Patient Safety

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• Conduct Patient Safety Leadership WalkRounds™
  Senior leaders wishing to demonstrate their commitment to safety and learn about the safety issues in their own organization can do so by making regular rounds for the sole purpose of discussing safety with the staff.
• Crossing the Quality Chasm: A New Health System for the 21st Century
  This report from the Institute of Medicine focuses on closing the quality gap between what we know to be good health care and the health care that people actually receive.
• Develop a Culture of Safety
  In a culture of safety, people are not merely encouraged to work toward change; they take action when it is needed.
• IHI Global Trigger Tool for Measuring Adverse Events (Second Edition)
  This white paper provides information on the development and methodology of the IHI Global Trigger Tool, enabling the ability to accurately identify adverse events and measure the rate of adverse events over time.
• Leadership Guide to Patient Safety
  This white paper presents eight steps that are recommended for leaders to follow to achieve patient safety and high reliability in their organizations.
• The Essential Guide for Patient Safety Officers
  This book is geared to help patient safety leaders create a culture of safety; plan, oversee, and implement new safety practices and improve safety-related management and operations.
• To Err Is Human: Building a Safer Health System
  This report lays out a strategy to reduce medical errors for government, industry, consumers, and health care providers, and it calls on the US Congress to create a national patient safety center to develop the new systems needed to address problems.

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• Adjust Anticoagulants with Thrombolytic and G2b/3A Inhibitors
  A system that reminds prescribers to take into account thrombolytic and G2b/3A inhibitors as they set anticoagulant doses can help reduce the risk of bleeding or other adverse drug events.
• Administer Low-Dose Steroids by a Standard Policy
  Initiate low-dose steroids for septic shock in accordance with a standardized ICU policy
• Allow Pharmacists to Manage an Anticoagulant Service
  Allow pharmacists to manage an anticoagulation service to improve efficiency and help prevent adverse drug events.
• Apply Vasopressors for Ongoing Hypotension
  Use of vasopressors in the presence of mean arterial pressures (MAP) less than 65 mm Hg is an essential practice to promote tissue perfusion and prevent worsening organ dysfunction.
• Appoint a Safety Champion for Every Unit
  Communicating information about patient safety is an important responsibility that should not always fall to managers alone.
• Assign Pharmacists to Patient Care Units
  When pharmacists are on patient care units full-time, they are a greater resource to nurses, physicians, and patients than when they’re in the pharmacy department.
• Blood Cultures Obtained Prior to Antibiotic Administration
  Checking blood cultures prior to antibiotic administration offers the best hope of identifying the causative organism for severe sepsis.
• Carry Reference Materials in Handheld Electronic Devices
  Handheld electronic devices (personal digital assistants) can give staff quick access to medication information anywhere on the unit.
• Changes to Prevent Healthcare-Associated Infections
  Organizations must test and implement changes to existing processes in order to prevent healthcare-associated infections (HAIs).
• Changes to Prevent Surgical Site Infection
  Effective surgical infection prevention requires redesigning systems to reduce risk factors and to optimize evidence-based processes of care. Essential processes for prevention are included in the Surgical Care Improvement Project (SCIP).
• Changes to Transform Care at the Bedside
  A framework for change on medical-surgical units built around innovations and improvements in four main categories is described, along with specific changes you can test.
• Check Multiple Variables When Ordering Medications
  When selecting medications and dosages, prescribers must check multiple variables.
• Collect Allergy Information on Admission
  Collecting allergy information at the moment of admission helps ensure it’s available before anyone orders or administers any medications.
• Computerize Medication Administration Records
  A computerized system that generates medication administration records and registers all doses administered makes medical information available to all clinical personnel who need it.
• Conduct Adverse Drug Event (ADE) Drills
  Adverse drug event (ADE) drills help staff to improve their ability to recognize when an ADE occurs and to respond quickly and appropriately in order to minimize harm to the patient.
• Conduct Independent Double-Checks on the Unit
  Independent double-checks before administration of high-alert medications can help prevent adverse drug events.
• Conduct Patient Safety Leadership WalkRounds™
  Senior leaders wishing to demonstrate their commitment to safety and learn about the safety issues in their own organization can do so by making regular rounds for the sole purpose of discussing safety with the staff.
• Conduct Safety Briefings
  Safety briefings in patient care units are tools to increase safety awareness among front-line staff and foster a culture of safety.
• Connect Medication Orders to Lab Results
  Connecting ordering systems directly to laboratory reporting systems helps prescribers consider the results of laboratory tests before ordering medications.
• Continue to Use Anticoagulation Flowsheets after Discharge
  A flowsheet that records all of a patient’s anticoagulation information in one place and goes home with the patient after discharge can help in the coordination and management of therapy.
• Create a Reporting System
  In a culture of safety, staff members are aware of safety issues and are free to report conditions that could lead to near misses or actual adverse events.
• Create an Adverse Event Response Team
  After any adverse event, members of the response team take prompt action.
• Designate a Patient Safety Officer
  True commitment to patient safety requires action, not just statements about its importance.
• Develop a Culture of Safety
  In a culture of safety, people are not merely encouraged to work toward change; they take action when it is needed.
• Develop a Warfarin Dosing Service or Clinic
  A dosing service or clinic for patients on warfarin can provide coordinated and consistent care and be a benefit to both patients and physicians.

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• Adverse Drug Events per 1,000 Doses
  The total number of ADEs identified in a sample of patient records, divided by the total number of medication doses administered to those patients. Multiply the result by 1,000.
• Central Line Bundle Compliance
  The compliance measure is an assessment of how well the team is adhering to the entire Central Line Bundle, not just parts of the bundle.
• Central Line Catheter-Related Bloodstream Infection (CR-BSI) Rate per 1,000 Central-Line Days
  The catheter-related bloodstream infection rate is defined as the number of central line catheter-related blood stream infections per 1,000 central line days.
• Central Venous Oxygen Saturation Goal
  A measure of compliance with the Sepsis Resuscitation Bundle element. In the event of persistent hypotension despite fluid resuscitation (septic shock) and/or lactate 4 mmol/L (36 mg/dl), achieve central venous oxygen saturation (ScvO2) of 70 percent.
• Central Venous Pressure Goal
  A measure of compliance with the Sepsis Resuscitation Bundle element. In the event of persistent hypotension despite fluid resuscitation (septic shock) and/or lactate 4 mmol/L (36 mg/dl), achieve central venous pressure (CVP) of 8 mm Hg.

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• Adopting a Service Operations Approach to the Evaluation and Management of Patients with Influenza-Like Illness in the Emergency Department in the H1N1 Era
  
  Materials developed by IHI to help hospitals develop a standardized approach to manage flow and maintain patient safety during an "every day" disaster, using an H1N1 outbreak as an example. Companion tools such as an implementation checklist and sepsis screening tool are also provided.
• Adverse Drug Event (ADE) Drill Scenario
  
  This simple simulation involving an adverse drug event (ADE) using the "Standard Orders for Epidural Catheters for Post-Operative Pain Relief on Nursing Units".
• Adverse Events Prevented Calculator
  
  This tool allows one to track the change in rate of any one type of adverse event over time and, when appropriate additional data are added, the consequent change in unnecessary deaths, cost savings, and return on investment of quality improvement work targeting those adverse events.
• Anticoagulant Toolkit: Reducing Adverse Drug Events
  
  ADEs associated with anticoagulants can be reduced by implementing recognized safe practices in high-risk areas, redesigning care processes, partnering with patients and families, and maximizing communications within and across the care continuum.
• Braden Scale Risk Assessment and Skin Inspection Flowchart
  
  A flowchart indicating the steps taken to assess a patient’s risk of developing pressure ulcers and steps to identify and treat pressure ulcers that have formed.
• Business Plan Template with Patient Safety Goals
  
  This tool is a template for creating a business plan document that incorporates patient safety goals.
• Business Profile for Reducing Ventilator-Associated Pneumonia
  
  This example of a business profile stating the need for work to reduce ventilator-associated pneumonia explores the projected impact on resources for a hospital participating in such an initiative.
• CATS Poster for Surgical Site Infection Intervention
  
  This tool is a visual aid to remind and educate caregivers, staff, patients, and families about the elements of the surgical site infection intervention.
• CDC Guideline for Prevention and Control of Catheter-Associated Urinary Tract Infections (2009)
  
  This 2009 guideline updates and expands the original Centers for Disease Control and Prevention (CDC) Guideline for Prevention of Catheter-Associated Urinary Tract Infections (CAUTI) published in 1981.
• CDC MRSA Patient Fact Sheet
  
  This patient fact sheet describes what is methicillin-resistant Staphylococcus aureus (MRSA) infection, who gets it, how it's treated, and how to keep Staph infections from spreading.
• Central Line Insertion Care Team Checklist
  
  Care teams can use this checklist to work together to decrease patient harm from catheter-related bloodstream infections.
• Central Line Insertion Checklist
  
  Implementing a central line checklist at the time of insertion will help to ensure a reliable process.
• Checklist for Assessing Institutional Resilience
  
  A short self-assessment survey for use by any health care organization wishing to gauge its patient safety climate.
• Colour Banded Early Warning Observation Chart
  
  This chart was introduced as a track and trigger tool to help nursing staff identify patients who are at risk of deteriorating through critical illness, and then obtain a timely response from either the doctor or outreach nurse.
• Communicating after an Adverse Event: Selected Bibliography and Resources
  
  An annotated bibliography of selected books, articles, tools, and other resources for communicating effectively with patients after an adverse event.
• Compendium of Strategies to Prevent Healthcare-Associated Infections in Acute Care Hospitals
  
  The Compendium distills current guidelines for the prevention of healthcare-associated infections and includes recommendations for implementation in the clinical setting, along with metrics and indicators of success.
• Contact Precautions Monitoring Tool
  
  This data collection tool is used to monitor whether providers practice contact precautions and hand hygiene with patients in isolation.
• Daily Skin Care Flow Sheet
  
  This tool is used by nurses to help identify the interventions needed for those patients with an identified deficit in any or all of the Braden sub-scales to help reduce the risk for pressure ulcers.
• Decision Tree for Unsafe Acts Culpability
  
  A decision tree that can be followed when analyzing an error or adverse event.
• Device Use – Safety Briefing Model
  
  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.
• Disclosure of Adverse Events to Patients: Annotated Bibliography
  
  An annotated bibliography of selected published literature on disclosure of adverse events to patients.
• Disclosure Toolkit and Disclosure Culture Assessment Tool
  
  The toolkit and assessment tool help health care organizations develop a culture that supports respect and effective communication with patient and families around adverse events; developed by the Institute for Healthcare Improvement (Cambridge, Massachusetts, USA).
• Educational Pamphlet on Patient Safety Leadership WalkRounds™
  
  The Luton and Dunstable Hospital NHS Trust (Luton, Bedfordshire, England) created this pamphlet to educate and communicate with staff about the implementation of the Patient Safety Leadership WalkRounds process as part of their activities to support front-line staff in raising patient safety issues with the executive team.
• Ensuring Safety in Surgery Brochure
  
  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.
• Evaluation for Severe Sepsis Screening Tool
  
  A single page document to assess whether patients in the emergency department, the clinical wards, or the intensive care unit meet criteria for entry into a severe sepsis treatment protocol.

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• Author in the Room: Aspirin Dose for the Prevention of Cardiovascular Disease
  
  June 2007 | A discussion with the author of the JAMA article "Aspirin Dose for the Prevention of Cardiovascular Disease."
• Author in the Room: Disclosure and Communicating with Patients after Medical Errors
  
  September 2009 | A discussion with the author of the JAMA article "A 62-Year-Old Woman With Skin Cancer Who Experienced Wrong-Site Surgery."
• Author in the Room: Gastric Acid-Suppressive Agents and C. difficile Risk
  
  January 2006 | A discussion with the author of the JAMA article "Use of Gastric Acid-Suppressive Agents and the Risk of Community-Acquired Clostridium difficile-Associated Disease."
• Author in the Room: Improving Patient Safety by Taking Systems Seriously
  
  March 2008 | A discussion with the author of the JAMA article "Improving Patient Safety by Taking Systems Seriously."
• Author in the Room: Invasive MRSA Infections in the US
  
  November 2007 | A discussion with the author of the JAMA article "Invasive Methicillin-Resistant Staphylococcus aureus (MRSA) Infections in the United States."
• Author in the Room: Managing Medications in Clinically Complex Elders
  
  November 2010 | A discussion with the author of the JAMA article "Managing Medications in Clinically Complex Elders."
• Author in the Room: Medical Error: Delayed Care for a Renal Mass
  
  July 2011 | A discussion with the author of the JAMA article "Medical Error: A 60-Year-Old Man with Delayed Care for a Renal Mass."
• Author in the Room: Medical Team Training and Surgical Mortality
  
  December 2010 | A discussion with the author of the JAMA article "Implementation of a Medical Team Training Program and Surgical Mortality."
• Author in the Room: Postlicensure Safety Surveillance for HPV Vaccine
  
  October 2009 | A discussion with the author of the JAMA article "Postlicensure Safety Surveillance for HPV Vaccine."
• Author in the Room: Screening for Patient Falls
  
  February 2007 | A discussion with the author of the JAMA article "The Rational Clinical Exam: Will My Patient Fall?"
• Author in the Room: The Patient Who Falls
  
  April 2010 | A discussion with the author of the JAMA article "The Patient Who Falls."
• Author in the Room: Trends in Opioid Prescribing in US EDs
  
  February 2008 | A discussion with the author of the JAMA article "Trends in Opioid Prescribing by Race/Ethnicity for Patients Seeking Care in US Emergency Departments."
• Passport Exclusive: Preventing Venous Thromboembolism in Hospitalized Patients
  
  This video addresses how to accurately and effectively identify VTE risk factors and how to implement those processes in your facility.
• Passport Exclusive: Reducing Patient Injuries from Falls
  
  In this video Chuck Meek and Suzanne Rita present an overview for the creation of customized interventions to prevent falls and subsequent injuries for the patients who are at most risk for serious injuries from a fall.
• Profiles in Improvement: Alide Chase of Kaiser Permanente
  
  Who's improving health care? People are — at hospitals and in office practices all across the US and internationally. Listen to the story of Alide Chase of Kaiser Permanente.
• Profiles in Improvement: Barbara Balik of Allina Hospitals and Clinics
  
  Who's improving health care? People are — at hospitals and in office practices all across the US and internationally. IHI decided to share the stories of these individuals. Here is a profile of Barbara Balik of Allina Hospitals and Clinincs.
• Profiles in Improvement: Charles Barnett of the Seton Family of Hospitals
  
  Who's improving health care? People are — at hospitals and in office practices all across the US and internationally. Listen to the story of Charles Barnett of the Seton Family of Hospitals.
• Profiles in Improvement: Doug Bonacum of Kaiser Permanente
  
  Who's improving health care? People are. Listen to the story of Doug Bonacum of Kaiser Permanente.
• Profiles in Improvement: Dr. David Gozzard of Conwy and Denbighshire Trust, Wales
  
  Who's improving health care? People are — at hospitals and in office practices all across the US and internationally. IHI decided to share the stories of these individuals. Here is a profile of Dr. David Gozzard of Conwy and Denbigshire Trust, Wales.
• Profiles in Improvement: John Senders of the University of Toronto
  
  Who's improving health care? People are. Listen to the story of John Senders of the University of Toronto.
• Profiles in Improvement: Lynn Eschenbacher of Duke University Hospital
  
  Who's improving health care? People are at hospitals and in office practices all across the US and internationally. Listen to the story of Lynn Eschenbacher of Duke University Hospital.
• Profiles in Improvement: Pat O’Connor of the National Health Service Tayside
  
  Who's improving health care? People are - at hospitals and in office practices all across the US and internationally. IHI decided to share the stories of these individuals. Here is a profile of Pat O'Connor of the National Health Service Tayside in Scotland.
• Profiles in Improvement: Tami Merryman from UPMC Shadyside
  
  Who's improving health care? People are, at hospitals and in office practices all across the US and internationally. IHI decided to share the stories of these individuals. Here is a profile of Tami Merryman (Pittsburgh, Pennsylvania, USA).
• Quality and Patient Safety on the Radio
  
  This series of downloadable podcasts on XM Radio's ReachMD taps into the thinking and activity of the quality improvement movement and features IHI experts and leaders.
• WIHI: Adverse Events and Their Aftermath: SOS from Clinicians
  
  February 4, 2010 | As organizations develop more accountable and transparent ways to interact with families and patients who've been harmed by medical care, the emotional and professional needs of doctors, nurses, and staff — whether directly or indirectly involved in an incident — also need to be addressed.

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• Passport Exclusive: A Principled Approach to Adverse Events
  
  In this video, Tim McDonald discusses the major issues hospitals face as they deal with adverse events and how leaders can foster a culture of transparency.
• Passport Exclusive: Developing, Testing, and Locally Adapting Sedation Protocols
  
  In this video, IHI faculty member Dr. Terry Clemmer details the steps to develop and test a sedation protocol at your organization.
• Passport Exclusive: Establishing Nurse-Driven Protocols
  
  Developing nursing protocols that allow for removal of urinary catheters if criteria for necessity are not met and there are no contraindications for removal (as defined in protocol) is one change that could lead to a reduction in unnecessary urinary catheterization.
• Passport Exclusive: Improvement Skills to Empower Front Line Nurses I
  
  This recording discusses Developing a Sensitivity to Risk, including many tools that can help uncover and reduce risk and patient harm.
• Passport Exclusive: Improvement Skills to Empower Front-Line Nurses II
  
  This recording discusses Managing Patient Care Risk: Beyond the Checklist. How does the front-line nurse engage her team, foster communication, and improve teamwork — the three requirements for effective use of a checklist?
• Passport Exclusive: Improving ICU Sedation and Delirium Monitoring
  
  In this video, Dr. Ely shares reliable tools for improving ICU sedation and delirium monitoring.
• Passport Exclusive: Leading Large-Scale Change
  
  Join Dr. James Anderson, President and CEO of Cincinnati Children’s Hospital, as he shares his experiences on leading large-scale, transformation changes.
• Passport Exclusive: Medication Reconciliation
  
  In this video, Frank Federico discusses the challenges many hospitals face with nedication reconciliation and ways health care providers can make implementing the process easier.
• Passport Exclusive: Minimizing Risk for Elderly Patients
  
  In this video, Kevin Stewart, describes the key things providers should consider when caring for elderly patients in order to reduce complications, avoid readmissions, and improve patient experience.
• Passport Exclusive: Providing Reliable Perinatal Care by Using Clinical Bundles
  
  In this video, Sue Leavitt-Gullo, MS, RN, Director for IHI, reviews providing reliable perinatal care through usings clinically proven bundles.
• Passport Exclusive: Reliable Practices to Prevent Hospital-Acquired Infections
  
  In this video, IHI Director Fran Griffin, RRT, MPA, reviews principles of reliability with examples to improve infection prevention processes.
• Passport Exclusive: Strategies to Prevent Catheter-Associated Urinary Tract Infections
  
  In this video IHI Director Fran Griffin, RRT, MPA reviews the four recommended components of care and the supporting evidence for improvement outlined in the Prevent Catheter-Associated Urinary Tract Infections How-to Guide.
• Passport Exclusive: Strategies to Prevent Pressure Ulcers
  
  In this video IHI Faculty Mamber Kathy Duncan, RN reviews the four recommended components of care and the supporting evidence for improvement outlined in the Prevent Pressure Ulcers How-to Guide.
• Passport Exclusive: Taking Steps to Improve Patient Mobility
  
  This video describes the effects of early activity for patients in the intensive care unit.
• Passport Exclusive: The Sepsis Bundle
  
  In this video, IHI faculty member Dr. Sean Townsend gives an overview of the Sepsis Bundle and how to get started on this work.