The first and foremost priority of care must always be to do no harm, and so IHI works with individuals, organizations, systems, and even countries to deliver the safest, most reliable care possible. IHI's work in patient safety covers many areas, including the culture of safety, leadership for safety, adverse events, medication reconciliation, teamwork and communication, high-alert medications, medication safety, surgical safety, Trigger Tools, and much more.
Suggested Resources for Getting Started
A Total Systems Approach to Patient and Workforce Safety
The
National Action Plan to Advance Patient Safety presents a total systems approach to patient and workforce safety. The National Action Plan provides clear direction that health care leaders, delivery organizations, and associations can use to make significant advances toward safer care and reduced harm across the continuum of care.
Essential Tools
Patient Safety Essentials Toolkit
Download these nine essential tools to guide your organization in improving patient safety and delivering safe, reliable care. Tools include FMEA, SBAR, root cause analysis, daily huddles, and more.
Creating a System of Safety / Creating a Culture of Safety
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. The framework can be used as a diagnostic tool for assessing work-to-date and also provides a roadmap for applying the principles.
Leading a Culture of Safety: A Blueprint for Success
The Blueprint provides clear actions for health care leaders to take in developing strong cultures of safety. This resource can be used to help determine the current state of an organization’s culture of safety, inform dialogue with the board and leadership team, and help leaders set priorities.
Measuring Harm
IHI Global Trigger Tool for Measuring Adverse Events
The IHI Global Trigger Tool provides an easy-to-use method for accurately identifying adverse events (harm) and measuring the rate of adverse events over time. Tracking adverse events over time is a useful way to tell if changes being made are improving the safety of the care processes.
Reliable Systems and Processes
IHI has some
recommended resources to help your organization develop more reliable systems and processes. Reliable systems can reduce defects and rework and facilitate safer care of our patients, thereby improving patient outcomes. Reliable systems can also improve respect for people’s work and joy in work.
Effective Communication
SBAR (Situation-Background-Assessment-Recommendation)
The SBAR technique provides a framework for communication between members of the health care team about a patient's condition. It is an easy-to-remember, concrete mechanism useful for framing any conversation, especially critical ones, requiring a clinician’s immediate attention and action. It allows for an easy and focused way to set expectations for what will be communicated and how between members of the team, which is essential for developing teamwork and fostering a culture of patient safety.
Leadership
Leadership Guide to Patient Safety
This IHI white paper shares the experience of senior leaders in addressing patient safety and quality as a strategic imperative within their organizations. It presents eight steps that are recommended for leaders to follow to achieve patient safety and high reliability in their organizations. Each step and its component parts are described in detail, and resources for more information are provided where available.
Improving Safety in Specific Hospital Processes
IHI’s How-to Guides describe the key evidence-based care components for a particular topic, describe how to implement these interventions, and recommend measures to gauge improvement.
Essential Reading
To Err Is Human: Building a Safer Health System
This landmark 2000 Institute of Medicine study highlights the extent of medical errors in the United States. Subsequently, a 13.5 percent level of harm was identified within the US Medicare population by the Office of Inspector General using the IHI Global Trigger Tool, and a study conducted in North Carolina and published in the
New England Journal of Medicine found similar results.
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