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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.
Profiles in Improvement: Jennifer Lenoci-Edwards, RN, MPH, IHI Director, Patient Safety
In this profile, Jennifer Lenoci-Edwards, IHI Director of Patient Safety, talks about the experiences that shaped her passion and dedication to improving safety, and the current focus of IHI's work in patient safety, which includes safety across the continuum of care, engaging patients in safety efforts, and supporting health care teams in improving system reliability and enhancing their joy in work.
"Conversation Ready": A Framework for Improving End-of-Life Care
This white paper presents a framework built on five core principles to help organizations begin the process of becoming "Conversation Ready" — that is, to develop reliable processes to engage patients in conversations about their wishes for end-of-life care, steward that information, and then respect those wishes at the appropriate time.
WIHI: From Prehospital to In-Hospital: The Continuum for Time-Sensitive Care
July 24, 2014 | In this WIHI, we discuss the dramatic changes underway with emergency medical services (EMS) in both the US and globally.
Always Events Toolkit
Always Events are aspects of the patient experience that are so important to patients and families that health care providers must perform them consistently for every patient, every time. The toolkit supports providers in partnering with patients and family members to co-design, reliably implement, and sustain and spread Always Events to dramatically improve the care experience.
WIHI: Improving Safety and Satisfaction in Ambulatory Care
November 7, 2013 |This WIHI dives into a three-year initiative known as PROMISES, which is charged with reducing malpractice risk in the ambulatory setting by making care safer, more efficient, and more reliable.
WIHI: Recognizing Person- and Family-Centered Care: Always Events at IHI
September 26, 2013 | This WIHI looks at Always Events – a set of reliable practices that should happen for all patients, all the time – and a recognition program to spotlight organizations committed to this level of transformation.
SMART Discharge Protocol
The SMART Discharge Protocol (Signs, Medications, Appointments, Results, and Talk with me) was developed to improve care for patients and families and to improve the discharge process. The tools include the SMART Discharge Checklist for patients and families, FAQs for health care staff and clinicians about implementing the SMART Discharge Protocol, a presentation, and a self-learning packet.
Always Events Blueprint for Action and Always Events Healthcare Solutions Book
These tools guide organizations in creating a more person- and family-centered culture through the development and implementation of Always Events, defined as aspects of the patient experience that are so important to patients and families that health care providers should always get them right.
An Extended Stay
A 64-year-old man with a number of health issues comes to the hospital because he is having trouble breathing. The care team helps resolve the issue, but forgets a standard treatment that causes unnecessary harm to the patient. A subsequent medication error makes the situation worse, leading a stay that is much longer than anticipated.
WIHI: Reliable Practices for Responding to Natural Disasters: Lessons from Long Island Jewish and Hurricane Sandy
May 16, 2013 | This WIHI looks at how health care organizations and first responders prepare for crises and disasters, and provides perspectives from leaders at North Shore-LIJ Health System who were responsible for every kind of decision imaginable before, during, and after Hurricane Sandy.
Severe Sepsis Bundles
The Severe Sepsis Bundles include the Severe Sepsis 3-Hour Rescuscitation Bundle and the 6-Hour Septic Shock Bundle. The Severe Sepsis Bundles have been revised in conjunction with the updated 2012 International Guidelines for Management of Severe Sepsis and Septic Shock.
Lists That Work: The Healthcare Leader's Role in Implementation
This article describes the experiences of several health care organizations in implementing checklists to improve patient safety, and the critical role leaders play in supporting this work.
Tapping Front-Line Knowledge: Identifying Problems as They Occur Helps Enhance Patient Safety
This article describes a methodology, developed and tested by IHI and Cedars-Sinai Medical Center, that helps front-line staff to "see" and solve patient safety problems in their systems using an informal unit visit “conversation” about safety issues.
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.
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.
WIHI: Situational Awareness and Patient Safety
June 7, 2012 | What exactly do systems look like that do everything possible to predict problems as a means of preventing failures in the first place?
When You Hear Hoofbeats, Don’t Think Zebras
In a new patient story, IHI Open School Academic Advisor Dr. James Moses introduces us to Lauren, an 18-year-old female who endured a painful journey through the health care system. One morning during her first semester of college in Boston, Lauren woke up with soreness in the side of her face. Several months – and a misdiagnosis later – the pain only got worse.
Using Care Bundles to Improve Health Care Quality
This IHI white paper describes the history, theory of change, design concepts, and outcomes associated with the development and use of bundles — a small set of evidence-based interventions for a defined patient population and care setting — and reflects on learning over the past decade.
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.
WIHI: Night Talks and Nocturnists: New Interventions for the Hospital at Night
December 1, 2011 | Three experts share how they are implementing innovative solutions to ensure that patients get the same kind of reliable, high-quality care, no matter the time of day or night.
Jill's Medication Crisis
A patient story activity – The Medication – that describes a patient’s journey to get her anticonvulsant medications. The breakdown in continuity of care and communication is an ideal learning opportunity for students and professionals.
Author in the Room: Medical Error: Delayed Care for a Renal Mass
July 2011 | A discussion with the author of the JAMA article "Medical Error: A 60-Year-Old Man with Delayed Care for a Renal Mass."
Passport Exclusive: Reliable Practices to Prevent Hospital-Acquired Infections
In this video, IHI Director Fran Griffin, RRT, MPA, reviews principles of reliability with examples to improve infection prevention processes.
Why Do Errors Happen? How Can We Prevent Them?
Millions of people suffer every year from mistakes in health care. Lucian Leape explains why those mistakes happen — and how to prevent them.