Patient Safety Tip of the Week

November 13, 2007   

AHRQ’s Free Patient Safety Tools DVD


Many healthcare organizations fail to avail themselves of the many patient safety tools that they can get for free. In our  May 22, 2007 Tip of the Week we talked about the TeamSTEPPS™ program, a great team training program developed by the Department of Defense (DoD) in collaboration with the Agency for Healthcare Research and Quality (AHRQ).


Another great free resource is the DVD “The Patient Safety Improvement Corps: Tools, Methods, and Techniques for Improving Patient Safety”, developed jointly by AHRQ, the Department of Veterans Affairs, and the VA National Center for Patient Safety (NCPS). The faculty for the DVD includes many well-known patient safety experts, including James Bagian, Carolyn Clancy, David Marx, John Grout, John Gosbee, among others.


The DVD is organized into modules, many of which also contain printable/downloadable tools use can use at your facility. Some of the highlights are:


Lessons from High Reliability Organizations are presented by James Bagian, M.D., who uses his past experience with NASA and the aviation industry to teach us valuable lessons for healthcare. Development of reporting systems are discussed, including the critically important need to report near-misses.


There are modules on the Culture of Safety, including Leadership, Creating a Culture of Safety, measuring safety culture, and David Marx’ always excellent presentation on Just Culture.


Modules on When and How to Do an RCA are excellent and based upon the well-known VA NCPS programs. The modules on Healthcare FMEA and other proactive tools include good discussions on decision trees, hazard scoring matrices, and other useful tools.


There are outstanding modules on Human Factors Engineering, Heuristics and Mistake Proofing, including practical advice on usability testing. These integrate very nicely with the sections on RCA and FMEA.


The module on mitigation of risk and risk management includes a very good section on disclosure, not only explaining why disclosure and apology are the right thing to do, but also giving useful “how to” tips.


There’s even a module on the Business Case for Patient Safety. This includes a whole host of downloadable worksheets into which you can plug your own data to demonstrate the ROI (return on investment) on various patient safety activities. Make sure your CFO, CEO, and Board of Trustees see this module! There’s also a module on how to use statistical tools and how you can use the AHRQ PSI’s (Patient Safety Indicators) in your organization.



How do I get it? Simply send an email to and order AHRQ Publication No. 07-0035-DVD and tell them where to send it. That’s all! You can’t go wrong with this one.







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