Alerts
Culture of Safety
Failure Modes and Effects Analysis
General Tools
High-Hazard Medications: Anticoagulants
High-Hazard Medications: Chemotherapy
High-Hazard Medications: Insulin
High-Hazard Medications: Narcotics/Sedatives
IHI Conference Presentation
Medication Core Processes
Medication Reconciliation
Patients
Trigger Tools
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Alerts
An alert to all pharmacists in the UK’s National Health Service, specifying actions to decrease the number of errors occurring during intravenous administration of potassium solutions; developed by the National Patient Safety Agency (London, UK)
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Culture of Safety
Senior leaders conduct weekly WalkRounds™ to have informal conversations with front-line staff about safety issues and to demonstrate their support of an organizational culture that promotes nonpunitive reporting of errors, adverse events, near misses, and unsafe conditions; developed by the Institute for Healthcare Improvement and Allan Frankel, MD (Boston, Massachusetts, USA)
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This Access database is designed to allow institutions performing Patient Safety Leadership WalkRounds to collect data and then keep track of how the information is used, what actions are taken, and generate feedback and reports; developed by the Brigham and Women's Hospital (Boston, Massachusetts, USA)
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A simple, easy-to-use tool that front-line staff can use to share information about potential safety problems and concerns on a daily basis, to promote safety consciousness and learning; developed by the Institute for Healthcare Improvement (Boston, Massachusetts, USA)
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This simple simulation involving an adverse drug event (ADE) using the "Standard Orders for Epidural Catheters for Post-Operative Pain Relief on Nursing Units" provides a low-cost mechanism to gain useful insights into fundamental safety characteristics of an organization's culture; developed by OSF St. Joseph Medical Center (Bloomington, Illinois, USA)
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This protocol outlines a systematic process of incident investigation and analysis suitable for all areas of health care; developed by the Clinical Safety Research Unit, Imperial College London (London, United Kingdom)
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St. John's Mercy Medical Center (St. Louis, Missouri, USA) created an institution-wide policy regarding non-punitive reporting, as well as a brochure entitled Living a Culture of Patient Safety that was developed by its Culture of Safety Subcommittee, signed by the president, and mailed to all co-worker homes.
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OSF Saint Francis Medical Center (Peoria, Illinois, USA) invites patients to play a vital role in making their surgical care safe with this surgical brochure.
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A tool for conducting brief, ad hoc staff meetings focused on sharing observations and concerns about safety hazards related to the use of medical devices and equipment; developed by Iowa Health System (Des Moines, Iowa, USA)
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A compilation of leadership strategies for enhancing patient safety; developed by the Dana-Farber Cancer Institute (DFCI) (Boston, Massachusetts, USA) in partnership with the American Hospital Association (AHA) (Washington, DC, USA)
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A policy on disclosure of serious events to patients and families that may be a helpful model for organizations developing or reviewing their own policies; developed by Wentworth-Douglass Hospital (Dover, New Hampshire, USA)
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A short self-assessment survey for use by any health care organization wishing to gauge its patient safety climate; developed by James Reason, PhD (Manchester, UK) and John Wreathall (Dublin, Ohio, USA)
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The Safety Climate Survey developed by Bryan Sexton, PhD, MA, and Robert Helmreich, PhD, The University of Texas at Austin (Austin, Texas, USA) is no longer available on IHI.org
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A data collection tool for use in recording data collected during tests of Safety Briefings to identify medication safety issues; developed by Iowa Health System (Des Moines, Iowa, USA)
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Example of a database for tracking patient safety issues; developed by Iowa Health System (Des Moines, Iowa, USA)
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A Patient Safety Program including definitions of terms and processes for collecting information and reviewing events; developed by Wentworth-Douglass Hospital (Dover, New Hampshire, USA)
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A helpful reference to organizations developing their own plans and programs for patient safety; developed by St. Joseph Hospital (Bloomington, Illinois, USA) part of the Order of St. Francis Health System
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A policy and procedure on non-punitive error reporting; developed by Wentworth-Douglass Hospital (Dover, New Hampshire, USA)
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A policy for non-punitive reporting in a hospital; developed by Luther Midelfort — Mayo Health System (Eau Claire, Wisconsin, USA)
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A decision tree that can be followed when analyzing an error or adverse event; developed by Partners HealthSystem (Boston, Massachusetts, USA)
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A policy describing the responsibilities of employees, management, and the medical staff in their culture of safety; developed by Wentworth-Douglass Hospital (Dover, New Hampshire, USA)
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Failure Modes and Effects Analysis
A systematic, proactive method for evaluating a process or product to identify where and how it might fail and to assess the relative impact of different failures, in order to identify the parts of the process that are most in need of change; developed by the Institute for Healthcare Improvement (Boston, Massachusetts, USA)
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Failure Modes and Effects Analysis (FMEA) of five common medication dispensing scenarios, included in the Failure Modes and Effects Analysis Tool; developed by the Institute for Healthcare Improvement (Boston, Massachusetts, USA)
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A Failure Modes and Effects Analysis for the computerized physician order entry process; developed by Fairview Southdale Hospital (Edina, Minnesota, USA)
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A system for rating the likelihood of occurrence, severity, and detection of failure modes when calculating Risk Priority Number (RPN); developed by Missouri Baptist Medical Center (St. Louis, Missouri, USA)
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General Tools
The Mind Your Meds card provides important information to patients about medication safety, key resources, and a place to list medications; developed by Missouri Baptist Medical Center (St. Louis, Missouri, USA)
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High-Hazard Medications: Anticoagulants
This toolkit is intended for use by health care providers and institutions to provide effective and safe anticoagulation therapy in all care settings; developed by Purdue University PharmaTAP (Indianapolis, Indiana, USA).
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This brochure explains what patients should expect and watch out for while undergoing Coumadin/warfarin therapy; developed by the Agency for Healthcare Research and Quality (Rockville, Maryland, USA).
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A set of standardized physician orders to reduce variation in the administration of anticoagulants; developed by OSF St. Joseph Medical Center (Bloomington, Illinois, USA)
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Form for Coumadin managemenet developed at Fairview Southdale Hospital (Edina, MN, USA)
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Flow sheet for use with warfarin developed at Fairview Southdale Hospital (Edina, MN, USA)
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Guidelines for use of anticoagulants developed at Fairview Southdale Hospital (Edina, MN, USA)
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Pre-printed order sheet and nomogram for use of heparin; developed by University of Utah (Salt Lake City, Utah, USA)
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A reference for prescribers, nurses, and pharmacists listing herbal agents known to interact with warfarin and the types of interactions to expect; developed by Fairview Southdale Hospital (Edina, Minnesota, USA)
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An educational and reference tool for patients that provides important information about Coumadin (warfarin) and answers many common questions about the drug; developed by Fairview Southdale Hospital (Edina, Minnesota, USA)
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High-Hazard Medications: Chemotherapy
An order form template created and used by Fairview Health Services (Minneapolis, Minnesota, USA) for chemotherapy in a community hospital.
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An assessment scale and automatic treatment protocol for patients with nausea; developed by Luther Midelfort — Mayo Health System (Eau Claire, Wisconsin, USA)
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High-Hazard Medications: Insulin
Correct dosing of insulin is based not only on the patient’s blood glucose values, but also on the patient’s weight. A pre-printed sliding scale for insulin is a tool that staff can use to quickly select the appropriate dose of insulin based on both criteria.
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A standard order set for intravenous insulin infusion used at Fairview Southdale Hospital (Minneapolis, Minnesota, USA).
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A protocol for post-operative insulin management developed at Luther Midelfort — Mayo Health System (Minneapolis, Minnesota, USA)
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High-Hazard Medications: Narcotics/Sedatives
A standard order set for adult postoperative pain management medications to help clinicians reduce the risk of errors when selecting medications and dosages; developed by Fairview Southdale Hospital (Edina, Minnesota, USA)
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A standard order set for epidural analgesia; developed by Fairview Southdale Hospital (Edina, Minnesota, USA)
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IHI Conference Presentation
Order of St. Francis — St. Joseph Medical Center's (Bloomington, Illinois, USA) PowerPoint presentation on how they reduced the number of ADEs per 1,000 doses by more than 50 percent.
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Medication Core Processes
A report with a methodology to help hospitals evaluate whether their CPOE systems meet the Leapfrog standard.
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A report about computerized physician order entry (CPOE) system vendors and the marketplace; developed by First Consulting Group
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A tool for use by clinical staff members and senior leaders to determine the presence or absence of known practices for patient safety; developed by Fairview Health Services(Minneapolis, Minnesota, USA)
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A policy for managing medication orders when dosages are given as a range; developed by Fairview Southdale Hospital (Edina, Minnesota, USA)
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Medication Reconciliation
A sample medication list to be used with patients pre- and postoperatively; developed by Contra Costa Regional Medical Center (Martinez, California, USA).
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This guide was designed to help patients and consumers create an easy-to-use "pill card" (medication list), a visual way to keep track of all of the medicines that a person needs to take on a regular basis; developed by the Agency for Healthcare Research and Quality (Rockville, Maryland, USA).
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This "blended model" medication reconciliation form defines specific criteria for seeking pharmacist involvement in the reconciliation process; developed by Moses Cone Health System (Greensboro, North Carolina, USA).
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This medication reconciliation form, created by the medical staff as a collaborative effort, was designed specifically for use with orthopedic patients; developed by Kernan Hospital Orthopaedics and Rehabilitation (Baltimore, Maryland, USA).
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