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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.
National Coordinating Council (NCC) for Medication Error Reporting and Prevention (MERP)
The National Coordinating Council (NCC) is an independent body of 27 national organizations whose aim is to maximize the safe use of medications and increase awareness of medication errors through open communication, increased reporting, and promotion of medication error prevention strategies.
Deciphering Harm Measurement
This article looks at several current approaches to measuring harm.
Saving lives by studying deaths: Using standardized mortality reviews to improve inpatient safety
Substantial variation existed in hospital standardized mortality ratios (HSMRs) across hospitals in the Kaiser Permanente system. In 2008, multidisciplinary teams at KP used the IHI Global Trigger Tool, along with other tools, to investigate hospital-level mortality in order to identify patterns of potential harm and focus improvement efforts.
WIHI: The Power to Detect and Improve: Revisiting the IHI Global Trigger Tool and Adverse Events
April 14, 2011 | The authors discuss a new study in Health Affairs that finds that the IHI Global Trigger Tool identified at least ten times more confirmed, serious events than other methods.
WIHI: The Power to Detect and Reduce Harm: IHI’s Global Trigger Tool and Adverse Events in the US
October 21, 2010 | This WIHI provides a window into research findings from a series of reports from the Office of Inspector General and their significance for patient safety, harm detection, improvement work, and policy reform going forward. The IHI Global Trigger Tool for identifying adverse events is also a focus of the discussion.
Global Trigger Tool shows that adverse events in hospitals may be ten times greater than previously measured
This study finds that the IHI Global Trigger Tool identifies at least ten times more confirmed, serious events than voluntary reporting and Patient Safety Indicators.
Temporal trends in rates of patient harm resulting from medical care
A retrospective study of a stratified random sample of 10 hospitals in North Carolina.
Estimating hospital deaths due to medical errors: preventability is in the eye of the reviewer
Studies using physician implicit review have suggested that the number of deaths due to medical errors in US hospitals is extremely high. However, some have questioned the validity of these estimates.
The reliability of medical record review for estimating adverse event rates
The data used by the U.S. Institute of Medicine to estimate deaths from medical errors come from a study that relied on nurse and physician reviews of medical records to detect the errors.
IHI Global Trigger Tool for Measuring Adverse Events (Second Edition)
This white paper provides information on the development and methodology of the IHI Global Trigger Tool, enabling the ability to accurately identify adverse events and measure the rate of adverse events over time.
Global Trigger Tool Implementation Toolkit
This compendium of resources was developed by Florida Hospital (Orlando, Florida, USA), or adapted from the Institute for Healthcare Improvement (IHI), in the hospital's implementation of the IHI Global Trigger Tool.
IHI Global Trigger Tool Training Resources
A suggested plan and materials to help train reviewers on the IHI Global Trigger Tool methodology.
Measuring Rare Events and Time-Between Measures
This presentation and related articles discuss how measuring the time or number of cases between adverse events, such as the number of surgeries between surgical site infections, is more effective for detecting changes and verifying improvements.
Training Record Set for IHI Global Trigger Tool
Use this Training Record Set to train new reviewers how to use the IHI Global Trigger Tool for Measuring Adverse Events.
IHI Global Trigger Tool for Measuring Adverse Events
The use of "triggers," or clues, to identify adverse events (AEs) is an effective method for measuring the overall level of harm in a health care organization.