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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.
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.
Ask Me 3: Good Questions for Your Good Health
Ask Me 3® is an educational program that encourages patients and families to ask three specific questions of their providers to better understand their health conditions and what they need to do to stay healthy.
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.
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.
WIHI: No Let Up on Safety
September 19, 2019 | It's been 20 years since the Institue of Medicine's groundbreaking report on patient safety first shook the American health care system. So, what has improved, and what still needs work?
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.
Medically Induced Trauma Support Services (MITSS)
Medically Induced Trauma Support Services (MITSS) offers resources for both patients and clinicians to support, educate, train and offer assistance to individuals affected by medically induced trauma.
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.
A huddle is a short, stand-up meeting — 10 minutes or less — that is typically used once at the start of each workday in a clinical setting and gives teams a way to actively manage quality and safety, including a review of important standard work such as checklists.
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.
IHI Trigger Tool for Measuring Adverse Drug Events
A method for using "triggers," or clues, in patient records to identify ADEs that may not have been reported through traditional mechanisms).
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.
WIHI: Mobility Matters for Age-Friendly Care
March 22, 2018 | A new initiative wants to emphasize the physical and mental health benefits of mobility and encourage greater mobility for older patients as part of a broadening vision of age-friendly care.
National Pressure Ulcer Advisory Panel-Pressure Ulcer Staging System
The NPUAP has redefined the definition of a pressure ulcer and the stages of pressure ulcers, including the original four stages and adding two stages on deep tissue injury and unstageable pressure ulcers.
Agency for Healthcare Research and Quality (AHRQ) Hospital Survey on Patient Safety Culture
A new survey for assessing patient safety culture in hospitals was released in November 2004 by the Agency for Healthcare Research and Quality (AHRQ
Focus on Quality
Get With The Guidelines is a program that helps ensure consistent application of the most recent scientific guidelines for heart disease and stroke treatment.
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.
Transforming Care at the Bedside How-to Guide: Reducing Patient Injuries from Falls
This How-to Guide highlights four promising changes designed to reduce patient injury from falls on medical-surgical units; specifies practical step-by-step changes that can be tested; and provides tips, tools, resources, and case studies of hospitals that have implemented many of the changes.
How-to Guide: Reduce MRSA Infection
This How-to Guide describes key evidence-based care components for reducing methicillin-resistant Staphylococcus aureus (MRSA) infections, describes how to implement these interventions, and recommends measures to gauge improvement.
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.
How-to Guide: Improved Care for Patients with Congestive Heart Failure
The goal of this How-to Guide is to significantly improve care and reduce readmissions for patients with congestive heart failure by reliably implementing the recommended components of care.
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.
How-to Guide: Improving Hand Hygiene
This How-to Guide is designed to help organizations reduce healthcare-associated infections, including infections due to antibiotic-resistant organisms, by improving hand hygiene practices and use of gloves among health care workers.