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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 second edition of the book offers a roadmap that enables health care organizations to create the necessary strategy, structure, environment, and metrics to improve the safety and reliability of the care they provide.
• 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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• IHI Severe Sepsis Bundles
  The Severe Sepsis Bundles include the Severe Sepsis 3-Hour Rescuscitation Bundle and the 6-Hour Septic Shock Bundle. The Severe Sepsis Bundles have been revised in conjunction with the updated 2012 International Guidelines for Management of Severe Sepsis and Septic Shock.

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• Compliance with Severe Sepsis Bundles (with the Goal of Reducing Mortality)
  Measuring compliance with the Severe Sepsis Bundles will allow your team to judge how well your institution is performing in achieving the goal of 100 percent compliance with all Severe Sepsis Bundles elements.
• Measures: Prevent Adverse Drug Events (Medication Reconciliation)
  Care teams should measure each of the evidence-based interventions for preventing adverse drug events using medication reconciliation recommended in the How-to Guide: Prevent Adverse Drug Events (Medication Reconciliation).
• Measures: Prevent Central Line Infection
  Care teams should measure each of the evidence-based interventions recommended by the How-to Guide: Prevent Central Line Infection.
• Measures: Prevent Harm from High-Alert Medications
  Care teams should measure each of the key interventions recommended in the How-to Guide: Prevent Harm from High-Alert Medications.
• Percent of Clean Surgery Patients with Surgical Infection
  Care teams seeking to prevent surgical site infection are encouraged to collect data on this outcome measure and other measures recommended in the How-to Guide: Prevent Surgical Site Infection.

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  CHG Bathing Patient Flyer: Prevent Surgical Site Infection for Hip and Knee Arthroplasty
  This customizable, educational poster/flyer can be used to inform patients that you encourage them to bathe or shower with chlorhexidine gluconate (CHG) soap to reduce the risk of surgical site infections from hip and knee arthroplasty.
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  Data Tracker Worksheet: Prevent Surgical Site Infection for Hip and Knee Arthroplasty
  This Excel spreadsheet is designed to aid in tracking compliance with implementing the interventions recommended in the IHI How-to Guide: Prevent Surgical Site Infection for Hip and Knee Arthroplasty.
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  Flyer of Participation: Prevent Surgical Site Infection for Hip and Knee Arthroplasty
  This customizable poster/flyer can be used to communicate to your patients that you are focused on reducing surgical site infections for hip and knee arthroplasty.
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  How-to Guide: Prevent Obstetrical Adverse Events
  This How-to Guide describes the essentials elements of preventing obstetrical adverse events, including the safe use of oxytocin and key evidence-based care components in the IHI Perinatal Bundles.
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  How-to Guide: Prevent Surgical Site Infection for Hip and Knee Arthroplasty
  This How-to Guide describes key evidence-based interventions for preventing surgical site infection for patients undergoing hip and knee replacement surgery, describes how to implement these interventions, and recommends measures to gauge improvement.

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  Author in the Room: Bariatric Surgery Complications Before vs After Implementation of a National Policy Restricting Coverage to Centers of Excellence
  May 2013 | A discussion with the author of the JAMA article "Bariatric Surgery Complications Before vs After Implementation of a National Policy Restricting Coverage to Centers of Excellence."
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  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."
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  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.
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  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.
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  WIHI: A Partnership to Reduce Deaths from Sepsis
  January 24, 2013 | This WIHI explores how North Shore–Long Island Jewish Health System has reduced its sepsis mortality rate significantly, and what others can learn from their progress.

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  A Surgeon Talks about Using Alcohol-Based Skin Prep to Prevent SSI
  This video offers a surgeon’s perspective on using an alcohol-based antiseptic agent for preoperative skin preparation to reduce the risk of surgical site infection from joint replacement surgery, one the evidence-based interventions recommended in IHI's How-to Guide: Prevent Surgical Site Infection for Hip and Knee Arthroplasty.
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  One Is Too Many: Viewing Infection Data from the Patient's Perspective
  A surgical patient who contracted MRSA following knee replacement surgery describes the effects of the surgical site infection (SSI) on her life, and how her experience led her health care providers to make changes to prevent SSIs.
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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.
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  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.
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  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.