Communication
Culture of Safety
Disclosure and Communication
Failure Modes and Effects Analysis
General Tools
IHI Conference Presentation
Information Gathering Tools
Leadership Tools
Set-up
Surgical Complications
Trigger Tools
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Communication
The SBAR (Situation-Background-Assessment-Recommendation) technique provides a framework for communication between members of the health care team and can be used as a tool to foster a culture of patient safety; developed by Kaiser Permanente of Colorado (Evergreen, Colorado, USA)
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This form uses the SBAR (Situation-Awareness-Background-Recommendation) format to improve the emergency department to floor patient report; developed by Alexian Brothers Medical Center (Elk Grove Village, Illinois, USA).
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This tool provides instructions on how to use the SBAR (Situation, Background, Assessment, Recommendation) technique and a form to gather necessary information to be communicated; developed by Catholic Health Initiatives (Denver, Colorado, USA)
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This toolkit contains multiple SBAR (Situation, Background, Assessment, Recommendation) tools that clinical teams can use to standardize communication about important information; developed by Kaiser Permanente (Oakland, California, USA)
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This tool uses the SBAR (Situation, Background, Assessment, Recommendation) technique to improve handoff communication among staff to ensure seamless patient care during shift changes; developed by Springfield Hospital (Springfield, Vermont, USA)
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This is a teaching skills manual that focuses on skills for small group facilitation, skills for teaching interviewing, and skills for working with adult learners; developed by the University of Washington School of Medicine (Seattle, Washington, USA)
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This toolkit helps hospitals create more patient- and family-focused care practices and includes a teaching video, video discussion guide, resource guide, and hospital self-assessment tool; developed by the American Hospital Association (Chicago, Illinois, USA)
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A reference list of articles about physician-nurse partnership, communication, collaboration, and critical thinking and how this relationship affects clinical outcomes; developed by Advocate Good Samaritan Hospital (Downers Grove, Illinois, USA).
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This survey can be utilized to better understand nurse experiences with and attitudes about communicating/collaborating with physicians and highlight areas that present the greatest opportunity for improvement; developed by Advocate Good Samaritan Hospital (Downers Grove, Illinois, USA).
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This survey can be used to better understand physician experiences with and attitudes about communicating/collaborating with nurses and highlight areas that present the greatest opportunity for improvement; developed by Advocate Good Samaritan Hospital (Downers Grove, Illinois, USA).
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Culture of Safety
Senior leaders conduct weekly WalkRounds™ to have informal conversations with front-line staff about safety issues and to demonstrate their support of an organizational culture that promotes nonpunitive reporting of errors, adverse events, near misses, and unsafe conditions; developed by the Institute for Healthcare Improvement and Allan Frankel, MD (Boston, Massachusetts, USA)
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This Access database is designed to allow institutions performing Patient Safety Leadership WalkRounds to collect data and then keep track of how the information is used, what actions are taken, and generate feedback and reports; developed by the Brigham and Women's Hospital (Boston, Massachusetts, USA)
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The Luton and Dunstable Hospital NHS Trust (Luton, Bedfordshire, England) created this pamphlet to educate and communicate with staff about the implementation of the Patient Safety Leadership WalkRounds process as part of their activities to support front-line staff in raising patient safety issues with the executive team.
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A simple, easy-to-use tool that front-line staff can use to share information about potential safety problems and concerns on a daily basis, to promote safety consciousness and learning; developed by the Institute for Healthcare Improvement (Boston, Massachusetts, USA)
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This simple simulation involving an adverse drug event (ADE) using the "Standard Orders for Epidural Catheters for Post-Operative Pain Relief on Nursing Units" provides a low-cost mechanism to gain useful insights into fundamental safety characteristics of an organization's culture; developed by OSF St. Joseph Medical Center (Bloomington, Illinois, USA)
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A policy describing the responsibilities of employees, management, and the medical staff in their culture of safety; developed by Wentworth-Douglass Hospital (Dover, New Hampshire, USA)
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A decision tree that can be followed when analyzing an error or adverse event; developed by Partners HealthSystem (Boston, Massachusetts, USA)
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A policy for non-punitive reporting in a hospital; developed by Luther Midelfort — Mayo Health System (Eau Claire, Wisconsin, USA)
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A policy and procedure on non-punitive error reporting; developed by Wentworth-Douglass Hospital (Dover, New Hampshire, USA)
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A helpful reference to organizations developing their own plans and programs for patient safety; developed by St. Joseph Hospital (Bloomington, Illinois, USA) part of the Order of St. Francis Health System
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A Patient Safety Program including definitions of terms and processes for collecting information and reviewing events; developed by Wentworth-Douglass Hospital (Dover, New Hampshire, USA)
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Example of a database for tracking patient safety issues; developed by Iowa Health System (Des Moines, Iowa, USA)
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A data collection tool for use in recording data collected during tests of Safety Briefings to identify medication safety issues; developed by Iowa Health System (Des Moines, Iowa, USA)
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The Safety Climate Survey developed by Bryan Sexton, PhD, MA, and Robert Helmreich, PhD, The University of Texas at Austin (Austin, Texas, USA) is no longer available on IHI.org
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A short self-assessment survey for use by any health care organization wishing to gauge its patient safety climate; developed by James Reason, PhD (Manchester, UK) and John Wreathall (Dublin, Ohio, USA)
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A policy on disclosure of serious events to patients and families that may be a helpful model for organizations developing or reviewing their own policies; developed by Wentworth-Douglass Hospital (Dover, New Hampshire, USA)
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A compilation of leadership strategies for enhancing patient safety; developed by the Dana-Farber Cancer Institute (DFCI) (Boston, Massachusetts, USA) in partnership with the American Hospital Association (AHA) (Washington, DC, USA)
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A tool for conducting brief, ad hoc staff meetings focused on sharing observations and concerns about safety hazards related to the use of medical devices and equipment; developed by Iowa Health System (Des Moines, Iowa, USA)
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OSF Saint Francis Medical Center (Peoria, Illinois, USA) invites patients to play a vital role in making their surgical care safe with this surgical brochure.
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St. John's Mercy Medical Center (St. Louis, Missouri, USA) created an institution-wide policy regarding non-punitive reporting, as well as a brochure entitled Living a Culture of Patient Safety that was developed by its Culture of Safety Subcommittee, signed by the president, and mailed to all co-worker homes.
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This protocol outlines a systematic process of incident investigation and analysis suitable for all areas of health care; developed by the Clinical Safety Research Unit, Imperial College London (London, United Kingdom)
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Disclosure and Communication
An annotated bibliography of selected books, articles, tools, and other resources for communicating effectively with patients after an adverse event; developed by the Institute for Healthcare Improvement (Cambridge, Massachusetts, USA)
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A policy for disclosure of adverse events related to clinical care of patients; developed by the Veterans Health Administration (Washington, DC, USA)
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A chapter in this toolkit is dedicated to the disclosure of medical errors or unanticipated outcomes; developed by University of Michigan Medical School (Ann Arbor, Michigan, USA).
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Failure Modes and Effects Analysis
A systematic, proactive method for evaluating a process or product to identify where and how it might fail and to assess the relative impact of different failures, in order to identify the parts of the process that are most in need of change; developed by the Institute for Healthcare Improvement (Boston, Massachusetts, USA)
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A system for rating the likelihood of occurrence, severity, and detection of failure modes when calculating Risk Priority Number (RPN); developed by Missouri Baptist Medical Center (St. Louis, Missouri, USA)
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A Failure Modes and Effects Analysis for the computerized physician order entry process; developed by Fairview Southdale Hospital (Edina, Minnesota, USA)
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General Tools
This How-to Guide is designed to help organizations reduce health-care-associated infections, including infections due to antibiotic-resistant organisms, by improving hand hygiene practices and use of gloves among health care workers.
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This tool helps individual physician practices measure safety and quality processes; developed by the Medical Group Management Association (Englewood, Colorado, USA) in collaboration with Health Research and Educational Trust and the Institute for Safe Medication Practices
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This tip sheet provides surgical patients with key questions they should ask their surgical care team prior to surgery; developed by Surgical Care Improvement Project, in coordination with the Oklahoma Foundation for Medical Quality (Oklahoma City, Oklahoma, USA).
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The labels were implemented to increase reliability and compliance of treatment for patients who are Methicillin-resistant Staphylococcus aureus (MRSA) positive; developed by Luton and Dunstable Hospital NHS Trust (Luton, Bedfordshire, England).
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This form is used to document that all elements of the Procedural Pause, implemented to prevent wrong site surgery or wrong procedures, have been completed prior to performing a procedure without sedation; developed by Virginia Mason Medical Center (Seattle, Washington, USA).
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To gauge compliance with a Procedural Pause protocol implemented to prevent wrong site surgery, monthly audits of departments are conducted every time ten or more procedures are performed; developed by Virginia Mason Medical Center (Seattle, Washington, USA).
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This chart was introduced as a track and trigger tool to help nursing staff identify patients who are at risk of deteriorating through critical illness, and then obtain a timely response from either the doctor or outreach nurse; developed by The Luton and Dunstable Hospital NHS Trust (Luton, Bedfordshire, England).
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IHI Conference Presentation
This presentation articulates the problems that hinder physician involvement with safety and quality, describes a framework to improve physician involvement, and applies practical improvement ideas to help get physicians involved.
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Information Gathering Tools
This tool provides a powerful yet simple method to detect medication-related harm in pediatric inpatients; developed by Child Health Corporation of America (Shawnee Mission, Kansas, USA).
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Leadership Tools
This tool allows one to track the change in rate of any one type of adverse event over time and, when appropriate additional data are added, the consequent change in unnecessary deaths, cost savings, and return on investment of quality improvement work targeting those adverse events; developed by the Institute for Healthcare Improvement (Cambridge, Massachusetts, USA).
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Set-up
This list of patient safety facts and statistics can be used as a source for compelling evidence when building will for improvement initiatives; developed by Safe & Sound, an Arizona patient safety initiative through the Arizona Hospital and Healthcare Association (Phoenix, Arizona, USA).
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This PowerPoint tool explains how to build a business plan that incorporates patient safety goals; developed by Safe & Sound, an Arizona patient safety initiative through the Arizona Hospital and Healthcare Association (Phoenix, Arizona, USA).
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Surgical Complications
Use this calculator tool to estimate the number of hospital-acquired venous thromboembolism (VTE) at your hospital, and the proportion that are potentially preventable; developed by the Society of Hospital Medicine (Philadelphia, Pennsylvania, USA)
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Trigger Tools
The use of "triggers," or clues, to identify adverse events (AEs) is an effective method for measuring the overall level of harm in a health care organization. This version of the IHI Global Trigger Tool has been adapted to reflect the lo |
