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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.
Safer Dx Checklist: 10 High-Priority Practices for Diagnostic Excellence
Organizations can use this self-assessment tool with 10 recommended practices for diagnostic excellence to understand current diagnostic practices, identify areas to improve, and track progress toward diagnostic safety and excellence over time.
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 the 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.
Virtual Learning Hour Special Series: Psychological Personal Protective Equipment (PPE)
August 7, 2020 | Psychological PPE, "personal protective equipment" to promote health care workforce mental health and well-being, has become even more essential during the COVID-19 pandemic.
“Psychological PPE”: Promote Health Care Workforce Mental Health and Well-Being
The COVID-19 pandemic is exacerbating existing issues with health care professional burnout and joy in work. Evidence-based recommendations for “psychological PPE” (protection and support for staff mental health and well-being) are intended for use by staff providing care during the COVID-19 pandemic.
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.
Virtual Learning Hour Special Series: Mobilizing to Respond to COVID-19
March 27, 2020 | Don Berwick and Derek Feeley share key coronavirus (COVID-19) learnings, innovations, and revelations they’ve been gathering and gleaning from health care leaders and improvers across the globe.
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.
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?
Four Steps for Developing Reliable Processes
Creating and sustaining reliable processes to ensure health care quality and patient safety requires thoughtful planning and execution. This checklist of four steps will help ensure your systems are designed with reliability in mind.
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.
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.
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?