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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.
WIHI: No Let Up on Safety
September 19, 2019 | Twenty years since the Institute of Medicine's groundbreaking report on patient safety in the American health care system, what has improved and what still needs work?
Four Steps for Developing Reliable Processes
Creating and sustaining reliable processes to ensure health care quality and patient safety requires thoughtful planning and execution. This checklist of four steps will help ensure your systems are designed with reliability in mind.
WIHI: Taking Acute Pain Seriously, Treating It Safely
May 30, 2019 | Health care needs to create safer processes for acute pain management. But what roles should patients play in this? A new IHI report provides reccomendations to sharpen acute pain management strategies in your health system.
Patient Safety Essentials Toolkit
Download these nine essential tools to guide your organization in improving patient safety and delivering safe, reliable care. Tools include FMEA, SBAR, root cause analysis, daily huddles, and more.
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?
WIHI: How to Make Patient Safety Easier to Explain and to Champion
March 21, 2019 | Why is it so hard to explain patient safety outside of health care?
Selected Resources: Improving Opioid and Pain Management
This document offers selected resources for clinicians and health care administrators to take action on opioid and pain management and opioid use disorder (OUD), organized into three categories: Patient Assessment, Intervention, and Treatment; Provider Training and Support; and Strategy and Planning.
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.
WIHI: The How and Why of Deprescribing
September 13, 2018 | The ground is shifting for prescription medication. There’s much talk and publicity about deprescribing, the process that entails taking patients off some of their medications or tapering down the dosages.
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.
WIHI: Sustaining and Strengthening Safety Huddles
April 5, 2018 | The safety huddle has become an important way for hospitals to surface safety concerns affecting patients and the workforce. But what does it mean for patient safety when it becomes just another meeting?
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.