Speaking up for patient safety

Millions of people suffer every year from mistakes in health care. Lucian Leape explains why those mistakes happen — and how to prevent them.

Communication failures are a leading root cause of the most serious harmful medical errors, which are a leading cause of death and harm in patients worldwide. New research evaluated a standardized communication structure to reduce those errors. They found that, although overall errors were unchanged, harmful medical errors decreased and family experience and communication processes improved after implementation of a structured communication intervention for family centered rounds coproduced by families, nurses, and physicians. Family centered care processes may improve safety and quality of care without negatively impacting teaching or duration of rounds.

Measuring Patient Safety in Real Time: An Essential Method for Effectively Improving the Safety of Care

IHI faculty member Doug Bonacum makes the case for high reliability as the cornerstone of patient safety.

David Westfall Bates, MD, Senior Vice President for Quality and Safety at Brigham and Women's Hospital, describes practices that reduce the frequency of medication dispensing errors in hospitalized patients including computerized physician order entry, medication bar coding and electronic medication administration records as well as new technologies that will further improve patient safety.

IHI's Don Berwick explains how patient safety must go beyond project by project efforts to a system-level approach.

Health care isn’t the only industry that’s working to protect people in dangerous conditions. Each year at the IHI National Forum, IHI faculty lead excursions to organizations outside of health care to learn about how they do their work. Kathy Duncan, RN, IHI Faculty, leads a trip to the Central Florida Zoo, which has one of North America’s largest collections of venomous snakes. In this video, Duncan goes behind the scenes to learn about the staff’s safety procedures for handling snakes when they need to be moved from their enclosures.

A key principle of the NHS Patient Safety Strategy is continuous improvement. Hugh McCaughey, National Director of Improvement discusses the relationship between Quality Improvement and patient safety. Find out more about the NHS Patient Safety Strategy

IHI Vice President Frank Federico, RPh, gives an overview of IHI's Patient Safety Essentials Toolkit including a look at what it includes, how it can be used, and how it can help make your organization safer and more reliable. Download the full toolkit at ihi.org/safetytoolkit

What patient safety beliefs get in the way of preventing harm? IHI’s Frank Federico lists some common misunderstandings, including the tendency to think of the Institute of Medicine’s six quality aims for improvement in silos.