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WIHI: What's an Apology Worth? The Case for Communication and Resolution
April 18, 2019 | When a patient is unintentionally harmed, how should organizations respond?
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.
RCA2: Improving Root Cause Analyses and Actions to Prevent Harm
This document examines best practices for using root cause analysis (RCA) to improve patient safety, and includes guidelines to help health professionals standardize the RCA process and improve the way they investigate medical errors, adverse events, and near misses.
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.
WIHI: Practicing Respect and Preventing Harm
February 9, 2017 | Most of us know what it feels like to have an interaction with someone that can feel rushed, incomplete, maybe even abrupt or downright rude. What are the consequences of these encounters?
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.
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.
IHI Skilled Nursing Facility Trigger Tool for Measuring Adverse Events
The IHI Skilled Nursing Facility Trigger Tool for Measuring Adverse Events provides an easy-to-use method for accurately identifying adverse events (harm) and measuring the rate of adverse event incidence over time in skilled nursing facilities (SNFs).
WIHI: Topping the Charts in Pediatrics and Adverse Events Reporting
February 26, 2015 | Leaders of the teams behind the winning presentations presented at IHI’s 20th Annual Scientific Symposium in December 2014 talk about their work, including the most recent data about each improvement endeavor and how new processes and pathways can be sustained.
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.
Preventing Infection After Hip and Knee Replacements
IHI's Project JOINTS initiative is helping to speed the adoption of proven practices to prevent surgical site infections (SSIs) after hip and knee replacement surgery. This article describes simple, affordable, evidence-based practices organizations can put into place to reduce such infections.
A Promise to Learn – A Commitment to Act: Improving the Safety of Patients in England
An independent group of experts, chartered to review issues that compromise patient safety in England’s National Health Service (NHS), report ten recommendations to improve systems, safety, and culture in the NHS. These recommendations are broadly applicable to other health care institutions and settings.
Ensuring Safe Use of Medical Devices
In this article, IHI's Frank Federico contributes his perspective and guidance on how to improve medical device safety. Among the considerations for improving safety are device design, ongoing staff training and assessment of device use, and establishing an effective reporting system for device-related issues that can cause patient harm.
Reducing Cardiac Arrests in the Acute Admissions Unit: A Quality Improvement Journey
A quality improvement project in the acute admissions unit at the Stirling Royal Infirmary in Scotland achieved a 71 percent reduction in the number of cardiac arrests per 1,000 admissions; a 68 percent increase in referrals to palliative care per 1,000 admissions per month; and a 24 percent relative reduction in the 30-day mortality of patients admitted to unit. These results were achieved through the application of improvement methodology to test new innovations and promotion of a safety culture, among other changes.
Lists That Work: The Healthcare Leader's Role in Implementation
This article describes the experiences of several health care organizations in implementing checklists to improve patient safety, and the critical role leaders play in supporting this work.
Tapping Front-Line Knowledge: Identifying Problems as They Occur Helps Enhance Patient Safety
This article describes a methodology, developed and tested by IHI and Cedars-Sinai Medical Center, that helps front-line staff to "see" and solve patient safety problems in their systems using an informal unit visit “conversation” about safety issues.
National Coordinating Council (NCC) for Medication Error Reporting and Prevention (MERP)
The National Coordinating Council (NCC) is an independent body of 27 national organizations whose aim is to maximize the safe use of medications and increase awareness of medication errors through open communication, increased reporting, and promotion of medication error prevention strategies.
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.
Profiles in Improvement: Frank Federico, Executive Director, IHI
IHI's Frank Federico talks about his early work as a pharmacist to improve medication safety, and his current role at IHI working with teams around the world to implement proven best practices in patient safety.
Supporting Involved Health Care Professionals (Second Victims) Following an Adverse Health Event: A Literature Review
Based on an extensive review, the authors found numerous supportive actions for second victims described in the literature.
Signal and Noise: Applying a Laboratory Trigger Tool to Identify Adverse Drug Events among Primary Care Patients
This study tests the use of six abnormal laboratory triggers for detecting adverse drug events among adults in outpatient care.
Adverse Clinical Outcome Disclosure Plans Aid Response Efforts, Reduce Liability Risks
This article discusses efforts to support the need for a comprehensive plan to proactively manage medical mistakes.
WIHI: Situational Awareness and Patient Safety
June 7, 2012 | What exactly do systems look like that do everything possible to predict problems as a means of preventing failures in the first place?
20 Tips to Help Prevent Medical Errors Patient Fact Sheet
These tips tell consumers what they can do to get safer care.
Planning for clinical crisis: Next steps
This article presents a summary of the learning gained and the challenges remaining for clinical crisis planning, along with comments on four areas of crisis management that are receiving the greatest attention.