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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.
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.
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.
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.
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.
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: 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?
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: 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.
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.
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.
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.
Creating a Culture of Excellence
This article discusses a theory of creating a culture of excellence based on a catalyst to rethink the status quo.
A Culture of Respect, Part 1 and Part 2
A two-part article that identifies common types of disrespectful behaviors in the health care setting and how to create a culture of respect in which such behaviors are prevented.
A Multicenter Collaborative Approach to Reducing Pediatric Codes Outside the ICU
Although the code rate for the collaborative did not decrease significantly, 12 hospitals reported additional data after the collaborative and saw significant improvement in code rates, and patient safety culture scores improved.
WIHI: Highly Reliable Hospitals: The Work Ahead
March 8, 2012 | This WIHI discusses what "high reliability" means — safe and effective processes that can be executed and sustained over long periods of time — and the key elements needed to improve safety and quality reliably.
Evaluation of organizational culture among different levels of healthcare staff participating in the Institute for Healthcare Improvement’s 100,000 Lives Campaign
This paper assessed how hospital organizational and cultural factors associated with implementation of quality initiatives such as the Institute for Healthcare Improvement’s 100,000 Lives Campaign differ among levels of healthcare staff.
WIHI: Unprofessional Behavior Not Permitted Here
July 1, 2010 | An expert panel discusses the complicated and controversial issues of unprofessional behavior in health care, what regulators have to say about unprofessional conduct, and a new determination among professional societies and hospitals to face up to behavior that truly has no place in a safe, high-performing organization.
WIHI: Patient Safety Officer: One Person’s Title, Everyone’s Responsibility
January 7, 2010 | It’s one thing for The Joint Commission to require that every US hospital have a Patient Safety Officer; it’s quite another to build the systems and teams to make the prevention of errors and injury a living mantra, and everyone’s priority, each and every day.
Profiles in Improvement: Alide Chase of Kaiser Permanente
Who's improving health care? People are — at hospitals and in office practices all across the US and internationally. Listen to the story of Alide Chase of Kaiser Permanente.
Principles of a Fair and Just Culture
This document describes Dana-Farber Cancer Institute's principles for establishing an organizational culture and work environment that supports just and fair behavior.
This book provides an overview of types of medication errors, processes that lead to errors, research on medication errors, and suggestions for minimizing the potential for future errors.
A delightful book that opens the world of complex systems and introduces the reader to concepts of coupling and opaque systems.
Views of practicing physicians and the public on medical errors
Though substantial proportions of the public and practicing physicians report that they have had personal experience with medical errors, neither group has the sense of urgency expressed by many national organizations.
Reporting of adverse events
This article focuses on the role of reporting in efforts to improve safety, assess the evidence that current reporting systems improve safety, review the characteristics of successful systems, and explore options for developing new reporting systems.