Patient Safety Essentials Toolkit.

Book/Report

Patient Safety Essentials Toolkit.

May 29, 2019

Boston, MA: Institute for Healthcare Improvement; 2019.

This toolkit provides access to nine key tools to help organizations improve teamwork, incident analysis, and communication as well as templates to support their use and instructions to begin associated processes. Featured tools include the Situation-Background-Assessment-Recommendation approach, huddle agendas, and failure modes and effects analysis.

Available at

Related Resources From the Same Author(s)

Advancing the Safety of Acute Pain Management.

March 27, 2019

No Place Like Home: Advancing the Safety of Care in the Home.

July 18, 2018

Providing Safe, High-Quality Maternity Care in Rural US Hospitals. IHI Innovation Report.

March 18, 2020

Moving Measurement into Action: Global Principles for Measuring Patient Safety.

January 8, 2020

Declaration to Advance Patient Safety.

May 25, 2022

Hospital Preparedness for a COVID-19 Surge: Assessment Tool.

November 25, 2020

Using Machine Learning to Improve Patient Safety in the Home or Remote Setting for Adults.

February 15, 2023

Improving the Reliability of Health Care.

February 8, 2006

Reducing Adverse Drug Events.

March 6, 2005

Safer Together: A National Action Plan to Advance Patient Safety.

September 16, 2020

Framework for Effective Board Governance of Health System Quality.

January 9, 2019

The Financial and Human Cost of Medical Error... and How Massachusetts Can Lead the Way on Patient Safety.

June 19, 2019

Telemedicine: Ensuring Safe, Equitable, Person-Centered Virtual Care.

March 2, 2022

How-to Guide: Prevent Obstetrical Adverse Events.

October 24, 2012

Rise to Health Coalition.

December 14, 2022

How-to Guides: Improving Transitions from the Hospital to Reduce Avoidable Rehospitalizations.

August 8, 2012

Closing the Loop: A Guide to Safer Ambulatory Referrals in the EHR Era.

December 13, 2017

Optimizing a Business Case for Safe Health Care: An Integrated Approach to Safety and Finance.

July 12, 2017

How to Talk About Patient Safety.

April 3, 2019

Leadership Guide to Patient Safety: Resources and Tools for Establishing and Maintaining Patient Safety.

September 28, 2005

Seven Leadership Leverage Points for Organization-Level Improvement in Health Care. Second edition.

June 1, 2005

Unmet Needs: Teaching Physicians to Provide Safe Patient Care.

March 17, 2010

Health Information Technology and Patient Safety: A Dynamic Discussion.

August 17, 2011

Order from Chaos: Accelerating Care Integration.

November 7, 2012

Shining a Light: Safer Health Care Through Transparency.

January 28, 2015

IHI Skilled Nursing Facility Trigger Tool for Measuring Adverse Events.

January 27, 2016

July 12, 2017

Respectful Management of Serious Clinical Adverse Events. Second Edition.

October 27, 2010

Achieving an Exceptional Patient and Family Experience of Inpatient Hospital Care.

March 23, 2011

IHI Framework for Improving Joy in Work.

August 9, 2017

Patient Safety in the Home: Assessment of Issues, Challenges, and Opportunities.

September 6, 2017

Addressing the Opioid Crisis in the United States.

November 2, 2016

IHI Global Trigger Tool for Measuring Adverse Events. 2nd Edition.

May 9, 2009

Patient Deaths at Arbour Health Systems—Westwood Lodge Hospital and Pembroke Hospital.

March 21, 2018

Transforming Health Care: A Compendium of Reports From the National Patient Safety Foundation's Lucian Leape Institute.

June 1, 2016

RCA2: Improving Root Cause Analyses and Actions to Prevent Harm.

June 24, 2015

Free From Harm: Accelerating Patient Safety Improvement Fifteen Years After To Err Is Human.

December 16, 2015

Reducing Diagnostic Errors.

November 21, 2012

National Agenda for Action: Patients and Families in Patient Safety.

March 6, 2005

Saving Lives, Saving Money: The Imperative for Computerized Physician Order Entry in Massachusetts Hospitals.

February 27, 2008

Medication Overload: America's Other Drug Problem.

June 19, 2019

How-to Guide: Multidisciplinary Rounds.

March 10, 2010

Health Information Technology through the Lens of Patient Safety.

November 20, 2013

Call to Action: Preventable Health Care Harm Is a Public Health Crisis and Patient Safety Requires a Coordinated Public Health Response.

March 22, 2017

The Public's Views on Medical Error in Massachusetts.

December 17, 2014

When Things Go Wrong: Responding to Adverse Events.

March 22, 2006

Roadmap to Health Care Safety for Massachusetts.

May 3, 2023

How Doctors Think.

March 28, 2007

When We Do Harm: A Doctor Confronts Medical Error.

April 22, 2020

Through the Eyes of the Workforce: Creating Joy, Meaning, and Safer Health Care.

March 20, 2013

Safer Together Survey: Advancing Patient and Workforce Safety

January 18, 2023

Safety Is Personal: Partnering With Patients and Families for the Safest Care.

April 2, 2014

Advancing Patient Safety in Cataract Surgery: A Betsy Lehman Center Expert Panel Report.

June 15, 2016

Patient Safety Executive Development Program.

September 10, 2024 - October 22, 2024

Introduction to Trigger Tools for Identifying Adverse Events.

December 6, 2006

What medications does your patient take? Enhancing medication safety in the outpatient setting.

April 4, 2007

5 Million Lives Campaign.

December 13, 2006

A Systems Approach to Quality Improvement in Long-Term Care: Safe Medication Practices Workbook.

April 18, 2007

Serious Reportable Events in Massachusetts.

May 22, 2023

Safety Quality and Informatics Leadership Program.

January 7, 2015

A Framework for Safe, Reliable, and Effective Care.

February 15, 2017

July 2011 Author in the Room Teleconference.

January 30, 2005

Thinking Outside the Pillbox: A System-wide Approach to Improving Patient Medication Adherence for Chronic Disease.

September 9, 2009

Voices from the Frontlines of Health Care Safety.

May 31, 2023

Death Inside Lemuel Shattuck Hospital: A Case Study on Medical Treatment for Persons with Mental Health Disabilities.

May 24, 2023

A Crisis in Health Care: A Call to Action on Physician Burnout.

January 30, 2019

Betsy Lehman Center for Patient Safety.

December 10, 2014

Sustaining Improvement.

July 20, 2016

Institute for Healthcare Improvement.

March 27, 2005

Working Knowledge: How Organizations Manage What They Know.

September 14, 2005

The NHS Patient Safety Strategy.

July 24, 2019

Creating a Safe Space: Psychological Health and Safety of Healthcare Workers.

June 5, 2019

Eliminating Medication Overload: A National Action Plan.

April 1, 2020

Patient Safety Toolkits.

October 30, 2013

Deep Dive: Safe Ambulatory Care, Strategies for Patient Safety & Risk Reduction.

November 13, 2019

Sources of Power: How People Make Decisions.

March 6, 2005

10 Medication Safety Tips for Hospitalized Patients.

September 25, 2019

Guidance for the Safe Use of Automated Dispensing Cabinets.

May 7, 2019

Toolkit To Improve Antibiotic Use in Acute Care Hospitals

December 11, 2019

The Essential Guide for Patient Safety Officers, Second Edition.

September 22, 2010

Canada continues to lag behind other OECD countries on measures of patient safety

December 4, 2019

ISMP Guidelines for Safe Electronic Communication of Medication Information.

February 6, 2019

Error and Uncertainty in Diagnostic Radiology.

March 20, 2019

Introducing the New SOPS Hospital Survey 2.0.

October 30, 2019

Hospital Survey on Patient Safety Culture 2.0.

June 1, 2022

IHI Open School Patient Safety Curriculum

February 22, 2012

The IHI Open School.

April 29, 2009

Leadership Response to a Sentinel Event: Respectful, Effective Crisis Management.

April 4, 2022

Patient Safety Awareness Week.

March 10, 2024 - March 16, 2024

IHI Lucian Leape Institute.

December 5, 2007

IHI Fellowship Program.

August 30, 2023

Safe Practices for Drug Allergies—Using CDS and Health IT.

August 7, 2019

Out of the Crisis.

March 27, 2005

AHRQ National Scorecard on Hospital-Acquired Conditions Updated Baseline Rates and Preliminary Results 2014–2017.

February 6, 2019

CUSP Toolkit.

September 26, 2019

Inadvertent Administration of an Oral Liquid Medicine into a Vein.

April 1, 2019

Investigation into Electronic Prescribing and Medicines Administration Systems and Safe Discharge.

November 13, 2019

Improving care by using patient feedback.

February 12, 2020

Accuracy at every step: the challenge of medication reconciliation.

April 5, 2006

HANYS' Report on Report Cards.

November 20, 2019

Related Resources

Rethinking Patient Safety: A Discussion Guide for Patients, Healthcare Providers and Leaders.

November 1, 2023

Delays in care during the COVID-19 pandemic in the Veterans Health Administration.

May 3, 2023

Positive approaches to safety: learning from what we do well.

August 31, 2022

The Top Six: standardized safety practices in U.S. Army Medical Department treatment facilities worldwide.

February 23, 2022

Preventing and mitigating radiology system failures: a guide to disaster planning.

February 2, 2022

Development of rapid response capabilities in a large COVID-19 alternate care site using Failure Modes and Effect Analysis with in situ simulation.

November 18, 2020

Root Cause Analysis in Health Care: A Joint Commission Guide to Analysis and Corrective Action of Sentinel and Adverse Events.

July 22, 2020

Overcoming COVID-19: what can human factors and ergonomics offer?

May 6, 2020

Teamwork Toolkit.

July 24, 2019

Quality and Safety in Anesthesia and Perioperative Care.

July 17, 2019

Cultural Issues Related to Allegations of Bullying and Harassment in NHS Highland: Independent Review Report.

June 26, 2019

Safer Hospital Care: Strategies for Continuous Innovation, Second Edition.

May 16, 2019

Meltdown: Why Our Systems Fail and What We Can Do About It.

February 6, 2019

Implementing bedside handoff in the emergency department: a practice improvement project.

January 23, 2019

ISMP Gap Analysis Tool (GAT) for Safe IV Push Medication Practices.

December 5, 2018

Implementing Optimal Team-Based Care to Reduce Clinician Burnout.

September 19, 2018

Health IT Safe Practices for Closing the Loop.

August 22, 2018

Toolkit to Promote Safe Surgery.

January 17, 2018

Toolkit to Engage High-Risk Patients in Safe Transitions Across Ambulatory Settings.

January 10, 2018

Optimizing a Business Case for Safe Health Care: An Integrated Approach to Safety and Finance.

July 12, 2017

Canadian Incident Analysis Framework.

November 30, 2016

Nursing Home Antimicrobial Stewardship Guide.

November 9, 2016

The 'go-between' study: a simulation study comparing the 'Traffic Lights' and 'SBAR' tools as a means of communication between anaesthetic staff.

September 21, 2016

Designing and Delivering Whole-Person Transitional Care: Hospital Guide to Reducing Medicaid Readmissions.

September 3, 2016

Implementing situation-background-assessment-recommendation in an anaesthetic clinic and subsequent information retention among receivers: a prospective interventional study of postoperative handovers.

June 1, 2016

Eliminating Harm Checklists: Reduce All-Cause, Preventable Harm.

May 25, 2016

Root Cause Analysis Workbook for Community/Ambulatory Pharmacy.

March 23, 2016

Health IT Safe Practices. Toolkit for the Safe Use of Copy and Paste.

March 23, 2016

Use of failure mode and effects analysis to improve emergency department handoff processes.

March 23, 2016

Improving Diagnosis in Health Care.

September 23, 2015

See More About The Topic

Health Care Executives and Administrators

Epidemiology of Errors and Adverse Events

Failure Mode Effects Analysis

Teamwork

SBAR

Patient Safety Essentials Toolkit.

Connect With Us

Sign up for Email Updates

Agency for Healthcare Research and Quality

Patient Safety Essentials Toolkit.

Connect With Us

Sign up for Email Updates

Agency for Healthcare Research and Quality

Submit Your Innovations

Continue as a Guest

Continue Logged In

Submit Your Innovations

Continue as a Guest

Continue logged in

New Users to the PSNet site