Please wait while you are being redirected ...
This site is best viewed with Internet Explorer version 8 or greater. Check your browser compatibility mode if you are using Internet Explorer version 8 or greater.
Log In / Register
Newsletter Sign Up
Newsletter Sign Up
Sign up for IHI's Email Services
Improving Health and Health Care Worldwide
Engage with IHI
Vision, Mission, Values
Science of Improvement
How to Get Involved
In the News
All Topics A-Z
Quality, Cost, and Value
Triple Aim for Populations
IHI National Forum
Passport to IHI Training
Audio and Video Programs
IHI Open School
How to Improve
IHI White Papers
Audio and Video
Engage with IHI
Engage with IHI Overview
592 items found
Use SHIFT+ENTER to open the menu (new window).
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.
10 IHI Innovations to Improve Health and Health Care
This curated publication highlights 10 ideas that have emerged from IHI's systematic 90-day innovation approach, including reflections on the Triple Aim, the concept of a health care Campaign, the Breakthrough Series Collaborative model, and other frameworks and fresh thinking that have been replicated around the world.
Reducing Inappropriate Medication Use by Implementing Deprescribing Guidelines
This case study from the IHI/Commonwealth Fund International Program for US Health Care System Innovation describes how a multidisciplinary team of clinical experts in Ottawa, Canada, created a credible, low-cost process for developing and implementing evidence-based deprescribing guidelines and tools for assessing, tapering, and stopping medications that may cause harm or no longer benefit patients.
Nature of Blame in Patient Safety Incident Reports: Mixed Methods Analysis of a National Database
A culture of blame and fear of retribution are recognized barriers to reporting patient safety incidents. This article finds a high frequency of blame in a random sample of safety incident reports in the UK, suggesting that there are still opportunities to shift toward a more systems-focused, blame-free culture in health care.
Patient Safety in the Home: Assessment of Issues, Challenges, and Opportunities
Based on a scan of peer-reviewed and grey literature and subject matter expert interviews, this report examines challenges related to patient safety in the home, including fragmentation of care; household hazards; ill-prepared family caregivers; limited training and regulation of home care workers; inadequate communication among patients, caregivers, and providers; and misaligned payment incentives.
Health Care Providers Must Act Now to Address the Prescription Opioid Crisis
While a community-wide approach is also needed to effectively address the opioid crisis, the authors describe some key actions that both providers and organizations can take to begin making a difference, including changing provider prescribing practices.
Does a Quality Improvement Campaign Accelerate Take-up of New Evidence? IHI’s Project JOINTS
IHI’s Project JOINTS initiative engaged a network of state-based organizations and professionals in a six-month QI campaign to promote adherence to three evidence-based practices to reduce surgical site infection (SSI) after joint replacement.
Development of a Trigger Tool to Identify Adverse Events and Harm in Emergency Medical Services
This article describes the development and implementation of the Emergency Medical Services Trigger Tool (EMSTT), a sampling strategy similar to the Global Trigger Tool with EMS-specific triggers, to identify and measure adverse events and harm over time in the Emergency Medical Services setting.
A Framework for Safe, Reliable, and Effective Care
The framework described in this white paper brings together the strategic, clinical, and operational concepts that are critical to creating a "system of safety" that achieves safe, reliable, and effective care.
Building a Culture of Improvement at East London NHS Foundation Trust
East London NHS Foundation Trust (ELFT) in the UK provides mental health and community services to a diverse and largely low-income population. By establishing an organization-wide culture of continuous improvement, and integrating quality improvement methodology and training at every level of work, ELFT has significantly reduced incidents of inpatient violence and improved staff satisfaction, among other achievements.
Patient Safety at the Crossroads
This article reevaluates the status of patient safety improvements 15 years after "To Err Is Human" was published, noting there have been varying levels of improvement and effectiveness, and proposes a course for future patient safety work.
Methods for Reducing Sepsis Mortality in Emergency Departments and Inpatient Units
North Shore-LIJ Health System (now Northwell Health) launched a strategic partnership with the Institute for Healthcare Improvement to accelerate the pace of sepsis improvement, focusing initially on sepsis recognition and treatment in emergency departments (EDs). The health system reduced overall sepsis mortality by approximately 50 percent in a six-year period and increased compliance with sepsis resuscitation bundle elements in the EDs and inpatient units in 11 acute care hospitals.
Performance of the Global Assessment of Pediatric Patient Safety (GAPPS) Tool
This study's objective was to develop and test the Global Assessment of Pediatric Patient Safety (GAPPS) trigger tool, which measures hospital-wide rates of adverse events (AEs) and preventable AEs. The study found that the GAPPS tool reliably identifies AEs among pediatric inpatients and can be used to guide and monitor quality and safety improvement efforts.
Addressing the Opioid Crisis in the United States
This IHI Innovation Report discusses key reasons why current efforts to reduce prescription opioid use and misuse in the US have thus far been largely ineffective in stemming the crisis; highlights gaps in current efforts that underscore the need for a coordinated and collaborative community-wide approach; identifies four primary drivers to reduce opioid use; and proposes a high-level construct for a system approach at the community level to address the US opioid crisis.
Radically Redesigning Patient Safety
Standardize what makes sense. Customize to the individual. Change the balance of power. These are three of the “10 Rules for Radical Redesign in Health Care,” developed by IHI Leadership Alliance members, that are particularly applicable to improving patient safety.This article highlights organizations that are using these rules to make care safer.
Rethinking Critical Care: Decreasing Sedation, Increasing Delirium Monitoring, and Increasing Patient Mobility
This article presents case studies of five hospitals/health systems participating in the Institute for Healthcare Improvement's Rethinking Critical Care program to reduce harm of critically ill patients by decreasing sedation, increasing monitoring and management of delirium, and increasing patient mobility.
Frontline Dyad Approach to Maximize Frontline Engagement in Improvement and Minimize Resource Use
The Frontline Dyad Approach begins with a conversation with frontline staff to identify potential defects in care processes. The approach encourages small-scale testing with the smallest working group (two frontline staff, or "dyad") and, because of the very important scoping function, provides improvement with minimal resource use in a very short timeframe (within 30 days or less).
Project JOINTS: What Factors Affect Bundle Adoption in a Voluntary Quality Improvement Campaign?
This article examines how hospital adherence to quality improvement (QI) methods and hospital engagement with a large-scale QI campaign — Project JOINTS, an IHI-led initiative — could facilitate the adoption of an enhanced prevention bundle designed to reduce surgical site infection (SSI) rates after orthopaedic surgery (hip and knee arthroplasty).
Enhancing Prehospital Emergency Care
This article makes the case that earlier prehospital interventions can positively affect downstream hospital patient outcomes and costs of care, describes how emergency medical services (EMS) are increasingly becoming part of an integrated care system, and discusses the expanded role of ambulance services and paramedics to increase access to care.
Measuring Hospital-wide Mortality: Pitfalls and Potential
This article explores potential uses for measures of risk-adjusted hospital-wide mortality, a proposed key indicator of health care quality at the system level.
Doing Right by Our Patients When Things Go Wrong in the Ambulatory Setting
The PROMISES Project (Proactive Reduction of Outpatient Malpractice: Improving Safety, Efficiency, and Satisfaction) released this statement, suggesting that disclosure and apology are essential first steps to learning from medical errorsthat may have harmed patients and families. The accompanying "Guidelines for Responding to Adverse Events" present practical tips and FAQs.