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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 report discusses barriers to integrating behavioral health in the ED; presents the results of a literature scan of existing models to address behavioral health needs in the ED and in communities; and identifies 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.
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.
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.
WIHI: Mindfulness and Patient Safety
March 8, 2018 | Clinicians are discovering that practicing mindfulness can be restorative in the middle of a hectic day, create mental space to be more tuned into patients, and reduce the likelihood of medical errors.
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.
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.
WIHI: Opioid Crisis: Changing Habits and Improving Pain Management
January 11, 2018 | As efforts continue to curb the opioid addiction epidemic in the US and reduce deaths from overdoses, the underlying problem of overprescribing remains very much in the spotlight.
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.
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.
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.
WIHI: A New Emergency Checklist for Office-Based Surgery
October 26, 2017 | While serious harm remains uncommon for outpatient surgeries, adverse events do occur, particularly when anesthesia is involved. A new safety checklist can help clinical teams be better prepared for what to do if something goes wrong.
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.
PFC 103: Incorporating Mindfulness into Clinical Practice
IHI Open School online courses are multimedia learning modules that offer continuing education credits and teach practical skills to improve quality and safety in health care. In PFC 103: Incorporating Mindfulness into Clinical Practice you'll learn how practicing mindfulness — that is, assuming an aware, nonjudgmental, present state of mind — can enhance quality and safety for patients and help foster joy in work for clinicians.
WIHI: Tuning Up Health System Boards for Patient Safety
September 15, 2017 | What do we need and expect from trustees of health systems when it comes to their oversight of quality and safety?