Leadership Response to a Sentinel Event IHI periodically receives urgent requests from organizations seeking help in the aftermath of a serious organizational event, most often a significant medical error.

In responding to such requests, we draw on learning and examples assembled from many courageous organizations over the last 15 years who have respectfully and effectively managed these crises.

A book by IHI authors

Featuring best practices, strategies, and case studies to help patient safety leaders create a culture of safety; plan, oversee, and implement new safety practices and improve safety-related management and operations.

Essential Articles about Error Rates

Jim Conway, Senior Vice President at IHI, asked a group of safety experts for a short list of the essential articles about error rates.  Here is the list they came up with:

Brennan TA, Leape LL, Laird NM, et al. Incidence of adverse events and negligence in hospitalized patients: Results of the Harvard Medical Practice Study I. New England Journal of Medicine. 1991;324(6):370-377.

Leape LL, Brennan TA, Laird NM, et al. The nature of adverse events in hospitalized patients. Results of the Harvard Medical Practice Study II. New England Journal of Medicine. 1991;324(6):377-384.

Bates DW, Cullen DJ, Laird NM, et al. Incidence of adverse drug events and potential adverse drug events. Implications for prevention. ADE Prevention Study Group. Journal of the American Medical Association. 1995;274(1):29-34.

World Alliance for Patient Safety Forward Programme 2005. (Page 2 has a great yet simple table showing worldwide results.)

The Canadian Adverse Events Study: The incidence of adverse events among hospital patients in Canada. (Page 1684 has a very detailed table of other studies.)