety safety Case studies of successful safety programs Safety Institute online Safety Store.
Resources to reduce
pediatric medicine http://66.77.20.158/ahrq/childhealth
September 2002 Patient Safety errors The materials outline methods for reducing errors in pediatric medicine. webconf/
http://my.premierinc.com/all/safety/
A recent study cautions doctors that air mattresses used in hospitals, publications/09-
nursing homes, and home care can have deadly consequences for 02_downloads/08_Air_mattresses_
September 2002 Patient Safety Air mattress dangers some patients abstract.doc
The Web notification will disseminate device-related safety information
Web-based safety useful to healthcare providers but inappropriate for the FDA’s existing http://www.fda.gov/cdrh/safety.html
September 2002 Patient Safety notification program notifications. #web
http://my.premierinc.com/all/safety/
American Society of A new survey indicates that larger hospitals reporting a shortage of publications/09-
Anesthesiologists anesthesiologists are also delaying elective surgery and limiting access 02_downloads/09_ASA_07-30-
September 2002 Patient Safety survey to operating rooms 02.doc
Radiation safety http://www.orau.gov/reacts/define.h
August 2002 Patient Safety basics An excellent resource for radiation information and training tm
Hospital emergency departments (EDs) are the source of more than 50 http://www.jcaho.org/about+us/new
percent of all reported cases of patient death or permanent injury due to s+letters/sentinel+event+alert/index
July 2202 Patient Safety ED delays delays in treatment .htm
http://my.premierinc.com/all/safety/
Institute for Safe Medication Practices (ISMP) offers six tips to reduce publications/06-
Medication Safety the risk of overdoses from patient- controlled analgesia (PCA) by proxy. 02_downloads/05_36_2002_niosh_
June 2002 Patient Safety Alert - May 29, 2002 Tips include selection criteria, protocols, monitoring, and education. ventilation_139.pdf
Excel: Premier / Modules / b24d7277-3ce3-4a13-baeb-3f4ffe9a8b03.xls / Patient Safety Share
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IHI
Month Year Topic by Tab Tool Description Tool Location
"Reducing Medication Errors," one
of a four-part videotape series titled
More than 40 nationally recognized safety experts sharing their "Safety Issues in Healthcare,"s is
Reducing Medication strategies for successful programs on patient safety, prevention of available from the Safety Institute's
June 2002 Patient Safety Errors medication errors, and occupational and environmental safety. Safety Store.
http://my.premierinc.com/all/safety/
Quality of Health The book describes the state of healthcare in the United States by publications/06-
Care in the United examining medical mistakes, substandard care for chronic conditions, 02_downloads/02_quality_care_US
June 2002 Patient Safety States: A Chartbook disparities in care, and the lack of preventive care. _status_rpt.pdf
The manual summarizes the report’s themes for improvements in the
U.S. healthcare system using a four-level framework: patients’ http://my.premierinc.com/all/safety/
experiences; functioning of small units of care delivery; functioning of publications/06-
Crossing the Quality the organizations that support microsystems; and the supporting 02_downloads/03_IOM2_manual.p
June 2002 Patient Safety Chasm environment that shapes the organization df
Nursing Home A pilot Web site that lists health deficiencies for nursing homes that
June 2002 Patient Safety Compare have been filed, examined, and confirmed following complaints. http://www.medicare.gov/
How to Protect http://my.premierinc.com/all/safety/
Yourself and Your publications/05-
Family from Medical The brochure outlines specific steps for preventing medication errors, 02_downloads/12_AHRQ_Protect_
May 2002 Patient Safety Errors wrong-site surgery, and infections Yourself_Family.doc
http://my.premierinc.com/all/safety/
Ways to Help Your publications/05-
Family Prevent A patient fact sheet with 20 tips on preventing medical errors and a 02_downloads/13_AHRQ_Patient_
May 2002 Patient Safety Medical Errors family-oriented brochure Fact_Sheet_20-Tips.doc
Excel: Premier / Modules / b24d7277-3ce3-4a13-baeb-3f4ffe9a8b03.xls / Patient Safety Share
Premier Safety Share
IHI
Month Year Topic by Tab Tool Description Tool Location
Audio files and slides are available from a recent Premier webcast that
describes how hospitals can bring their organizations into compliance
with current EPA hazardous waste regulations and Joint Commission
requirements while preparing for future disposal restrictions. Increasing
national interest in a sustainable environment has accelerated the
healthcare industry's attention to waste management and recycling
practices. Among those challenges in waste management and recycling
is safe disposal of leftover medications, antibiotics, and other chemicals
that may find their way into our drinking water and food chain. Premier
hosted a public webcast titled “Implementing a pharmacy waste
management system” to understand the problem of pharmaceutical
waste and suggest solutions and tips on how to separate, label and
dispose of common chemicals and drugs. Charlotte Smith, president of
Implementing a PharmEcology Associates, LLC, presented the topic, noting that http://www.premierinc.com/quality-
pharmaceutical managing pharmaceutical waste is becoming a nationwide issue, and safety/tools-
waste management highlighted the impact on the ecosystem from disposal of leftover drugs services/safety/news/2007/11/Phar
December 2007 Pharmaceutical Waste Management system through flushing and landfilling. maSafetyStory_11162007.jsp
A standardized hazardous waste manifest form that must be used by all
hazardous waste generators and treatment, storage, and disposal More information on the Uniform
facilities to track waste's progress from generation to disposal is Hazardous Waste Manifest,
available from the U.S. Environmental Protection Agency (EPA). including a list of printers approved
Handlers of waste (generators, or treatment, storage or disposal by EPA to supply the new form and
facilities) must obtain the new forms from any source that has been state requirements for use of the
approved for printing and distribution by the EPA Manifest Registry. new form, can be found at:
Uniform Hazardous Some states have additional requirements regarding the use of the new http://www.epa.gov/epaoswer/hazw
Oct 2006 Pharmaceutical Waste Management Waste Manifest Uniform Hazardous Waste Manifest. aste/gener/manifest/
The document, "Managing Pharmaceutical Waste: A 10-Step Blueprint,"
is designed to help hospitals develop and implement a comprehensive
pharmaceutical hazardous waste management program. The plan
Managing combines regulatory compliance and best management practices with http://www.premierinc.com/quality-
Pharmaceutical waste minimization while minimizing risk in a cost effective manner. It is safety/tools-services/safety/safety-
Waste: A 10-Step organized to permit using the steps as needed, and not necessarily share/06-06-downloads/13-h2e-
June 2006 Pharmaceutical Waste Management Blueprint consecutively. pharma-blueprint-04-15-06.pdf
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Premier Safety Share
IHI
Month Year Topic by Tab Tool Description Tool Location
Hospitals for a Healthy Environment (H2E) hosted a March 11
teleconference on disposal of chemotherapeutic wastes. Presenters
from a waste consultancy and H2E offered an overview of proper
chemotherapeutic waste segregation, treatment, and minimization
techniques to reduce the safety, health, and environmental impacts of
managing this hazardous waste stream. The conference included
education on safest practices, with the understanding that many
chemotherapeutic agents in use today are not regulated under
Environmental Protection Agency's (EPA) Resource Conservation and Teleconference materials are at
Recovery Act, but should be included from a safety and health http://www.h2e-
perspective. H2E as provided six free Microsoft® Excel spreadsheets to online.org/events/teleconf/molydes
help hospitals collect and manage waste data (solid waste, solid waste c.cfm?Date=2005-03-11&t. at
recyclables, hazardous waste, hazardous waste recyclables, infectious http://www.hercenter.org/wms.html
H2E resources - waste and general facility information). The bottom half of the to access the H2E Waste
Chemo conference; spreadsheet contains basic data and the top half of the spreadsheet Management System and receive
waste disposal does the calculations. Users register and then receive a notice if the updates about the tool.
May 2005 Pharmaceutical Waste Management management tools database is updated.
The Environmental Protection Agency (EPA) has new guidance about
how the general public should handle used syringes/needles and other
sharps generated at home or other non-healthcare locations. The
guidance suggests that syringe users dispose of used syringes in ways
that keep the sharps out of the general trash, with a goal of protecting
workers along the solid waste "stream" and at land fills. The new EPA
guidance is published in two brochures: Protecting Your Community
from Sharps: Options for Safe Disposal of Sharps and Protect Yourself,
EPA guidance - Protect Others: Safe Options for Needle Disposal.
Safer needle, sharps http://www.premierinc.com/all/safet
disposal in public y/publications/02-05-downloads/10-
February 2005 Pharmaceutical waste management areas med-govt.pdf
Preventing
Occupational
Exposures to
Antineoplastic and http://www.premierinc.com/all/safet
Other Hazardous y/resources/pharma-
Drugs in Healthcare waste/downloads/2004-
September 2004 Pharmaceutical waste management Settings NIOSH Alert on antineoplastic drugs HazDrugAlert.pdf
Excel: Premier / Modules / b24d7277-3ce3-4a13-baeb-3f4ffe9a8b03.xls / Patient Safety Share
Premier Safety Share
IHI
Month Year Topic by Tab Tool Description Tool Location
The Guidance for
Industry and FDA
Staff: Frequently The Food and Drug Administration's (FDA) Center for Devices and
Asked Questions Radiological Health (CDRH) has released a new FAQ on single-use
(FAQs) on the Status devices. The document, titled, "The Guidance for Industry and FDA
of Reprocessed Staff: Frequently Asked Questions (FAQs) on the Status of
Single Use Devices Reprocessed Single Use Devices (SUDs) that receive a Not
(SUDs) that receive a Substantially Equivalent (NSE) Letter," (.pdf) (140 KB) explains
Not Substantially instances in which a NSE letter pertains to a reprocessed SUD and http://www.premierinc.com/all/safet
Equivalent (NSE) whether in-stock, reprocessed SUDs can be used once the reprocessor y/publications/12-04-downloads/14-
December 2004 Reuse of Single Use Devices Letter can no longer distribute the SUDs as a result of a NSE letter. sud-guidance-nse-ltr.pdf
The CD-ROM is $475 for AAMI
members and $655 for non-
The collection has every AAMI document covering sterilization in members. Contact AAMI at
healthcare facilities, sterilization equipment, and industrial sterilization 800.332.2264, Ext. 217, or visit
AAMI sterilization process control. It includes FDA and CDC guidance documents and the http://aami.org and click on
July 2004 Reuse of Single Use Devices documents Code of Federal Regulations sections pertaining to sterilization. "marketplace."
Revised forms and instructions for voluntary and mandatory reporting to
MedWatch for healthcare facilities and others to use in reporting
MedWatch reporting adverse events involving single-use medical devices that have been http://www.fda.gov/medwatch/getfo
March 2004 Reuse of Single Use Devices forms reprocessed for reuse. rms.htm
An Overview of the
Regulatory
Requirements for
Reprocessing of
Single-Use Devices A two-CD set that covers the regulatory requirements that a hospital http://www.fda.gov/cdrh/reuse/reus
August 2002 Reuse of Single Use Devices by Hospitals must meet if it reprocesses single-use devices (SUDs). e-important.shtml
A new pamphlet being released by the CDC – Sharps Safety for
Healthcare Personnel – describes healthcare worker risk, how and when
injuries occur, how sharps safety devices reduce injuries, and the
importance of developing a "culture of safety" for sharps injury
prevention. This and other sharps injury prevention brochures are
publicly accessible on the Safety Institute Web site to assist frontline http://www.premierinc.com/quality-
workers in selecting safety devices to evaluate for their institutions. The safety/tools-
Web site also contains links to national lists of sharps safety products. A services/safety/topics/needlestick/d
Sharps Safety for new addition to the available tools is the needlestick prevention booklet ownloads/cdc-sharps-brochure-10-
October 2007 Sharps Injury Prevention Healthcare Personnel for non-acute care. 01-07.pdf
Excel: Premier / Modules / b24d7277-3ce3-4a13-baeb-3f4ffe9a8b03.xls / Patient Safety Share
Premier Safety Share
IHI
Month Year Topic by Tab Tool Description Tool Location
The U.S. Public Health Service has updated the recommendations for
the management of healthcare personnel (HCP) with occupational
exposure to blood and other body fluids that might contain human
immunodeficiency virus (HIV). Published in the September 30, 2005
Morbidity and Mortality Weekly Report (MMWR) , the recommendations
(.pdf) (267 KB) emphasize adherence to postexposure prophylaxis
(PEP) regimens when indicated, expert consultation in managing http://www.premierinc.com/all/safet
HIV post-exposure exposures, follow-up to improve HCP adherence to PEP, and monitoring y/publications/10-05-downloads/11-
October 2005 Sharps Injury Prevention prophylaxis for adverse events, including seroconversion. hiv-rr5409.pdf
A resource book for healthcare organizations, clinicians and others
designed to make it easier to find sharps injury prevention, blood The Compendium is now available
exposure prevention and infection control products that can protect for immediate purchase as in e-
patients, healthcare workers and others. A cooperative effort from book. The printed version will be
medical device and infection control product manufacturers, the available in a few months. The
Compendium is sponsored by the Premier Safety Institute, ISIPS, price will be $129.95, but for a
Managing Infection Control Magazine, AOHP and NAPPSI. It will be limited time, a pre-publication price
published both as a printed book and as an e-book. In the printed book, of $89.95 is available. For more
The Compendium of each device is paired with a custom evaluation form to facilitate record information, call 801.280.8797 or
Infection Control keeping. The digital edition of the Compendium will have each product send an e-mail to
July 2005 Sharps Injury Prevention Technologies linked directly to the Sample Procurement Center. info@medicalsafetybook.com.
The Environmental Protection Agency (EPA) has new guidance about
how the general public should handle used syringes/needles and other
sharps generated at home or other non-healthcare locations. The
guidance suggests that syringe users dispose of used syringes in ways
that keep the sharps out of the general trash, with a goal of protecting
workers along the solid waste "stream" and at land fills. The new EPA
guidance is published in two brochures: Protecting Your Community
from Sharps: Options for Safe Disposal of Sharps and Protect Yourself,
EPA guidance - Protect Others: Safe Options for Needle Disposal.
Safer needle, sharps http://www.premierinc.com/all/safet
disposal in public y/publications/02-05-downloads/10-
February 2005 Sharps Injury Prevention areas med-govt.pdf
Excel: Premier / Modules / b24d7277-3ce3-4a13-baeb-3f4ffe9a8b03.xls / Patient Safety Share
Premier Safety Share
IHI
Month Year Topic by Tab Tool Description Tool Location
A free copy of the book, "Preventing Occupational Exposures to
Preventing Bloodborne Pathogens," a collection of articles from Advances in
Occupational Exposure Prevention (1994 to 2003), is available from the Premier Order free copies of the book from
Exposures to Safety Store. This 235-page book is edited by Jeannie Jagger and Jane the Premier Safety Store at:
Bloodborne Perry from the International Healthcare Worker Safety Center at the http://www.premierinc.com/all/safet
December 2004 Sharps Injury Prevention Pathogens University of Virginia. y/store/
A list of journal articles published between 1988 and 2004 that pertains Document:
to the review, selection, testing, or evaluation of safer needle devices. http://www.premierinc.com/all/safet
The document, titled "Articles and abstracts," includes a list of selected y/resources/needlestick/downloads/
Literature review for references, followed by the citation and full abstract. Detailed analysis of sharps-journal-lit-listing-abstract-08-
review, selection, the same journal list is provided in a tabular summary format (link 04.doc Tabular format:
testing or evaluation below), permitting ease in sorting the journals by: study focus, author, http://www.premierinc.com/all/safet
of safer needle journal, title, population-setting, study design, key findings-summary, y/resources/needlestick/downloads/
Sept 2004 Sharps Injury Prevention devices conclusions and key words for searching. sharps-journal-lit-analysis-08-04.xls
Sequence for
Donning and
Removing Personal http://www.premierinc.com/all/safet
Protective Equipment y/publications/05-04-downloads/09-
May 2004 Sharps Injury Prevention (PPE) ppeposter-1322.pdf
The “Frequently Asked Questions” (FAQs) regarding sharps safety were
updated following a recent Premier-sponsored audio conference that
featured speakers from OSHA and CDC. Issues addressed include
specific devices, device selection, evaluation and replacement, worker http://www.premierinc.com/all/safet
Frequently Asked training and compliance, record keeping, schedules and implementation y/resources/needlestick/downloads/
April 2004 Sharps Injury Prevention Questions and a list of OSHA resources. OSHA-FAQs.pdf
http://www.epa.gov/epaoswer/other
/medical/sharps.htm, Disposal Tips
for Home Health Care (patient
flyer) (.pdf), Disposal Tips for
Home Health Care (professional
A new at-home sharps disposal options based on the recommendations brochure) (.pdf), New Information
of the Coalition for Safe Community Needle Disposal. It has added to its About Disposing of Medical Sharps
Sharps disposal current recommendations additional new options for disposal of medical (.pdf)
March 2004 Sharps Injury Prevention information flyers sharps outside the healthcare setting.
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Premier Safety Share
IHI
Month Year Topic by Tab Tool Description Tool Location
A link to an order form, is available
at:
ECRI presents ratings of eight sharps disposal containers designed for http://www.ecri.org/Newsroom/PR_
September 2003 Sharps Injury Prevention Health Devices patient rooms or patient treatment areas. Detail.asp?DN=20030828_73
The Premier Safety Institute's Bloodborne Pathogen (BBP) Assessment
Bloodborne Tool provides a comprehensive checklist for assessing compliance with
Pathogen (BBP) OSHA's complete bloodborne pathogen rule, including considerations Download the tool from the Sharps
August 2003 Sharps Injury Prevention Assessment Tool for a complete sharps injury prevention program. Injury Prevention module
http://www.premierinc.com/all/safet
This site from the CDC’s Business/Labor division provides helpful y/publications/08-
HIV/AIDS workplace information and toolkits that help businesses tailor a program specific to 03_downloads/12_HIV_wkpl_mgr_
August 2003 Sharps Injury Prevention policy materials their workplace. kit.pdf
ECRI - General In addition to standard performance and human-factors design issues,
infusion pumps and the report addresses patient safety, reflecting some exciting
December 2002 Sharps Injury Prevention patient safety advancements in infusion pump technology info@ecri.org
OSHA Compliance OSHA compliance tools and resources for implementing a Premier Safety Web resource:
May 2002 Sharps Injury Prevention Tools comprehensive sharps injury prevention program. OSHA compliance tools
States the agency's policy on disposal of contaminated needles and
blood tube holders following blood-drawing procedures. The bulletin also
provides the most recent sharps injury data from the Exposure
Prevention Information Network. OSHA developed this “Information
Regarding the Disposal of Contaminated Needles and Blood Tube
Policy on Holders Used for Phlebotomy” to provide relevant information regarding http://my.premierinc.com/all/safety/
contaminated blood its policy on the prohibition of contaminated needle removal from publications/12-03-downloads/10-
December 2003 Sharps Injury Prevention tube holders medical devices. OSHA-tib-10-15-03.pdf
Excel: Premier / Modules / b24d7277-3ce3-4a13-baeb-3f4ffe9a8b03.xls / Patient Safety Share
Premier Safety Share
IHI
Month Year Topic by Tab Tool Description Tool Location
Available resources include: An audio-conference with downloadable
materials, including DVT research slides, physician and nurse
assessments, sample order sets, and a recording of the audio
conference. A webcast on anticoagulation therapy includes speakers
from hospitals with successful anticoagulation therapy programs who
share their journey to reduce adverse events and discuss The Joint
Commission's 2008 National Patient Safety Goals for anticoagulation
therapy. Slides and an audio file of the webcast and other resources
also are available. An Informatics comparative data tools help users
identify potential problems, track progress and monitor variations,
enabling users to actively reduce the rates of DVT and other serious
avoidable conditions, establish performance benchmarks and share
best practice interventions. Premier’s "Performance Improvement
Premier Safety Portal" is a resource for clinicians to get information on performance http://www.premierinc.com/quality-
Institute – QI and improvement advice and best practices on key clinical quality and safety safety/tools-
patient education issues, including prevention of VTE. AHRQ Consumer’s Guide –just services/safety/topics/Venous-
tools for VTE released in August 2008 Your Guide to Preventing and Treating Blood Thromboembolism/venous-
September 2008 Venous Thromboembolism prevention Clots. thromboembolism.jsp
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Premier Safety Share
Excel: Premier / Modules / b24d7277-3ce3-4a13-baeb-3f4ffe9a8b03.xls / Patient Safety Share
Premier Safety Share
Excel: Premier / Modules / b24d7277-3ce3-4a13-baeb-3f4ffe9a8b03.xls / Patient Safety Share
Premier Safety Share
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Premier Safety Share
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Premier Safety Share
Excel: Premier / Modules / b24d7277-3ce3-4a13-baeb-3f4ffe9a8b03.xls / Patient Safety Share
Premier Safety Share
Excel: Premier / Modules / b24d7277-3ce3-4a13-baeb-3f4ffe9a8b03.xls / Patient Safety Share
Premier Safety Share
Excel: Premier / Modules / b24d7277-3ce3-4a13-baeb-3f4ffe9a8b03.xls / Patient Safety Share
Premier Safety Share
Excel: Premier / Modules / b24d7277-3ce3-4a13-baeb-3f4ffe9a8b03.xls / Patient Safety Share
Premier Safety Share
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Premier Safety Share
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Premier Safety Share
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Premier Safety Share
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Premier Safety Share
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Premier Safety Share
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Premier Safety Share
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Premier Safety Share
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Premier Safety Share
Excel: Premier / Modules / b24d7277-3ce3-4a13-baeb-3f4ffe9a8b03.xls / Patient Safety Share
Premier Safety Share
Excel: Premier / Modules / b24d7277-3ce3-4a13-baeb-3f4ffe9a8b03.xls / Patient Safety Share
Premier Safety Share
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Premier Safety Share
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Premier Safety Share
be downloaded at http://www.premierinc.com/all/safety/public-health/downloads/preparingterroristbombing.pdf
Excel: Premier / Modules / b24d7277-3ce3-4a13-baeb-3f4ffe9a8b03.xls / Patient Safety Share
Premier Safety Share
Excel: Premier / Modules / b24d7277-3ce3-4a13-baeb-3f4ffe9a8b03.xls / Patient Safety Share
Premier Safety Share
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Premier Safety Share
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Premier Safety Share
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Premier Safety Share
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Premier Safety Share
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Premier Safety Share
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Premier Safety Share
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Premier Safety Share
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Premier Safety Share
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Premier Safety Share
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Premier Safety Share
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Premier Safety Share
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Premier Safety Share
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Premier Safety Share
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Premier Safety Share
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Premier Safety Share
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Premier Safety Share
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Premier Safety Share
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Premier Safety Share
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Premier Safety Share
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Premier Safety Share
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Premier Safety Share
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Premier Safety Share
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Premier Safety Share
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Premier Safety Share
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Premier Safety Share
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Premier Safety Share
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Premier Safety Share
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Premier Safety Share
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Premier Safety Share
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Premier Safety Share
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Premier Safety Share
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Premier Safety Share
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Premier Safety Share
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Premier Safety Share
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Premier Safety Share
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Premier Safety Share
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Premier Safety Share
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Premier Safety Share
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Premier Safety Share
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Premier Safety Share
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Premier Safety Share
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Premier Safety Share
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Premier Safety Share
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Premier Safety Share
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Premier Safety Share
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Premier Safety Share
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Premier Safety Share
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Premier Safety Share
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Premier Safety Share
Excel: Premier / Modules / b24d7277-3ce3-4a13-baeb-3f4ffe9a8b03.xls / Patient Safety Share
IHI Tools
Month Year Topic/Module by Tab Tool Description IHI Tool Location
The first tool is a "Global Trigger Tool" designed to help
get started in the approach; the other tools focus on Access IHI Trigger Tools
specific areas such as measuring adverse drug events, at:http://www.ihi.org/IHI/Topics/PatientSaf
IHI – Patient perioperative care, neonatal intensive care, and adverse ety/SafetyGeneral/Tools/IntrotoTriggerTo
Dec 2006 PSS News safety trigger tools events in outpatient settings. √ olsforIdentifyingAEs.htm
1.) http://www.premierinc.com/quality-
safety/tools-services/safety/safety-
share/07-06-downloads/07-sbar-nurse-
survey.pdf; 2.)
http://www.premierinc.com/quality-
safety/tools-services/safety/safety-
A toolkit containing five SBAR (Situation-Background- share/07-06-downloads/08-sbar-survey-
Assessment-Recommendation) tools adapted for physician.pdf; 3.)
improving communication in labor and delivery is http://www.premierinc.com/quality-
available from the Institute for Healthcare Improvement safety/tools-services/safety/safety-
(IHI). The SBAR technique provides a framework for share/07-06-downloads/09-sbar-perinatal-
communication between members of the healthcare report.pdf; 4.)
team about a patient's condition. SBAR is an easy-to- http://www.premierinc.com/quality-
remember, concrete mechanism useful for framing any safety/tools-services/safety/safety-
conversation, especially critical ones, requiring a share/07-06-downloads/10-sbar-fetal-
clinician's immediate attention and action. It allows for an heartrate-tracing.pdf; 5.)
easy and focused way to set expectations for what will http://www.premierinc.com/quality-
be communicated and how between members of the safety/tools-services/safety/safety-
Perinatal SBAR team, which is essential for developing teamwork and share/07-06-downloads/11-sbar-physician-
July 2006 PSS News toolkit fostering a culture of patient safety. √ critical-situation.pdf
Changes in four key elements of the service delivery
system are described in the IHI white paper. The
changes include the care team, patient activation, clinical
information system, and leadership. IHI identifies the
IHI white paper – challenges faced in the current system, introduces a new http://www.premierinc.com/quality-
Planning a design for the delivery of primary care, and encourages safety/tools-services/safety/safety-
primary care office practices and clinics to move ahead with their own share/06-06-downloads/14-planned-care-
June 2006 PSS News delivery system efforts to strive for better patient outcomes. √ white-paper-2006.pdf
Excel: Premier / Modules / b24d7277-3ce3-4a13-baeb-3f4ffe9a8b03.xls / IHI
IHI Tools
Month Year Topic/Module by Tab Tool Description IHI Tool Location
Reviews of perinatal care have consistently pointed to
failures of communication among the care team and
documentation of care as common factors in adverse
events that occur in labor and delivery. Such failures also
have been shown to be prime factors leading to
malpractice claims. A new white paper from the Institute
for Healthcare Improvement (IHI), "Idealized Design of
Perinatal Care," is an innovative project based on the
principles of reliability science and the IHI's model for
applying these principles to improve care. The Idealized Go to:
Design model focuses on comprehensive redesign to http://www.premierinc.com/all/safety/publi
IHI white paper – enable a care system to perform substantially better in cations/03-06-downloads/10-idealized-
March 2006 PSS News perinatal care the future than the best it can do at present. √ design-perinatal-care-2005.pdf
A leadership guide offering eight steps for senior health
care leaders to help their organizations achieve patient
safety and high reliability is available from the Institute
for Healthcare Improvement (IHI). "The Leadership
Guide to Patient Safety: Resources and Tools for
Establishing and Maintaining Patient Safety" introduces
The Leadership the concept of "reliability," defined as patients getting the
Guide to Patient intended tests, medications, information, and procedures
Safety: Resources at the appropriate time and in accordance with their
and Tools for values and preferences. Strategies for redesign of
Establishing and healthcare systems are presented using examples that http://www.premierinc.com/all/safety/publi
Maintaining IHI has gleaned from its experience in guiding cations/11-05-full-txt.jsp#story-06-
November 2005 PSS News Patient Safety organizations in improving patient safety. √ downloads
A new Institute for Healthcare Improvement (IHI)
Innovation Series white paper expands on a previous
paper, "Move Your Dot: Measuring, Evaluating, and
Reducing Hospital Mortality Rates," that introduced a
novel perspective and methodology for understanding
and reducing inpatient deaths. "Reducing Hospital
Move Your Dot: Mortality Rates (Part 2)" summarizes preliminary results
Measuring, from a three-year pilot project in which eight hospitals, White papers are free and available
Evaluating, and working with IHI, are testing the theory that hospital online at:
Reducing Hospital mortality can be consistently reduced through a http://www.ihi.org/IHI/Products/WhitePap
August 2005 Patient Safety Mortality Rates combination of evidence-based interventions. √ ers/
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IHI Tools
Month Year Topic/Module by Tab Tool Description IHI Tool Location
To assist institutions in making the business case for
quality programs, the Institute for Healthcare
Improvement (IHI) is unveiling the Adverse Events
Prevented Calculator. This tool helps model the financial
implications of reductions in adverse event rates in an
organization and assists in translating actual and
potential improvement results into projected lives and
dollars saved. The tool allows one to track the change in
rate of any one type of adverse event over time and,
when appropriate additional data are added, the
consequent change in unnecessary deaths ("lives
saved"), real and additional potential cost savings ("dark
IHI tool – Adverse green dollar" savings and "light green dollar" savings, http://www.ihi.org/IHI/Topics/PatientSafet
Events Prevented respectively), and the return on investment of quality y/SafetyGeneral/Tools/adverseeventspre
September 2008 Culture - Safety - Tool Calculator improvement work targeting those adverse events. √ ventedcalculator.htm
December 2007 Patient Safety Advancing the √ http://www.premierinc.com/quality-
Practice of Patient- safety/tools-services/safety/safety-
and Family- share/12-07-downloads/6_Patient-Family-
Centered Care The Institute for Healthcare Improvement (IHI) recently Centered-Care-2007.pdf
released a report titled “Advancing the Practice of Patient-
and Family-Centered Care” that includes assessment
tools to help hospitals determine the degree to which
patient- and family-centered approaches exist in their
current organizational culture; IHI also released a tool
that helps gather information about the perceptions and
attitudes of staff and administrative leaders. The report
describes how hospitals can get started with
understanding how quality and safety are advanced by
bringing patients and families directly into the planning,
delivery and evaluation processes. This 25-page report
provides rationale for a patient- and family-centered
approach to care and defines its core concepts and
outlines steps that a hospital can take to create
partnerships with patients and families.
Excel: Premier / Modules / b24d7277-3ce3-4a13-baeb-3f4ffe9a8b03.xls / IHI
IHI Tools
Month Year Topic/Module by Tab Tool Description IHI Tool Location
Advance directives, the legal documents that allow
individuals to make their personal healthcare wishes
known before a serious illness or injury, can be
confusing and difficult to understand. The Institute for
Healthcare Advancement has an advance directive form
designed for American adults who read below a fifth-
grade level. The forms are available in both English
(.pdf) (906 KB) and Spanish (.pdf) (911 KB). The form is The forms are available in both English
designed in a simple fill-in-the-blank format with http://www.premierinc.com/all/safety/publi
illustrations and easy-to-read bullet points. Low-literacy cations/05-05-downloads/09-advance-
Americans will be able to choose an agent to make directive-english.pdf (.pdf) (906 KB) and
medical decisions for them, make their healthcare Spanish
Simplifying wishes known so that their loved ones don't have to http://www.premierinc.com/all/safety/publi
advanced guess for them, and provide the necessary signatures to cations/05-05-downloads/10-advance-
May 2005 Patient Safety directives make the document legally binding. √ directive-spanish.pdf (.pdf) (911 KB).
A method for analyzing any process to see where it is
Failure Modes likely to fail; to see how changes you are considering
and Effects might affect the safety of the process; and to track
Analysis (FMEA) changes in the Risk Priority Number (or RPN) of the
September 2003 Patient Safety Tool process over time. √
A simple yet powerful method of identifying and tracking
Trigger Tool for the number of medication errors in your hospital — using
Measuring a retrospective review of patient records to look for
Adverse Drug sentinel clues or "triggers" that indicate a medication http://www.ihi.org/IHI/Topics/PatientSafet
May 2003 Patient Safety Events (ADEs) error has occurred. √ y/MedicationSystems/Tools/
The brochure outlines how a patient can become an
Ensuring Safety in active, involved, and informed member of the health care Adobe;Patient Safety/Medication
July 2004 Patient Safety Surgery team. √ Systems/Tools; Under: Culture of Safety
The tool was developed by safety administrators at Iowa
Health System (IHS) to help front-line staff initiate Device
Use – Safety Briefings, which provide a forum for shared
Device Use – observations and concerns related to the use of medical
Safety Briefing devices, equipment, and complex software in the Word;Patient Safety/Medication
IHI Patient Safety Model institution. √ Systems/Tools; Under: Culture of Safety
A simple, easy-to-use tool that front-line staff can use to
share information about potential safety problems and
Safety Briefings concerns on a daily basis, to promote safety Adobe;Patient Safety/Medication
IHI Patient Safety (IHI Tool) consciousness and learning √ Systems/Tools; Under: Culture of Safety
The tool enumerates data elements to collect during a
Safety Huddle test of Safety Briefings, including medication safety
Results Collection issues and "near miss" medication errors that are Word;Patient Safety/Medication
IHI Patient Safety Tool identified before they cause harm. √ Systems/Tools; Under: Culture of Safety
Decision Tree for A decision tree that can be followed when analyzing an
Unsafe Acts error or adverse event; developed by Partners Patient Safety/Medication Systems/Tools;
IHI Patient Safety Culpability HealthSystem √ Under: Culture of Safety
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IHI Tools
Month Year Topic/Module by Tab Tool Description IHI Tool Location
Patient Safety
Tracking Patient Safety/Medication Systems/Tools;
IHI Patient Safety Database Example of a database for tracking patient safety issues √ Under: Culture of Safety
Senior leaders conduct weekly WalkRounds™ in
different areas of the hospital, to have informal
conversations with front-line staff about safety issues
Patient Safety and to demonstrate their support of an organizational http://www.ihi.org/IHI/Topics/PatientSafet
Leadership culture that promotes nonpunitive reporting of errors, y/MedicationSystems/Tools/PatientSafety
July 2004 Patient Safety WalkRounds™ adverse events, near misses, and unsafe conditions √ LeadershipWalkRoundsDatabase.htm
Checklist for
Assessing A short self-assessment survey for use by any health
Institutional care organization wishing to gauge its patient safety Word;Patient Safety/Medication
IHI Patient Safety Resilience climate √ Systems/Tools; Under: Culture of Safety
Strategies for
Leadership:
Hospital http://www.ihi.org/IHI/Topics/PatientSafet
Culture - Safety -Tool Adobe;Patient Executives and y/MedicationSystems/Tools/Strategiesfor
Safety/Medication Systems/Tools; Their Role in A compilation of leadership strategies for enhancing LeadershipHospitalExecutivesandTheirR
HSOPSC Under: Culture of Safety Patient Safety patient safety √ oleinPatientSafety.htm
A tool for conducting brief, ad hoc staff meetings focused
Device Use – on sharing observations and concerns about safety
Safety Briefing hazards related to the use of medical devices and Word;Patient Safety/Medication
IHI Patient Safety Model equipment √ Systems/Tools; Under: Culture of Safety
Executive Review
of Projects (IHI A guide for executives on how to channel senior Word;Improvement Methods/Tools;
IHI Patient Safety Tool) management attention to quality projects √ Under: Information Gathering Tools
Sampling is used to simplify the gathering of data for
Sampling (IHI improvement and to prevent unnecessary data Excel;Improvement Methods/Tools;
IHI Patient Safety Tool) collection. √ Under: Information Gathering Tools
Walk-throughs enable providers to better understand the http://www.ihi.org/IHI/Topics/Improvemen
Walk-through (IHI experience of care from the patient’s and family’s points t/ImprovementMethods/Tools/Walk-
HSOPSC Culture - Safety - Tool Tool) of view — by going through the experience themselves √ through.htm
An institution-wide policy regarding non-punitive
reporting, this brochure reinforces the non-punitive
reporting policy and encourages all co-workers to report http://www.premierinc.com/all/safety/publi
Living a Culture of errors, it was signed by the hospital president and mailed cations/02-04-downloads/10-st-john-
February 2004 Patient Safety Patient Safety to all co-worker homes. √ nonpunitive-brochure.pdf
Patient Safety Collects data and then keeps track of how the http://www.ihi.org/IHI/Topics/PatientSafet
Leadership information is used, what actions are taken, and y/MedicationSystems/Tools/PatientSafety
July 2004 Patient Safety WalkRounds generate feedback and reports. √ LeadershipWalkRoundsDatabase.htm
Excel: Premier / Modules / b24d7277-3ce3-4a13-baeb-3f4ffe9a8b03.xls / IHI
IHI Tools
Month Year Topic/Module by Tab Tool Description IHI Tool Location
Hospital flow can be measured at five levels: patient and
community; hospital throughput; hospital activity; hospital
performance; and unit performance. Each level provides
Measurement a portion of the total measurement picture. Use this http://www.ihi.org/IHI/Topics/Flow/Patient
guide for hospital guide to learn how to measure data in these key areas to Flow/EmergingContent/HospitalFlowMea
July 2004 Patient Safety flow patterns help you improve patient flow. √ surementGuide.htm
Excel: Premier / Modules / b24d7277-3ce3-4a13-baeb-3f4ffe9a8b03.xls / IHI
IHI Tools
Excel: Premier / Modules / b24d7277-3ce3-4a13-baeb-3f4ffe9a8b03.xls / IHI
IHI Tools
Excel: Premier / Modules / b24d7277-3ce3-4a13-baeb-3f4ffe9a8b03.xls / IHI
IHI Tools
Excel: Premier / Modules / b24d7277-3ce3-4a13-baeb-3f4ffe9a8b03.xls / IHI
IHI Tools
Excel: Premier / Modules / b24d7277-3ce3-4a13-baeb-3f4ffe9a8b03.xls / IHI
IHI Tools
Resource Print
Tool Electronic
Excel: Premier / Modules / b24d7277-3ce3-4a13-baeb-3f4ffe9a8b03.xls / IHI
IHI Tools
Tool Electronic
Excel: Premier / Modules / b24d7277-3ce3-4a13-baeb-3f4ffe9a8b03.xls / IHI
Premier Safety Share
IHI
Month Year Topic by Tab Tool Description Tool Location
The RFID Resource Center includes an implementation guide describing
the use of HIBC (Health Industry Bar Code) Standards with RFID, an
RFID – Web-based overview of RFID technology (including its potential applications and
resource center costs), a white paper, "RFID In Healthcare: Benefits, Limitations & http://www.hibcc.org/AUTOIDUPN/
May 2007 Bar Coding available Recommendations," and other related articles. RFID.htm
Excel: Premier / Modules / b24d7277-3ce3-4a13-baeb-3f4ffe9a8b03.xls / Bar Coding
Premier Safety Share
IHI
Month Year Topic by Tab Tool Description Tool Location
Catheter-related blood stream infections (BSI) are a significant source of
morbidity and mortality associated with a variety of devices used to
access the vascular system. Meticulous aseptic technique is both
required and effective to prevent BSI. Faculty share their observations,
Webcast – Best best practices, and outcome data as they discuss this important topic.
practices to reduce This free webcast is a replay from the original August 17, 2007, webcast
Bundling - catheter-related provided by Cardinal Health's Center for Safety and Clinical Excellence
evidence based blood stream and will remain available for one full year. Continuing education credit is http://www.cardinal.com/clinicalcent
September 2007 practice infections also provided. er/materials/webcasts/index.asp
A recent AHRQ audio newscast series featured an interview with Peter
Pronovost, M.D., Ph.D., of The Johns Hopkins University School of
Medicine. Dr. Pronovost discussed his research about interventions to
reduce bloodstream infections in hospital ICUs caused by central venous
catheters. Patients in the United States spend about 18 million days in
the intensive care unit per year and in more than 50 percent of the
cases, an ICU patient will have a central venous catheter inserted.
Bundling - AHRQ tools – Unfortunately, approximately 80,000 patients each year develop catheter- AHRQ podcast:
evidence based Podcast on reducing related bloodstream infections, and about 28,000 of them will die from http://www.healthcare411.org/podc
May 2007 practice BSI the infection. ast.aspx?id=197
Excel: Premier / Modules / b24d7277-3ce3-4a13-baeb-3f4ffe9a8b03.xls / Bundling
Premier Safety Share
IHI
Month Year Topic by Tab Tool Description Tool Location
A free interactive video module that will help identify and treat C. difficile
is available from the British Medical Journal (BMJ) and the Department of
Health. Titled "How you can reduce C. difficile infections," the video
demonstrates how a major UK hospital successfully managed an
outbreak and introduced measures that can be applied to prevent
infections. The module discusses how to diagnose and treat patients with
C. diffcile infections, the importance of hand hygiene in preventing
C. difficile infection, the cautious use of prescribing antibiotics, and understanding
associated Online learning the patient experience. To begin the module, go to
September 2007 disease module – C. difficile http://bmjlearning.com/cdifficile. http://bmjlearning.com/cdifficile
Excel: Premier / Modules / b24d7277-3ce3-4a13-baeb-3f4ffe9a8b03.xls / CDAD
Premier Safety Share
IHI
Month Year Topic by Tab Tool Description Tool Location
Community hospitals implementing computerized physician order entry http://my.premierinc.com/all/safety/
Computerized are succeeding in gaining physician participation and addressing the publications/07-
physician order gaps in safety and quality they were targeting, according to a new report 03_downloads/10_CPOE_comm_h
July 2003 entry CPOE Report & Tips by the California HealthCare Foundation and First Consulting Group. osp.pdf
Computerized http://www.hospitalconnect.com/ah
physician order CPOE evaluation and The report explores CPOE implementation, costs, challenges, benefits, a/key_issues/patient_safety/resourc
March 2003 entry case studies and lessons learned. es/index.html#patientsafety
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Premier Safety Share
IHI
Month Year Topic by Tab Tool Description Tool Location
The recommendations include the assessment of the electromagnetic
Recommendations environment of the facility, identification of areas where critical medical http://my.premierinc.com/all/safety/
for Electromagnetic devices are used, coordination of the purchase and management of all publications/01-
Cell Phones and Compatibility in electronic equipment, and the reporting of problems to FDA MedWatch 02_downloads/CDRH-%20EMC-12-
January 2002 EMC Healthcare Facilities program. 01.doc
Excel: Premier / Modules / b24d7277-3ce3-4a13-baeb-3f4ffe9a8b03.xls / Cell Phones
Premier Safety Share
IHI
Month Year Topic by Tab Tool Description Tool Location
Advances in technology are making it easier to improve patient safety.
The September/October issue of Patient Safety and Quality Healthcare
focuses on recent technology designed to reduce the risk of medical
Computers and On-line resources – errors. Among the topics featured in this issue are bar coding to reduce
electronics in bar coding, RFID and medication errors, electronic medical records (EMR) and radio frequency http://www.psqh.com/sepoct05/tocc
November 2005 healthcare patient safety identification (RFID) systems. .html
Premier, the first GPO to win Hospitals for a Healthy Environment's
Web-based resource (H2E) Champions of Change Award (in 2003) and again in 2004, has
to assist healthcare launched a new Web-based resource to assist healthcare organizations
organizations with with environmentally friendly selection, recycling and disposal of
environmentally computers and electronics. These resources are also being used to
friendly selection, guide the selection of electronic device manufacturers for Premier
recycling and members and for recycling of electronics in Premier's corporate offices.
Computers and disposal of The Web-based resource was produced by Premier's Safety Institute
electronics in computers and with assistance and support from Health Care Without Harm and the http://www.premierinc.com/all/safet
March 2005 healthcare electronics. Computer Take Back Campaign. y/resources/computers/index.jsp
Excel: Premier / Modules / b24d7277-3ce3-4a13-baeb-3f4ffe9a8b03.xls / Computers
Month Year Topic by Tab Tool Description
This manual was written to assist hospitals in developing strategies for
temporary negative pressure isolation and provides instruction on the
use of equipment used for airborne infectious disease management. In
addition to graphic "how to" portrayals, the guide includes tools such as
Minnesota manual – preventative maintenance schedules and a sample log for measuring
Methods for particle counts for performance improvement planning. Additional
Construction - temporary negative information, including education/training slides, are located at the Web
Mar 2007 ICRA pressure isolation site below.
Created by the University of Minnesota, InformeDesign®
www.informedesign.umn.edu brings research and practice aspects of
the design professions together. Designers face a multitude of complex
challenges that are environmental, behavioral, and design in nature.
This Web site focuses on providing the design community with
reputable research sources that address those challenges. A monthly
publication, Implications, addresses the issues facing practitioners and
researchers who focus on design and human behavior. Under the links,
Inform eDesign – "SPACE," then "Healthcare," there is a wide variety of healthcare related
Construction - Healthcare design articles and research summaries on topics from ambulatory care to
Feb 2007 ICRA implications wellness centers.
The construction and ICRA concept and matrix as described and
promoted by the Association for Professionals in Infection Control and
Epidemiology (APIC) and the American Society for Healthcare
Engineering (ASHE) are available in two training videos. One is directed
to healthcare professionals (20 minutes) and one to construction
Construction - Construction; ICRA personnel (eight minutes), with availability in English and Spanish. Go to
Sept 2006 ICRA training www.EnvisionInc.net.
IHI
Tool Location
Download the manual from the
Safety Institute's Construction,
ICRA, risk assessment web site, or
go to:
http://www.health.state.mn.us/oep/t
raining/bhpp/isolation.html
http://www.informedesign.umn.edu/
Rs.aspx?s=space&tId=664
For more information on and
resources about construction on
Premiers Web site:
www.premierinc.com/quality-
safety/tools-
services/safety//resources/construc
tion/.
Premier Safety Share
IHI
Month Year Topic by Tab Tool Description Tool Location
This model program engages nurses and leaders at all levels of the
organization to improve the quality and safety of patient care on medical
and surgical units. Ten hospitals graduated from the third phase of the
five-year program in May. TCAB is not a traditional quality improvement
program; one primary characteristic that sets it apart is its focus on
engaging frontline staff and unit managers. Ideas for transforming the
way care is delivered on medical/surgical units come from the nurses
Transforming Care at and other care team members who spend the most time with patients http://www.rwjf.org/pr/product.jsp?id
September 2008 Culture - Safety - Tool the Bedside and their families. =30051&c=EMC-CA137
To assist institutions in making the business case for quality programs,
the Institute for Healthcare Improvement (IHI) is unveiling the Adverse
Events Prevented Calculator. This tool helps model the financial
implications of reductions in adverse event rates in an organization and
assists in translating actual and potential improvement results into
projected lives and dollars saved. The tool allows one to track the
change in rate of any one type of adverse event over time and, when
appropriate additional data are added, the consequent change in
unnecessary deaths ("lives saved"), real and additional potential cost
IHI tool – Adverse savings ("dark green dollar" savings and "light green dollar" savings, http://www.ihi.org/IHI/Topics/Patient
Events Prevented respectively), and the return on investment of quality improvement work Safety/SafetyGeneral/Tools/adverse
September 2008 Culture - Safety - Tool Calculator targeting those adverse events. √ eventspreventedcalculator.htm
The Joint Commission offers an Internet-based collaborative forum to
help frontline workers; healthcare administrators, researchers and other
healthcare professionals collaborate on developing performance
improvement solutions. One feature currently being test piloted allows
registered users to discuss solutions, edit existing solutions and create
new solutions that will then be available to the entire healthcare The site, titled WikiHealthCareTM,
community. The first quality improvement topics posted to the site can be accessed through a link on
address smoking cessation counseling programs and smoke-free The Joint Commission's home page,
hospital campuses. Development of the site was funded, in part, through or directly at
a research grant from the Smoking Cessation Leadership Center at the http://wikihealthcare.jointcommission
October 2007 Culture - Safety - Tool WikiHealthCareTM University of California, San Francisco. .org.
Now AHRQ is providing a new tool developed for small and critical
access hospitals to benchmark and compare their results from the AHRQ
Hospital Survey on Patient Safety Culture. However, the tool can be
used by any size hospital because it allows the addition of any
benchmarking data. The tool is from Statis Health and the Oklahoma
Small hospital Foundation for Medical Quality and the Hospital Interventions Quality http://www.premierinc.com/quality-
benchmarking tool for Improvement Organization Support Center (HIQIOSC) and is adapted safety/tools-
AHRQ hospital with permission for a benchmarking tool developed by the Nebraska services/safety/topics/culture/bench
July 2007 Culture - Safety - Tool survey Center for Rural Health Research. marking-data.jsp#cah-tool
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Premier Safety Share
IHI
Month Year Topic by Tab Tool Description Tool Location
The Premier Performance Suite is a comprehensive offering of hospital For more information on the Premier
performance tools to integrate quality and safety, labor management, Performance Suite, visit the home
and supply chain channels for a global approach to improving overall page at:
quality and cost. The Performance Suite provides Web-based http://www.premierinc.com/quality-
Premier – New performance measurement and benchmarking, real time surveillance, safety/tools-services/performance-
Mar 2007 Culture - Safety - Tool Performance Suite™ and best practices to allow hospitals to make better decisions. suite/.
The first monograph, "Are You Rolling the Dice on CEO Succession?" is
designed to help trustees navigate the CEO selection process. The
monograph contains a Leadership Continuity Risk Management Model to To order any of the monographs,
help trustees understand how to effectively define the requirements for a contact the Center at 888.540.6111
new CEO, assess candidates and approach the final selection process. or e-mail at:
The second, "The Board's Fiduciary Role: Legal Responsibilities of info@americangovernance.com.
Health Care Governing Boards," describes the basic legal duties and Access the tool at:
obligations of the boards of not-for-profit hospitals. This guidance can be http://www.americangovernance.co
CEO assessment tool used to support trustee recruitment and orientation, and as a reference m/americangovernance/ctool/welco
Feb 2007 Culture - Safety - Tool for leadership tool for existing board members. me.html.
The Center for Healthcare Governance has provided the first tool in a
series of Collaborative Leadership Tools. "Collaborative Leadership: A
New Model for Developing Truly Effective Relationships Between CEOs
and Trustees" explores the board/CEO relationship in the context of
governance reform, which calls for boards in all sectors to raise the bar
on their performance and accountability. This CEO resource discusses
what governance reform means in terms of how boards and CEOs work
together to lead their healthcare organizations. It also provides an
assessment tool and process that CEOs can use to take the lead in
diagnosing their current relationship with their board, and to work Access the tool at:
together with board leaders to re-energize and strengthen the http://www.americangovernance.co
CEO assessment tool relationship to achieve maximum effectiveness and value. If completed m/americangovernance/ctool/welco
Jan 2007 Culture - Safety - Tool for leadership online, all responses are confidential. me.html
The tool is for physician practices to use to enhance awareness of
patient safety issues, heighten awareness of characteristics that make a
practice safer, and create a new reference point and baseline for
practices to enhance and support patient safety. The tool can be There is a $200 per practice fee to
completed electronically so users can receive a feedback report complete the assessment online and
comparing themselves to other practices (percentile rankings on each access the comparative report site.
Assessing physician question). Users also can receive a workbook with information and Download the file or use online at
Nov 2006 Culture - Safety - Tool practices resources on how the practice can improve their performance. http://www.physiciansafetytool.org.
The tool is designed to help hospital CEOs and their boards forge a
Collaborative stronger relationship. This CEO resource discusses what governance
Leadership: A New reform means in terms of how boards and CEOs work together to lead
Model for Developing their healthcare organizations. It also provides an assessment tool and
Truly Effective process that CEOs can use to take the lead in diagnosing their current
Relationships relationship with their board, and to work together with board leaders to Access the tool at:
Between CEOs and re-energize and strengthen the relationship to achieve maximum http://www.americangovernance.co
Nov 2006 Culture - Safety - Tool Trustees effectiveness and value. m/americangovernance/
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Premier Safety Share
IHI
Month Year Topic by Tab Tool Description Tool Location
The consensus statement is intended to provide a deeper understanding
of preventable adverse events, their impact on patients, families, and
providers, and how to manage such events. The report provides detailed
guidelines based on the premise that all care should be safe and patient-
centered and proposes a full disclosure when adverse events or medical
errors occur, including an apology to the patient. The report is divided
into three major sections: the patient and family experience, the
caregiver experience, and the management of the event. Each section
contains a summary of the expert consensus of the issue, including the
reasoning and evidence behind the consensus, and recommendations.
The report also offers appendices that include recommendations, a case Go to:
When Things Go study on communicating with patients and families, elements of http://www.premierinc.com/all/safety/
Wrong: Responding emotional support of caregivers, and a bibliography on medical publications/04-06-downloads/07-
April 2006 Culture - Safety - Tool to Adverse Events disclosure. responding-adverse-events.pdf
A recent directive from the U.S. Veterans Health Administration provides
background information on the disclosure of adverse events related to
clinical care to patients or their representatives. VA Directive 2005-049
(.pdf) (163 KB), "Disclosure of Adverse Events to Patients," is consistent
with the Joint Commission on Accreditation of Healthcare Organizations
Directive on requirements, and includes key definitions and a policy statement on http://www.premierinc.com/all/safety/
disclosure of adverse disclosure for all VA hospitals. publications/12-05-downloads/09-va-
December 2005 PSS News events adverse-events.pdf
A leadership guide offering eight steps for senior health care leaders to
help their organizations achieve patient safety and high reliability is
available from the Institute for Healthcare Improvement (IHI). "The
The Leadership Leadership Guide to Patient Safety: Resources and Tools for
Guide to Patient Establishing and Maintaining Patient Safety" introduces the concept of
Safety: Resources "reliability," defined as patients getting the intended tests, medications,
and Tools for information, and procedures at the appropriate time and in accordance
Establishing and with their values and preferences. Strategies for redesign of healthcare http://www.premierinc.com/all/safety/
Maintaining Patient systems are presented using examples that IHI has gleaned from its publications/11-05-full-txt.jsp#story-
November 2005 PSS News Safety experience in guiding organizations in improving patient safety. √ 06-downloads
Premier's Safety Institute has developed a Spanish version of the
Agency for Healthcare Research and Quality's (AHRQ) Hospital Survey
Hospital Survey on on Patient Safety Culture survey tool, as well as a customized The survey tool can be accessed at
Patient Safety Microsoft® Excel data tool for easy entry and rapid display of survey http://www.premierinc.com/all/safety/
August 2005 Culture - Safety - Tool Culture results. culture/
The long awaited Patient Safety and Quality Improvement Act (P.L.109-
41) was signed into law on July 29, 2005, to encourage a culture of
safety in healthcare organizations by providing legal protection of
Patient Safety and information on medical errors and adverse events voluntarily reported to http://thomas.loc.gov/cgi-
Quality Improvement patient safety organizations (PSOs). Lawmakers intend the information bin/bdquery/z?d109:SN00544:|TOM:
August 2005 PSS News Act (P.L.109-41) to be used to improve patient safety and reduce medical errors. /bss/d109query.html
Excel: Premier / Modules / b24d7277-3ce3-4a13-baeb-3f4ffe9a8b03.xls / Culture - Safety
Premier Safety Share
IHI
Month Year Topic by Tab Tool Description Tool Location
Reconciling medications across the continuum of care is a new 2005
JCAHO safety goal. Experience has shown that poor communication of
medical information at transition points is responsible for as many as 50
percent of all medication errors in the hospital and up to 20 percent of
adverse drug events. A Massachusetts Coalition Web site describes how
a group of hospitals in Massachusetts implemented a medication Go to http://www.macoalition.org
Medication strategy reconciliation strategy and provides various tools and forms for others to and look under “Coalition Initiatives,”
July 2005 Culture - Safety - Tool tools adopt or adapt. then “Reconciling Medications.”
Copies of "5 Steps to Safer Health
A campaign designed to help distribute valuable information about Care" and the public service
improving patient safety to healthcare providers and patients across the announcement are available on the
country has been initiated by the Agency for Healthcare Research and AHRQ's Web site: English version:
Quality (AHRQ), the American Hospital Association (AHA). The http://www.ahrq.gov/consumer/5step
campaign, called "5 Steps to Safer Health Care," includes posters and s.htm
fact sheets that offer evidence-based, practical tips on the role patients Spanish version:
5 Steps to Safer can play to help avoid errors related to prescription medicines, laboratory http://www.ahrq.gov/consumer/cinco
June 2005 Culture - Safety - Tool Health Care tests, procedures, and surgery. rec.htm
The Agency for Healthcare Research and Quality (AHRQ) has published View entire document at
a new fact sheet entitled "30 Safe Practices for Better Health Care" http://www.premierinc.com/all/safety/
(.doc) (42 KB). These are AHRQ-supported, evidence-based practices publications/05-05-downloads/07-
from the National Quality Forum (NQF) that demonstrate they can work fact-sheet-30-practices.doc; An
to reduce or prevent adverse events and medical errors. The safe executive summary (.pdf) (495 KB)
practices were endorsed by the NQF member organizations, which of the report is available from AHRQ
30 safe practices in strongly urge that these 30 safe practices be universally adopted in all and contains information on how to
May 2005 Culture - Safety - Tool healthcare applicable healthcare settings to reduce the risk of harm to patients. obtain copies of the com
Most hospital leaders are concerned that mandatory, non-confidential
public reporting would discourage internal reporting of patient incidents http://www.premierinc.com/all/safety/
and encourage lawsuits while failing to provide substantial benefits to publications/05-05-downloads/04-
Error Reporting and patient safety, according to a recent survey of hospital executives in the abst-error-report-disclosure-
May 2005 PSS News Disclosure Systems Journal of the American Medical Association. systems.doc
Premier has developed a customized data collection and analysis tool
that provides immediate feedback on the results of the hospital culture
survey tool released by the Agency for Healthcare Research and Quality
Premier - customized (AHRQ). The customized Excel™ data tool was developed for easy entry http://www.premierinc.com/all/safety/
data collection and and rapid display of the results from the surveys to provide immediate publications/03-05-full-txt.jsp#story-
March 2005 PSS News analysis tool internal review and feedback. 08-downloads
A new tool to assess the safety culture of a hospital as a whole, or in
specific units within hospitals, as well as to track changes in patient
safety over time and evaluate the impact of patient safety interventions.
Premier's Safety Institute is providing the complete tool kit, which All components may be downloaded
Hospital Survey on includes the survey, detailed user's guide for administration of paper or at
Patient Safety web-based methods, data collection and analysis, customizable www.premierinc.com/all/safety/cultur
November 2004 Culture - Safety - Tool Culture templates for reporting results, references, and results of the pilot study. e.
Excel: Premier / Modules / b24d7277-3ce3-4a13-baeb-3f4ffe9a8b03.xls / Culture - Safety
Premier Safety Share
IHI
Month Year Topic by Tab Tool Description Tool Location
The video discusses how best to inform patients and their families in the
Discussing event of a medical error that causes harm. The video includes clinical
Unanticipated scenarios and comments from a medical ethicist, a hospital risk For information on how to obtain the
Outcomes and manager, and two healthcare attorneys. The comments offer videotape, go to:
Disclosing Medical suggestions on how to effectively disclose adverse events to patients http://www.gha.org/pha/video/index.
October 2004 Culture - Safety - Tool Errors and their families. asp.
http://www.ihi.org/IHI/Topics/Patient
Patient Safety Safety/MedicationSystems/Tools/Pat
Leadership Collects data and then keeps track of how the information is used, what ientSafetyLeadershipWalkRoundsD
July 2004 Culture - Safety - Tool WalkRounds actions are taken, and generate feedback and reports. √ atabase.htm
http://www.premierinc.com/safety/re
The majority of hospitals responding to a Premier survey have formal, sources/disclosure/downloads/Premi
board approved policies to disclose medical errors to patients, according er-disclosure-survey-results.pdf;
to a survey conducted by Premier, Inc. The survey uncovered some survey discussion:
Premier Patient promising trends in medical error disclosure practices. A full discussion http://www.premierinc.com/all/safety/
Safety Culture of the survey may be downloaded. publications/08-04-downloads/02-
June 2004 PSS News Survey results disclosure-release.doc
Michigan Hospital Association toolkit is a series of recommendations
based on current research and best practices. It was developed by a http://my.premierinc.com/all/safety/p
nine-member volunteer workgroup of health professionals experienced in ublications/06-04-downloads/09-icu-
June 2004 Culture - Safety - Tool ICU toolkit leading ICUs and improving patient safety and quality of care. toolkit.pdf
An institution-wide policy regarding non-punitive reporting, this brochure
reinforces the non-punitive reporting policy and encourages all co- http://www.premierinc.com/all/safety/
Living a Culture of workers to report errors, it was signed by the hospital president and publications/02-04-downloads/10-st-
February 2004 Culture - Safety - Tool Patient Safety mailed to all co-worker homes. √ john-nonpunitive-brochure.pdf
Improvements in medication list accuracy, allergy list accuracy, and safe
prescription writing practices that were observed by Gundersen Lutheran
Ambulatory Patient Medical Center.
December 2003 Culture - Safety - Tool Safety - Toolkit http://www.gundluth.org/SCOPE
“Disclosure of unanticipated events: Creating an effective patient
communication policy," the monograph covers considerations for
developing policies and procedures in specific settings such as acute http://my.premierinc.com/all/safety/p
Disclosure policy care, long-term care and pediatric care. It also examines the effect of ublications/12-03-downloads/09-
December 2003 Culture - Safety - Tool guide disclosure policies on litigation. disclosure-part2-1-policy.pdf
In a report released by the Institute of Medicine, a panel recommends
work hour limits and other changes to the work environment for nurses to
Keeping Patients strengthen patient safety. The panel also noted that regulators and
Safe: Transforming healthcare leaders should work to reduce workplace inefficiencies, such
the Work as excessive paperwork and documentation, which reduce the time Purchase the report online at
Environment of nurses have to spend with patients. http://books.nap.edu/catalog/10851.
November 2003 PSS News Nurses html?onpi_newsdoc110403
http://www.qualityhealthcare.org/QH
C/Topics/PatientSafety/MedicationS
Safety Climate Organizations working to develop or improve a culture of safety need a ystems/Tools/Safety+Climate+Surve
July 2003 Culture - Safety - Tool Survey Tool reliable measure to monitor the success of their initiatives. √ y+(IHI+Tool).htm
Excel: Premier / Modules / b24d7277-3ce3-4a13-baeb-3f4ffe9a8b03.xls / Culture - Safety
Premier Safety Share
IHI
Month Year Topic by Tab Tool Description Tool Location
Disclosure of
Unanticipated Focus on three aspects of the disclosure process: 1.The initial impact of
Events: The Next the Joint Commission for Accreditation of Healthcare Organizations http://my.premierinc.com/all/safety/p
Step in Better (JCAHO) Patient Safety Standards 2.Psychological and legal barriers ublications/06-
Communication with that can impede disclosure, and 3.Successful models used by 03_downloads/07_disclosure_ASHR
June 2003 Culture - Safety - Tool Patients organizations to manage the disclosure process. M_part1of3.pdf
The Agency for Healthcare Research and Quality (AHRQ) PSIs are a
tool to help health system leaders identify potential adverse events
occurring during hospitalization. They are a set of indicators providing
AHRQ Patient Safety information on potential in-hospital complications and adverse events http://www.qualityindicators.ahrq.gov
April 2003 PSS News Indicators following surgeries, procedures, and childbirth. /psi_download.htm
Senior leaders conduct weekly WalkRounds™ in different areas of the
Creating a Culture of hospital, to have informal conversations with front-line staff about safety
Safety Through issues and to demonstrate their support of an organizational culture that http://www.premierinc.com/safety/pu
Executive promotes nonpunitive reporting of errors, adverse events, near misses, blications/03-
TM
March 2003 Culture - Safety - Tool WalkRounds and unsafe conditions 03_downloads/01_b.pdf
http://www.premierinc.com/all/safety/
Medication System A sample medication error reporting form designed to collect and analyze publications/03-
TM
March 2003 Culture - Safety - Tool Analyze-ERR actual and potential medication errors. 03_downloads/01_d.pdf
Checklist/Action Plan
for the Management http://www.premierinc.com/all/safety/
of High-Alert publications/03-
March 2003 Culture - Safety - Tool Medications A checklist/action plan for the safe use of high-alert medications. 03_downloads/01_g.pdf
Policy for Non-
punitive, System-
based Adverse Drug http://www.premierinc.com/all/safety/
Event Reporting A sample policy detailing a blame-free adverse drug event reporting publications/03-
March 2003 Culture - Safety - Tool Program program. 03_downloads/01_h.pdf
http://www.premierinc.com/all/safety/
Medication Safety A patient safety tool helping patients understand their rights and publications/03-
March 2003 Culture - Safety - Tool Pledge for Patients responsibilities regarding safe medication use. 03_downloads/01_j.pdf
The video provides step-by-step instructions on how to disclose medical
errors, why disclosure is important, and how open communication can
February 2003 Culture - Safety - Tool Let's Talk strengthen the patient-provider relationship. http://www.npsf.org/
Participating organizations will work to create a system of safety,
Breakthrough Series including changing organizational culture and attitudes of leadership and
Collaborative on front line staff, improving critical core processes, encouraging http://www.ihi.org/collaboratives/bre
Improving Patient appropriate use of technology, and establishing an effective system for akthroughseries/PatientSafety/index.
August 2002 Culture - Safety - Tool Safety measuring harm. √ asp
Patient Safety A job description for a safety officer, an organization-wide safety plan,
Program Resource Power Point slides of program elements and key committees, sample
June 2002 Culture - Safety - Tool Guide grids for documenting interdisciplinary components, and other tools. Download at Safety Store.
Patient Safety Topics - http://my.premierinc.com/all/safety/re
Patient safety - Patient Safety The intent of the sample Patient Safety Program is to provide tools to sources/patient_safety/patient_safet
HSOPSC downloads (*.doc) Program assist organizations in implementation of a patient safety program. y_downloads.htm
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The ED is part of a larger, complex system. Given the complexity of the
system, for the thousands of patients treated each day, there are many
opportunities for medical errors, as well as opportunities to reduce such http://www.premierinc.com/all/safety/
Patient Safety Topics - errors. This document includes the recommendations of the Patient resources/patient_safety/downloads/
Patient safety - ACEP Patient Safety Safety Task Force and the Principles of Patient Care in the Emergency 24_ACEP_patient_safety_program.d
HSOPSC downloads (*.doc) Program Care Environment. oc
Patient Safety Topics - ECRI Disclosure of Reviews the JCAHO's disclosure standard, discusses how to develop a http://www.premierinc.com/all/safety/
Patient safety - unanticipated disclosure policy and what the policy should address, and analyzes the resources/patient_safety/downloads/
HSOPSC downloads (*.pdf) outcomes impact of the standard on medical malpractice claims. disclosure_ecri.pdf
ASHRM: Perspective
Patient Safety Topics - on Disclosure of A perspective paper on the disclosure of information involving http://www.premierinc.com/all/safety/
Patient safety - Unanticipated unanticipated outcomes of diagnostic tests, medical treatments, and resources/patient_safety/downloads/
HSOPSC downloads (*.pdf) Outcome Information surgical interventions. ASHRM_disclosure_05-01.pdf
http://www.premierinc.com/all/safety/
Patient Safety Topics - Provides guidance for minimizing the chance of the occurance of resources/patient_safety/downloads/
Patient safety - VA Patient Safety untoward outcomes consequent to medical care. This handbook 25_VA_patient_safety_handbook.pd
HSOPSC downloads (*.pdf) Handbook incorporates Root Cause Analysis. f
Disclosure: What
works now & what
can work even better
of unanticipated
Patient Safety Topics - events: the next step ASHRM Monograh addresses the components of effective
Patient safety - sample in better communication of unanticipated outcome, considerations for each of the http://www.premierinc.com/all/safety/
policies - disclosure communication with components and the unique perspectives to be taken in various clinical resources/patient_safety/downloads/
HSOPSC resources and policies patients settings. disclosure-part3-02-04.pdf
ASHRM American Society of Healthcare Risk Management: Disclosure
Patient Safety Topics - Disclosure of Medical of Medical Errors: Demonstrated Strategy to Enhance Communication, a
Patient safety - Errors: Demonstrated one-hour video produced by ASHRM, focuses on practical risk http://www.ahaonlinestore.com/Prod
Education & training - Strategy to Enhance management strategies to approach disclosure. The video is available uctDisplay.asp?ProductID=555&cartI
HSOPSC ASHRM Communication for $50 to ASHRM members, $60 to non-members. Catalog #169520. D=163827&PCatID=25
Culture - Safety -Tool
Adobe;Patient Strategies for http://www.ihi.org/IHI/Topics/Patient
Safety/Medication Leadership: Hospital Safety/MedicationSystems/Tools/Str
Systems/Tools; Under: Executives and Their ategiesforLeadershipHospitalExecuti
HSOPSC Culture of Safety Role in Patient Safety A compilation of leadership strategies for enhancing patient safety √ vesandTheirRoleinPatientSafety.htm
Walk-throughs enable providers to better understand the experience of http://www.ihi.org/IHI/Topics/Improv
Walk-through (IHI care from the patient’s and family’s points of view — by going through ement/ImprovementMethods/Tools/
HSOPSC Culture - Safety - Tool Tool) the experience themselves √ Walk-through.htm
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The Emergency Preparedness Atlas includes maps showing the location
of hospitals and nursing homes in each state, and case studies for six
states that show bed capacity and the emergency management and
bioterrorism preparedness regions for each facility. The Atlas is intended
to help nursing homes plan how they may be used to handle a surge of
patients in response to emergency situations; it is not a review of the
quality or adequacy of preparedness efforts in any area. The Atlas can
help explain the state-specific regulatory environment of nursing homes
with respect to surge capacity and illustrate nursing home geographic
distribution in the United States. A separate report, "Nursing Homes in
AHRQ – Emergency Public Health Emergencies – Special Needs and Potential Roles,"
prep guide to locate addresses the role that nursing homes could play in regional
Emergency healthcare sites preparedness, and is based on focus groups with nursing homes in the http://www.ahrq.gov/prep/nursingho
August 2007 Preparedness during disaster case study states. mes/atlas.htm
The Department of Health & Human Services' (HHS) Agency for
Healthcare Research and Quality (AHRQ) has released a DVD titled,
"Cross Training Respiratory Extenders for Medical Emergencies (Project
XTREME)," that trains healthcare professionals who are not respiratory
care specialists to provide basic respiratory care and ventilator
management to adult patients in any mass casualty event. The DVD
includes six training modules with interactive quizzes to test viewers'
knowledge. Meant for physicians, physician assistants, nurses and
others, the modules cover topics such as infection control, respiratory
care terms and definitions, manual ventilation (using hand-held bags), A free, single copy of the DVD and
AHRQ DVD – mechanical ventilation (using the two types of ventilators included in the a CD-ROM with the report may be
Training for federal government's Strategic National Stockpile of medicines and ordered by calling 800.358.9295 or
Emergency respiratory care/vents medical supplies for emergencies), airway maintenance, and airway by sending an e-mail to
June 2007 Preparedness in disasters suctioning. ahrqpubs@ahrq.hhs.gov.
AHRQ has released a questionnaire that hospitals and other healthcare
facilities can use to plan and evaluate their readiness for a public health
emergency involving a chemical, biological, radiological, nuclear or
explosive event. The 43-question document is divided into eight
categories: administration and planning; education and training;
communication and notification; patient (surge) capacity; staffing and
Emergency Emergency response support; isolation and decontamination; supplies, pharmaceuticals, and
May 2007 Preparedness planning tool laboratory support; and surveillance. http://www.ahrq.gov/prep/cbrne/
The CDC has provided advance data from vital and health statistics
demonstrating wide variations in terrorism preparedness training. A study The report and many updates on
CDC – QuickStats on by Niska et al., "Training for terrorism-related conditions in hospitals: Emergency Preparedness may be
training ER staff for United States, 2003-04; No. 380," used data to determine which hospital downloaded from the Safety
Emergency emergency characteristics are associated with providing terrorism preparedness Institute's Emergency
May 2007 Preparedness preparedness training to clinical staff. Preparedness Web site.
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Two courses designed to help hospital personnel implement the National
Incident Management System (NIMS) are available from the Federal
Emergency Management Agency (FEMA). NIMS was developed so
responders from different jurisdictions and disciplines can better
collaborate to respond to natural disasters and other emergencies.
Course IS-100. HC, "Introduction to the Incident Command System for
Healthcare/Hospitals," describes the history, features, principles and
organizational structure of ICS. FEMA notes that the course is for
hospital personnel who would have a direct role in emergency
preparedness, incident management, and/or emergency preparedness.
Course IS-200. HC, "Applying ICS to Healthcare Organizations," is http://www.training.fema.gov/EMIW
designed to enable healthcare personnel to operate efficiently during an eb/IS/is100HC.asp;
FEMA – incident or event within the ICS and is for personnel whose primary http://www.training.fema.gov/EMIW
Implementing the responsibility is emergency management. FEMA's Web site has eb/IS/is200HC.asp;
National Incident additional information on NIMS implementation activities for hospitals. http://www.fema.gov/emergency/ni
Emergency Management System Other professional groups such as the American Society for Healthcare ms/compliance/assist_non_govt.sht
Feb 2007 Preparedness (NIMS) Engineering also offer similar training courses for ICS. m
Providing Mass Medical Care with Scarce Resources: A Community
Planning Guide (.pdf) (1.1 MB) is the product of a collaborative effort
between AHRQ and the Office of Public Health Emergency
Preparedness. Experts in the areas of mass casualty care, including pre-
hospital care, hospital and acute care, alternative care sites, palliative
care, ethical issues, and legal considerations, contributed to this guide. It
describes shortages (such as of hospital beds and ambulances)
healthcare workers may face and gives planners specific
recommendations, such as providing off-site care and using taxis, buses, http://www.premierinc.com/quality-
AHRQ emergency and private cars to transport sick or injured patients. The report provides safety/tools-services/safety/safety-
Emergency planning – Mass planning checklists and tips for making wise use of limited medical share/12-06-downloads/08-ahrq-
Dec 2006 Preparedness casualty care guide resources. mce-guide.pdf
A Web-based interactive decision tool designed to assist emergency
preparedness and recovery planners is available from the Department of
Health and Human Services. The new tool helps determine how to
access and use health information about various populations such as the
HIPAA Privacy Rule: elderly and those with disabilities, and is consistent with the Health
Disclosures for Insurance Portability and Accountability Act's privacy rule in emergency
Emergency preparedness situations. The tool should help planners organize their Go to:
Emergency Preparedness - A activities, and provide useful information to a range of potential http://www.hhs.gov/ocr/hipaa/decisi
July 2006 Preparedness Decision Tool programs. ontool/.
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The 27-minute training video teaches hospital personnel how to
decontaminate children after being exposed to hazardous chemicals
during a bioterrorist attack or other type of disaster. It reviews strategies,
tools and key preparedness planning issues. The training video is
intended for hospitals and emergency and pediatric professionals
because it explains the unique needs of children versus adults during
The Decontamination public health emergencies. The video also covers three main areas: a
of Children: step-by-step presentation of the decontamination process; a real-time
Preparedness and demonstration of the decontamination of children from infancy to To obtain a free single copy,
Response for adolescence, and; a section for administrators that outlines the steps contact the AHRQ Publications
Emergency Hospital Emergency involved in establishing and maintaining a pediatric decontamination Clearinghouse at 800.358.9295, or
April 2006 Preparedness Departments facility in any emergency department. via email at ahrqpubs@ahrq.gov.
The Joint Commission on Accreditation of Healthcare Organizations
(JCAHO) has issued a guide, "Surge Hospitals: Providing Safe Care in
Emergencies". A "surge hospital" is designed to treat a surge in the
number of patients needing care, triage, treatment, and even surgical
interventions. They are temporary facilities, such as shuttered hospitals,
closed wards in existing hospitals, and mobile facilities designed to serve Go to:
as a stopgap measure to provide medical care until an area's healthcare http://www.premierinc.com/all/safet
Surge Hospitals: organizations can reopen. The guide also includes case studies that y/resources/disaster_readiness/dow
Emergency Providing Safe Care describe how surge hospitals were established during the recent nloads/surge-hospitals-jcr-12-08-
January 2006 Preparedness in Emergencies hurricanes on the Gulf Coast. 05.pdf
Emergency NIOSH pocket guide - http://www.cdc.gov/niosh/npg/defau
December 2005 Preparedness Chemical hazards lt.html
Mold: Prevention Mold: Prevention Strategies and Possible Health Effects in the Aftermath
Strategies and of Hurricanes Katrina and Rita and a mold table includes population
Possible Health specific recommendations for protection from exposure to mold in
Effects in the buildings flooded after hurricanes by specific activity and risk factors, as
Aftermath of well as information on how to identify and prevent mold-related health http://www.premierinc.com/all/safet
Emergency Hurricanes Katrina effects. The documents include recommendations for control of mold y/resources/disaster_readiness/dow
November 2005 Preparedness and Rita exposure. nloads/2005-mold-report.pdf
http://www.premierinc.com/all/safet
y/public-health/downloads/03-
reoccupancy-post-hurricane-10-18-
A fact sheet and checklist were recently developed by the Centers for 05.pdf,
Disease Control and Prevention to assist healthcare facilities with the http://www.premierinc.com/all/safet
tasks involved during clean-up and reopening following extensive water y/public-health/downloads/02-ic-
damage. "Remediation and Infection Control Considerations for checklist-reoccupancy-post-
Reopening Healthcare Facilities Closed due to Extensive Water and hurricane-10-18-05.doc, and
Wind Damage" notes that implementation of these measures is meant to http://www.premierinc.com/all/safet
be followed in accordance with state and local certification requirements, y/public-health/downloads/01-ic-
Emergency completion of building and fire inspections, and other relevant state or checklist-reoccupancy-post-
November 2005 Preparedness Reopening a facility local regulations. hurricane-10-18-05.pdf
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The Joint Commission on Accreditation of Healthcare Organizations
(JCAHO) has issued a step-by-step guide, "Standing Together: An
Emergency Planning Guide for America's Communities," for small, rural
and suburban communities to both prepare for and successfully respond
to major local and regional emergencies such as hurricanes, floods,
Standing Together: terrorist attacks, major infectious outbreaks, hazardous materials spills,
An Emergency or other catastrophic occurrences. This comprehensive planning guide
Planning Guide for provides 13 essential steps that local government and public health http://www.premierinc.com/all/safet
Emergency America's leaders can use to establish an effective community-based emergency y/publications/10-05-downloads/10-
October 2005 Preparedness Communities management planning and response process. emergency-planning-guide.pdf
A recently released Archives of Internal Medicine article describes
improvements in a physician's ability to diagnose and manage diseases
caused by bioterrorism agents. Such improvements were documented
after the completion of an online pre-test that assessed physicians'
baseline knowledge and ability to diagnose and manage potential cases
of smallpox, anthrax, botulism, and plague. An educational module
following the pre-test reviewed diagnosis and decision-making for
patients presenting with anthrax, botulism, plague, smallpox, or a
common disorder that has clinical overlap with these diseases. The
educational module was followed by a post-test, which measured the
module's effectiveness. Extra cases were presented to the physicians The bioterrorism-education module
between the pre- and post-tests on each of the four potential bioterrorism is available for registered users on
Educational module agents. Improvement in results led the study's authors to conclude that the Johns Hopkins Medicine's
Emergency for physicians – the online education module may improve physician's diagnosis and Internet Learning Center at:
October 2005 Preparedness Bioterrorism agents management of diseases caused by these agents. http://www.hopkinsilc.org.
Premier Safety
Institute's Emergency The Premier Safety Institute's Emergency and Public Health
Emergency and Public Health Preparedness page also contains relevant and timely news and http://www.premierinc.com/all/safet
September 2005 Preparedness Preparedness resources related to the disaster. y/public-health/
During clean up and recovery operations following hurricanes, OSHA
Emergency issues alerts on the dangers associated with cleanup and recovery from http://www.osha.gov/OshDoc/hurric
September 2005 Preparedness Keeping workers safe hurricanes. aneRecovery.html
Increased incidence of acute diarrhea may occur in post-disaster
Acute diarrhea - situations where access to electricity, clean water, and sanitary facilities http://www.premierinc.com/all/safet
Emergency guidelines for are limited. In addition, usual hygiene practices may be disrupted and y/publications/09-05-downloads/14-
September 2005 Preparedness management healthcare seeking behaviors may be altered. guide-acute-diarrhea.pdf
Food may not be safe to eat during and after a natural disaster or power http://www.premierinc.com/all/safet
Emergency outage. Safe water guidelines provide guidance for using bottled, boiled, y/publications/09-05-downloads/13-
September 2005 Preparedness Safe food and water or treated water for drinking, cooking, and personal hygiene. food-water-safety.pdf
Information on water supply disruptions excerpted from the CDC
Guidelines for Environmental Infection Control in Health-Care Facilities, http://www.premierinc.com/all/safet
Emergency 2003 - Recommendations of CDC and the Healthcare Infection Control y/publications/09-05-downloads/12-
September 2005 Preparedness Water system repair Advisory Committee (HICPAC). water-system-repair.pdf
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Community shelters provide housing for persons displaced from their
homes following natural disasters such as hurricanes, floods, and
earthquakes. In these settings, individuals share living space. Some
individuals may have health problems, including acute or chronic
Community shelter infectious diseases. These recommendations provide basic infection http://www.premierinc.com/all/safet
Emergency guidance following control information that will help to prevent exposure to or transmission y/publications/09-05-downloads/11-
September 2005 Preparedness disasters of infectious agents. community-shelters.pdf
Immunization recommendations (.pdf) (85 KB) are available for
individuals displaced by Hurricane Katrina. Although measles and rubella
are no longer endemic to the United States, introductions do occur, and
crowded conditions may facilitate their spread. Although Hepatitis A
incidence is low in the affected areas, post-exposure prophylaxis in these
settings would be logistically difficult. Consequently, vaccination is
recommended. In addition, the influenza season will begin soon and http://www.premierinc.com/all/safet
Emergency Interim immunization influenza can spread easily under crowded conditions. Interim y/publications/09-05-downloads/09-
September 2005 Preparedness after hurricane recommendations are provided. cdc-advisory-interim-immun.pdf
http://www.premierinc.com/all/safet
After an emergency, it can be difficult to find running water. However, it y/publications/09-05-downloads/06-
is still important to wash your hands (.pdf) (75 KB) to avoid illness. It is handwashing-emergencies.pdf and
best to wash your hands with soap and water but when water isn't http://www.premierinc.com/all/safet
Emergency Hand hygiene in available, you can use alcohol-based products (.pdf) (34 KB) made for y/publications/09-05-downloads/21-
September 2005 Preparedness emergency situations washing hands. clean-hands-cards.pdf
This summary addresses preventing electrocutions associated with
generators plugged into household circuits. Homeowners should not
attempt to install any generator that requires hard-wiring into an existing http://www.premierinc.com/all/safet
Emergency Electrical safety and electrical circuit or that requires a trained, qualified electrician to hard- y/publications/09-05-downloads/05-
September 2005 Preparedness generators wire any generator into a household circuit. electrical-safety.pdf
After a natural disaster, snakes may have been forced from their natural
habitats and move into areas where they would not normally be seen or
expected. When you return to your home, be cautious of snakes that http://www.premierinc.com/all/safet
Emergency Snake bite - How to may have sought shelter in your home. If you see a snake in your home, y/publications/09-05-downloads/08-
September 2005 Preparedness prevent or respond immediately call the animal control agency in your county. snake-bite.pdf
Animal disposal Most states have guidelines on disposal of dead animals so people with http://www.premierinc.com/all/safet
Emergency following an questions regarding the specific situation in their state are encouraged to y/publications/09-05-downloads/07-
September 2005 Preparedness emergency contact local or state health and agricultural officials for clarification. animal-disposal.pdf
ASHE's Hurricane Relief Resources provides a link to the University of
Minnesota, "Managing Water Infiltration into Buildings: A Systematized See also CDC's "Healthcare Water
Approach for Remediating Water Problems in Buildings due to Floods, System Repair" at
Emergency Roof Leaks, Potable Water Leaks, Sewage Backup, Steam Leaks and http://www.dehs.umn.edu/iaq/flood.
September 2005 Preparedness Flood remediation Groundwater Infiltration." html.
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The information is available at
http://www.ahrq.gov/research/shutt
ered/. Related: Use of shuttered
The new report from the Agency for Healthcare Research and Quality hospitals report
(AHRQ) entitled "Use of Former (Shuttered) Hospitals to Expand Surge http://www.premierinc.com/all/safet
Capacity" that gives emergency responders and public health officials y/publications/09-05-downloads/02-
useful, practical tools for opening shuttered hospitals when an ahrq-shutreport.pdf, Tool kit to
emergency is underway. The information is available at open a facility
http://www.ahrq.gov/research/shuttered/. The report gives surrounding http://www.premierinc.com/all/safet
communities that aren't immediately affected by the hurricane a way to y/publications/09-05-downloads/03-
assess their existing facilities to meet future needs. It includes lists of ahrq-toolkit.pdf, and Checklist to
Use of Former supplies and medications needed by stable medical/surgical patients and open a facility found at
(Shuttered) Hospitals checklists to assess facility readiness, staffing needs and levels, and http://www.premierinc.com/all/safet
Emergency to Expand Surge patient transport readiness. The report also contains a tool kit with a list y/publications/09-05-downloads/04-
September 2005 Preparedness Capacity of supplies and equipment needed for operation of a reopened facility. ahrq-checklist.pdf.
Although terrorists use a variety of methods to inflict harm and create
fear, bombs are used most frequently. According to the FBI, bombings
accounted for nearly 70 percent of all terrorist attacks in the United
States and its territories between 1980 and 2001. This practical summary
focuses on common sense principles that will be useful in a bombing
event. It describes how every person, family or organization should This CDC document can be
prepare for an emergency or disaster, including knowledge of work, downloaded at
school and community disaster plans. If you are not familiar with the http://www.premierinc.com/all/safet
plans, contact your supervisor, school administrators, or your local fire y/public-
Emergency Preparing for a department for more information. This document details what should be health/downloads/preparingterrorist
August 2005 Preparedness terrorist bombing done if a bomber is suspected. bombing.pdf
The Occupational Safety and Health Administration (OSHA) has
released a best practices document (.pdf) (1.9 MB) for hospital-based
first receivers of victims of chemical, biological, and radiological events.
The "Hospital-Based First Receivers of Victims from Mass Casualty
Incidents Involving the Release of Hazardous Substances" document will
assist hospitals in developing and implementing emergency management
plans that address the protection of emergency department personnel,
OSHA 'best practice' while receiving contaminated victims from mass casualty incidents. It http://www.premierinc.com/all/safet
Emergency guidance for hospital- also includes information on victim decontamination, personal protective y/publications/01-05-downloads/08-
January 2005 Preparedness based first receivers equipment (PPE), and employee training first-receivers-hosp.pdf
The Department of Homeland Security has released a new National
Response Plan. The Department of Health and Human Services will lead
the federal government in providing public health and medical services
during major disasters and emergencies. The National Response Plan The Plan can be downloaded at:
Emergency National Response establishes a comprehensive all-hazards approach to enhance the ability http://www.dhs.gov/dhspublic/intera
January 2005 Preparedness Plan of the United States to manage domestic incidents. pp/
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Clinician Registry for
Terrorism and
Emergency The registry provides real-time information to help healthcare providers
Response Updates prepare for (and possibly respond to) emerging diseases and terrorism
Emergency and Training events. CDC also uses the registry to announce new clinician training
October 2004 Preparedness Opportunities opportunities related to terrorism and emergency response topics. editorial/editorial_0566.xml.
http://my.premierinc.com/all/safety/
Emergency Minnesota's surge publications/08-04-downloads/08-
August 2004 Preparedness capacity plan Minnesota's surge capacity plan surge-amacdc-email.ppt
Healthcare Facility A study conducted by several disaster medicine experts on strategies to The plan is available from the
and Community manage patient surges in healthcare facilities following a biological or Annals of Emergency Medicine
Emergency Strategies for Patient chemical terrorist attack, provides sample response plans for (contact Colleen Hughes at
August 2004 Preparedness Care Surge Capacity communities in Colorado, Massachusetts, Minnesota, and Virginia. 202.728.0610, Ext. 3010).
The tool helps regional planners locate and rank potential alternative To view the full report and tool, go
sites such as stadiums, schools and recreation centers based on to:
Emergency Surge capacity whether they have adequate ventilation, plumbing, food supply, kitchen http://www.ahrq.gov/research/altsite
August 2004 Preparedness planning facilities and other factors. s.htm.
The Centers for Disease Control and Prevention (CDC) has established
partnerships with national clinician organizations for the purpose of
disseminating timely information on disease outbreaks and terrorism
events. COCA's Web site was successfully launched July 20. The site
Clinician Outreach offers many resources for COCA members, including past COCA
Emergency and Communication conference call summaries and slides, listings of COCA members, Visit the COCA Web site at
August 2004 Preparedness Activity (COCA) information on future conference calls and training updates. www.bt.cdc.gov/coca/index.asp.
The Centers for Disease Control and Prevention has a Web-based The module can be completed at
Emergency Plague training module designed to teach the natural epidemiology of plague and how to http://www.bt.cdc.gov/agent/plague/
July 2004 Preparedness module manage it as both a natural disease and an intentional attack. trainingmodule/.
The full report, Evidence
Report/Technology Assessment
No. 95, Training of Hospital Staff to
Training of Clinicians This evidence report updates the evidence report "Training of Clinicians Respond to a Mass Casualty
for Public Health for Public Health Events Relevant to Bioterrorism Preparedness" and Incident, may be obtained free from
Events Relevant to focuses on the effectiveness of hospital disaster drills, computer the AHRQ Publications
Emergency Bioterrorism simulations, and tabletop or other exercises used in training hospital staff Clearinghouse by calling
June 2004 Preparedness Preparedness to respond to a mass casualty incident. 800.358.9295.
The tool, developed by the Evidence-based Practice Center at the Johns
Hopkins University, helps hospitals identify their strengths and
weaknesses during a disaster drill and improve their ability to meet
required emergency management plans. Areas assessed include pre-drill
Evaluation of Hospital planning, incident command, decontamination, triage and treatment. The
Disaster Drills: A tool also includes checklists to help hospitals tailor drills to specific health
Emergency Module-Based threats, such as a biological or radiation incidents, and a spreadsheet to
June 2004 Preparedness Approach track and compare drill performance among hospital units or hospitals.
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The plan calls for specialized response teams, an emergency
preparedness executive steering committee, and regional emergency
response plans during a national emergency. The agency recently
published its National Emergency Management Plan that details the
agency's roles and responsibilities during responses to national
Emergency National Emergency emergencies and outlines procedures to ensure assistance is in place for http://www.osha.gov/SLTC/emerge
March 2004 Preparedness Management Plan responder and recovery workers' health and safety. ncypreparedness/index.html
The report, HHS bioterrorism preparedness programs: States reported
progress but fell short of program goals for 2002, examines the extent to
which states completed 2002 cooperative agreement requirements and
whether they identified any factors that hindered implementation of the http://www.premierinc.com/all/safet
Emergency Centers for Control and Prevention (CDC) and Health Resources and y/publications/03-04-downloads/04-
March 2004 Preparedness Services programs: States reported progress agreement of program
HHS bioterrorism preparedness Administration’s (HRSA) cooperativebut fell shortprograms. goals for 2002
d04360r.pdf
A training course originally developed by the World Health Organization
and Centers for Disease Control and Prevention for training smallpox Order at
Emergency response teams, these presentations help planners and first responders http://www.bt.cdc.gov/agent/smallp
January 2004 Preparedness CDC Training Slides prepare for the possibility of the use of smallpox as a terrorist weapon. ox/training/overview/index.asp
OSHA has a Web-based training tool on implementing an incident
command system as part of emergency response preparedness. The
Emergency Incident command toolprovides guidance on planning for an incident command system and http://www.osha.gov/SLTC/etools/ic
December 2003 Preparedness syatem addresses applicable OSHA standards. s/index.html
http://www.premierinc.com/all/safet
y/publications/11-03-downloads/09-
illness-associated-exposure-chem-
Emergency Recognizing chemical agents.doc
November 2003 Preparedness agent exposure
A health information bulletin, provides recommendations on preventing http://www.osha.gov/dts/shib/shib1
mold growth, proper use of personal protective equipment, and safe 01003.html
Emergency Brief Guide to Mold in cleanup methods.
November 2003 Preparedness the Workplace
A matrix tool, provides information on how facilities can reduce
Emergency Fire and Explosion vulnerability to and consequences of a terrorist attack that involves fire or http://www.osha.gov/dep/fire-
November 2003 Preparedness Planning Matrix an explosive device. expmatrix/index.html.
The Pink Book – “Epidemiology and Prevention of Vaccine Preventable
Epidemiology and Diseases,” the 7th edition from 2002, is now in its second printing. The book is available for download
Prevention of or purchase at
Emergency Vaccine Preventable http://www.cdc.gov/nip/publications/
October 2003 Preparedness Diseases pink/default.htm
Provides employers with information on helping to protect workers from
injuries and illnesses resulting from possible terrorist incidents related to
Chemical, Biological, chemical, biological, radiological, or nuclear attacks.
Radiological, and
Nuclear (CBRN) http://www.osha.gov/dts/shib/revCB
Emergency Warfare Agents RN_EscapeRespirators_8-29-
October 2003 Preparedness Escape Respirators 03.html
An Excel program version (1.4 MB)
Computer staffing A new computer model is available to help hospitals and health systems may be downloaded from:
Emergency model - Bioterrorism plan antibiotic dispensing and vaccination campaigns to respond to http://www.ahrq.gov/research/biom
July 2003 Preparedness Response bioterrorism or large-scale natural disease outbreaks. odel.htm.
Excel: Premier / Modules / b24d7277-3ce3-4a13-baeb-3f4ffe9a8b03.xls / Emergency Prep
Premier Safety Share
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Month Year Topic by Tab Tool Description Tool Location
The Evacuation Planning Matrix,
available at
Emergency Evacuation Planning http://www.osha.gov/dep/evacmatri
June 2003 Preparedness Matrix Online tool to help employers with emergency planning. x/index.html
Guidance for
Protecting Building
Environments from A new federal guidance is now available to help facility specialists in http://my.premierinc.com/all/safety/
Airborne Chemical, business and government strategically select and use air-filtration and air- publications/06-
Emergency Biological, or cleaning systems for protecting occupants in buildings from chemical, 03_downloads/08_NIOSH_2003-
June 2003 Preparedness Radiological Attacks biological, or radiological attacks. 136.pdf
Disaster
Preparedness and
Response in Texas http://www.healthpolicyinstitute.org/
Emergency Hospitals: Part I, projects/disaster_response/dis_res
May 2003 Preparedness Bioterrorism A bioterrorism disaster preparedness guide for hospitals. p.asp
Information on agents likely to be used in a chemical terrorist attack. This
resource highlights agent-specific identification, medical symptoms,
Emergency Emergency personal protective equipment, and decontamination considerations for http://www.cdc.gov/niosh/topics/em
May 2003 Preparedness Response Resources responding to events involving cyanide, sarin, and nitrogen mustard. res/chemagent.html
Disaster drills are most effective when designed by an interdisciplinary
team that clearly establishes goals before the drill begins. A
Planning and teleconference on disaster drills and readiness assessment asserts that http://www.hsrnet.net/ahrq-
Emergency executing disaster the drills should also include a plan to evaluate whether the goals were ulp/bioterrorism/events/0415/materi
May 2003 Preparedness drills reached. als.htm
Addressing the
Smallpox Threat: http://www.hsrnet.net/ahrq-
Emergency Issues, Strategies, Copies of a 90-minute audiotape may be purchased for $10 from the ulp/bioterrorism/events/0218/materi
May 2003 Preparedness and Tools AHRQ Publications Clearinghouse als.htm
Clinician Registry for
E-mail Updates on Clinician's registry to provide real-time information to help prepare for
Terrorism and and respond to terrorism and emergency situations. As participants,
Emergency Emergency physicians will receive regular updates on terrorism and emergency
April 2003 Preparedness Response response issues targeted to clinicians. http://www.bt.cdc.gov/
Emergency Smallpox Vaccine A guide addressing legal and risk management issues for hospitals http://biotech.law.lsu.edu/blaw/bt/s
March 2003 Preparedness Injury and Law Guide related to the smallpox vaccine. mallpox/svlaw.htm
Risk Management
Guidance for Health,
Safety and
Environmental The report covers several issues related to infrastructure and
Security under environmental risks during disaster events, including food, mail, and http://my.premierinc.com/all/safety/
Emergency Extraordinary personnel security and safety; transportation; childcare; and building publications/03-
March 2003 Preparedness Incidents access 03_downloads/11_extraordinary.pdf
Excel: Premier / Modules / b24d7277-3ce3-4a13-baeb-3f4ffe9a8b03.xls / Emergency Prep
Premier Safety Share
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Month Year Topic by Tab Tool Description Tool Location
The chart presents a concise summary of signs and symptoms to assist
Emergency Chemical terrorism with early recognition, as well as to alert healthcare workers about the
February 2003 Preparedness agents potential for chemical terrorism agents. http://www.unc.edu/depts/spice/
The program provides basic information required to implement a
Bioterrorism Update: smallpox vaccination preparedness program. Presented in a series of
Emergency Smallpox modules, it is directed at state and local health department and clinical http://bookstore.phf.org/prod250.ht
February 2003 Preparedness Preparedness personnel. m
http://my.premierinc.com/all/safety/
Emergency Vaccine Information The smallpox VIS must be used with a separate consent form that publications/01-
January 2003 Preparedness Statement (VIS) requires a signature. 03_downloads/11_small02.pdf
This comprehensive module addresses the vaccine, methods of
Emergency Smallpox training inoculation, prevention of contact transmission, laboratory testing and
December 2002 Preparedness module use of vaccinia immunoglobulins (VIGs). http://www.bt.cdc.gov/
More than 70 metropolitan hospital executives heard how hospitals near
"Ground Zero" in lower Manhattan and the Pentagon responded to the
National Symposium immediate tragedies of September 11, 2001, as well as strategies related http://www.hospitalconnect.com/ah
Emergency on Hospital Disaster to ongoing disaster readiness preparations against possible future a/key_issues/disaster_readiness/E
December 2002 Preparedness Readiness biological, and chemical, and natural disasters. mWhatsNew.html
Go to
Emergency http://www.premierinc.com/all/safet
Emergency preparedness On-line catalogs provide emergency preparedness supplies available y/resources/disaster_readiness/pro
November 2002 Preparedness materials from several companies d_equip.htm.
AHRQ's Bioterrorism
Emergency Planning http://my.premierinc.com/all/safety/
and Preparedness Biological weapons training for personnel, procedures to permit rapid publications/09-
Emergency Questionnaire for recognition of credentialed staff from other facilities, on-call nursing 02_downloads/11_AHRQ_bioterror
October 2002 Preparedness Healthcare Facilities policies, and designated areas of emergency overflow for patients _checklist.pdf
Disaster kit — Tools
Emergency to meet children’s To aid pediatricians, community leaders, parents, and others in preparing
October 2002 Preparedness needs for and meeting children's needs during a disaster. http://www.aap.org/terrorism/
Preparing for
Terrorism: Tools for
Evaluating the A set of measurement tools and a process for evaluating the extent to
Metropolitan Medical which communities have implemented the disaster preparedness plans
Emergency Response System required by the Department of Health and Human Services’ Metropolitan http://www.nap.edu/catalog/10412.
August 2002 Preparedness Program Medical Response System program. html
Excel: Premier / Modules / b24d7277-3ce3-4a13-baeb-3f4ffe9a8b03.xls / Emergency Prep
Premier Safety Share
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Month Year Topic by Tab Tool Description Tool Location
Guidance for
Protecting Building
Environments from http://my.premierinc.com/all/safety/
Airborne Chemical, The guidelines address the physical security of ventilation systems, publications/06-
Emergency Biological, or airflow and filtration, systems maintenance, program administration, and 02_downloads/05_36_2002_niosh_
June 2002 Preparedness Radiological Attacks maintenance staff training. ventilation_139.pdf
Resources on bioterrorism – including an evidence report on training
Training of Clinicians clinicians, a summary of a workshop on strengthening the nation's
for Public Health response capabilities, the results of a survey noting the gaps and
Events Relevant to resources needed by local public health agencies to respond effectively
Emergency Bioterrorism to bioterrorism, and a report from ECRI on personal protective
May 2002 Preparedness Preparedness equipment. http://www.ahrq.gov/
Excel: Premier / Modules / b24d7277-3ce3-4a13-baeb-3f4ffe9a8b03.xls / Emergency Prep
Premier Safety Share
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Month Year Topic by Tab Tool Description Tool Location
The Food and Drug Administration joined with the CDC, the EPA and
OSHA in releasing guidelines on how to prevent hazards due to
inappropriate use of cleaners and disinfectants on electronic medical
equipment. Such solutions can cause the equipment to malfunction.
Many stakeholders, including AHA, APIC, and ASHE, provided input to
the guidelines for handling and cleaning of electronic medical devices.
Minimizing the potential for cross contamination and patient and worker http://www.premierinc.com/quality-
Environmental FDA guidance – injuries is critical, but of equal importance is the emphasis on the process safety/tools-services/safety/safety-
and Safety Electronic equipment of proper cleaning and disinfecting in accordance with manufacturers’ share/12-07-downloads/5_FDA-
December 2007 Products cleaning hazards guidelines in the interest of safety Equipment-10_31_07.doc
The newsletter provides news and success stories about topics such as
reduction of medical waste, computer recycling, green cleaning
programs, conversion to reusable products, laboratory chemical
recycling, energy efficient lighting and light bulb recycling. Premier's EPP
program is a collaboration of the Premier Safety Institute and Premier's
Environmental group purchasing services. The program is part of Premier's commitment
and Safety to helping healthcare facilities with their environmental efforts, including Go to:
March 2006 Products Green Link waste minimization and the elimination of the use of mercury. http://www.premierinc.com/safety
The Clinician Outreach and Communication Activity (COCA) offered a
program in Medical Waste Management on August 23, 2005. Lynne
Sehulster, Ph.D, M(ASCP), of the Centers for Disease Control and
Prevention (CDC) Division of Healthcare Quality Promotion presented
materials addressing: identification of general categories of medical
waste; regulations governing the management of medical waste; insight
Environmental Medical waste into how the recent influenza A (H2N2) situation revealed weaknesses in http://www.premierinc.com/all/safet
and Safety management the current system of waste management; and understanding the y/publications/10-05-downloads/09-
October 2005 Products teleconference importance of reinstating on-site capacity for medical waste treatment. waste-management-slides.ppt
The American Society for Healthcare Environmental Services has
partnered with Orkin, Inc. to promote more effective and environmentally
friendly pest-control practices in healthcare settings, including the
release of a guide on integrated pest management. The partners also See Premier Safety Institute's
plan to publish educational articles and host two educational sessions on Environmental and Safety Product
Environmental Environmentally the recommended practice at ASHES' annual conference in September. list at:
and Safety friendly pest control The partnership was launched in response to a growing movement in http://www.premierinc.com/all/safet
May 2005 Products list practices healthcare toward hazardous-chemical reduction. y/resources/lists/
Excel: Premier / Modules / b24d7277-3ce3-4a13-baeb-3f4ffe9a8b03.xls / Env and Safety Products
Premier Safety Share
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Month Year Topic by Tab Tool Description Tool Location
Two new handbooks are available online from Occupational Safety and
Health Administration (OSHA): "Best Practices for the Safe Use of
Glutaraldehyde in Health Care," which helps employers and employees
understand and control exposures to glutaraldehyde, a chemical used to Go to:
disinfect and clean heat-sensitive medical, surgical and dental http://www.osha.gov/Publications/gl
Environmentally equipment, and "Preventing Mold-Related Problems in the Indoor utaraldehyde.pdf and
Preferred OSHA online Workplace," which offers recommendations to owners, managers, and http://www.osha.gov/Publications/pr
May 2006 Purchasing handbooks occupants on how to fix mold problems in buildings eventing_mold.pdf
Environmentally A four-CD set containing all the presentations from "Environmentally Order free copies of the book and
Preferable Preferable Purchasing and Healthcare Practices Conference" held in CDs from the Premier Safety Store
Environmentally Purchasing and Boston, April 29, 2004. Topics include green buildings, mercury at:
Preferred Healthcare Practices elimination, recycling medical waste processing, solvent recovery, and http://www.premierinc.com/all/safet
December 2004 Purchasing Conference more. y/store/.
Premier's Safety Institute has added one more important section to the
Environmental Environmental Preferable Purchasing (EPP) module addressing
Chemical Preferable chemical cleaners and pesticides. The EPP "Topic summary" describes
cleaners and Purchasing (EPP) a number of important and useful resources. "Key documents" includes a http://www.premierinc.com/all/safet
September 2004 pesticides module case study of a safer, successful integrated pest management program. y/resources/EPP/index.htm
An online resource that aids employers in addressing air quality http://www.cdc.gov/niosh/topics/ind
concerns. The Indoor Environmental Quality topic page provides links to oorenv
a variety of air quality topics, including how to identify, correct, and
prevent indoor air problems; how to implement an effective air quality
Environmental Indoor Environmental plan; and resources on mold, asbestos, asthma and allergies, and
November 2003 Safety Quality topic page chemical safety.
Cleaning for Health: http://my.premierinc.com/all/safety/
Environmentally Products and One-stop guide to environmentally preferable cleaning products and publications/04-
Preferred Practices for a Safer methods that have been effectively used in office buildings, schools, 03_downloads/04_cleaning_for_he
April 2003 Purchasing Indoor Environment hospitals and other facilities in the United States and Canada. alth.pdf
Environmentally Environmentally A checklist is available which can be used by healthcare organizations to
Preferred preferred purchasing guide purchasing decisions or by manufacturers to assess the http://www.ahrmm.org/info/HCEPT/t
October 2002 Purchasing checklist environmental friendliness of products. ool.html
Excel: Premier / Modules / b24d7277-3ce3-4a13-baeb-3f4ffe9a8b03.xls / Env Preferred Purchasing
Premier Safety Share
IHI
Month Year Topic by Tab Tool Description Tool Location
The handbook is available for a
The most current knowledge on concepts and methods of human factors discounted price of $95 at
and ergonomics and their applications to help improve quality, safety, http://www.erlbaum.com/ME2/dirmo
efficiency, and effectiveness in patient care. The handbook provides d.asp?sid=28807ECF50FE49F083
specific information on how to analyze medical errors with the 7125BE640E681F&nm=&type=eCo
Handbook of Human fundamental goal of reducing errors and the potential harm that results. mmerce&mod=CommerceProductC
Factors and Contributors discuss the design of work environment and working atalog&mid=CD22EA0F118949C09
Ergonomics in conditions to improve satisfaction and well being, and the reduction of A932248C040F650&tier=3&id=119
Healthcare and burnout and other ailments often experienced by healthcare providers DCAD843B64A54BC20DE1F72531
Nov 2006 Fall Prevention Patient Safety and professionals. 996&itemid=0-8058-4885-1
The draft document titled "Safe Patient Handling and Movement
Principles," a collaboration between NIOSH, the American Nurses
Safe Patient Handling Association and the Veterans Affairs Patient Safety Center, is a new Available at the NIOSH Web site at:
and Movement Safe Patient Handling and Movement curriculum module to be used in http://www.cdc.gov/niosh/review/pu
June 2006 Fall Prevention Principles schools of nursing. blic/safe-patient
Minimizing the risk of falls and falls injuries: Guidelines for acute, sub-
acute and residential care settings from the Victorian Quality Council of
Australia provides a framework and supporting resources to support falls
prevention activities in hospital and residential care settings. This falls available for download from the
Minimizing the risk of reduction guideline packet, or tool kit, contains research, tools, and Premier Safety Institute's Falls
falls and falls injuries: education materials, including a sample Microsoft® Excel spreadsheet module
Guidelines for acute, report to track falls data and trends, as well as algorithms for assessing http://www.premierinc.com/all/safet
sub-acute and and reassessing an individual's fall risk. The packet includes numerous y/resources/falls/procedures-
residential care tips for screening, assessing risk, reducing personal and environmental tools.jsp#Tool (under "Sample
January 2006 Fall Prevention settings risk factors, and properly responding to falls. Procedures").
http://www.osha.gov/SLTC/hospital
May 2002 Fall Prevention Ergonomic eTools OSHA ergonomic plan and eTools _etool/mainpage.html
Excel: Premier / Modules / b24d7277-3ce3-4a13-baeb-3f4ffe9a8b03.xls / Fall Prevention
IHI
Month Year Topic by Tab Tool Description Tool
The ALFA Institute of Biomedical Sciences Educational Portal contains
medical education material on topics that include pediatric infections,
zoonoses, infectious diseases, internal medicine, dermatology, upper
and lower respiratory infections, surgical infections, antimicrobial
resistance, clinical research tools, biomedical databases, critical care
and sepsis, cardiovascular infections, nosocomial infections, hepatitis B
virus, orthopedic infections, OB/GYN infections and urogenital
infections. A selection of case studies that can be used as interactive
case-based learning tools from the Academy of Infection Management
Web-based are also available. The case studies include the specialties of surgery,
educational tools – pediatrics, ICU, and pneumonia. Specific topics include patient
Infection prevention outcomes related to antibiotic usage and healthcare associated
February 2008 Guidelines case studies infections
Diseases are spread by poor coughing and sneezing techniques. Most
people put their hands in front of their mouths and noses to stop germs
from getting into the air. Unfortunately, this technique puts the germs on
their hands. The germs are then spread to telephones and doorknobs
and many other surfaces, where the next user then acquires. This five-
minute video was designed by three Maine hospitals to encourage
people to cough and sneeze according to the infection control guidelines
put forth by the Centers for Disease Control and Prevention (CDC). It is
aimed at the common citizen. The message is serious, but it is
presented with humor in such a way that it engages the viewer's
Why Don’t We Do It attention for a full five minutes while the message is repeated in
February 2008 Guidelines in Our Sleeves? interesting new ways. and Educational Trust (HRET) has developed a
The Health Research
comprehensive guide for clinicians and administrators to help
AHA/HRET – incorporate routine HIV testing in their emergency departments (EDs).
Comprehensive tool This practical guide describes different approaches, considerations, and
August 2007 Guidelines for HIV testing in ED resources for making HIV testing routine in ED care. It is based on
Nine presentations from Premier's conference on "Healthcare-
associated infections – What everyone needs to know," held June 19,
2007, in Orlando, FL, are available online for download. Featured faculty
include: Graeme Forrest, M.D., University Maryland Medical Center;
Peter Gross, M.D., Hackensack University Medical Center; Carol
Haraden, Ph.D., IHI; Eli Perencevich, M.D., M.S., VA Maryland
Premier – Healthcare Healthcare System; Chesley Richards, M.D., M.P.H, FACP,
associated infection CDC/DHQP; Richard Van Enk, Ph.D., Bronson Methodist Hospital;
presentations Daniel Varga, M.D., SSM Healthcare; and Premier's Dan Peterson, M.D,
August 2007 Guidelines available online M.P.H.; Gina Pugliese, R.N., M.S.; and Scott Pope, Pharm.D.
The Association for Professional in Infection Control and Epidemiology
(APIC) has released a white paper on healthcare associated infections
(HAI) titled "Dispelling the Myths: The True Cost of Healthcare-
Associated Infections." Featured in the March issue of Healthcare
Financial Management magazine, the white paper presents the
business case for reducing HAIs from the perspective of the healthcare
executive. Case studies of cost saving are detailed, along with a
methodology for determining the cost of different categories of HAIs.
APIC – A business APIC's goal with the white paper is to help healthcare executives
case for preventing understand the costs involved with these infections, evaluate HAIs in
healthcare- their own institutions and take a more aggressive approach to infection
Mar 2007 Guidelines associated infections prevention.
Patients undergoing MRI exams while wearing ECG electrodes and
cables have experienced second and third degree burns sometimes
FDA – Avoiding requiring plastic surgery to repair. After a FDA investigation into reports
burns from received regarding these burns, precautions that can be taken to
electrodes and prevent these types of burns were released. The problem is the
cables during MRI radiofrequency fields created during an MRI exam can heat ECG cables
Mar 2007 Guidelines exams AHRQ released seriously burningReport/Technology Assessment
and electrodes, a new Evidence the underlying skin.
(Number 9), which concludes that several approaches and practices
implemented to prevent healthcare-associated infections (HAI) are
promising and warrant additional research. The objective of the report
was to determine the effects of quality improvement strategies on HAI
and on HAI rates. The selected infections (.pdf) (785 KB) included
surgical site infections (SSI), central line-associated bloodstream
infections (CLABSI), ventilator-associated pneumonia (VAP), and
catheter-associated urinary tract infections (CAUTI) The AHRQ
Evidence Report concludes that there is insufficient evidence to
recommend quality improvement strategies that will improve adherence
to preventive interventions for healthcare-associated infections. The
evidence is generally of suboptimal quality, consisting primarily of single-
center, simple before-after studies of limited internal and external
validity. Results from the limited data suggest that certain strategies
require additional study and potential wider implementation. Those
AHRQ – Report on strategies include reducing unnecessary catheter use by using "stop
strategies to prevent orders" (which require that a catheter be removed after a certain period
healthcare- of time if it is no longer needed), reminders to improve surgical antibiotic
Feb 2007 Guidelines associated infections prophylaxis, the use of checklists to improve adherence to central line
A new toolkit designed to provide guidance on issues that should be
considered when designing measures for public reporting of healthcare-
associated infections (HAI) is available from the Centers for Disease
Control and Prevention (CDC). The kit was designed in conjunction with
the Association of Professionals in Infection Control and Epidemiology
(APIC), the Society for Healthcare Epidemiology of America (SHEA) and
other professional groups. Many states are considering making HAI
reporting mandatory. "Essentials of Public Reporting of Healthcare-
Associated Infections: A Tool Kit" (.pdf) (199 KB) details recommended
steps, including the identification or creation of a responsible agency at
CDC – Tools for the state level, personnel for data collection and quality improvement,
reporting healthcare- strategies to prevent unintended consequences of public reporting, and
Feb 2007 Guidelines associated infections recommended outcome measures.
Several new tools have recently been added to the Surgical Care
Improvement Project (SCIP) Web site. The first, "Preventive Antibiotics
in Colon and Rectal Surgery: Discontinuation Within 24 Hours After
Operation," is a presentation that discusses the importance of giving
recommended antibiotics in colorectal surgery with the equally important
factor of discontinuing the antibiotics within 24 hours. Other tools related
to venous thromboembolism include: Deep Vein Thrombosis
SCIP – New surgical, Prophylaxis Risk Factor Assessment, and Thrombosis Screen and
Dec 2006 Guidelines VTE tools Prophylaxis Recommendations.
Cough hygiene video, NSF Scrub Club provides an interactive Web-
based educational program with music, games and cartoons that aims
Humor in infection to help protect children from dangerous food borne illnesses as well as
control – Online infectious diseases, and MARR has useful antibiotic information
educational downloads on fighting antibiotic resistance, a parent's guide for colds,
resources for adults runny noses, and otitis media. Posters on handwashing include a
Sept 2006 Guidelines and children reminder for children on when to wash their hands.
The Advisory Committee on Immunization Practices (ACIP) has issued
recommendations for preventing rotavirus gastroenteritis in infants and
children. The recommendations call for American infants to be
immunized with the recently licensed rotavirus vaccine. Infants should
receive three doses of the vaccine, administered orally at two, four and
six months. It is the most common cause of severe gastroenteritis in
infants and young children worldwide. Although rotavirus causes few
deaths among U.S. children, almost all children will become infected
with rotavirus by age five. Most of them will develop gastroenteritis,
ACIP – New rotavirus resulting in up to 272,000 emergency department visits and 70,000
Sept 2006 Guidelines vaccine hospitalizations each year.
Antibiotic Prophylaxis
in Cardiac Surgery –
Duration of This guideline provides for one recently CMS approved exception for
March 2006 Guidelines prophylaxis discontinuance of antibiotic prophylaxis.
Antimicrobial
Prophylaxis for
Surgery: An Advisory
Statement from the This advisory statement provides an overview of issues related to
National Surgical antimicrobial prophylaxis, including specific suggestions regarding
Infection Prevention antimicrobial selection, initiation and discontinuance of prophylactic
March 2006 Guidelines Project antimicrobials.
New guidelines are designed specifically for the cardiovascular
catheterization laboratory and provide information on such issues as the
selection of antibacterial soaps, the circumstances under which patients
CV Cath Lab: should receive an antibiotic, protective masks and other garb to be worn
Infection control by catheterization lab staff, and the acceptable level of air circulation in
January 2006 Guidelines guidelines the catheterization lab.
New resources on community-acquired MRSA CA-MRSA and a
Template for Gene Vector Guidance have been made available from the
Association for Professionals in Infection Control and Epidemiology
(APIC) Practice Guidance Council. These resources were developed in
collaboration with APIC's Emerging Issues Committee. The CA-MRSA
resource identifies key resources available via national, state, and local
Community-acquired public health agencies. The Template for Gene Vector Guidance is
MRSA CA-MRSA intended to assist facilities in developing infection control policies to
and a Template for regulate gene vector therapy. APIC recommends any study be reviewed
Gene Vector and approved by their Institutional Review Board (IRB) but also include
January 2006 Guidelines Guidance the involvement of an affiliated Biosafety Committee.
The U.S. Public Health Service has updated the recommendations for
the management of healthcare personnel (HCP) with occupational
exposure to blood and other body fluids that might contain human
immunodeficiency virus (HIV). Published in the September 30, 2005
Morbidity and Mortality Weekly Report (MMWR) , the recommendations
(.pdf) (267 KB) emphasize adherence to postexposure prophylaxis
(PEP) regimens when indicated, expert consultation in managing
HIV post-exposure exposures, follow-up to improve HCP adherence to PEP, and monitoring
October 2005 Guidelines prophylaxis for adverse events, including seroconversion.
EPA Notebook -
Healthcare waste
management
June 2005 Guidelines profiles, resources
A guide to assist with compliance with the JCAHO Environmental of
Care Standards. Hospitals for a Healthy Environment (H2E) is working
on a clipboard version for JCAHO surveyors. This guide relates each
JCAHO Element of Performance (EP) to specific federal regulations, to
help facilities be in compliance with both. The guide also suggests steps
JCAHO/H2E guide - that facilities can take to encourage environmental performance
Environment-of-care improvements. A comprehensive environmental program, including
compliance and waste minimization and pollution prevention initiatives, can help ensure
June 2005 Guidelines improvement compliance and reduce costs.
Two new guidance documents from the Association for the
Advancement of Medical Instrumentation (AAMI) are designed to assist
manufacturers in assessing the device reprocessing information they
provide. These documents help address concerns that manufacturer's
instructions are often inadequate or don't consider the common
reprocessing methods facilities use. The first document, entitled
"Designing, testing, and labeling reusable medical devices for
reprocessing in healthcare facilities: A guide for device manufacturers"
(TIR12: 2004), is intended to help manufacturers validate the
reprocessing procedures they recommend and guide them in choosing
AAMI guidance facility protocols. The second, "Sterilization of medical devices -
documents - Information to be provided by the manufacturer for the processing of re-
Cleaning and sterilizable medical devices" (ANSI/AAMI/ISO ST81: 2004), sets forth
May 2005 Guidelines sterilization requirements for labeling and reprocessing instructions.
The comprehensive lists published by the Food and Drug Administration
(FDA) are available on the FDA Web site. The FDA Guidance
FDA Guidance Documents for Regulated Industry - Annual Comprehensive List of
March 2005 Guidelines Documents Guidance Documents - and the corrections to that list
A presentation titled, From SIP to SCIP (referring to the National
Surgical Infection Prevention Project and the current Surgical Care
Improvement Project) is available from the Surgical Care Improvement
From SIP to SCIP Project. Dale W. Bratzler, M.D., provides a background summary of the
(referring to the Surgical Infection Prevention Project (SIP) and shows some of the
National Surgical national data that has been collected, as well as findings in the clinical
Infection Prevention literature. The presentation also highlights the transition of the SIP into
Project and the the Surgical Care Improvement Project (SCIP), which goes beyond just
current Surgical Care preventing surgical infection and focuses on improving the outcomes for
January 2005 Guidelines Improvement Project) surgery patients.
A new telephone hotline that provides clinicians with immediate access
to expert advice on treating HIV-infected pregnant women and their
children is available through the federal Health Resources and Services
Administration's National HIV/AIDS Clinicians' Consultation Center at
San Francisco (CA) General Hospital. The Perinatal Hotline
(888.448.8765) provides 24-hour consultation from HIV experts,
including advice on interpreting HIV testing in pregnancy and
December 2004 Guidelines The Perinatal Hotline implementing the U.S. Public Health Service's clinical care guidelines.
CDC also provides PowerPoint presentations that describe West Nile
July 2004 Guidelines West Nile Virus Virus and methods of treatment and prevention.
New practice guidelines are available to assist with the administration of
outpatient antimicrobial therapy (OPAT). Due to the lack of evidence-
based studies, these guidelines were formulated from the collective
experience of the Infectious Diseases Society of America Guidelines
Committee and advisors from related organizations. The Practical
Guidelines for Outpatient Parenteral Antimicrobial Therapy updates the
1997 guidelines and are intended to aid in the successful
Practical Guidelines implementation of parenteral antimicrobial services for patients in a
for Outpatient variety of outpatient settings including the home, physician offices, and
Parenteral skilled nursing facilities. The guidelines are general and need to be
Antimicrobial adapted for each specific setting.
July 2004 Guidelines Therapy The poster provides clinical guideline reminders for surgical infection
prevention, acute myocardial infarction, congestive heart failure, and
community-acquired pneumonia. The tool is intended to be displayed in
CMS clinical areas where staff document the care provided, such as in nurses'
July 2004 Guidelines guideline reminder stations, doctors' dictation areas, and medical record areas, among
A printed copy of the Centers for Disease Control and Prevention’s
(CDC) "Guidelines for Environmental Infection Control in Health-Care
Facilities - 2003" has been published by the American Society of
Healthcare Engineering (ASHE). Topics covered in this publication
Guidelines for include indoor air quality, construction, ventilation in specialized care
Environmental areas, water quality, water quality in hemodialysis settings, cleaning and
Infection Control in disinfection of environmental surfaces, pest control, principles of
Health-Care Facilities environmental sampling, laundry and bedding, animals in health care,
May 2004 Guidelines - 2003 and regulated medical waste.
New guidelines for preventing healthcare-associated pneumonia and
other severe lower respiratory infections. These guidelines update and
replace the 1981 guideline. In addition to the latest pneumonia and
respiratory infection recommendations, the guidelines expand the list of
Guidelines for recommended antiviral treatments for influenza patients and
Preventing Health- recommends that potable water be kept at temperatures above 124
Care-Associated degrees Fahrenheit or below 68 degrees Fahrenheit to reduce the risk of
April 2004 Guidelines Pneumonia, 2003 Legionnaire's disease.
National Surgical
Infection Prevention New web site for accessing current information on the National Surgical
January 2004 Guidelines (SIP) Infection Prevention (SIP)
Pneumonia Medicare New web site for accessing current information on the Pneumonia
January 2004 Guidelines National Project Medicare National Project
Location
Go to http://www.e-meducation.org/
and http://infectionacademy.org/
http://coughsafe.com/
http://www.edhivtestguide.org/
Download from:
http://www.premierinc.com/advisorli
ve/
http://www.premierinc.com/quality-
safety/tools-
services/safety/topics/guidelines/an
timicrobials.jsp#business-case
http://www.premierinc.com/quality-
safety/tools-services/safety/safety-
share/03-07-downloads/07-burns-
during-mri.doc
http://www.premierinc.com/quality-
safety/tools-services/safety/safety-
share/02-07-downloads/12-
hainfgap.pdf
Access the CDC Web site for the
Public Reporting of Healthcare-
Associated Infections
(http://www.cdc.gov/ncidod/dhqp/P
ublicReportingHAIs.html) for the
toolkit, as well as the February
2005 American Journal of Infection
Control article, Guidance on Public
Reporting of Healthcare-Associated
Infections (.pdf) (150 KB).
VTE guidelines are available from
the Premier Safety Institute
Infection Prevention and Safety
Module under "Other guidelines,
selected resources."
http://www.coughsafe.com/;
http://www.scrubclub.org/;
http://www.mi-
marr.org/cons_materials.html
http://www.premierinc.com/quality-
safety/tools-services/safety/safety-
share/09-06-downloads/12-mmwr-
rotavirus.pdf
Go to:
http://www.premierinc.com/all/safet
y/resources/guidelines/other.jsp
Go to:
http://www.premierinc.com/all/safet
y/resources/guidelines/other.jsp
Go to:
http://www.premierinc.com/all/safet
y/resources/guidelines/other.jsp#ca
rd-cath
Go to :
http://www.premierinc.com/all/safet
y/publications/01-06-downloads/11-
ca-mrsa.pdf and
http://www.premierinc.com/all/safet
y/publications/01-06-downloads/12-
gene-vector-therapy.pdf
http://www.premierinc.com/all/safet
y/publications/10-05-downloads/11-
hiv-rr5409.pdf
The Notebook can be accessed at:
http://www.epa.gov/compliance/res
ources/publications/assistance/sect
ors/notebooks/health.html
To view this guide, go to:
http://ecm.ncms.org/herc/jcaho3.10
.3.html.
To order, call 800.332.2264, Ext.
217, or visit www.aami.org.
http://www.fda.gov/opacom/morech
oices/industry/guidedc.htm
View a PowerPoint® summary
(.ppt) (1.6 MB) or watch a full
presentation with sound in a video
clip at:
http://www.medqic.org/scip/scip_ne
ws_fromsiptoscip.html
http://my.premierinc.com/all/safety/
publications/07-04-downloads/11-
opat-cid-06-04.pdf
http://my.premierinc.com/all/safety/
publications/07-04-downloads/10-
clinical-guideline-poster-ar-02-
04.pdf
http://www.premierinc.com/all/safet
y/resources/guidelines/index.htm
http://www.premierinc.com/all/safet
y/resources/guidelines/cdc_guidelin
es.htm#Pneumonia2003
www.MedQIC.org/sip
www.MedQIC.org/pneumonia
Premier Safety Share
IHI
Month Year Topic by Tab Tool Description Tool Location
The CDC Hand Hygiene Resource Web page provides an interactive
training course on hand hygiene and other standard precautions to
prevent healthcare associated infections. The course reviews key
concepts of both hand hygiene and standard precautions. The learner is
The CDC Hand asked a series of hand hygiene questions as they work through the
Hand Hygiene Hygiene Resource module and again at the end. The course also contains a short 60- http://www.cdc.gov/handhygiene/tra
September 2008 Guideline Web page second video on hand hygiene. ining/interactiveEducation/
Diseases are spread by poor coughing and sneezing techniques. Most
people put their hands in front of their mouths and noses to stop germs
from getting into the air. Unfortunately, this technique puts the germs on
their hands. The germs are then spread to telephones and doorknobs
and many other surfaces, where the next user then acquires. This five-
minute video was designed by three Maine hospitals to encourage
people to cough and sneeze according to the infection control guidelines
put forth by the Centers for Disease Control and Prevention (CDC). It is
aimed at the common citizen. The message is serious, but it is presented
Hand Hygiene Why Don’t We Do It with humor in such a way that it engages the viewer's attention for a full
February 2008 Guideline in Our Sleeves? five minutes while the message is repeated in interesting new ways. Order at: http://coughsafe.com/
The World Health Organization's (WHO) first global patient safety
challenge, "Clean Care is Safer Care," acknowledges the importance of
addressing the global challenge of healthcare-associated infections (.pdf)
( 2 MB). Low-cost WHO strategies that help reduce infection risks in
areas such as blood products and their use, injection practices and
immunization, safe water, basic sanitation and waste management, and The draft is available for download
clinical procedures, particularly in first-level emergency care, are already at:
Hand Hygiene WHO – Testing hand available. These strategies are combined with efforts to implement the http://www.who.int/gpsc/resources/
Mar 2007 Guideline hygiene guidelines WHO Guidelines on Hand Hygiene in Healthcare (Advanced Draft). newsalert/jan2007/en/
An eight-minute video on proper handwashing technique titled "Last
Clean Chance" has been produced by the Mecklenburg (NC) County
Health Department. The science fantasy thriller is set in a bio-research
lab. The video involves a doomsday scenario in which a virus is leaked Access the video and information
into the lab space. Tailored for the young viewer, the video teaches a online at
Hand Hygiene valuable skill and reminds us that handwashing is the number one way to http://www.charmeck.org/Departme
May 2006 Guideline Last Clean Chance prevent the spread of disease. nts/Health+Department/
http://www.premierinc.com/all/safet
y/publications/09-05-downloads/06-
handwashing-emergencies.pdf and
http://www.premierinc.com/all/safet
Hand Hygiene Hand hygiene in y/publications/09-05-downloads/21-
September 2005 Guideline emergency situations Communications/Last+Clean+Chance.htm. clean-hands-cards.pdf
Excel: Premier / Modules / b24d7277-3ce3-4a13-baeb-3f4ffe9a8b03.xls / Hand Hygiene
Premier Safety Share
IHI
Month Year Topic by Tab Tool Description Tool Location
The CDC slide sets are available
Slides - Hand at:
Hand Hygiene hygiene educational http://www.cdc.gov/handhygiene/m
July 2003 Guideline resource aterials.htm.
Hand Hygiene Hand Hygiene Provides updated educational materials dealing with hand hygiene
November 2002 Guideline Resource Center practices. http://www.handhygiene.org/
Excel: Premier / Modules / b24d7277-3ce3-4a13-baeb-3f4ffe9a8b03.xls / Hand Hygiene
Premier Safety Share
IHI
Month Year Topic by Tab Tool Description Tool Location
Word:
Premier's Safety Institute is now offering a checklist to save on your http://www.premierinc.com/quality-
computer and complete or update at your own pace. The Word safety/tools-
document (.doc) (463 KB) retains the HTML format and features services/safety/topics/influenza/inde
developed by the Centers for Disease Control and Prevention (CDC), x.jsp#checklist; also offers this as
with input from other federal partners. It is intended to help hospitals an Adobe® PDF (2 MB) or online
assess and improve their preparedness for responding to pandemic at:
Comprehensive influenza. Because of differences among hospitals (e.g., characteristics http://www.pandemicflu.gov/plan/he
hospital checklist – of the patient population, size of the hospital/community and scope of althcare/
Influenza - pandemic influenza services), each hospital will need to adapt this checklist to meet its hospitalchecklist.html.
July 2007 pandemic preparation unique needs and circumstances.
The new guidance focuses specifically on healthcare workers and their
employers. The diversity among the providers of healthcare, from
emergency departments to ambulances to temporary patient care
facilities, makes preparing for a pandemic influenza challenging. The 104-
page document is organized in four major sections: clinical background
information on influenza, infection control, pandemic influenza
preparedness planning, and OSHA standards of special importance. It
addresses flu diagnosis and treatment, healthcare worker vaccination,
and personal protective equipment. The appendices include additional
resources for healthcare institutions, such as communication tools for
promoting employee infection control practices, strategies for planning
OSHA – Complete respiratory protections programs, triage algorithms, supply and pandemic http://www.premierinc.com/quality-
HCW pandemic flu planning checklists, and even a crisis communication guide for handling safety/tools-
Influenza - preparedness questions from the media. services/safety/topics/influenza/inde
June 2007 pandemic guidance x.jsp#pandemic
checklist that describes steps that long-term care and other residential
facilities can take to prepare for influenza pandemic is available from the
Department of Health and Human Services (HHS) and the Centers for
Disease Control and Prevention (CDC). The checklist was developed to
help long-term care and other residential facilities assess and improve
their preparedness for responding to pandemic influenza. Based on
differences among facilities (e.g., patient/resident characteristics, facility
size, scope of services, hospital affiliation), each facility will need to
adapt this checklist to meet its unique needs and circumstances. The
checklist states that facilities should have a structure for planning and
decision-making, overseen by a multidisciplinary group focused on
pandemic flu planning, and to develop a written influenza plan. The
written influenza plan should include flu surveillance and detection
measures; communications; education and training in basic prevention
and control measures for personnel, residents, and residents' family
members; and an infection control plan for managing residents and
Pandemic flu visitors with pandemic influenza; an occupational health plan to address The checklist is available at:
Influenza - checklist – Long-term staff absences and related issues; and plans for vaccine and antiviral http://www.pandemicflu.gov/plan/
June 2006 pandemic care use and surge capacity. LongTermCareChecklist.html.
Excel: Premier / Modules / b24d7277-3ce3-4a13-baeb-3f4ffe9a8b03.xls / Influenza - pandemic
Premier Safety Share
IHI
Month Year Topic by Tab Tool Description Tool Location
Online resources and information from the California Distance Learning
Health Network (CDLHN), a non-profit organization of the Graduate
School of Public Health at San Diego State University. The section on
pandemic influenza resources includes the U.S. national strategy for
pandemic influenza and World Health Organization avian influenza
updates. A summit designed to inform California leaders in business,
education, local government, healthcare, social services and other
sectors to better prepare California for influenza pandemic is available as Go to:
California Distance a Webcast. The summit presents the current threat of avian influenza http://cdlhn.com/create_frameset.cf
Influenza - Learning Health and the risk of a human influenza pandemic and several training videos m?id=32&CFID=523799&CFTOKE
May 2006 pandemic Network (CDLHN) related to mass vaccinations and disease investigation. N=19783253
The Department of Health and Human Services (HHS) has developed a
checklist to help home healthcare providers care for the sick during an Go to: English -
influenza pandemic. The checklist will help organizations assess their http://www.premierinc.com/all/safet
readiness to respond by identifying strengths and weaknesses. It also y/publications/04-06-downloads/06-
Home Healthcare explains that building community contacts will provide a strategic healthcare-checklist.pdf; Spanish -
Services Pandemic advantage if a pandemic influenza strikes. The checklist was designed http://www.premierinc.com/all/safet
Influenza - Influenza Planning with a pandemic influenza in mind, although it may be used in other types y/publications/04-06-downloads/06a-
April 2006 pandemic Checklist of emergencies. spanish-healthcare-checklist.pdf
http://www.premierinc.com/all/safet
y/publications/12-05-downloads/10-
Use of personal questions-answers-ppe-during-flu-
protective equipment outbreaks.doc and
Influenza - during influenza http://www.premierinc.com/all/safet
December 2005 pandemic outbreaks y/resources/influenza/index.jsp
Excel: Premier / Modules / b24d7277-3ce3-4a13-baeb-3f4ffe9a8b03.xls / Influenza - pandemic
Premier Safety Share
IHI
Month Year Topic by Tab Tool Description Tool Location
A home care influenza toolkit, published by Montgomery County's
Advanced Practice Center, is designed to help people manage influenza
at home. This simple toolkit, "Stay At Home Toolkit for Influenza,"
includes checklists on what to keep in the home, tips on how to
recognize flu signs and symptoms, instructions on using thermometers,
isolating the sick, making disinfectant with bleach, and cleaning
potentially contaminated areas, a personal care log to help caregivers http://www.premierinc.com/quality-
track observations and action, guidelines for those returning to work after safety/tools-services/safety/safety-
Influenza - Stay At Home Toolkit recovering from flu, and items to keep on hand for pets for disaster share/02-08_downloads/13_Stay-at-
February 2008 seasonal for Influenza preparedness. home-toolkit.pdf
For the beginning of the new influenza season, the Centers for Disease
Control and Prevention (CDC) is releasing updates of a few new flu
resources. The CDC's flu Web site at www.cdc.gov/flu has been revised
and is easy to navigate as a resource. This year, the CDC is Downloads are available for printing
CDC updates emphasizing high-risk children (such as those with asthma or diabetes) at:
Influenza - influenza tools for the and their caregivers, as well as focusing on protecting infants and the http://www.cdc.gov/flu/professionals
October 2007 seasonal new season elderly through family and community vaccination. /flugallery/.
A Web site sponsored by the National Influenza Vaccine Summit called
New Web site "Prevent Influenza Now!" provides information updates on the current
Influenza - provides influenza influenza vaccination season. The site contains vaccine information for
Dec 2006 seasonal vaccination updates the public about influenza, the benefits of v http://www.preventinfluenza.org/
http://www.premierinc.com/all/safet
y/publications/12-05-downloads/10-
Use of personal questions-answers-ppe-during-flu-
protective equipment outbreaks.doc and
Influenza - during influenza http://www.premierinc.com/all/safet
December 2005 seasonal outbreaks y/resources/influenza/index.jsp
The National Foundation for Infectious Diseases' "Kids Need Flu
Vaccine" initiative now includes a new patient education resource for
Influenza - Children's vaccine physicians and healthcare providers. The new patient education
October 2005 seasonal education kit resource kit includes a parental brochure, fact sheet and http://64.242.251.230/index1.html
Last year's National Influenza
Vaccine Summit guide is available
online at
The purpose of the guide is to provide frontline healthcare personnel with http://www.immunize.org/influenza/
Influenza Vaccination information about indications and contraindications for the two types of pocketguide.htm, and this site
Influenza - Pocket Information influenza vaccines, as well as groups to be vaccinated and how to should be checked periodically for
August 2005 seasonal Guide administer the vaccines. The draft of the the 2005-2006 version.
As reports of influenza increase during the current season, the Centers
New posters in five for Disease Control and Prevention (CDC) continues to offer new
Influenza - languages for resources in the fight to prevent the illness. The "Cover Your Cough" http://www.cdc.gov/flu/protect/cover
January 2005 seasonal healthcare, schools campaign has new language-specific flyers and pos cough.htm
Excel: Premier / Modules / b24d7277-3ce3-4a13-baeb-3f4ffe9a8b03.xls / Influenza - seasonal
Premier Safety Share
IHI
Month Year Topic by Tab Tool Description Tool Location
Summary of
resources to prevent http://www.premierinc.com/all/safet
Influenza - spread of flu in the This latest tool from the CDC provides various resources, including y/publications/11-04-downloads/08-
November 2004 seasonal workplace important telephone numbers, Web pages, and poster/flyer links. flu-tools.pdf
The tool is supported by the
A free online resource to help health care providers conduct influenza National Influenza Vaccine Summit
immunization programs for children is available from The National and can be accessed through the
Influenza - Kids Need Flu Foundation for Infectious Diseases (NFID). The "Kids Need Flu Vaccine, NFID Web site at
August 2004 seasonal Vaccine, Too! Too!" program aims to increase immunization ra http://64.242.251.230/.
Excel: Premier / Modules / b24d7277-3ce3-4a13-baeb-3f4ffe9a8b03.xls / Influenza - seasonal
Premier Safety Share
IHI
Month Year Alpha Keyword Topic by Tab Tool Description Tool Location Type Media
Excel: Premier / Modules / b24d7277-3ce3-4a13-baeb-3f4ffe9a8b03.xls / Latex Allergies
Premier Safety Share
IHI
Month Year Topic by Tab Tool Description Tool Location
The newsletter provides news and success stories about topics such as
reduction of medical waste, computer recycling, green cleaning
programs, conversion to reusable products, laboratory chemical
recycling, energy efficient lighting and light bulb recycling. Premier's EPP
program is a collaboration of the Premier Safety Institute and Premier's
Environmental group purchasing services. The program is part of Premier's commitment
and Safety to helping healthcare facilities with their environmental efforts, including Go to:
March 2006 Products Green Link waste minimization and the elimination of the use of mercury. http://www.premierinc.com/safety
Pollution prevention reduces some of the regulatory compliance issues,
such as the hazardous waste rules, by encouraging the use of less toxic
materials. The fact sheets are: Mercury in Healthcare
Lab Reagents
Mercury in Labs and Pharmacies
Mercury in Patient Care Areas
Mercury in Non-Patient Care Areas The fact sheets may be obtained
Formalin Recovery in Health Care Labs from the MnTAP Web site at
Suction Canister Waste Reduction http://www.mntap.umn.edu (click on
Mercury Pollution Ten Tools To Get Below the Regulatory Radar "Industries" and "Healthcare" for
August 2004 Prevention Mercury fact sheets MnTAP Profile, a general fact sheet on MnTAP's services more information).
This resource provides information on such topics as the health effects
Healthcare Hazard of mercury exposure; reducing occupational exposures, including
Mercury Pollution Control System thorough training and personal protective equipment; and applicable http://www.osha.gov/SLTC/mercury
September 2003 Prevention Volume 2 OSHA standards and guidelines. /index.html
Excel: Premier / Modules / b24d7277-3ce3-4a13-baeb-3f4ffe9a8b03.xls / Mercury Pollution Prevention
Premier Safety Share
Month Year Topic by Tab Tool Description IHI Location
Tool
September 2008 Patient Safety Patient Safety and This three-volume, 1,400-page handbook for nurses on patient safety http://www.ahrq.gov/qual/nurseshdb
Quality: An Evidence- and quality resources contains 89 contributions that represent the work k/
Based Handbook for of a broad range of nurses and other patient safety researchers
Nurses throughout the nation. The handbook is grouped into six sections:
Patient Safety and Quality; Evidence-based Practice; Patient-centered
February 2008 Patient Safety AHRQ toolkits – 17 Care; Working Conditions and the Work Environment for Nurses; Critical
The Agency for Healthcare Research and Quality (AHRQ) has http://www.ahrq.gov/qual/pips
patient safety developed a series of toolkits designed to help reduce medical errors.
resources These 17 toolkits, "Patient Safety at the Point of Care," 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, and can be adapted to most healthcare settings.
February 2008 Patient Safety FDA – Downloadable The latest FDA medication safety-related videos, including some http://www.ismp.org/Tools/fdavideos
medication safety developed in cooperation with ISMP, are now available free for viewing .asp
videos or downloading on the ISMP Web site.The videos added from October
include warnings about Vincristine errors, luer misconnection, and how
the use of a disposable straw with Exactacain, a local anesthetic spray,
may pose a safety risk to patients. November videos highlight side
effects of codeine in nursing mothers, avoiding mix-ups with
Amphotericin B formulations, and warnings for Rocephin use with any IV
product that contains calcium.
February 2008 Patient Safety NIH tool kit – Online http://nihseniorhealth.gov/toolkit/tool
health information for kit.html
seniors
February 2008 Patient Safety Free tool for A free DVD from the Agency for Healthcare Research and Quality, Order at:
designing hospitals "Transforming Hospitals: Designing for Safety and Quality," reviews http://www.ahrq.gov/qual/transform.
for patient safety evidence-based hospital design and how it increases patient and staff htm
satisfaction and safety, quality of care, employee retention, and results in
a positive return on investment. Key concepts of evidence-based design
in a hospital include single-patient rooms, the use of noise reducing
construction materials, easily accessible workstations, and improved
layout for patients and staff. Patient safety issues addressed are falls,
hospital-associated infections and medical errors. The DVD also
presents cases of three hospitals that have incorporated evidence-based
design elements in their construction and renovation.
December 2007 Patient Safety AHRQ free DVD – A new free DVD addressing patient safety consists of eight modules Order at:
Patient safety involving one to five separate lessons, and provides processes and tools http://www.ahrq.gov/qual/psicdvd.ht
that can be used to develop a systems-based approach to patient safety. m
The modules include the investigation of medical errors and their root
causes; identification, implementation and evaluation of system-level
interventions to address patient safety concerns; and steps necessary to
promote a culture of safety within a hospital or other healthcare facility.
Excel: Premier / Modules / b24d7277-3ce3-4a13-baeb-3f4ffe9a8b03.xls / Patient Safety
Premier Safety Share
Month Year Topic by Tab Tool Description IHI Location
Tool
December 2007 Patient Safety Advancing the √ http://www.premierinc.com/quality-
Practice of Patient- safety/tools-services/safety/safety-
and Family-Centered The Institute for Healthcare Improvement (IHI) recently released a report share/12-07-downloads/6_Patient-
Care titled “Advancing the Practice of Patient- and Family-Centered Care” that Family-Centered-Care-2007.pdf
includes assessment tools to help hospitals determine the degree to
which patient- and family-centered approaches exist in their current
organizational culture; IHI also released a tool that helps gather
information about the perceptions and attitudes of staff and
administrative leaders. The report describes how hospitals can get
started with understanding how quality and safety are advanced by
bringing patients and families directly into the planning, delivery and
evaluation processes. This 25-page report provides rationale for a
patient- and family-centered approach to care and defines its core
concepts and outlines steps that a hospital can take to create
partnerships with patients and families.
October 2007 Patient Safety Drug safety The FDA has released the first issue of its new Drug Safety newsletter. A fact sheet and the inaugural issue
newsletter from FDA The online newsletter will be published quarterly and provide information of the newsletter can be found at
for healthcare professionals, such as physicians, physician assistants, http://www.fda.gov/cder/dsn/.
nurse practitioners, nurses, pharmacists, dentists, other allied healthcare
professionals, health professional associations and drug information
centers. The newsletter will feature findings of selected post-marketing
drug safety reviews from the agency's Center for Drug Evaluation and
Research (CDER), important emerging drug safety issues, and recently
approved new drugs. The newsletter provides post-marketing information
to healthcare professionals to enhance communication of new drug
safety information, raise awareness of reported adverse events, and
stimulate additional adverse event reporting.
September 2007 Patient Safety NCI – End-of-life care The National Cancer Institute (NCI) has published a free palliative-care The CD can be ordered or a
tool training program for health professionals caring for cancer patients. The brochure downloaded online. For
"Education in Palliative and End-of-Life Care for Oncology" CD-ROM and more information, go to the NCI Web
DVD teaches palliative care competencies and interventions for cancer site at
patients. The curriculum is designed to provide the practicing clinician http://www.nci.nih.gov/aboutnci/epec
with information and strategies necessary to provide palliative o
interventions to his or her patients and to provide educational tools and
materials to use in teaching the core competencies of palliative care to
trainees. This curriculum is eligible for continuing education credit for
physicians and nurses.
September 2007 Patient Safety Webcast – Best Catheter-related blood stream infections (BSI) are a significant source of http://www.cardinal.com/clinicalcente
practices to reduce morbidity and mortality associated with a variety of devices used to r/materials/webcasts/index.asp
catheter-related access the vascular system. Meticulous aseptic technique is both
blood stream required and effective to prevent BSI. Faculty share their observations,
infections best practices, and outcome data as they discuss this important topic.
This free webcast is a replay from the original August 17, 2007, webcast
provided by Cardinal Health's Center for Safety and Clinical Excellence
and will remain available for one full year. Continuing education credit is
also provided.
Excel: Premier / Modules / b24d7277-3ce3-4a13-baeb-3f4ffe9a8b03.xls / Patient Safety
Premier Safety Share
Month Year Topic by Tab Tool Description IHI Location
Tool
September 2007 Patient Safety FDA – Free patient The latest medication safety-related videos, developed by the FDA in http://www.ismp.org/Tools/fdavideos
safety videos cooperation with ISMP, are now available free for viewing or .asp
downloading on the ISMP Web site
(http://www.ismp.org/Tools/fdavideos.asp).
August 2007 Patient Safety OSHA – New The new Healthcare Industry Quick Start module is directed primarily to http://www.osha.gov/dcsp/complianc
healthcare "Quick small employers in the healthcare field. The module is designed to help e_assistance/quickstarts/
Start" compliance tool users find free resources on the OSHA Web site related to the
healthcare industry. The eight-step module includes information on
July 2007 Patient Safety ACR – Updated OSHA requirements that apply to many healthcare employers;
The white paper titled "ACR Guidance Document for Safe MR Practices" http://www.premierinc.com/quality-
guidance on (.pdf) (335 KB) details MR safety, from the design of the MR suite and safety/tools-services/safety/safety-
magnetic resonance the qualifications of personnel to screening patients and what to do in an share/07-07-downloads/08-safe-
safety emergency. mr07.pdf
July 2007 Patient Safety CDC – New One young man's experience with meningococcal meningitis and his English:
meningococcal subsequent recovery is available in both English (.doc) ( KB) and http://www.premierinc.com/quality-
vaccine information Spanish (.doc) (59 KB) to be shared with patients and staff (.doc) (1.9 safety/tools-services/safety/safety-
available in Spanish MB). His story emphasizes the importance of receiving the available share/07-07-downloads/04-meninge-
and English vaccine. survivor-story-english.doc; Spanish:
http://www.premierinc.com/quality-
safety/tools-services/safety/safety-
share/07-07-downloads/05-meninge-
survivor-story-spanish.rtf
June 2007 Patient Safety AHRQ – Sample The new Health Care Report Card Compendium is a searchable http://www.talkingquality.gov/compe
healthcare quality directory of more than 200 samples of report cards produced by a variety ndium/
report cards of organizations. The samples show formats and approaches for
providing comparative information on the quality of health plans,
hospitals, medical groups, individual physicians, nursing homes, and
other providers of care. The purpose of the AHRQ Report Card
Compendium is to inform and support the various organizations that
develop healthcare quality reports, to provide easy access to examples
of different approaches to content and presentation, and to meet the
needs of health services researchers.
June 2007 Patient Safety AHRQ toolkit – A new guide available from the Agency for Healthcare Research and http://www.premierinc.com/quality-
"Mistake-proofing" Quality (AHRQ) titled "Mistake-Proofing the Design of Health Care safety/tools-services/safety/safety-
healthcare process Processes" describes simple, low-cost interventions that organizations share/06-07-downloads/07-
design can undertake to improve patient safety that includes more than 150 real mistakeproofing.pdf
world examples of process or design features that have been
implemented as a result of root-cause analyses and other interventions
to help ensure that processes help prevent errors or the negative impact
of an error.
June 2007 Patient Safety AORN Patient Hand- The AORN "Patient Hand-Off Toolkit" helps caregivers effectively The toolkit can be downloaded free
Off toolkit – Free communicate key information such as the patient’s current and past of charge at:
Web-based surgical condition, ongoing treatments, and possible changes or complications http://www.aorn.org/PracticeResourc
patient transfer that should be monitored closely. The kit includes sample checklists and es/ToolKits/
forms, slide presentations on standardizing communication and
information exchanges, and a guide to additional resources.
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May 2007 Patient Safety CDC – HAI summary The CDC has published a national estimate of the number of healthcare- http://www.premierinc.com/quality-
and slide set associated infections (HAI) and HAI-related deaths in the United States safety/tools-
in a March-April issue of Public Health article, "Estimating Health Care- services/safety/topics/guidelines/anti
Associated Infections and Deaths in U.S. Hospitals, 2002." The authors microbials.jsp#hc-assoc-infections;
concluded that the method they used for estimating the number of HAIs http://www.premierinc.com/quality-
made the best use of existing national data. Data were obtained from the safety/tools-
National Nosocomial Infections Surveillance (NNIS) System (1990-2002), services/safety/topics/guidelines/anti
the National Discharge Survey (2002), and the American Hospital microbials.jsp#hc-assoc-infections
Association Survey (2000). Study findings are summarized in a
PowerPoint presentation.
May 2007 Patient Safety The Joint The new information explains what the Joint Commission is looking for in http://www.premierinc.com/quality-
Commission – FAQs adverse tissue reaction policies, such as the reporting of potential safety/tools-
on tissue storage disease transmission to the recipient when notified by the donor source services/safety/topics/patient_safety/
facility and reporting adverse patient reactions to the donor source downloads/jc-standards-faqs.doc
facility. These actions must be carried out and the tissue's unique
identifier must also allow the organization to easily trace the records
when notified of a problem by either the donor facility or the patient's
physician. Tracing the tissue records includes the complete chain of
events, including who handled the tissue, how it was transported, stored
and processed, dates and times such activities occurred.
May 2007 Patient Safety AHA – CEO The second in a series of collaborative leadership tools for CEOs, Tool 2 is available at
leadership tools "Clarifying Expectations: A First Step in Developing Truly Effective http://www.americangovernance.co
Relationships Between CEOs and Trustees," focuses on clarifying m/americangovernance/resources/C
trustees' and CEOs' mutual expectations. It includes a simple exercise LT/CLTtool2.html
for helping trustees and CEOs refine the way they work together. It also
includes information on the sources of misunderstandings and typical
expectations and describes the roles of and relationships between the
CEO and the board.
Mar 2007 Patient Safety AHRQ – Audio This site provides the agency's latest healthcare research findings, news, This link is available from the Safety
newscast series and information. This site enables viewers to also hear the newscasts Institute's Patient safety web site
through a computer or permit a download to a portable digital player such under "Resources."
as an iPod.
Feb 2007 Patient Safety New Hampshire – An online tool created by the Foundation for Healthy Communities in http://www.healthynh.com/fhc/resour
Health forms in New Hampshire has a directory that enables healthcare workers working ces/translateddocuments.php
multiple languages with culturally and linguistically diverse communities to easily find
translated health forms and documents. The directory provides access to
documents created and translated by New Hampshire health agencies
and organizations. The documents are intended for use by any
healthcare organization. Translated documents include consent forms,
patient bills of rights, financial assistance applications, and information
about cholesterol, asthma and child immunizations. Part of the
Foundation's Cultural Effectiveness and Quality Health Care Project, the
tool will be updated with documents and language translations. Access
the tool on the Foundation Web site.
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Jan 2007 Patient Safety Hospital Compare - Beginning in June 2007, all hospitals, including Critical Access Hospitals Hospital Compare Web site
Mock data (CAH), will have 30-day (risk adjusted) mortality rates for acute (http://www.hospitalcompare.hhs.go
myocardial infarction (AMI) and heart failure (HF) published on the v/). Information and updates about
Hospital Compare Web site through an initiative led by the Hospital this initiative will be posted
Quality Alliance (HQA) . The data reported in June will cover the period periodically to
July 1, 2005, to June 30, 2006; reported data will also soon include http://www.qualitynet.org/ under the
pneumonia patients. So that hospitals may become familiar with the "Hospitals" section.
background of the measures and their own mortality rates, Centers for
Medicare and Medicaid Services (CMS) will provide a mock report based
on 2003 Medicare claims. The rates contained in these initial reports will
not be posted publicly on the Hospital Compare Web site. IThe CMS
timeline from November 2006 contains additional information, including
the important dates for public reporting. More information is available at
QNet exchange.
Dec 2006 Patient Safety H2E – New Hospitals for a Healthy Environment (H2E) has developed an http://www.h2e-
environmental "Environmental Compliance and Improvement Guide" that matches each online.org/regsandstandards/jcahoin
compliance and JCAHO Element of Performance to specific federal regulations. This tro.html
improvement guide guide helps facilities identify how to be in compliance with both. The
guide also suggests steps that facilities can take to encourage
environmental performance improvements. A comprehensive
environmental program, including waste minimization and pollution
prevention initiatives, not only ensures compliance, but can also help
reduce the costs of compliance. The guide provides links, tips and tools
that enumerate specific management practices, materials, regulatory
requirements, and facility infrastructure relevant to the specific JCAHO
Element of Performance (EP).
Dec 2006 Patient Safety IHI – Patient safety The first tool is a "Global Trigger Tool" designed to help get started in the √ Access IHI Trigger Tools
trigger tools approach; the other tools focus on specific areas such as measuring at:http://www.ihi.org/IHI/Topics/Patie
Dec 2006 Patient Safety Medication safety Creighton University perioperative care, neonatal provides care, to
adverse drug events,Medical Center, Omaha, NE, intensive a tool and ntSafety/SafetyGeneral/Tools/Introto
http://www.premierinc.com/quality-
guide – Ambulatory guide considerations of resource requirements when evaluating the safety/tools-services/safety/safety-
care ambulatory care environment for medication safety. The guide is titled share/12-06-downloads/07-chrp-best-
Dec 2006 Patient Safety "Medication tools Best Practices Guide for to the Surgical Care
SCIP – New surgical, Several newSafetyhave recently been addedAmbulatory Care Use" (.pdf) practices.pdf
VTE guidelines are available from
VTE tools Improvement Project (SCIP) Web site. The first, "Preventive Antibiotics the Premier Safety Institute Infection
in Colon and Rectal Surgery: Discontinuation Within 24 Hours After Prevention and Safety Module under
Operation," is a presentation that discusses the importance of giving "Other guidelines, selected
recommended antibiotics in colorectal surgery with the equally important resources."
factor of discontinuing the antibiotics within 24 hours. Other tools related
to venous thromboembolism include: Deep Vein Thrombosis Prophylaxis
Risk Factor Assessment, and Thrombosis Screen and Prophylaxis
Recommendations.
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November 2006 Patient Safety Workplace Violence Information in the report includes discussions of the scope of WPV, http://www.premierinc.com/quality-
Prevention Strategies barriers to violence prevention, prevention programs and strategies, and safety/tools-services/safety/safety-
and Research Needs research needs. The report discusses information on barriers and gaps share/11-06-downloads/10-
that impede the development and implementation of WPV prevention workplace-violence-prevention.pdf
programs, and summarizes the best workplace violence
strategy/program practices presented by conference participants, general
research needs and the importance of linking research findings to
practical prevention efforts.
November 2006 Patient Safety The Med Form tool The Med Form tool helps patients maintain a single, updated record of The Med Form is available in
their medications, vitamins, immunizations and allergies to share with Spanish and English at
their healthcare providers. The Arizona Hospital and Healthcare http://www.themedform.com/.
Association's Safe & Sound Patient Safety Initiative, Arizona Medical
Association, and Arizona Partnership for Implementing Patient Safety
sponsored the form and it is available statewide in physician offices and
hospitals.
Oct 2006 Patient Safety New JCAHO Meeting the Joint Commission's 2007 National Patient Safety Goals, is To order, call JCR Customer Service
resource – 2007 available as a tool for all accredited organizations preparing to implement toll-free at 877.223.6866, 8 a.m. to 8
National Patient the 2007 National Patient Safety Goals. The publication explains how to p.m. CT, weekdays, or visit
Safety Goals comply with the 2007 goals and requirements of the goals, through a www.jcrinc.com
compilation of articles, book excerpts and tips. Detailed topics such as
identifying safety risks inherent in patient populations, and encouraging
the involvement of patients and families in patient care are among those
covered in the book.
Sept 2006 Patient Safety Sentinel event and The Joint Commission on Accreditation of Healthcare Organizations has The automated complaint tool is also
complaint reporting a secure extranet Web site that offers new automated tools for reporting available on the Joint Commission
sentinel events and complaints. Full transition to the online tools is Web site at:
required by January 1, 2007. Locate the tool on the extranet home page http://www.jointcommission.org/Gen
under "Self Report Sentinel Event" in the "Continuous Compliance Tools" eralPublic/Complaint/
section. Root cause analyses (RCA), action plans, and sentinel event
measures of success may be submitted to the Joint Commission using
an online RCA collection tool, also accessible from the "Continuous
Compliance Tools" section under the "Sentinel Event Activities" link.
July 2006 Patient Safety AMA – Guidelines for A new consensus report from the American Medical Association Ethical http://www.premierinc.com/quality-
improving patient Force Program offers guidelines to help healthcare organizations ensure safety/tools-services/safety/safety-
communications effective, patient-centered communications with patients of diverse share/07-06-downloads/06-
backgrounds. This report lists a number of specific, measurable improving-communication.pdf
expectations for performance that organizations can use as a framework
for evaluating performance, as well as a guide for improving
communication quality. An organizational self-assessment toolkit based
on the report is being field-tested.
July 2006 Patient Safety SCIP – Surgical care The Surgical Care Improvement Project (SCIP) Web site has added http://www.premierinc.com/quality-
improvement tools practical tools for the four SCIP areas: cardiac, infections, venous safety/tools-services/safety/safety-
thromboembolism, and respiratory. Tools include help with antibiotic share/07-06-downloads/13-scip-
timing, glucose management, and prevention of deep vein thrombosis. antibiotics-pocket-card.pdf,
Visitors can download a DVT order set, an antibiotic recommendations additional tools at
chart, and a glucose management protocol order set. http://www.medqic.org/scip
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May 2006 Patient Safety Patient Safety The Joint Commission International Center for Patient Safety has a new Go to:
Practices - JCAHO online resource that links to resources related to sentinel events and http://www.jcipatientsafety.org/psp
web site Joint Commission on Accreditation of Healthcare Organizations (JCAHO)
National Patient Safety Goals. The site, "Patient Safety Practices,"
contains tools and resources addressing issues related to the causes
and types of adverse events, U.S. and International Patient Safety Goals
and free access to many of their articles from a variety of journals,
including the "Environment of Care." http://www.jcipatientsafety.org/psp
April 2006 Patient Safety Evaluation of Safe The National Institute for Occupational Safety and Health (NIOSH) draft, Go to:
Patient Handling and "Evaluation of Safe Patient Handling and Movement Principles", http://www.cdc.gov/niosh/review/pub
Movement Principles available for comment until May 30, 2006. The presentation was lic/safe-patient/
developed for use in nursing schools to improve work practices for
patient care workers. It covers the definition of ergonomics, risk factors
for musculoskeletal injury during patient handling and movement,
recognizing high-risk patient care activities and conditions that result in
high-risk patient-care environments, and identifying the best solutions for
patient handling.
March 2006 Patient Safety IHI white paper – Reviews of perinatal care have consistently pointed to failures of √ Go to:
perinatal care communication among the care team and documentation of care as http://www.premierinc.com/all/safety/
common factors in adverse events that occur in labor and delivery. Such publications/03-06-downloads/10-
failures also have been shown to be prime factors leading to malpractice idealized-design-perinatal-care-
claims. A new white paper from the Institute for Healthcare Improvement 2005.pdf
(IHI), "Idealized Design of Perinatal Care," is an innovative project based
on the principles of reliability science and the IHI's model for applying
these principles to improve care. The Idealized Design model focuses on
comprehensive redesign to enable a care system to perform substantially
better in the future than the best it can do at present.
March 2006 Patient Safety AHRQ toolkit – The toolkit presents strategies for comprehensively redesigning and Go to:
Hospital process transforming processes of care in a hospital. It details how healthcare http://www.premierinc.com/all/safety/
redesign strategies systems can redesign (including the planning steps needed for such publications/03-06-downloads/09-
transformation) and presents strategies for translating information hospital-redesign-toolkit.pdf
gathered into proposed projects for implementation. Many of the
techniques included in the toolkit can be used to guide process
improvements without embarking on comprehensive system
transformation.
March 2006 Patient Safety Medication safety tool guide is designed to help outpatient physician practices incorporate safer Go to:
– ambulatory care systems for medication sample prescribing and dispensing. The checklist http://www.premierinc.com/all/safety/
format helps users rate their current medication use processes publications/03-06-downloads/08-
(prescribing, dispensing, administering, counseling, and monitoring) so best-practices-ambulatory-care.pdf
plans for improvements can be prioritized and implemented. The guide
also addresses processes in technology and safety, office environment,
error management, workplace conditions, safety education, and safety
perceptions.
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January 2006 Patient Safety Having Surgery? Having Surgery? What You Need to Know is designed to help patients Go to
What You Need to make informed decisions when planning for surgery. The brochure :http://www.premierinc.com/all/safety
Know" suggests questions to help patients obtain needed information including /publications/01-06-downloads/13-
how and where their operation will be performed, what kind of anesthesia surgery.pdf. A Spanish language
will be used, whether non-surgical medical treatment and watchful version,
waiting are options, possible risks of not having the surgery, potential http://www.premierinc.com/all/safety/
risks and expected benefits if they have the surgery, and how long publications/01-06-downloads/14-sp-
recovery is expected to take. Additional questions include cost, surgery.pdf, is available.
insurance and whether a second opinion is required and/or covered. The
publication is part of a series of healthcare resources from AHRQ to help
people be more active in making informed decisions that can help them
obtain high-quality healthcare.
November 2005 Patient Safety ASA Practice The American Society of Anesthesiologists (ASA) has approved a http://www.premierinc.com/all/safety/
Advisory – reduce practice advisory on anesthesia awareness intended to help publications/11-05-downloads/09-
awareness under anesthesiologists reduce the risk of unintended patient awareness under aware-advisory-10-05.pdf
anesthesia general anesthesia. The ASA reports that one to two out of every 1,000
November 2005 Patient Safety Pediatric Indicator patients receiving general anesthesiaimprove population health using the
This module applies the AHRQ QI to regains consciousness and may http://qualityindicators.ahrq.gov/user
Module AHRQ QI as a catalyst for quality improvement, implications of ICD-9-CM meeting_presentations_2005.htm
coding practices, the use of the AHRQ QI in the National Healthcare
Quality Reports, methods for creating aggregate performance indices,
and considerations in using the AHRQ QI for comparative reporting and
pay-for-performance.
November 2005 Patient Safety Multimedia safety tool A free multimedia safety tool kit is available and contains a five-minute, http://www.emmisafety.com/ashrm
kit for patient Web based version of the patient safety Emmi TM tool that explains the
education patient's role in preventing mistakes and infections in hospitals. The tool
kit is sponsored by the American Society of Hospital Risk Management
(ASHRM), Rightfield Solutions, the creators of Emmi patient education
system, and the Health Research and Educational Trust (HRET) of the
American Hospital Association. Hospitals can post this program on their
Web sites for patients to view prior to coming to the hospital, or
broadcast the two-minute version on an in-house television network.
October 2005 Patient Safety Toolkit – Medication The South Carolina Hospital Association (SCHA) Patient Safety http://scha.org/document.asp?docu
safety Committee has developed three tools to help consumers, healthcare ment_id=2,3,32,3491
facilities, and healthcare workers keep track of all personal medications.
These tools can help consumers, hospital inpatients and outpatients,
hospitals, nursing homes, physician offices, emergency medical workers,
and pharmacists "stay on the same page" so that everyone knows all of
the medications a person takes. The tools are: Universal Medication
Form (UMF), Patient Medication Brochure, and Medication Reconciliation
Form (MRF)
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October 2005 Patient Safety Regional The agenda at the regional forums and networking meetings includes For more information about these
Performance results from the CMS-Premier Hospital Quality Improvement programs and a schedule and
Improvement forums, Demonstration project (how-to's and success stories from top decile registration, visit:
Rapid Improvement performers), patient safety, managing length of stay, physician http://www.premierinc.com/all/confer
Web tool engagement, interactive working groups, and live demonstrations of the ences/ceo/index.jsp?ref=october-
Rapid Improvement Program and Web portal). safety-share
August 2005 Patient Safety Suggestions on The Joint Commission's August issue of Perspectives on Patient Safety Access the suggestions at
meeting the 2006 offers suggestions on meeting the 2006 National Patient Safety Goals http://www.premierinc.com/all/safety/
National Patient (.pdf) (345 KB). The special issue, provided free for a limited time, publications/08-05-downloads/11-
Safety Goals describes each goal and accompanying requirements and offers perspectives-07-05.pdf
compliance tips. For example, JCAHO describes measures implemented
by some organizations to increase compliance with hand hygiene
guidelines from the Centers for Disease Control and Prevention (CDC),
which is required under the goal for reducing the risk of healthcare-
associated infections. Tips for non-hospital settings, such as home care
or long-term care, are also included where compliance needs could differ
from acute care settings.
August 2005 Patient Safety Move Your Dot: A new Institute for Healthcare Improvement (IHI) Innovation Series white √ White papers are free and available
Measuring, paper expands on a previous paper, "Move Your Dot: Measuring, online at:
Evaluating, and Evaluating, and Reducing Hospital Mortality Rates," that introduced a http://www.ihi.org/IHI/Products/Whit
Reducing Hospital novel perspective and methodology for understanding and reducing ePapers/
Mortality Rates inpatient deaths. "Reducing Hospital Mortality Rates (Part 2)"
summarizes preliminary results from a three-year pilot project in which
eight hospitals, working with IHI, are testing the theory that hospital
mortality can be consistently reduced through a combination of evidence-
based interventions.
July 2005 Patient Safety Self-Study Modules “Self-Study Modules on Tuberculosis,” a new education tool specifically The modules can be accessed at
on Tuberculosis designed for healthcare workers and other professionals involved in the http://www.phppo.cdc.gov/phtn/tbmo
identification, treatment, and care of individuals with tuberculosis and dules/Default.htm.
latent tuberculosis infection is now available. The tool is the result of a
partnership between the Centers for Disease Control and Prevention’s
(CDC) Division of Tuberculosis Elimination and the Division of Media and
Training Services. These courses are also appropriate for staff of
correctional facilities, drug treatment centers, migrant clinics, nursing
homes, homeless shelters, or other facilities serving persons with or at
risk for tuberculosis. Each course has a separate set of modules,
registration process, exam, and credits. The modules can also be
worked through without registering. Content from both the print-based
Self-Study Modules on Tuberculosis and the video-based "A Satellite
Primer on Tuberculosis" was used to create Self-Study Modules on
Tuberculosis that can be delivered via the World Wide Web.
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July 2005 Patient Safety Alternative medical Alternatives to using medical waste incinerators for treating regulated Additional information is available
waste treatment medical waste were the focus of a free teleconference July 8, 2005, and from H2E at www.h2e-
hosted by Hospitals for a Healthy Environment (H2E). Teleconference online.org/events/teleconf/index.cfm.
speaker Sally M. Patterson, regulated medical waste program The slide presentation, (Append
coordinator, New York State Department of Health, discussed the 8_RMW_NY.ppt) as well as a chart
advantages and disadvantages of using alternative treatment of alternative technologies can be
technologies approved in the state of New York, including low-heat downloaded. (Append
treating systems, high-heat treating systems, and chemical treatment 9_alttechchart.pdf
systems.
July 2005 Patient Safety Tools for managing A checklist that can aid safety and environmental managers managing To review the checklist and
obese patients obese patients is now available on the Healthcare Hazard Control (HHC) assessment tool, login at
Members' Web site. The list can help staff ensure that a healthcare http://www.ecri.org, click "HHC
facility's physical structures and equipment safely accommodates Homepage," and click the "Sample
extremely obese patients and visitors. An assessment tool to guide Policies" link on the left-hand side of
caregivers on the safe handling of extremely obese patients has also the screen. The tools can be found
been added. An analysis on the safe accommodation of extremely obese under the "Miscellaneous" heading.
patients and visitors will be published in the August 2005 HHC mailing.
July 2005 Patient Safety Roadmaps for The American Medical Association (AMA) has released a new primer The project is supported by an
Clinical Practice, designed to help physicians improve immunization rates, particularly in unrestricted educational grant from
Improving minority populations. The primer, “Roadmaps for Clinical Practice, Sanofi Pasteur and is available
Immunization: Improving Immunization: Addressing Racial and Ethnic Populations,” online at www.ama-
Addressing Racial addresses the leading health indicator of immunization and infectious assn.org/go/roadmaps.
and Ethnic diseases, with a special focus on reducing racial and ethnic disparities in
Populations immunizations. In addition to resources, the primer provides tools to help
physicians ensure that patients are up-to-date with their vaccinations and
includes immunization schedules for both children and adults. The primer
is the latest volume in the AMA’s “Roadmaps for Clinical Practice: Case
Studies in Disease Prevention and Health Promotion” series, which
provides physicians and other health professionals with clinical strategies
and tools to address the leading causes of preventable morbidity and
premature mortality.
June 2005 Patient Safety HHS pocket guide A new pocket guide recently released by Health and Human Services Download the guide at
offers resources to (HHS), "Helping Smokers Quit: A Guide for Nurses," was developed by http://www.premierinc.com/all/safety/
assist patients with AHRQ in collaboration with "Tobacco Free Nurses," a national initiative publications/06-05-downloads/13-
smoking cessation funded by The Robert Wood Johnson Foundation. This new tool is hlpsmksqt.pdf or go to
designed to give nurses evidence-based information that they can use to http://www.ahrq.gov/about/nursing/hl
help their patients quit smoking. The free guide gives nurses' easy psmksqt.htm
access to information based on the "5 A's" approach to cessation
intervention: Ask, Advise, Assess, Assist, and Arrange. It also includes a
current listing of smoking cessation medications approved by Food and
Drug Administration (FDA) and a referral to HHS' National Quitline, 1-800-
QUIT NOW.
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June 2005 Patient Safety Quality of Care for The Commonwealth Fund's chart book assesses the quality of care All chart books are available at:
Medicare provided to elderly and disabled Medicare beneficiaries. This is just one http://www.cmwf.org/index.htm.
Beneficiaries of several chart books available from the Commonwealth Fund on health
policy matters. The chart books are available in either Adobe or
PowerPoint Other topics available include insurance, access, and quality
of care among Hispanic populations, the state of child health care in the
United States, adults' primary care experiences in five industrialized
countries, the health of women in New York City, and the value of state
pharmacy assistance programs.
June 2005 Patient Safety TrendWatch The 5th annual collection of charts and graphs depicts key trends Go to:
Chartbook 2005 affecting hospitals and health systems. Sections include trends in the http://www.ahapolicyforum.org/ahap
overall health care market, organizational trends, utilization and volume, olicyforum/trendwatch/chartbook200
trends in hospital financing, workforce, and the economic contribution of 5.html
hospitals.
June 2005 Patient Safety AHRQ-DOD A compendium of 140 peer-reviewed articles on patient safety studies by Go to:
compendium - Four- government-sponsored researchers. These studies include findings on http://www.ahrq.gov/qual/advances/.
volume set of patient medication safety, technology, and investigative approaches to better
safety research treatment, process analyses, human factors and practical tools for
studies preventing medical errors. The 140 articles in the four-volume set cover
a wide range of research paradigms, clinical settings, and patient
populations. Where the research is complete, the findings are presented;
where the research is still in process, the articles report on its progress.
In addition to articles with a research and methodological focus, the
compendium includes articles that address implementation issues or
present useful tools and products that can be used to improve patient
safety.
May 2005 Patient Safety New self-assessment The Institute for Safe Medication Practices (ISMP) announced it has Find the tool at
survey for developed a new tool (.doc) (33 KB) designed to assist hospitals in http://www.premierinc.com/all/safety/
antithrombotic evaluating antithrombotic therapy. The survey has been mailed to publications/05-05-downloads/11-
therapy hospitals with a submission deadline of September 1, 2005. The self- ismp-self-assessment-launch.doc.
assessment will help organizations examine medication safety practices Further information is available at
associated with the use of antithrombotic drugs in their facilities. http://www.ismp.org.
Hospitals may submit data through a secure Web-based form, which will
allow them to compare their weighted scores with aggregate data from
similar hospitals.
May 2005 Patient Safety Environmentally The American Society for Healthcare Environmental Services has See Premier Safety Institute's
friendly pest control partnered with Orkin, Inc. to promote more effective and environmentally Environmental and Safety Product
practices friendly pest-control practices in healthcare settings, including the list at:
release of a guide on integrated pest management. The partners also http://www.premierinc.com/all/safety/
plan to publish educational articles and host two educational sessions on resources/lists/
the recommended practice at ASHES' annual conference in September.
The partnership was launched in response to a growing movement in
healthcare toward hazardous-chemical reduction.
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May 2005 Patient Safety Simplifying advanced Advance directives, the legal documents that allow individuals to make √ The forms are available in both
directives their personal healthcare wishes known before a serious illness or injury, English
can be confusing and difficult to understand. The Institute for Healthcare http://www.premierinc.com/all/safety/
Advancement has an advance directive form designed for American publications/05-05-downloads/09-
adults who read below a fifth-grade level. The forms are available in both advance-directive-english.pdf (.pdf)
English (.pdf) (906 KB) and Spanish (.pdf) (911 KB). The form is (906 KB) and Spanish
designed in a simple fill-in-the-blank format with illustrations and easy-to- http://www.premierinc.com/all/safety/
read bullet points. Low-literacy Americans will be able to choose an publications/05-05-downloads/10-
agent to make medical decisions for them, make their healthcare wishes advance-directive-spanish.pdf (.pdf)
known so that their loved ones don't have to guess for them, and provide (911 KB).
the necessary signatures to make the document legally binding.
May 2005 Patient Safety Rapid HIV antibody The Health Research & Educational Trust, an affiliate of the American To view the charts go to:
screening tests Hospital Association (HRET/AHA), has developed two charts to help http://www.hret.org/hret/programs/hi
hospitals select the best rapid HIV test for their needs. The charts, vtransmrpd.html
developed with input from the Centers for Disease Control and
Prevention (CDC), are designed to help hospitals as they implement the
CDC's recommendation that the test be offered to all women presenting
to labor and delivery with undocumented HIV status. One chart
compares information on test price, external controls, numbers of tests
per case, catalog number, storage temperature, operating temperature,
shelf lives of tests and controls, time required to conduct test, and
validity window periods; the other chart compares information on FDA-
approval date, specimen type, CLIA-status, specificity, sensitivity,
manufacturer, HIV-2 detection capabilities, list price, and external
controls.
March 2005 Patient Safety Communicating The February issue of the Joint Commission Journal on Quality and http://www.jcrinc.com/subscribers/jo
critical test results Patient Safety has been made available for a free download now online, urnal.asp?durki=8739&site=14&retur
the issue focuses on communicating critical test results and includes n=455#FEBRUARY%202005
numerous important topics.
March 2005 Patient Safety Clinical Simulation The American Hospital Association's (AHA) Health Research and http://www.hret.org/hret/programs/si
Tools Educational Trust (HRET) Web site has a section with information on mulations.html
studies that describe the use of clinical simulations to train physicians
and other healthcare workers in the latest medical developments. An
advantage of clinical simulations training is that skills are learned without
risking harm to real patients. Simulation-based training also provides
trainees with a broad range of learning experiences, including the
treatment of uncommon conditions unlikely to be encountered in
traditional patient-based training. The Clinical Simulation Tools site links
to AHA simulation resources.
Excel: Premier / Modules / b24d7277-3ce3-4a13-baeb-3f4ffe9a8b03.xls / Patient Safety
Premier Safety Share
Month Year Topic by Tab Tool Description IHI Location
Tool
March 2005 Patient Safety Medical liability White The Joint Commission on Accreditation of Healthcare Organizations has http://www.premierinc.com/all/safety/
parper released a white paper (.pdf) (643 KB) recommending demonstration publications/03-05-downloads/08-
projects to test alternatives to the nation's medical liability system. A medical-liability.pdf
commission of medical liability and patient safety experts states that the
current liability system does not do enough to reduce negligence and
compensate victims of medical errors. The paper recommends
encouraging the adoption of information and simulation technology by
considering plans to offset implementation costs and by expanding
evidence-based reporting. The white paper states that any medical
liability changes need to ensure that the greatest number of injured
patients is fairly compensated, while allowing practitioners and providers
the opportunity to report errors, learn from them, and ensure that those
errors are not repeated.
February 2005 Patient Safety OSHA Memo http://www.premierinc.com/all/safety/
publications/02-05-downloads/14-
standard-interpretations.doc
February 2005 Patient Safety Tool kit for physician The American Society for Healthcare Risk Management (ASHRM) has a A sample tool kit has been made
office risk managers CD-ROM tool kit created for the various healthcare professionals who available,
work in the physician practice area. Risk managers can use it to conduct http://www.premierinc.com/all/safety/
an on-site survey of a practice for auditing purposes and also as a publications/02-05-downloads/13-
baseline tool to develop additional checklist items. Key areas covered in physician-office-toolkit-sample.pdf,
the tool kit include principles of documentation; what to report to the and the complete kit can be
insurance claims representative; medical practice office systems risk purchased at
prevention strategies; qualities of effective patient relations for office http://www.ashrm.org/ashrm/resourc
staff; and risks and strategies related to effective telephone es/products.html#toolkits.
communication. The tool kit also can be used as a pre-assessment tool
to identify potential risk areas. The tool kit contains Adobe Acrobat® and
PowerPoint® files.
February 2005 Patient Safety Health information Health information managers are directly involved in clinical quality To read the complete article, go to:
manager role in issues and outcomes through quality management programs, according http://library.ahima.org/xpedio/group
patient safety to the January practice brief titled, "The HIM Role in Patient Safety and s/public/
Quality of Care." Issued by the American Health Information
Management Association, the document discusses the legal and
regulatory environment, data standards, and return on investment in
technology. Health Information Managers also affect quality through
improved medical record documentation, accurate coding, and index
integrity. The author concludes that the health information managers'
ability to affect patient safety is great, particularly through data reporting.
As the coordinators of data quality, the health information managers are
the "overseers" of consistent and accurate quality data.
Excel: Premier / Modules / b24d7277-3ce3-4a13-baeb-3f4ffe9a8b03.xls / Patient Safety
Premier Safety Share
Month Year Topic by Tab Tool Description IHI Location
Tool
January 2005 Patient Safety Safety Share toolkit One of the special resources developed from past issues of Safety Share documents/ahima/pub_bok1_02548
is an archive of all safety tools published in the monthly newsletter. The 7.html.
resources are organized in an Excel® spreadsheet, with descriptions of
each tool and where they can be accessed. The spreadsheet is
categorized by topic and includes many tools that are available from the
Institute for Healthcare Improvement. These are listed separately as well
as included under each pertinent topic.
December 2004 Patient Safety Preventing A free copy of the book, "Preventing Occupational Exposures to Order free copies of the book from
Occupational Bloodborne Pathogens," a collection of articles from Advances in the Premier Safety Store at:
Exposures to Exposure Prevention (1994 to 2003), is available from the Premier http://www.premierinc.com/all/safety/
Bloodborne Safety Store. This 235-page book is edited by Jeannie Jagger and Jane store/
Pathogens Perry from the International Healthcare Worker Safety Center at the
University of Virginia.
December 2004 Patient Safety First, Do No Harm™, For ordering and more information,
Part 3: Healing Lives, go to: www.p4ps.org.
Changing Cultures
November 2004 Patient Safety Guiding Principles for The National Diabetes Education Program (NDEP) has two new Obtain the booklets at the following
Diabetes Care; 4 evidence-based publications for healthcare providers and patients. The addresses:
Steps to Control Your first helps providers identify people with pre-diabetes and undiagnosed http://www.premierinc.com/all/safety/
Diabetes for Life diabetes, and provide patient-centered care. The second booklet publications/11-04-downloads/06-
complements the first and is for people with diabetes. It helps healthcare guide-prin-hc-eng.pdf;
providers educate patients about self-care principles and how to be http://www.premierinc.com/all/safety/
active partners in their own care. publications/11-04-downloads/07-4-
steps.pdf
October 2004 Patient Safety Guidance for Using Using the AHRQ Inpatient Quality Indicators or Patient Safety Indicators
the AHRQ Quality to report on hospital quality or make payment decisions are discussed in
Indicators for Hospital- a new guide. AHRQ's Quality Indicators are measurement tools that
Level Public were developed by AHRQ and researchers to help individual hospitals
Reporting or Payment use their own discharge data to better understand and improve the care
they provide.
October 2004 Patient Safety Look alike/Sound The JCAHO has updated its frequently asked questions (FAQs) on the http://www.jcaho.org/accredited+org
alike drug list 2005 NPSGs and included a new look-alike/sound alike drug list. anizations/patient+safety/05+npsg/0
5_npsg_faqs.htm
October 2004 Patient Safety Rationale and This document provides insight into how surveyors will be interpreting http://www.premierinc.com/all/safety/
Interpretive the goals next year. publications/10-04-downloads/11-
Guidelines" for the npsg-guidelines-09-04.pdf
2005 National Patient
Safety Goals
August 2004 Patient Safety Measuring Safety This conference brought together a diverse group of medication safety To learn more about this or past
with Smart IV leaders from nursing, pharmacy and technology to explore the newest conferences,
systems generation of medication safety technology – designed to help prevent http://my.premierinc.com/all/safety/p
infusion programming errors and to collect data on IV delivery practices. ublications/08-04-downloads/09-
The specific focus of this conference was using the data the technology alaris-conf-grid4.doc
yields as a road map for process improvement at hospitals
Excel: Premier / Modules / b24d7277-3ce3-4a13-baeb-3f4ffe9a8b03.xls / Patient Safety
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Month Year Topic by Tab Tool Description IHI Location
Tool
July 2004 Patient Safety Pay-for-performance The database is intended to raise awareness among healthcare The Leapfrog Compendium can be
programs purchasers, providers and plans to improve care quality. The Leapfrog freely accessed at
Compendium documents and categorizes financial and non-financial http://www.leapfroggroup.org/ircomp
programs, such as those that reward providers with quality bonuses, and endium.htm.
those that reward providers with public recognition. Incorporated are the
Leapfrog standards of computerized physician order entry, evidence-
based hospital referrals and hospital intensivist programs. The site can
be searched by state for programs targeting hospitals, physicians,
consumers and health plans, or it can be searched from a nationwide list.
July 2004 Patient Safety Measurement guide Hospital flow can be measured at five levels: patient and community; √ http://www.ihi.org/IHI/Topics/Flow/P
for hospital flow hospital throughput; hospital activity; hospital performance; and unit atientFlow/EmergingContent/Hospita
patterns performance. Each level provides a portion of the total measurement lFlowMeasurementGuide.htm
picture. Use this guide to learn how to measure data in these key areas
to help you improve patient flow.
June 2004 Patient Safety Patient Safety: Your The National Patient Safety Foundation (NPSF) has a brochure and Purchase information at:
Role in Making companion video entitled "Patient Safety: Your Role in Making http://www.mederrors.org/Merchant2
Healthcare Safer Healthcare Safer." It was created to help patients become more involved /merchant.mv?Screen=SFNT&Store
in their healthcare safety. The companion video will help supplement and _Code=NO
reinforce the safety message with patients. The brochure and video are
part of the National Patient Safety Foundation's Stand up for Patient
Safety campaign, which is designed to help patients learn practical ways
to help ensure their safety in both inpatient and outpatient settings.
June 2004 Patient Safety Five steps to patient The poster, available in English and Spanish, succinctly describes the http://my.premierinc.com/all/safety/p
safety five steps patients can take to ensure safer care. ublications/06-
04_full_txt.htm#Safety_tools
June 2004 Patient Safety Designing the 21st The webcast features researchers, design professionals, and hospital http://www.rwjf.org/news/hospitaldes
Century Hospital: leaders presenting and discussing how hospitals of the future should be ign
Serving Patients and built, organized, and managed to maximize patient safety and outcomes
Staff and improve staff performance and satisfaction. Featured are up-to-the-
minute evidence-based design concepts for healthcare buildings. With
an anticipated $20 billion in new hospital construction and major
renovations projected annually for the next decade, the central question
of the conference was how hospitals' physical design, operating systems,
and "corporate culture" affect patients, staff, and hospitals' bottom line.
May 2004 Patient Safety Preventing A new NIOSH Alert is meant to increase healthcare worker awareness http://www.premierinc.com/all/safety/
Occupational about the health risks when working with hazardous drugs. The alert also publications/05-04-downloads/11-
Exposures to is intended to educate workers on the steps they can take to protect their 2004-hazdrug-alert.pdf
Antineoplastic and health. “Preventing Occupational Exposures to Antineoplastic and other
other Hazardous Hazardous Drugs in healthcare Settings” may be downloaded in
Drugs in healthcare prepublication form. Pharmaceutical agents are classified as hazardous
Settings drugs if research indicates that they may cause cancer, have
developmental or reproductive toxicity, or harm organs in exposure at
low doses.
Excel: Premier / Modules / b24d7277-3ce3-4a13-baeb-3f4ffe9a8b03.xls / Patient Safety
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May 2004 Patient Safety JCAHO tips - Suggestions on how to comply with the National Patient Safety Goal http://www.premierinc.com/all/safety/
Compliance with related to dangerous abbreviations are now available from the JCAHO. publications/05-04-downloads/10-
prohibited implementation-tips.doc
abbreviations
May 2004 Patient Safety Prevention of wrong- The Ohio Hospital Association and Patient Safety Institute have http://www.premierinc.com/all/safety/
site, wrong-patient, developed a surgical protocol (232 KB) to help Ohio providers prevent publications/05-04-downloads/08-
wrong-procedure the incidence of wrong-site; wrong-patient and wrong-procedure surgery. ohio-surgical-protocol.pdf
errors The protocol outlines three steps for caregivers to follow prior to surgery:
patient verification, marking of the surgical site and a "time-out" before
incision to conduct a final checklist.
April 2004 Patient Safety The Tools and A new Web site, "The Tools and Techniques of Improved Medication http://www.aahp.org/content/navigati
Techniques of Use," is intended for those in the healthcare community who design onmenu/medcollab/medcollab.htm
Improved Medication medication safety programs and/or seek information to enhance existing
Use patient safety efforts.
April 2004 Patient Safety Drugs @ FDA A new easy-to-use Web site to help consumers and health professionals http://www.accessdata.fda.gov/script
find information about FDA-approved drug products more quickly and s/cder/drugsatfda/
efficiently. The new interface, Drugs @ FDA, is a searchable database
that includes information on approved prescription drugs, some over-the-
counter drugs, and discontinued drugs.
April 2004 Patient Safety Nurse Advise-ERR A peer-reviewed newsletter published by the Institute for Safe Medication Register at
Practices (ISMP), Nurse Advise-ERR (February, 2004), addresses www.ismp.org/NursingArticles/index.
issues such as mixing up IV lines while setting up or programming a htm
multiple-channel IV pump, the risks of leaving an unnecessary intra-
arterial line in place, a list of high-alert medications, and questions to use
when evaluating infusion pumps. Nurse Advise-ERR, a medication safety
newsletter written especially for nurses by nurses, is offered free for the
remainder of 2004.
April 2004 Patient Safety Patient The Institute for Family Centered Care has produced a number of useful http://www.familycenteredcare.org/
representative on resources to support the involvement of patients on hospital/healthcare
safety committee advisory committees and boards. These resources have been developed
from the experiences of many hospitals/healthcare facilities and the
patients, family members and community representatives who have
worked with them.
March 2004 Patient Safety Hospital e-tool OSHA’s Hospital e-tool is a Web-based training tool for safety and health http://www.premierinc.com/all/safety/
hazard assessments in hospitals that provides a virtual hospital using resources/needlestick/resources.htm
graphics and visual assists for learning. l#OSHA
March 2004 Patient Safety Quick Takes A free electronic bi-monthly newsletter produced by OSHA to inform the http://www.premierinc.com/all/safety/
public about recent OSHA activities. resources/needlestick/resources.htm
l#OSHA
February 2004 Patient Safety Internal Bleeding: This book includes stories of all types of medical errors such as wrong The book can be purchased from
The Truth Behind patient cases, judgment calls gone awry, and retained sponges. The Rugged Land at
America's Terrifying analysis of the causes of errors leads to their suggestions of what http://www.ruggedland.com.
Epidemic of Medical providers, patients, policymakers, and healthcare leaders need to do to
Mistakes cure this epidemic. The 320-page hardcover book includes an extensive
bibliography and 40 pages of footnotes.
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Month Year Topic by Tab Tool Description IHI Location
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February 2004 Patient Safety Checklist - Tips for conducting a self-evaluation of compressed gas and cylinder http://www.premierinc.com/all/safety/
Compressed gas safety. The article includes a checklist of 10 questions addressing proper publications/02-04-downloads/09-
safety storage, use, and handling of compressed gas cylinders to prevent oregon-OSHA-checklist.doc
associated hazards such as oxygen displacement, fires, explosions, and
toxic exposure.
January 2004 Patient Safety Fire safety tips The National Fire Protection Association (NFPA) provides information on http://www.premierinc.com/all/safety/
how to interface elevators and fire alarm systems. The information publications/01-04-downloads/08-
ensures safe emergency operation of modern elevators that meet interfacing-elevators-fire-alarms.doc
requirements under NFPA and American Society of Mechanical
Engineers codes.
January 2004 Patient Safety Fire safety tips Safety tips for preventing hospital bed fires, the safety recommendations http://www.premierinc.com/all/safety/
apply to both electrically powered and manual healthcare beds, as well publications/01-04-downloads/07-
as adjustable medical beds. Some of the initial safety-check suggestions FDA-bedfires-12-18-03.pdf
involve simple observations.
January 2004 Patient Safety Governance, Quality Through interviews, narration and a viewer's guide, the program The video can be purchased for
and Safety: The highlights actions that trustees can take to improve patient safety within $275 using order code V02/03AAH.
Impact of Joint their organizations. This video can also aid orientation efforts for new To order, call Joint Commission
Commission trustees while reinforcing current trustees' understanding of their role in Resources (JCR) Customer Service
Accreditation on creating an organizational culture that focuses on patient safety. at 877.223.6866 weekdays from 8
Health Care Delivery a.m. to 8 p.m. CT, or visit Infomart
on the JCR Web site at:
www.jcrinc.com.
December 2003 Patient Safety Healthy Hospitals: The report offers tips and resources for how hospitals can manage pests http://my.premierinc.com/all/safety/p
Controlling Pests while also protecting the health of people and the environment. ublications/12-03-downloads/11-
Without Harmful pesticides.pdf
Pesticides
December 2003 Patient Safety Magnetic resonance The paper is an educational tool designed to provide consensus-based, http://my.premierinc.com/all/safety/p
safety valid and medically credible information and features detailed, useful ublications/12-03-downloads/12_MR-
checklists. safety.pdf
November 2003 Patient Safety Conversations Before A resource guide designed to help the elderly and their children start http://www.premierinc.com/all/safety/
the Crisis discussions about end-of-life wishes before an unexpected illness arises. publications/11-03-downloads/08-
The booklet is geared toward the elderly and children of the aging, and crisis-convo.pdf
includes a resources list with helpful books and Web sites.
November 2003 Patient Safety Strategies for A resource folder designed to help hospitals communicate with patients http://www.premierinc.com/all/safety/
Leadership: and families. publications/11-03-downloads/10-
Improving pcp-english.pdf
Communications with
Patients and Families
October 2003 Patient Safety Epidemiology and The Pink Book – “Epidemiology and Prevention of Vaccine Preventable The book is available for download
Prevention of Diseases,” the 7th edition from 2002, is now in its second printing. or purchase at
Vaccine Preventable http://www.cdc.gov/nip/publications/
Diseases pink/default.htm
October 2003 Patient Safety The Pocket Guide to This guide is intended to remind providers to deliver appropriate The guide is available in English at
Good Health for preventive services while involving patients directly in their preventive http://www.ahrq.gov/ppip/adguide/
Adults care. It includes recommendations on screening tests and
immunizations, questions for patients to ask health care providers, and
resources for additional information.
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September 2003 Patient Safety The Failure Modes The Failure Modes and Effects Analysis (FMEA) tool is a method for √ http://www.qualityhealthcare.org/.
and Effects Analysis analyzing any process to see where it is likely to fail; to see how changes
(FMEA) you are considering might affect the safety of the process; and to track
changes in the Risk Priority Number (or RPN) of the process over time.
September 2003 Patient Safety The Trigger Tool for The Trigger Tool for Measuring Adverse Drug Events (ADEs), developed √ http://www.ihi.org/IHI/Topics/Patient
Measuring Adverse with Premier, is a simple yet powerful method of identifying and tracking Safety/MedicationSystems/Tools/
Drug Events (ADEs) the number of medication errors in your hospital – using a retrospective
review of patient records to look for sentinel clues or "triggers" that
indicate a medication error has occurred.
September 2003 Patient Safety Learning from Each The award recognizes excellence in graphic design, editorial content, http://www.premierinc.com/all/safety/
Other: Success and the ability to achieve overall communications excellence. publications/09-03_downloads/08-
Stories and Ideas for learning-from-each-other.pdf
Reducing
Restraint/Seclusion in
Behavioral Health
September 2003 Patient Safety Quality Colloquium Sessions on patient safety officer training, along with general conference The CD-ROMs can be purchased at
conference at sessions on error reduction and quality enhancements; the role of http://www.qualitycolloquium.com/.
Harvard University technology; informatics; competition for quality and six sigma process
improvement.
September 2003 Patient Safety Flu Gallery This season's flu campaign emphasizes protecting yourself and the ones http://www.cdc.gov/nip/flu/gallery.ht
you love by getting a flu vaccine. You'll find materials for parents, m
Spanish speakers, those at high risk for flu complications, and
immunization providers. Materials are free and can be downloaded
easily.
August 2003 Patient Safety The Priority Focus The fourth installment of the Joint Commission's free video information To view this video, go to:
Process and Tracer series, "The Priority Focus Process and Tracer Methodology". The five to http://www.jcaho.org/accredited+org
Methodology seven-minute videos highlight the key components of the new anizations/svnp/svnp_video.htm
accreditation process.
August 2003 Patient Safety Resource for PCA The ISMP Medication Safety Alert's a two-part series on PCA pumps. http://www.premierinc.com/all/safety/
pumps publications/08-
03_downloads/09_ISMP_PCA_pum
psafety_07-03.doc
August 2003 Patient Safety 5 Steps to Safer Posters and fact sheets providing tips to help patients avoid errors http://www.premierinc.com/all/safety/
Healthcare related to prescription medicines, laboratory tests, procedures and publications/08-03_downloads/10_5-
surgery steps.pdf
July 2003 Patient Safety Surgical Site Infection QHC requires free registration to access all tools. The site will include √ All materials are available at:
Tools results from teams that participated in the collaborative, as well as tools, http://www.qualityhealthcare.org/QH
such as forms, policies and order sets. C/
Topics/PatientSafety/SurgicalSiteInf
ections/
July 2003 Patient Safety The Effect of Health Evidence in the scientific literature to make specific recommendations http://my.premierinc.com/all/safety/p
Care Working about these strategies for improving patient safety. ublications/07-
Conditions on Patient 03_downloads/11_AHRQ_worksum.
Safety Report pdf
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June 2003 Patient Safety Your Medicine: Play It To help consumers use prescription medicines safely. http://www.ahrq.gov/consumer/safe
Safe meds/safemeds.htm for the English
version,
http://www.ahrq.gov/consumer/safe
medsp/safemedsp.htm for the
Spanish version.
June 2003 Patient Safety IHI’s global online Improving access in the office practice √ http://www.QualityHealthCare.org
improvement
resource
June 2003 Patient Safety Standing Orders A collaborative effort to improve influenza vaccination rates http://www.ama-
assn.org/ama/pub/article/2403-
7702.html
May 2003 Patient Safety SARS Triage Tools Tools for rapid assessment of a patient who may present with one or These algorithms and a “stop” sign
more symptoms suggestive of SARS that can be printed and used in
these settings – if this becomes
necessary – are available on
Premier’s Emergency and Public
Health Preparedness site.
May 2003 Patient Safety Trigger Tool for The trigger tool measures adverse drug events and provides instructions √ http://www.qualityhealthcare.org/QH
Measuring Adverse for conducting a retrospective review of patient records using triggers to C/Topics/PatientSafety/MedicationS
Drug Events (ADEs) identify possible ADEs. ystems/Tools/Trigger+Tool+for+Mea
suring+Adverse+Drug+Events+(IHI+
Tool).htm
April 2003 Patient Safety First, Do No Harm Case studies and safety responses http://my.premierinc.com/all/safety/st
ore/P4PS_video_form.doc
April 2003 Patient Safety National Quality The site enables searching for measures by specific disease, treatment, http://www.qualitymeasures.ahrq.go
Measures age range, gender, and a variety of other topics. The clearinghouse also v/
Clearinghouse™ permits side-by-side comparative measurements that identify which will
best work for a given organization.
March 2003 Patient Safety Pathways for A set of tools designed to reduce medication errors and help hospitals http://my.premierinc.com/all/safety/p
Medication Safety take a system-based approach to address such errors. ublications/03-
03_downloads/11_extraordinary.pdf
March 2003 Patient Safety Wrong-site surgery Recommendations for eliminating as well as managing the discovery of a http://my.premierinc.com/all/safety/p
checklist wrong-site surgery. ublications/03-
03_downloads/11_extraordinary.pdf
February 2003 Patient Safety Perspectives on The report is devoted entirely to JCAHO'S 2003 National Patient Safety http://my.premierinc.com/all/safety/p
Patient Safety Goals and provides practical advice and tips for meeting those goals. ublications/02-
03_downloads/13_ps_01-03.pdf
February 2003 Patient Safety Web M & M (Web A new online peer-reviewed journal to showcase patient safety lessons http://www.webmm.ahrq.gov/
Morbidity and drawn from actual cases of medical errors. The journal is designed to
Mortality), educate healthcare providers about medical errors in an engaging, blame-
free environment.
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Premier Safety Share
Month Year Topic by Tab Tool Description IHI Location
Tool
January 2003 Patient Safety Pathways for A set of tools designed to reduce medication errors and help hospitals http://www.medpathways.info/
Medication Safety take a system-based approach to address such errors
January 2003 Patient Safety www.orprecautions.c The site provides safety resources, injury and exposure data, industry http://www.orprecautions.com/
om information, information about the Needlestick Safety Act, and
convenient links to much more OR safety information.
January 2003 Patient Safety Veterans’ Tools to help reduce the potential for entrapment in hospital bed http://my.premierinc.com/all/safety/p
Administration guide systems. ublications/01-
on bed safety zones 03_downloads/12_VHA_bed_entrap
ment.pdf
January 2003 Patient Safety Sample OR guides - Increased attention to medical errors and patient safety as they relate to http://my.premierinc.com/all/safety/p
Veterans' correct surgery sites is leading institutions to develop guides and other ublications/01-
Administration instructional materials to help reduce such errors. 03_downloads/12_VHA_bed_entrap
ment.pdf,
http://my.premierinc.com/all/safety/p
ublications/01-
03_downloads/14_CorrSurgPt.pdf,
http://my.premierinc.com/all/safety/p
ublications/01-
03_downloads/14_CorrSurgPt.
December 2002 Patient Safety First, Do No Harm Takes the dialog within the patient safety movement to new levels http://www.fdnh.com/
Part 2: Taking the
Lead
December 2002 Patient Safety AHRQ WebM&M Peer-reviewed, Web-based medical journal to showcase patient safety http://www.webmm.ahrq.gov/
(Morbidity and lessons drawn from actual cases of medical errors.
Mortality Rounds on
the Web)
December 2002 Patient Safety Physician drug e- It organizes the technology into four categories based on function: (1) http://my.premierinc.com/all/safety/p
prescribing electronic drug references, (2) e-prescribing solutions, (3) integrated ublications/12-
drug references and formulary tools, and (4) integrated electronic 02_downloads/07_improv_drug_pre
medical records and e-prescribing systems. scrib.pdf
November 2002 Patient Safety Role of the Patient Valuable tips on how patients can choose "advocates" to look out for http://my.premierinc.com/all/safety/p
Advocate their best healthcare interests ublications/11-
02_downloads/08_nspf.pdf
November 2002 Patient Safety OR design tools This site includes details of the design process, infection control and http://www.ordesignandconstruction.
case studies. com/
October 2002 Patient Safety Preventing Infections Provides patients with helpful principles for managing their healthcare http://www.npsf.org/download/Preve
in the Hospital — and becoming an active partner with their healthcare team through ntingInfections.pdf
What You as a infection prevention
Patient Can Do
October 2002 Patient Safety Let's Talk Step-by-step instructions on how to disclose medical errors, why http://www.npsf.org/htm/prevent_infe
disclosure is important, and how open communication can strengthen the ctions.html
patient-provider relationship are some of the subjects on the video.
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Month Year Topic by Tab Tool Description IHI Location
Tool
October 2002 Patient Safety Videotapes: Patient, Case studies of successful safety programs Case studies of successful safety
worker, environment programs –Order from Premier
and medication safety Safety Institute online Safety Store.
September 2002 Patient Safety Resources to reduce The materials outline methods for reducing errors in pediatric medicine. http://66.77.20.158/ahrq/childhealth
pediatric medicine webconf/
errors
September 2002 Patient Safety Air mattress dangers A recent study cautions doctors that air mattresses used in hospitals, http://my.premierinc.com/all/safety/p
nursing homes, and home care can have deadly consequences for some ublications/09-
patients 02_downloads/08_Air_mattresses_a
bstract.doc
September 2002 Patient Safety Web-based safety The Web notification will disseminate device-related safety information http://www.fda.gov/cdrh/safety.html#
notification program useful to healthcare providers but inappropriate for the FDA’s existing web
notifications.
September 2002 Patient Safety American Society of A new survey indicates that larger hospitals reporting a shortage of http://my.premierinc.com/all/safety/p
Anesthesiologists anesthesiologists are also delaying elective surgery and limiting access ublications/09-
survey to operating rooms 02_downloads/09_ASA_07-30-
02.doc
August 2002 Patient Safety Radiation safety An excellent resource for radiation information and training http://www.orau.gov/reacts/define.ht
basics m
July 2002 Patient Safety ED delays Hospital emergency departments (EDs) are the source of more than 50 http://www.jcaho.org/about+us/news
percent of all reported cases of patient death or permanent injury due to +letters/sentinel+event+alert/index.h
delays in treatment tm
June 2002 Patient Safety Medication Safety Institute for Safe Medication Practices (ISMP) offers six tips to reduce http://my.premierinc.com/all/safety/p
Alert - May 29, 2002 the risk of overdoses from patient- controlled analgesia (PCA) by proxy. ublications/06-
Tips include selection criteria, protocols, monitoring, and education. 02_downloads/05_36_2002_niosh_v
entilation_139.pdf
June 2002 Patient Safety Reducing Medication More than 40 nationally recognized safety experts sharing their "Reducing Medication Errors," one
Errors strategies for successful programs on patient safety, prevention of of a four-part videotape series titled
medication errors, and occupational and environmental safety. "Safety Issues in Healthcare,"s is
available from the Safety Institute's
Safety Store.
June 2002 Patient Safety Quality of Health The book describes the state of healthcare in the United States by http://my.premierinc.com/all/safety/p
Care in the United examining medical mistakes, substandard care for chronic conditions, ublications/06-
States: A Chartbook disparities in care, and the lack of preventive care. 02_downloads/02_quality_care_US_
status_rpt.pdf
June 2002 Patient Safety Crossing the Quality The manual summarizes the report’s themes for improvements in the http://my.premierinc.com/all/safety/p
Chasm U.S. healthcare system using a four-level framework: patients’ ublications/06-
experiences; functioning of small units of care delivery; functioning of the 02_downloads/03_IOM2_manual.pdf
organizations that support microsystems; and the
June 2002 Patient Safety Nursing Home A pilot Web site that lists health deficiencies for nursing homes that have http://www.medicare.gov/
Compare been filed, examined, and confirmed following complaints.
Excel: Premier / Modules / b24d7277-3ce3-4a13-baeb-3f4ffe9a8b03.xls / Patient Safety
Premier Safety Share
Month Year Topic by Tab Tool Description IHI Location
Tool
May 2002 Patient Safety How to Protect The brochure outlines specific steps for preventing medication errors, http://my.premierinc.com/all/safety/p
Yourself and Your wrong-site surgery, and infections ublications/05-
Family from Medical 02_downloads/12_AHRQ_Protect_Y
Errors ourself_Family.doc
May 2002 Patient Safety Ways to Help Your A patient fact sheet with 20 tips on preventing medical errors and a http://my.premierinc.com/all/safety/p
Family Prevent family-oriented brochure ublications/05-
Medical Errors 02_downloads/13_AHRQ_Patient_F
act_Sheet_20-Tips.doc
Excel: Premier / Modules / b24d7277-3ce3-4a13-baeb-3f4ffe9a8b03.xls / Patient Safety
Premier Safety Share
IHI
Month Year Topic by Tab Tool Description Tool Location
Audio files and slides are available from a recent Premier webcast that
describes how hospitals can bring their organizations into compliance
with current EPA hazardous waste regulations and Joint Commission
requirements while preparing for future disposal restrictions. Increasing
national interest in a sustainable environment has accelerated the
healthcare industry's attention to waste management and recycling
practices. Among those challenges in waste management and recycling
is safe disposal of leftover medications, antibiotics, and other chemicals
that may find their way into our drinking water and food chain. Premier
hosted a public webcast titled “Implementing a pharmacy waste
management system” to understand the problem of pharmaceutical
waste and suggest solutions and tips on how to separate, label and
dispose of common chemicals and drugs. Charlotte Smith, president of
PharmEcology Associates, LLC, presented the topic, noting that http://www.premierinc.com/quality-
Pharmaceutical Implementing a managing pharmaceutical waste is becoming a nationwide issue, and safety/tools-
Waste pharmaceutical waste highlighted the impact on the ecosystem from disposal of leftover drugs services/safety/news/2007/11/Phar
December 2007 Management management system through flushing and landfilling. maSafetyStory_11162007.jsp
A standardized hazardous waste manifest form that must be used by all
hazardous waste generators and treatment, storage, and disposal More information on the Uniform
facilities to track waste's progress from generation to disposal is Hazardous Waste Manifest,
available from the U.S. Environmental Protection Agency (EPA). including a list of printers approved
Handlers of waste (generators, or treatment, storage or disposal by EPA to supply the new form and
facilities) must obtain the new forms from any source that has been state requirements for use of the
Pharmaceutical approved for printing and distribution by the EPA Manifest Registry. new form, can be found at:
Waste Uniform Hazardous Some states have additional requirements regarding the use of the new http://www.epa.gov/epaoswer/hazw
Oct 2006 Management Waste Manifest Uniform Hazardous Waste Manifest. aste/gener/manifest/
The document, "Managing Pharmaceutical Waste: A 10-Step Blueprint,"
is designed to help hospitals develop and implement a comprehensive
pharmaceutical hazardous waste management program. The plan
Managing combines regulatory compliance and best management practices with http://www.premierinc.com/quality-
Pharmaceutical Pharmaceutical waste minimization while minimizing risk in a cost effective manner. It is safety/tools-services/safety/safety-
Waste Waste: A 10-Step organized to permit using the steps as needed, and not necessarily share/06-06-downloads/13-h2e-
June 2006 Management Blueprint consecutively. pharma-blueprint-04-15-06.pdf
Excel: Premier / Modules / b24d7277-3ce3-4a13-baeb-3f4ffe9a8b03.xls / Pharmaceutical Waste Management
Premier Safety Share
IHI
Month Year Topic by Tab Tool Description Tool Location
Hospitals for a Healthy Environment (H2E) hosted a March 11
teleconference on disposal of chemotherapeutic wastes. Presenters from
a waste consultancy and H2E offered an overview of proper
chemotherapeutic waste segregation, treatment, and minimization
techniques to reduce the safety, health, and environmental impacts of
managing this hazardous waste stream. The conference included
education on safest practices, with the understanding that many
chemotherapeutic agents in use today are not regulated under
Environmental Protection Agency's (EPA) Resource Conservation and Teleconference materials are at
Recovery Act, but should be included from a safety and health http://www.h2e-
perspective. H2E as provided six free Microsoft® Excel spreadsheets to online.org/events/teleconf/molydesc
help hospitals collect and manage waste data (solid waste, solid waste .cfm?Date=2005-03-11&t. at
recyclables, hazardous waste, hazardous waste recyclables, infectious http://www.hercenter.org/wms.html
H2E resources - waste and general facility information). The bottom half of the to access the H2E Waste
Pharmaceutical Chemo conference; spreadsheet contains basic data and the top half of the spreadsheet Management System and receive
Waste waste disposal does the calculations. Users register and then receive a notice if the updates about the tool.
May 2005 Management management tools database is updated.
The Environmental Protection Agency (EPA) has new guidance about
how the general public should handle used syringes/needles and other
sharps generated at home or other non-healthcare locations. The
guidance suggests that syringe users dispose of used syringes in ways
that keep the sharps out of the general trash, with a goal of protecting
workers along the solid waste "stream" and at land fills. The new EPA
guidance is published in two brochures: Protecting Your Community from
Sharps: Options for Safe Disposal of Sharps and Protect Yourself,
EPA guidance - Safer Protect Others: Safe Options for Needle Disposal.
Pharmaceutical needle, sharps http://www.premierinc.com/all/safet
waste disposal in public y/publications/02-05-downloads/10-
February 2005 management areas med-govt.pdf
Preventing
Occupational
Exposures to
Antineoplastic and http://www.premierinc.com/all/safet
Pharmaceutical Other Hazardous y/resources/pharma-
waste Drugs in Healthcare waste/downloads/2004-
September 2004 management Settings NIOSH Alert on antineoplastic drugs HazDrugAlert.pdf
Excel: Premier / Modules / b24d7277-3ce3-4a13-baeb-3f4ffe9a8b03.xls / Pharmaceutical Waste Management
Premier Safety Share
IHI
Month Year Topic by Tab Tool Description Tool Location
The Guidance for
Industry and FDA
Staff: Frequently The Food and Drug Administration's (FDA) Center for Devices and
Asked Questions Radiological Health (CDRH) has released a new FAQ on single-use
(FAQs) on the Status devices. The document, titled, "The Guidance for Industry and FDA
of Reprocessed Staff: Frequently Asked Questions (FAQs) on the Status of Reprocessed
Single Use Devices Single Use Devices (SUDs) that receive a Not Substantially Equivalent
(SUDs) that receive a (NSE) Letter," (.pdf) (140 KB) explains instances in which a NSE letter
Not Substantially pertains to a reprocessed SUD and whether in-stock, reprocessed SUDs http://www.premierinc.com/all/safet
Reuse of Single Equivalent (NSE) can be used once the reprocessor can no longer distribute the SUDs as y/publications/12-04-downloads/14-
December 2004 Use Devices Letter a result of a NSE letter. sud-guidance-nse-ltr.pdf
The CD-ROM is $475 for AAMI
members and $655 for non-
members. Contact AAMI at
800.332.2264, Ext. 217, or visit
Reuse of Single AAMI sterilization http://aami.org and click on
July 2004 Use Devices documents "marketplace."
Revised forms and instructions for voluntary and mandatory reporting to
MedWatch for healthcare facilities and others to use in reporting adverse
Reuse of Single MedWatch reporting events involving single-use medical devices that have been reprocessed http://www.fda.gov/medwatch/getfor
March 2004 Use Devices forms for reuse. ms.htm
An Overview of the
Regulatory
Requirements for
Reprocessing of
Reuse of Single Single-Use Devices A two-CD set that covers the regulatory requirements that a hospital http://www.fda.gov/cdrh/reuse/reus
August 2002 Use Devices by Hospitals must meet if it reprocesses single-use devices (SUDs). e-important.shtml
Excel: Premier / Modules / b24d7277-3ce3-4a13-baeb-3f4ffe9a8b03.xls / Reuse of Single Use Devices
Premier Safety Share
IHI
Month Year Topic by Tab Tool Description Tool Location
A new pamphlet being released by the CDC – Sharps Safety for
Healthcare Personnel – describes healthcare worker risk, how and when
injuries occur, how sharps safety devices reduce injuries, and the
importance of developing a "culture of safety" for sharps injury
prevention. This and other sharps injury prevention brochures are
publicly accessible on the Safety Institute Web site to assist frontline http://www.premierinc.com/quality-
workers in selecting safety devices to evaluate for their institutions. The safety/tools-
Web site also contains links to national lists of sharps safety products. A services/safety/topics/needlestick/d
Sharps Injury Sharps Safety for new addition to the available tools is the needlestick prevention booklet ownloads/cdc-sharps-brochure-10-
October 2007 Prevention Healthcare Personnel for non-acute care. 01-07.pdf
The U.S. Public Health Service has updated the recommendations for
the management of healthcare personnel (HCP) with occupational
exposure to blood and other body fluids that might contain human
immunodeficiency virus (HIV). Published in the September 30, 2005
Morbidity and Mortality Weekly Report (MMWR) , the recommendations
(.pdf) (267 KB) emphasize adherence to postexposure prophylaxis
(PEP) regimens when indicated, expert consultation in managing http://www.premierinc.com/all/safet
Sharps Injury HIV post-exposure exposures, follow-up to improve HCP adherence to PEP, and monitoring y/publications/10-05-downloads/11-
October 2005 Prevention prophylaxis for adverse events, including seroconversion. hiv-rr5409.pdf
A resource book for healthcare organizations, clinicians and others
designed to make it easier to find sharps injury prevention, blood The Compendium is now available
exposure prevention and infection control products that can protect for immediate purchase as in e-
patients, healthcare workers and others. A cooperative effort from book. The printed version will be
medical device and infection control product manufacturers, the available in a few months. The
Compendium is sponsored by the Premier Safety Institute, ISIPS, price will be $129.95, but for a
Managing Infection Control Magazine, AOHP and NAPPSI. It will be limited time, a pre-publication price
published both as a printed book and as an e-book. In the printed book, of $89.95 is available. For more
The Compendium of each device is paired with a custom evaluation form to facilitate record information, call 801.280.8797 or
Sharps Injury Infection Control keeping. The digital edition of the Compendium will have each product send an e-mail to
July 2005 Prevention Technologies linked directly to the Sample Procurement Center. info@medicalsafetybook.com.
Excel: Premier / Modules / b24d7277-3ce3-4a13-baeb-3f4ffe9a8b03.xls / Sharps Injury Prevention
Premier Safety Share
IHI
Month Year Topic by Tab Tool Description Tool Location
The Environmental Protection Agency (EPA) has new guidance about
how the general public should handle used syringes/needles and other
sharps generated at home or other non-healthcare locations. The
guidance suggests that syringe users dispose of used syringes in ways
that keep the sharps out of the general trash, with a goal of protecting
workers along the solid waste "stream" and at land fills. The new EPA
guidance is published in two brochures: Protecting Your Community
from Sharps: Options for Safe Disposal of Sharps and Protect Yourself,
EPA guidance - Protect Others: Safe Options for Needle Disposal.
Safer needle, sharps http://www.premierinc.com/all/safet
Sharps Injury disposal in public y/publications/02-05-downloads/10-
February 2005 Prevention areas med-govt.pdf
A free copy of the book, "Preventing Occupational Exposures to
Preventing Bloodborne Pathogens," a collection of articles from Advances in
Occupational Exposure Prevention (1994 to 2003), is available from the Premier Order free copies of the book from
Exposures to Safety Store. This 235-page book is edited by Jeannie Jagger and Jane the Premier Safety Store at:
Sharps Injury Bloodborne Perry from the International Healthcare Worker Safety Center at the http://www.premierinc.com/all/safet
December 2004 Prevention Pathogens University of Virginia. y/store/
A list of journal articles published between 1988 and 2004 that pertains Document:
to the review, selection, testing, or evaluation of safer needle devices. http://www.premierinc.com/all/safet
The document, titled "Articles and abstracts," includes a list of selected y/resources/needlestick/downloads/
Literature review for references, followed by the citation and full abstract. Detailed analysis of sharps-journal-lit-listing-abstract-08-
review, selection, the same journal list is provided in a tabular summary format (link 04.doc Tabular format:
testing or evaluation below), permitting ease in sorting the journals by: study focus, author, http://www.premierinc.com/all/safet
Sharps Injury of safer needle journal, title, population-setting, study design, key findings-summary, y/resources/needlestick/downloads/
Sept 2004 Prevention devices conclusions and key words for searching. sharps-journal-lit-analysis-08-04.xls
Sequence for A poster from the Centers for Disease Control and Prevention (CDC)
Donning and that describes the order for donning and removing personal protective
Removing Personal equipment may be downloaded. Entitled “Sequence for Donning and http://www.premierinc.com/all/safet
Sharps Injury Protective Equipment Removing Personal Protective Equipment (PPE),” the poster (643 KB) is y/publications/05-04-downloads/09-
May 2004 Prevention (PPE) available in both English and Spanish. ppeposter-1322.pdf
The “Frequently Asked Questions” (FAQs) regarding sharps safety were
updated following a recent Premier-sponsored audio conference that
featured speakers from OSHA and CDC. Issues addressed include
specific devices, device selection, evaluation and replacement, worker http://www.premierinc.com/all/safet
Sharps Injury Frequently Asked training and compliance, record keeping, schedules and implementation y/resources/needlestick/downloads/
April 2004 Prevention Questions and a list of OSHA resources. OSHA-FAQs.pdf
Excel: Premier / Modules / b24d7277-3ce3-4a13-baeb-3f4ffe9a8b03.xls / Sharps Injury Prevention
Premier Safety Share
IHI
Month Year Topic by Tab Tool Description Tool Location
http://www.epa.gov/epaoswer/other
/medical/sharps.htm, Disposal Tips
for Home Health Care (patient
flyer) (.pdf), Disposal Tips for
Home Health Care (professional
A new at-home sharps disposal options based on the recommendations brochure) (.pdf), New Information
of the Coalition for Safe Community Needle Disposal. It has added to its About Disposing of Medical Sharps
Sharps Injury Sharps disposal current recommendations additional new options for disposal of medical (.pdf)
March 2004 Prevention information flyers sharps outside the healthcare setting.
States the agency's policy on disposal of contaminated needles and
blood tube holders following blood-drawing procedures. The bulletin also
provides the most recent sharps injury data from the Exposure
Prevention Information Network. OSHA developed this “Information
Regarding the Disposal of Contaminated Needles and Blood Tube
Policy on Holders Used for Phlebotomy” to provide relevant information regarding http://my.premierinc.com/all/safety/
Sharps Injury contaminated blood its policy on the prohibition of contaminated needle removal from publications/12-03-downloads/10-
December 2003 Prevention tube holders medical devices. OSHA-tib-10-15-03.pdf
A link to an order form, is available
at:
Sharps Injury ECRI presents ratings of eight sharps disposal containers designed for http://www.ecri.org/Newsroom/PR_
September 2003 Prevention Health Devices patient rooms or patient treatment areas. Detail.asp?DN=20030828_73
The Premier Safety Institute's Bloodborne Pathogen (BBP) Assessment
Bloodborne Tool provides a comprehensive checklist for assessing compliance with
Sharps Injury Pathogen (BBP) OSHA's complete bloodborne pathogen rule, including considerations Download the tool from the Sharps
August 2003 Prevention Assessment Tool for a complete sharps injury prevention program. Injury Prevention module
http://www.premierinc.com/all/safet
This site from the CDC’s Business/Labor division provides helpful y/publications/08-
Sharps Injury HIV/AIDS workplace information and toolkits that help businesses tailor a program specific to 03_downloads/12_HIV_wkpl_mgr_
August 2003 Prevention policy materials their workplace. kit.pdf
ECRI - General In addition to standard performance and human-factors design issues,
Sharps Injury infusion pumps and the report addresses patient safety, reflecting some exciting
December 2002 Prevention patient safety advancements in infusion pump technology info@ecri.org
Sharps Injury OSHA Compliance OSHA compliance tools and resources for implementing a Premier Safety Web resource:
May 2002 Prevention Tools comprehensive sharps injury prevention program. OSHA compliance tools
Excel: Premier / Modules / b24d7277-3ce3-4a13-baeb-3f4ffe9a8b03.xls / Sharps Injury Prevention
Month Year Topic by Tab Tool Description
Available resources include: An audio-conference with downloadable
materials, including DVT research slides, physician and nurse
assessments, sample order sets, and a recording of the audio
conference. A webcast on anticoagulation therapy includes speakers
from hospitals with successful anticoagulation therapy programs who
share their journey to reduce adverse events and discuss The Joint
Commission's 2008 National Patient Safety Goals for anticoagulation
therapy. Slides and an audio file of the webcast and other resources
also are available. An Informatics comparative data tools help users
identify potential problems, track progress and monitor variations,
enabling users to actively reduce the rates of DVT and other serious
avoidable conditions, establish performance benchmarks and share
best practice interventions. Premier’s "Performance Improvement
Premier Safety Portal" is a resource for clinicians to get information on performance
Institute – QI and improvement advice and best practices on key clinical quality and safety
patient education issues, including prevention of VTE. AHRQ Consumer’s Guide –just
Venous tools for VTE released in August 2008 Your Guide to Preventing and Treating Blood
September 2008 Thromboembolism prevention Clots.
IHI
Tool Location
http://www.premierinc.com/quality-
safety/tools-
services/safety/topics/Venous-
Thromboembolism/venous-
thromboembolism.jsp
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