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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.
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?
WIHI: Workplace Violence in Health Care Can't Be the Norm
August 10, 2017 | It's estimated that nearly 50 percent of workplace assaults happen in a health care setting. What solutions are health care organizations putting in place to help deal with this unique and dangerous problem?
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.
Optimizing a Business Case for Safe Health Care: An Integrated Approach to Safety and Finance
Team-based collaboration of safety and financial leaders is necessary to successfully create and present business cases to advance safety initiatives. This toolkit includes specific recommendations and practices for a Safety–Finance Team and provides a framework for understanding, framing, and advancing patient and workforce safety.
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.
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.
WIHI: The Next Wave of Patient Safety
January 26, 2017 | We are heading into the new year more determined than ever to help hospitals and health systems make greater gains in reducing harm to patients, anchored by a renewed focus and new framing. What is your plan for patient safety in 2017?
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.
WIHI: How to Speak Up for Safety
November 17, 2016 | We like to think that robust safety cultures are so common in health care organizations today, everyone is comfortable pointing out missteps and discrepancies to their colleagues and even getting better at bringing them to the attention of their supervisors. Not so fast.
WIHI: Building Systems of Safety
November 3, 2016 | Systems of safety, culture change, reliability, and a continuous learning system. These are not just theoretical concepts; they’re grounded in a lot of keen observations and careful work over many years and may be key to sustaining improvements in safety.
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.