When Things Go Wrong: Responding to Adverse Events
This consensus paper of the Harvard-affiliated hospitals proposes a full disclosure when adverse events or medical errors occur, including an apology to the patient. The paper represents the …
IHI Global Trigger Tool for Measuring Adverse Events
The IHI Global Trigger Tool for Measuring Adverse Events provides an easy-to-use method for accurately identifying adverse events (harm) and measuring the rate of adverse events over …
RCA2: Improving Root Cause Analyses and Actions to Prevent Harm
This tool describes best practices for conducting a comprehensive Root Cause Analyses and Actions (RCA2) to improve patient safety by reducing medical errors, adverse events, and …
Addressing the Long-Term Impact of Patient Harm
Mar 7, 2019 · The safety movement has focused most of its efforts on preventing errors and adverse events while patients receive medical care. But when harm occurs, the extent of the …
Respectful Management of Serious Clinical Adverse Events
The risks of not responding to these adverse events in a timely and effective manner are significant, and include loss of trust, absence of healing, no learning and improvement, the …
IHI Forum | Institute for Healthcare Improvement
Nov 1, 2024 · The IHI Forum is a four-day conference that has been the home of quality improvement in health care for more than 30 years. Dedicated improvement professionals …
Failure Modes and Effects Analysis (FMEA) Tool
Teams use FMEA to evaluate processes for possible failures and to prevent them by correcting the processes proactively rather than reacting to adverse events after failures have occurred. …
Introduction to Trigger Tools for Identifying Adverse Events
Tracking adverse events over time is a useful way to tell if changes being made are improving the safety of the care processes. The use of "triggers," or clues, to identify adverse events (AEs) is …
o Step 4: Check the medical record. Resist the impulse to fiddle with potentially malfunctioning equipment after an adverse event. When you initially communicate, keep it simple, express …
Every day, clinical adverse events occur within our health care system, causing physical and psychological harm to one or more patients, their families, staff (including medical staff), the …