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IHI Releases Patient Safety Toolkit

Toolkit establishes framework for keeping patients safe


Arundi Venkayya
Curator of EngagingPatients.org

In the journey to keep patients safe, there are many potential stumbling blocks. As recently as 2016, some experts said that foreign objects were left inside patients as many as 39 times a week and wrong procedure/wrong site surgeries happen more than 40 times a week.

Barriers to patient safety include:

  • Failure to attain staff buy-in: Some question the value of checklists that have become prevalent in healthcare while others are suffering “checkbox fatigue” and go through the motions.
  • Individual misconduct and noncompliance: Often healthcare professionals are reluctant to adhere to checklist implementation because they don’t feel involved in the creation process or they believe they disrupt flow, reduce efficiency and have a minimal impact on improvements in care. Pointing to successful safety programs and research can minimize this resistance.
  • Communication failures. Effective communication and teamwork between physicians, nurses and other team members is critical to improving patient safety. Equally important is recognizing that there are opportunities to improve communication and teamwork regardless of how good it is believed to be.
  • Distractions related to technology: EHRs were designed to make healthcare safer and more efficient. However, the work involved in entering data and documentation has become a drain on many providers and is reported to be considered inefficient and create distractions.

Nurses also routinely identify culture and communication issues at the top of the list of barriers. In a survey conducted by GE Healthcare and the American Nurses Association, nurses cited issues with:

  • Receiving follow up or feedback related to patient safety data
  • Concerns about handoff communication
  • Issues with nurse/doctor communication

How to address these patient safety issues?

Experts recommend a multi-tiered approach and that patient safety must be considered a bedrock of good care at all levels of an organization.

To help address these barriers, the Institute for Healthcare Improvement also recently released their Patient Safety Essentials Toolkit. The kit is a bundle of helpful information and resources designed to help healthcare facilities deliver “safe, reliable care every time, for every patient.”

The toolkit was designed and tested by IHI’s patient safety experts and includes documents focused on improving teamwork and communication and helping understand the underlying issues that cause patient safety. The tools have a short description, instructions, examples and a blank template for your use.

The tools include:

  • The SBAR technique (Situation-Background-Assessment-Recommendation) technique, a framework for communication between team members about a patient’s condition.
  • Action Hierarchy which will help teams identify which actions will have the strongest effect for successful and sustained system improvement.
  • A daily huddle agenda

While there is debate about the best way to achieve patient safety, there is no debate about its importance. Patient safety is fundamental and most organizations have opportunities to improve the way they address barriers to it.


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