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This article presents specific steps leaders can take to reinforce effective patient safety practices and address workarounds that may unintentionally result in harm.

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.

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.

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.

Selected Resources: Improving Opioid and Pain Management

This document offers selected resources for clinicians and health care administrators to take action on opioid and pain management and opioid use disorder (OUD), organized into three categories: Patient Assessment, Intervention, and Treatment; Provider Training and Support; and Strategy and Planning.

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.

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: 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.

Reducing Inappropriate Medication Use by Implementing Deprescribing Guidelines

This case study from the IHI/Commonwealth Fund International Program for US Health Care System Innovation describes how a multidisciplinary team of clinical experts in Ottawa, Canada, created a credible, low-cost process for developing and implementing evidence-based deprescribing guidelines and tools for assessing, tapering, and stopping medications that may cause harm or no longer benefit patients.

Health Care Providers Must Act Now to Address the Prescription Opioid Crisis

While a community-wide approach is also needed to effectively address the opioid crisis, the authors describe some key actions that both providers and organizations can take to begin making a difference, including changing provider prescribing practices.

Addressing the Opioid Crisis in the United States

This IHI Innovation Report discusses key reasons why current efforts to reduce prescription opioid use and misuse in the US have thus far been largely ineffective in stemming the crisis; highlights gaps in current efforts that underscore the need for a coordinated and collaborative community-wide approach; identifies four primary drivers to reduce opioid use; and proposes a high-level construct for a system approach at the community level to address the US opioid crisis.

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.

ISMP Medication Safety Best Practices

Developed with the help of leading medication safety experts, and patterned after the Joint Commission’s National Patient Safety Goals, the ISMP has issued six 2014-15 Targeted Medication Safety Best Practices for hospitals.

Reduction in Medication Errors in Hospitals Due to Adoption of Computerized Provider Order Entry Systems

The findings of this study suggest that computerized provider order entry (CPOE) systems can substantially reduce the frequency of medication errors in inpatient acute-care settings; however, it is unclear whether this translates into reduced harm for patients.

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.

Signal and Noise: Applying a Laboratory Trigger Tool to Identify Adverse Drug Events among Primary Care Patients

This study tests the use of six abnormal laboratory triggers for detecting adverse drug events among adults in outpatient care.

20 Tips to Help Prevent Medical Errors Patient Fact Sheet

These tips tell consumers what they can do to get safer care.

MATCH Medication Reconciliation Toolkit

Use the materials in the toolkit as guidance for developing a medication reconciliation process in your hospital or outpatient practice setting.

Measures: Prevent Harm from High-Alert Medications

Care teams should measure each of the key interventions recommended in the How-to Guide: Prevent Harm from High-Alert Medications.

Measures: Prevent Adverse Drug Events (Medication Reconciliation)

Care teams should measure each of the evidence-based interventions for preventing adverse drug events using medication reconciliation recommended in the How-to Guide: Prevent Adverse Drug Events (Medication Reconciliation).

What's in your toolbox to improve care quality?

This article describes tools and skills that hospitals and pharmacists need to test, change, and improve health care quality and to establish multidisciplinary medication safety programs.

WIHI: Managing Medication Shortage: Best Practices for a Crisis

September 22, 2011 | Three pharmacy-trained improvers who’ve tapped their expertise on medication safety share strategies that can enable hospital staff to stay on top of the fast-moving drug shortage problem on a daily basis.

Drug shortages: A patient safety crisis

This article outlines the key issues surrounding prescription drug shortages and the errors and harm that can result, and provides guidance for leaders in supporting their medical staff members.

Passport Exclusive: Providing Reliable Perinatal Care by Using Clinical Bundles

In this video, Sue Leavitt-Gullo, MS, RN, Director for IHI, reviews providing reliable perinatal care through usings clinically proven bundles.