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- Always Events Toolkit - Institute for Healthcare Improvement
IHI’s Always Events Framework and create guidelines and a toolkit for implementing Always Events® Between February 2015 and April 2016, the program engaged 10 provider pilot sites across England to evaluate implementation of Always Events and assess the impact on improving health care quality in these settings
- IHI Global Trigger Tool for Measuring Adverse Events
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 The IHI Global Trigger Tool provides instructions for training reviewers in this methodology and conducting a retrospective review of patient records using triggers to identify possible AEs
- Respectful Management of Serious Clinical Adverse Events
improvement of health care throughout the world IHI helps accelerate change by cultivating promising concepts for improving patient care and turning those ideas into action Thousands of health care providers participate in IHI’s groundbreaking work We have developed IHI’s Innovation Series white papers as one means for advancing our mission
- Always Events Toolkit - Institute for Healthcare Improvement
Always Events are aspects of the patient experience that are so important to patients, their care partners, and service users that health care providers must aim to perform them consistently for every individual, every time An Always Event ® is a clear, action-oriented, and pervasive practice or set of behaviors that provides the following:
- Putting Always Events at the Center of Patient-Centered Care
Why It Matters“By co-producing improvement, you focus on the things that really matter, rather than wasting your time ” It can be easy to make assumptions about what matters most to patients The Always Events® approach to co-design compels health care providers to hear directly from patients and families about the aspects of the care experience that are so important they must be
- To Err Is Human – To Design for Safety Is Essential: Why Human Factors . . .
The groundbreaking research of anesthesia safety pioneer Jeffrey Cooper, and pediatric surgeon Lucian Leape, for whom IHI’s patient safety think tank, the IHI Lucian Leape Institute, is named, revealed critical factors associated with adverse health care events These include cognitive overload, poor design of equipment and systems
- Respectful Management of Serious Clinical Adverse Events
This white paper introduces an overall approach and tools designed to support two processes: the proactive preparation of a plan for managing serious clinical adverse events, and the reactive emergency response of an organization that has no such plan
- Trigger Tool for Measuring Adverse Drug Events
Adverse drug events present the single greatest risk of harm to patients in hospitals Traditional efforts to detect ADEs have focused on voluntary reporting and tracking of errors However, public health researchers have established that only 10 to 20 percent of errors are ever reported and, of those, 90 to 95 percent cause no harm to patients
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