Door-to-Doc Patient Safety Toolkit

Door-to-Doc is a patient flow redesign process that improves the safety of care for patients in the
emergency department by reducing the time patients wait to be seen and by expediting admission
to the most appropriate hospital unit. A main feature is that patient flow is split into “less sick”
and “sicker” patient subgroups based on a “quick look” rather than a full triage. This has the
advantage of keeping less sick patients, which is the vast majority, flowing (rather than waiting
in the lobby) during busy times.

Coordinated-Transitional Care Toolkit

This tool was developed by the University of Wisconsin-Madison School of Medicine & Public
Health and the William S Middleton Memorial Veterans Hospital. The Coordinated-Transitional
Care (C-TraC) Toolkit is a low-resource, telephone-based, protocol-driven program designed to
reduce 30-day rehospitalizations and to improve care transitions during the early post-hospital
period. The goal of this toolkit is to help hospital systems that serve populations with high rates
of patient dispersion, cognitive impairment, and vulnerability improve care coordination and
post-discharge outcomes such as reduced medication discrepancies. The toolkit is designed to
help clinicians and researchers execute the C-TraC program protocol. In addition to the full
toolkit, C-TraC developed a COMPASS module to support hospital to nursing home transitions.

Hospital Nurse Staffing and Quality of Care

This report summarizes the findings of Agency for Healthcare Research and Quality-funded
projects and other research on the relationship of nurse staffing levels to adverse patient
outcomes. This information can be used by decision makers to make more informed choices in
terms of adjusting nurse staffing levels and increasing nurse recruitment while optimizing quality
of care and improving nurse satisfaction.

Achieving Efficiency: Lessons from Four Top-Performing Hospitals

This report from the Commonwealth Fund presents case studies of four of the 13 Leapfrog
Group-designated “Highest Value Hospitals” that offer strategies that may help hospital and
health system leaders achieve greater efficiency. During site visits conducted in 2010, hospital
leaders and staff were asked about the activities they credit with having contributed to high
quality and low resource use. Managing staffing and adjusting roles to reduce or improve
handoffs and promote teamwork to meet patient needs was cited as a way to increase efficiency.

Improving Patient Flow and Reducing Emergency Department Crowding: A Guide for Hospitals

This guide from the Agency for Healthcare Research and Quality presents step-by-step
instructions that can be used by hospitals in planning and implementing patient flow
improvement strategies to ease emergency department crowding.

Patient Safety Primer: Voluntary Patient Safety Event Reporting (Incident Reporting)

This AHRQ primer provides background information on voluntary patient safety event reporting
(incident reporting), including key components of an effective event reporting system,
limitations of event reporting, and how event reports can be used to improve safety.

Multifaceted Program Increases Reporting of Potential Errors, Leads to Action Plans to Enhance Safety

This featured profile is available on the Agency for Healthcare Research and Quality’s Health
Care Innovations Exchange Web site. The University of Texas M.D. Anderson Cancer Center
implemented a multifaceted initiative, known as the Good Catch Program. The program was
designed to increase the reporting of potential errors related to medication, equipment, and
patient care. Key elements of the program include (1) a change in use of terminology from
negative to positive terms and phrases (e.g., from “close call” or “near miss” to “good catch”);
(2) friendly, team-based competition to promote reporting; (3) development of an end-of-shift
safety report; (4) executive leadership-sponsored rounds and incentives; and (5) a
multidisciplinary workgroup to promote reporting. The program increased the reporting of
potential errors dramatically, by 1,468 percent, in the 6-month pilot phase of the program and
spurred the development of action plans designed to address the common causes of potential

SBAR Technique for Communication: A Situational Briefing Model

The SBAR (Situation-Background-Assessment-Recommendation) technique provides a
framework for communication between members of the health care team about a patient’s
condition. This downloadable tool from the Institute for Healthcare Improvement contains two
• “Guidelines for Communicating With Physicians Using the SBAR Process” explains how
to carry out the SBAR technique.
• “SBAR Report to Physician About a Critical Situation” is a worksheet/script that a
provider can use to organize information in preparing to communicate with a physician
about a critically ill patient.

Rapid Response Team Record with SBAR

Both the primary nurse for the patient and the Rapid Response Team nurse have responsibility
for completing the form when a Rapid Response Team call is initiated. The form then becomes a
permanent part of the patient’s medical record. The Rapid Response Team record includes
approved protocol orders that may be initiated by the Rapid Response Team nurse.
The SBAR (Situation-Background-Assessment-Recommendation) tool is printed on the back of
the form and is used as a guide for the primary nurse when calling the physician to ensure that
concise, pertinent information is reported.

Provide Feedback to Extra Line Staff

Feedback to the front-line staff is a critical component of demonstrating a commitment to safety
and ensuring that staff members continue to report safety issues. This Institute for Healthcare
Improvement Web page identifies tips and tools for how to communicate feedback.


PSO Case Law: Ungurian v. Beyzman, et al., 2020 PA Super 105:

A recent Pennsylvania case shows how courts narrowly interpret the PSQIA, ignoring the D & A pathway and the clear language of the Final Rule. (Ungurian v. Beyzman, et al., 2020 PA Super 105). The cour

Joint Commission New Sentinel Event Alert 61: Managing the Risks of Direct Oral Anticoagulants:

The Center for Patient Safety wants to share this important harm-prevention advice from The Joint Commission and its Sentinel Event Alert: Managing the Risks of Direct Oral Anticoagulants. The Joint Commis

CPS Safety Watch/Alert – Culture Can Improve the Control of Multi-Drug Resistant Organisms:

Issue: A number of events reported co CPS’ Patient Safety Organization (PSO) demonstrate poor handoff communication about the patients’ infectious disease status Examples include: Patient with

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The Center for Patient Safety believes that collaboration and sharing are the best ways to drive improvement. We strive to provide the right solutions and resources to improve healthcare safety and quality.