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Zero Harm in Health Care
This article describes a comprehensive systems-focused approach to patient safety to achieve the goal of zero harm for patients, families, and the health care workforce. The approach includes four interdependent elements: the psychology of change, a culture of safety, an optimal learning system, and codesigning care and improvement with patients.
Advancing Safety and Equity Together
There are widespread inequities in health outcomes in the United States based on race, sex, language, and other factors. But there is no such thing as high-quality, safe care that is inequitable. Health systems can leverage patient-safety programs to advance equity.
The Role of Racism as a Core Patient Safety Issue
Maternal mortality rates in the US are rising, particularly among black women. This article describes three things health care leaders can do to understand the contributing causes of mortality, including racism, and factors to reduce inequities and improve safety in maternal health.
Factors Influencing a Hospital-wide Intervention to Promote Professionalism and Build a Safety Culture
A three-year qualitative study at an Australia hospital identifies valuable insights into factors influencing implementation of a multifaceted behavior change intervention to promote professionalism and build a culture of safety. The multiple interrelated factors impacting the hospital-wide intervention are discussed and analyzed.
Effective Strategies for Hospitals Responding to the Opioid Crisis
This document provides hospital and health system administrators and leaders with specific improvement ideas for five system-level strategies that address the challenges of preventing, identifying, and treating opioid use disorder.
Advancing the Safety of Acute Pain Management
This report specifically and uniquely addresses acute pain management as a patient safety issue, including the overuse of opioids for acute pain. It provides health care safety leaders in hospitals, emergency departments (EDs), urgent care clinics, outpatient surgery facilities, and other acute care settings with specific action steps to improve the safety of acute pain management in their organizations.
Framework for Effective Board Governance of Health System Quality
This white paper presents an actionable framework with the core processes needed for effective board governance of all dimensions of health system quality; an assessment tool; and support guides for three central knowledge areas for trustee oversight of quality.
Effectiveness of a Multistate Quality Improvement Campaign in Reducing Risk of Surgical Site Infections Following Hip and Knee Arthroplasty
This article provides an assessment of IHI’s Project JOINTS initiative, a multistate QI campaign to promote adoption of evidence-based practices to reduce surgical site infections (SSIs) following hip and knee arthroplasty.
Invite the Next Generation to Lead
Reflecting on lessons from 10 years of the IHI Open School, this article shares five practical ideas for how can health care organizations can engage the next generation of health professionals as powerful change agents and leaders.
Transforming Concepts in Patient Safety: A Progress Report
This article reviews progress to date to advance patient safety in the US in five essential areas of health care, as first identified in 2009 by the IHI/NPSF Lucian Leape Institute.
Leadership and Vision for a Culture of Safety
Leaders seeking to transform their health care organization’s culture would do well to commit focused attention on six key areas described in this article.
No Place Like Home: Advancing the Safety of Care in the Home
This report provides expert panel recommendations, strategies, and tools for realizing five guiding principles for advancing the safety of home care.
The Scottish Improvement Journey: A Nationwide Approach to Improvement
Learn about Scotland’s 10-year effort to apply quality improvement on a national scale to improve patient safety, including an in-depth review of the successful Scottish Patient Safety Programme, and further QI efforts that spread across Scotland into new social policy areas such as children’s services, education, and justice.
Integrating Behavioral Health in the Emergency Department and Upstream
This IHI Innovation Report discusses barriers to integrating behavioral health in the ED, and presents five drivers (emerging from six key themes from existing approaches) that form the building blocks of a theory of change for making improvements in this area.
Transforming Health Care: A Compendium of Reports from the NPSF Lucian Leape Institute
A guide for health care leaders in assessing where their organizations stand in the journey to safer care and what steps they can take to make greater progress.
Shining a Light: Safer Health Care Through Transparency
This Lucian Leape Institute report offers sweeping recommendations to bring greater transparency in four domains: between clinicians and patients; among clinicians within an organization; between organizations; and between organizations and the public. It makes the case that true transparency will result in improved outcomes, fewer medical errors, more satisfied patients, and lowered costs of care.
Safety Is Personal: Partnering with Patients and Families for the Safest Care
This Lucian Leape Institute report is a call to action for health leaders, clinicians, and policy makers to take the necessary steps to ensure patient and family engagement at all levels of health care. It identifies specific action items for health leaders, clinicians, and policy makers to pursue in making patient and family engagement a core value in the provision of health care.
Through the Eyes of the Workforce: Creating Joy, Meaning, and Safer Health Care
This Lucian Leape Institute report details how workplace safety is inextricably linked to patient safety. It highlights vulnerabilities common in health care organizations, discusses the costs of inaction, outlines what a healthy and safe workplace would look like, and offers seven recommendations for actions that organizations need to pursue to effect real change.
Order from Chaos: Accelerating Care Integration
Too often, care integration — the planned, thoughtful design of the care process for the benefit and protection of the patient — is lacking. This Lucian Leape Institute report addresses the issue of care integration with the aim of outlining the major barriers to effective integration and providing a framework for further consideration and action among stakeholders.
Unmet Needs: Teaching Physicians to Provide Safe Patient Care
Unmet Needs is the culmination of three Lucian Leape Institute roundtable discussions and makes key recommendations for reforming medical education in order to improve patient safety. The paper was the first in a series of such reports on issues identified as top priorities in ongoing efforts to improve patient safety.
Leading a Culture of Safety: A Blueprint for Success
Creating a culture of safety in health care settings has proven to be a challenging endeavor, and there is a lack of clear actions for organizational leaders to take in developing such a culture. This guide provides chief executive officers and other health care leaders with a useful tool for assessing and advancing their organization’s culture of safety, and can be used to help determine the current state, inform dialogue with the board and leadership team, and help leaders set priorities.
Is Your Organization Highly Reliable?
This article presents common high-reliability organization (HRO) characteristics that apply to all health care organizations seeking to improve patient safety, and cross-walks them with the IHI Framework for Safe, Reliable, and Effective Care to help leaders build a culture and learning system to support HRO characteristics and safer systems of care.
Free from Harm: Accelerating Patient Safety Improvement Fifteen Years after To Err Is Human
This report assesses the state of patient safety in health care, advocating for a total systems approach across the continuum of care and establishment of a culture of safety, and calling for action by government, regulators, health professionals, and others to place higher priority on patient safety improvement and implementation science.
Measuring Patient Safety in Real Time: An Essential Method for Effectively Improving the Safety of Care
The continuing evidence of preventable deaths due to medical error has led to recent calls to improve measurement of safety in hospitals. This need can be adequately addressed by harnessing health information technology.
Closing the Loop: A Guide to Safer Ambulatory Referrals in the EHR Era
The recommendations outlined in this publication are designed to help standardize the ways in which primary care practitioners activate referrals to specialists, and then keep track of the information over time. It describes a nine-step, closed-loop process in which all relevant patient information is communicated to the correct person through the appropriate channels and in a timely manner.