Related Topics

Medication Reconciliation to Prevent Adverse Drug Events

Reliable Systems and Processes

SBAR Communication Technique

Trigger Tools for Measuring Harm

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Resources

​Resources and tools to help you improve patient safety.
Videos
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What Is the Goal of Reliable Design? (Part 3 of 5)
IHI Executive Director Frank Federico explains the goal behind reliable design — and why capability is just as important as reliability.
How Can You Make Processes Reliable? (Part 2 of 5)
IHI Executive Director Frank Federico discusses steps you can take to make your processes more reliable.
What Is Reliability? (Part 1 of 5)
IHI Executive Director Frank Federico provides an introduction to reliability, including a definition, some examples, and components of IHI’s proven methodology.
The Patient and the Anesthesiologist
Linda Kenney went into the hospital for an ankle replacement. She came out with a host of complications resulting from a mistake that no one was willing to admit. Until Rick van Pelt, MD, her anesthesiologist, stepped forward. In this three-part video case study, you’ll find out what happened in the immediate aftermath of the surgery, watch Kenney and van Pelt describe their first meeting after the surgery, and watch Kathy Duncan, RN, and Don Berwick, MD, analyze the case.
Why Is Reducing Harm — Not Just Error — Important to Patient Safety?
Dr. David Bates, a world renowned patient safety expert, explains why the field of patient safety has shifted from reducing error to also encompass efforts to reduce harm.
How Have Computers Changed Patient-Provider Relationships?
In a new video, patient safety expert Dr. Bob Wachter explores how computers have changed patient-provider relationships.
What Are the Dangers of Alert Fatigue?
In a new IHI Open School short, patient safety expert Dr. Bob Wachter talks about the dangers of alert fatigue in health care.
Why Is Psychological Safety So Important in Health Care?
Why is psychological safety in health care so important? In a short video, Amy Edmondson, Novartis Professor of Leadership and Management at Harvard Business School, describes four specific outcomes associated with a psychologically safe work environment.
Three Ways to Create Psychological Safety in Health Care
How can leaders ― with or without formal authority ― create psychological safety in health care? In a short video, Amy Edmondson, Novartis Professor of Leadership and Management at Harvard Business School, describes three key actions to foster a psychologically safe work environment.
How Can You Apply Clinical Skills to QI?
MIT senior lecturer and IHI Senior Fellow Steve Spear explains why he thinks seven steps needed to care for patients are essentially the same as those needed to fix systems of care. He also shares common trouble areas and gives an example of a successful improvement.
What Happened to Josie?
In 2001, 18-month-old Josie King died of dehydration and a wrongly-administered narcotic at Johns Hopkins Hospital. How did this happen? Her mother, Sorrel King, tells the story and explains how Josie’s death spurred her to work on improving patient safety in hospitals everywhere.
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.
Learning from Medical Errors (Part 2)
A baby falls gravely ill after a botched blood transfusion. A student nearly commits a medication error. A patient dies after a clumsy surgery. In this video, current and former clinicians (including IHI’s Former CEO Don Berwick) describe the errors that still haunt them today — and point out ways those errors could have been prevented.
Learning from Medical Errors (Part 1)
A patient suffers horrible burns. An operation takes twice as long as it should. A child dies from internal bleeding. All because a doctor, a nurse, or another care provider made a mistake. In this video, prominent clinicians describe the errors that still haunt them today — and point out ways those errors could have been prevented.
How Can Data Drive Reliability? (Part 5 of 5)
IHI Executive Director Frank Federico discusses the role of measurement and the role of leadership in achieving reliable designs.
Why Do You Need a Back-Up Plan? (Part 4 of 5)
IHI Executive Director Frank Federico discusses why and when to create a back-up plan for a reliable process.
Disruptive Behavior: The Arterial Stick
A resident tells a medical student to do a blood gas on a patient. The student says, “I don’t know how.” The resident is annoyed – and he says something that he’ll regret for years. Physician Ron Wyatt reflects on what he said (and wishes he had said) to the student.
How Can Disruptive Behavior Be Harmful?
Physician Kevin Stewart explains how he accidentally hurt a patient when he was trying to avoid a confrontation with his foul-tempered supervisor. He offers advice for people who find themselves on the receiving end of disrespectful behavior.
Disruptive Behavior: A Slap on the Hand
When you’re rude and disrespectful to your co-workers, you put your patients at risk. In this video, former nurse Jill Duncan recalls watching a senior nurse bully a medical resident. She explains why this behavior happens, and how you should respond if you’re on the receiving end.
How Do You Apologize After a Medical Error?
When you make a mistake that affects a patient, what should you say? Should you apologize, or will that put you at greater risk of being sued? Lucian Leape, MD, Adjunct Professor of Health Policy at the Harvard School of Public Health, describes how to talk with patients and families after a mistake has occurred.
What Is a Culture of Safety?
Dr. David Bates, a world-renowned patient safety expert, describes a culture of safety and what organizations can do to foster it.
What Can a Zoo Teach Health Care about Patient Safety?
Kathy Duncan goes behind the scenes to learn about the Central Florida Zoo's safety procedures for handling snakes.
Why Should Providers Talk to Patients after Adverse Events?
Lewis Blackman, a healthy 15-year-old boy, died in 2000 after an elective surgery. In this video, Helen Haskell, his mother, explains why providers should communicate with patients and families after adverse events.
What Is the Long-Term Impact of Adverse Events on Patients?
Lewis Blackman, a healthy 15-year-old boy, died in 2000 after an elective surgery. In this video, Helen Haskell, his mother, gives an example of the long-term impact of adverse events on patients and families.
Why Don’t Providers Always Communicate with Patients after Adverse Events?
Lewis Blackman, a healthy 15-year-old boy, died in 2000 after an elective surgery. In this video, Helen Haskell, his mother, explains why communication isn’t always the norm after adverse events, and why this dynamic is changing.
What Is Your Advice for Providers about Communicating with Patients After Adverse Events?
Lewis Blackman, a healthy 15-year-old boy, died in 2000 after an elective surgery. In this video, Helen Haskell, his mother, offers advice for providers who are involved in adverse events about how they should communicate with patients and families.
Why Patient Safety Is at the Top of the List
In 2001, the National Academy of Science’s Institute of Medicine (IOM) laid out six dimensions of quality for health care. According to the IOM, care should be safe, effective, patient-centered, timely, efficient, and equitable. Carol Haraden, patient safety expert, tells us why safety is at the top of that list.
Meet the Students: Desiree de la Torre
Desiree de la Torre’s grandfather acquired an infection in a hospital. Now, Desiree, a recent business school graduate, wants to ensure that other patients have a better experience.
Josie's Story
Eighteen-month-old Josie King died from medical errors incurred at Johns Hopkins Hospital. Her mother, Sorrel King, later worked with hospitals to develop a way for patients and their families to summon a Rapid Response Team to the bedside within minutes.
Improving the Health Care of an Entire Country
Is it possible to cut adverse events by 30 percent – and hospital mortality by 15 percent – across an entire country? The Scottish Patient Safety Programme (SPSP) is an ambitious attempt to do just that.
What Is It Like to Experience a Medical Error?
Get an inside look at a patient's perspective through the personal story of Linda Kenney, President of Medically Induced Trauma Support Services.

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  • Organizational Trustworthiness in Health Care
    The Institute for Healthcare Improvement partnered with the American Board of Internal Medicine Foundation to identify key organizational-level drivers and change ideas that repair, build, and strengthen trust between health care organizations and clinicians, and between health care organizations and the communities they serve. This report describes a theory of how to repair, build, and strengthen trust, presented as a three-step approach with specific change ideas and associated measures for improvement.
  • Using Machine Learning to Improve Patient Safety in the Home or Remote Setting for Adults
    The primary aim of the IHI innovation project described in this report was to assess the use of predictive analytics, specifically machine learning, to improve patient safety through emerging and existing approaches to predict risk, such as technologies and decision support tools. Specific attention was given to how predictive analytics and machine learning can assist in monitoring patient deterioration in the home setting for adults ages 18 and older.
  • Avoiding "Drift" into Harm
    This article presents specific steps leaders can take to reinforce effective patient safety practices and address workarounds that may unintentionally result in harm.
  • Preventing Health Care Workforce Suicide
    Based on available literature and consensus among leading suicide prevention experts, this article highlights three key areas of mental health that all health care leaders need to prioritize: reduce stigma, increase access to mental health services, and address job-related challenges.
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  • WIHI: No Let Up on Safety
    September 19, 2019 | Twenty years since the Institute of Medicine's groundbreaking report on patient safety in the American health care system, what has improved and what still needs work?
  • WIHI: Taking Acute Pain Seriously, Treating It Safely
    May 30, 2019 | Health care needs to create safer processes for acute pain management. But what roles should patients play in this? A new IHI report provides reccomendations to sharpen acute pain management strategies in your health system.
  • WIHI: What's an Apology Worth? The Case for Communication and Resolution
    April 18, 2019 | When a patient is unintentionally harmed, how should organizations respond?
  • WIHI: How to Make Patient Safety Easier to Explain and to Champion
    March 21, 2019 | Why is it so hard to explain patient safety outside of health care?
  • WIHI: The How and Why of Deprescribing
    September 13, 2018 | The ground is shifting for prescription medication. There’s much talk and publicity about deprescribing, the process that entails taking patients off some of their medications or tapering down the dosages.
  • WIHI: Sustaining and Strengthening Safety Huddles
    April 5, 2018 | The safety huddle​ has become an important way for hospitals to surface safety concerns affecting patients and the workforce. But what does it mean for patient safety when it becomes just another meeting?
  • WIHI: Mobility Matters for Age-Friendly Care
    March 22, 2018 | A new initiative wants to emphasize the physical and mental health benefits of mobility and encourage greater mobility for older patients as part of a broadening vision of age-friendly care.
  • WIHI: Mindfulness and Patient Safety
    March 8, 2018 | Clinicians are discovering that practicing mindfulness can be restorative in the middle of a hectic day, create mental space to be more tuned into patients, and reduce the likelihood of medical errors.
  • 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.
  • 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.
  • 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?
  • 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?
  • 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?
  • 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.
  • WIHI: Nurturing Trust: Addiction and Maternal and Newborn Health
    June 2, 2016 | Addiction is always a complex challenge, but when a woman using substances is pregnant, suddenly two lives are at stake.
  • WIHI: The Opioid Crisis: How Health Care and the Community Can Act
    April 21, 2016 | The US is in the midst of a serious opioid addiction epidemic, driven largely by an explosion of prescribed pain medications. This WIHI discusses IHI's work to scan for best practices that comprise a community-driven, integrated, and multi-sector approach to address the opioid crisis, as well as efforts underway in New Hampshire and California.
  • WIHI: A New Framework for Safety in Ambulatory Care
    March 10, 2016 | What contributes to patient harm? It depends, of course, on the setting. Safety is important in every clinical setting. Find out how some experts are applying new frameworks and ways of thinking to improving safety in ambulatory settings.
  • WIHI: New Tools and Thinking for Shared Decision Making
    January 28, 2016 | If you work in primary care today, odds are good that you’re seeing patients with multiple chronic conditions. Even if a provider and patient work together to choose the right medications and agree on making some lifestyle changes that will improve health, the best-laid plans often fall apart.
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first last

  • Organizational Trustworthiness in Health Care
    The Institute for Healthcare Improvement partnered with the American Board of Internal Medicine Foundation to identify key organizational-level drivers and change ideas that repair, build, and strengthen trust between health care organizations and clinicians, and between health care organizations and the communities they serve. This report describes a theory of how to repair, build, and strengthen trust, presented as a three-step approach with specific change ideas and associated measures for improvement.
  • Using Machine Learning to Improve Patient Safety in the Home or Remote Setting for Adults
    The primary aim of the IHI innovation project described in this report was to assess the use of predictive analytics, specifically machine learning, to improve patient safety through emerging and existing approaches to predict risk, such as technologies and decision support tools. Specific attention was given to how predictive analytics and machine learning can assist in monitoring patient deterioration in the home setting for adults ages 18 and older.
  • Avoiding "Drift" into Harm
    This article presents specific steps leaders can take to reinforce effective patient safety practices and address workarounds that may unintentionally result in harm.
  • Preventing Health Care Workforce Suicide
    Based on available literature and consensus among leading suicide prevention experts, this article highlights three key areas of mental health that all health care leaders need to prioritize: reduce stigma, increase access to mental health services, and address job-related challenges.
  • Telemedicine: Ensuring Safe, Equitable, Person-Centered Virtual Care
    This white paper describes a framework to guide health care organizations in their efforts to provide safe, equitable, person-centered telemedicine. The framework includes six elements to consider: access, privacy, diagnostic accuracy, communication, psychological and emotional safety, and human factors and system design.
  • Making Healthcare Safe
    Written by Lucian Leape, a pioneer of t​he patient safety movement, this book describes how patient safety became recognized as an important problem, the underlying science, and the efforts to implement changes.
  • Prioritizing People and Rapid Learning in Times of Crisis: A Virtual Learning Initiative to Support Health Workers During the COVID‐19 Pandemic
    This article reports on an initiative set up within Africa's Western Cape provincial Department of Health early in the COVID-19 pandemic to facilitate collective learning and support for health workers and managers across the health system. Strategies and three transformational actions that protect staff are shared.
  • How to Safely Restart Elective Surgeries After a COVID Spike
    The COVID-19 pandemic has affected surgical schedules and staff: some staff are fatigued and stressed, some may be out of practice, and there are large backlogs of procedures that were postponed. To keep surgical staff and patients safe during these difficult times, this article recommends that health systems should take four steps
  • A Guide to Promoting Health Care Workforce Well-Being During and After the COVID-19 Pandemic
    This guide provides ideas and lessons learned to improve the well-being of the health care workforce and includes actions that individuals, leaders, and organizations can take to combat health care workforce burnout, fatigue, and emotional distress during the COVID-19 pandemic and beyond.
  • Workforce Safety Key to Patient Safety
    Health care leaders increasingly recognize that patient safety is not possible without a workforce that is physically and psychologically safe, joyful, and thriving. This article describes three actionable recommendations to improve workforce safety.
  • Telemedicine: Center Quality and Safety
    This article offers four elements on which health care leaders must focus to ensure safe, high-quality telemedicine for patients.
  • COVID-19: Patient Safety and Quality Improvement Skills to Deploy During the Surge
    The authors suggest a five-step strategy and actions for patient safety and quality improvement staff to employ their skills to support patients, clinical staff, and health care organizations during the COVID-19 pandemic.
  • Adopting a Systems Approach to the Opioid Crisis
    Rather than a myopic focus on opioid prescription reduction, this article describes five strategies health care leaders can employ to implement a systems approach to timely and effective treatment of opioid use disorder, in tandem with pain assessment and management.
  • 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.
  • Advancing Safety and Equity Together
    There are widespread inequities in health outcomes in the United States based on race, sex, language, and other factors. But there is no such thing as high-quality, safe care that is inequitable. Health systems can leverage patient-safety programs to advance equity.
  • The Role of Racism as a Core Patient Safety Issue
    Maternal mortality rates in the US are rising, particularly among black women. This article describes three things health care leaders can do to understand the contributing causes of mortality, including racism, and factors to reduce inequities and improve safety in maternal health.
  • 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.
  • Effective Strategies for Hospitals Responding to the Opioid Crisis
    This document provides hospital and health system administrators and leaders with specific improvement ideas for five system-level strategies that address the challenges of preventing, identifying, and treating opioid use disorder.
  • Advancing the Safety of Acute Pain Management
    This report specifically and uniquely addresses acute pain management as a patient safety issue, including the overuse of opioids for acute pain. It provides health care safety leaders in hospitals, emergency departments (EDs), urgent care clinics, outpatient surgery facilities, and other acute care settings with specific action steps to improve the safety of acute pain management in their organizations.
  • Framework for Effective Board Governance of Health System Quality
    This white paper presents an actionable framework with the core processes needed for effective board governance of all dimensions of health system quality; an assessment tool; and support guides for three central knowledge areas for trustee oversight of quality.
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