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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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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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 brochure explains what patients should expect and watch out for while using the blood thinner Coumadin/warfarin, including potential dangerous side effects, tips for lifestyle changes, and how to communicate effectively with health care providers; 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 anticoagulation therapy for patients who take 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
The Kaiser Permanente MedRite Program was created to reduce nurse interruptions during medication administration and to create a standard workflow for the administration process; developed by Kaiser Permanente (Oakland, California, USA).
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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
This medication card includes a medication list, health condition, past surgeries, allergy information, and questions that patients should ask their doctor and pharmacists; developed by Iowa Health Home Care (Urbandale, Iowa, USA).
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This web-based resource contains information on effective strategies for training all staff involved in the medication reconciliation process, and also includes support materials and tools; developed by Northwestern Memorial Hospital (Chicago, Illinois, USA).
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An ambulatory medication list printed in triplicate (one copy for the patient chart, one for the patient, and one for other uses); developed by New-York Presbyterian Hospital (New York, New York, USA).
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Patients can use this wallet-sized medication list to keep an up-to-date list of medications and to share this information with all of their health care providers; developed by St. John's Mercy Medical Center (St. Louis, Missouri, USA).
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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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To promote patient safety and reduce the growing incidence of medication errors in the office setting, this patient medication list was created for patients and their families to carry with them to medical appointments; developed by the Massachusetts Coalition for the Prevention of Medical Errors (Burlington, Massachusetts, USA) in collaboration with the Massachusetts Medical Society
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The tool kit provides extensive detail on where and how to reconcile medications at all transition points of care, and provides sample process maps, algorithms, and forms; developed by the North Carolina Center for Hospital Quality and Patient Safety (Cary, North Carolina, USA)
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Use this form with patients after an oupatient visit or ambulatory procedure to reconcile medications; developed by Cooper University Hospital (Camden, New Jersey, USA)
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This brochure gives health care providers essential information about medication reconciliation, including a description of JCAHO National Patient Safety Goals, the provider's role in reconciliation, and the process for when and how to complete reconciliation; developed by Lewiston Hospital (Lewiston, Pennsylvania, USA)
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This form assists health care providers in collecting a patient medication list, including whether to continue or discontinue taking a medications and space for indicating patient instructions; developed by Cooper University Hospital (Camden, New Jersey, USA)
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The passport is a tool to provide patients with a place to list their medications, health history, and other relevant information and can be used as part of an organization's efforts to improve medication reconciliation; developed by California Pacific Medical Center (San Francisco, California, USA)
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Guide for parents to help monitor medication safety for their children; includes a medical information form to capture essential details. Available in English and Spanish; developed by the Dana-Farber Cancer Institute Center for Patient Safety (Boston, Massachusetts, USA).
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This form was developed to obtain a list of "medications as at home" prior to admission, and it has been used extensively in all outpatient areas and on a medical/surgical unit; developed by Winter Haven Hospital (Winter Haven, Florida, USA)
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A two-page form that can be used by patients to register information about their medication use, allergies, and immunization record. The form can also help prevent adverse drug events (ADEs) and improve communication between health care providers, patients, and families; developed by McLeod Health (Florence, South Carolina, USA).
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A medication form to be used by patients and families to keep track of medications including over-the-counter, prescription, and herbal medications; developed by The Arizona Hospital and Healthcare Association (Phoenix, Arizona, USA) and Arizona Partnership in Implementing Patient Safety (Phoenix, Arizona, USA).
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A medication reconciliation order form that can be used as a tool for reconciling medications at admission, transfer, and discharge; developed by UMass Memorial Medical Center (Worcester, Massachusetts, USA)
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This medication reconciliation form includes a detailed section to reconcile patient medication upon admission or transfer, as well as patient discharge instructions; developed by Baptist Memorial Hospital, Memphis (Memphis, Tennessee, USA)
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Physician order form to ensure reconciliation of medications at the time initial orders are written; developed by Missouri Baptist Medical Center (St. Louis, Missouri, USA)
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A tool created and used by Fairview Health Services (Minneapolis, Minnesota, USA) to take medication histories and reconcile them with the physician’s orders.
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Guidelines and a home medication list for reconciling medications within 24 hours of admission; developed by Luther Midelfort — Mayo Health System (Eau Claire, Wisconsin, USA)
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Step-by-step instructions for reviewing closed patient records to identify errors related to unreconciled medications; developed by Roger Resar, MD, Luther Midelfort — Mayo Health System (Eau Claire, Wisconsin, USA) and the Institute for Healthcare Improvement (Boston, Massachusetts, USA)
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A tool for tracking data during a test of medication reconciliation during admission. Please note that the tool is an Excel spreadsheet; developed by The Johns Hopkins Medical Center (Baltimore, Maryland, USA)
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A form to be used to collect data during a retrospective review of patient records to identify errors related to unreconciled medications; developed at Luther Midelfort — Mayo Health System (Eau Claire, Wisconsin, USA)
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An interdisciplinary procedure for conducting medication reconciliation within 24 hours of admission and at the time of discharge in order to generate an accurate medication list and thereby decrease adverse drug events; developed by Luther Midelfort — Mayo Health System (Eau Claire, Wisconsin, USA)
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A flowsheet designed to help nursing personnel determine the appropriate next steps to take when an unreconciled medication is identified during a medication reconciliation review at the time a patient is admitted; developed by Luther Midelfort — Mayo Health System (Eau Claire, Wisconsin, USA)
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Instructions about medications to reduce the number of errors and adverse events related to unreconciled medications at discharge; developed at Luther Midelfort — Mayo Health System (Eau Claire, Wisconsin, USA).
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Patients
This tool is designed to help patients remember why, when, where, and how to take their medicine(s); developed by New York City Department of Health and Mental Hygiene (New York, New York, USA).
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A list of medication safety guidelines for patients to follow before treatment, during treatment and after treatment, including a medication card where patients can list all medications, including herbal supplements, that they are taking; developed by Dana-Farber/Brigham and Women’s Cancer Center (Boston, Massachusetts, USA).
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An extensive eight-page guide for patients and their families about how to ensure safe medication use in a variety of settings including the pharmacy, hospital, and home. If followed, these guidelines can help to reduce the risk of adverse drug events (ADEs); developed by The Massachusetts Coalition for the Prevention of Medical Errors (Burlington, Massachusetts, USA).
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Trigger Tools
A Trigger Tool specifically developed to help identify potential adverse drug events in the nursing home setting; developed by the University of Pittsburgh, Division of Geriatric Medicine and Department of Biomedical Informatics (Pittsburgh, Pennsylvania, USA).
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This Trigger Tool, developed for use with mental health inpatients, includes a list of known adverse drug event triggers in mental health settings and provides instructions for conducting a retrospective review of patient records using these triggers to identify possible ADEs; developed by the Institute for Healthcare Improvement (Cambridge, Massachusetts, USA).
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This tool provides a powerful yet simple method to detect medication-related harm in pediatric inpatients; developed by Child Health Corporation of America (Shawnee Mission, Kansas, USA).
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A method for using "triggers," or clues, in patient records to identify ADEs that may not have been reported through traditional mechanisms); developed by the Institute for Healthcare Improvement (Boston, Massachusetts, USA) and Premier, Inc. (San Diego, California, USA)
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A one-page form that can be used to register information obtained from individual pediatric patient records during a review for adverse drug events (ADEs), included in the Trigger Tool for Measuring Adverse Drug Events; developed by the Institute for Healthcare Improvement (Boston, Massachusetts, USA) and Premier, Inc. (San Diego, California, USA)
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