ihi patient safety report 1999

What is the IHI Patient Safety Congress?

The IHI Patient Safety Congress, brings together people who are passionate about ensuring safe care equitably for all across the globe. This annual meeting is the must-attend event for those who continue to shape smarter, safer care for patients wherever it’s provided – from the hospital to outpatient settings to the home.

What is the goal of IHI?

Our goal: To advance a total systems approach to safety around the world. Together with like-minded health care leaders, organizations, practitioners, and patients, IHI drives innovative thinking and bold leaps forward that none of us could achieve on our own. More >>

Are patient safety concerns still a public health issue?

Fifteen years after the Institute of Medicine published the report, To Err Is Human, which brought public attention to the issue of medical errors and adverse events, patient safety concerns remain a serious public health issue that must be tackled with a more pervasive response.

Is health care safety a property of the system?

Instead, the aim means that safety must be a property of the system. No one should ever be harmed by health care again. Second, health care must be effective.

What was the result of the 1999 Institute of Medicine IOM report?

The Institute of Medicine (IOM) released a report in 1999 entitled “To Err is Human: Building a Safer Health System”. The report stated that errors cause between 44 000 and 98 000 deaths every year in American hospitals, and over one million injuries.

What does IHI stand for in Hipaa?

​For 30 years, the Institute for Healthcare Improvement (IHI) has used improvement science to advance and sustain better outcomes in health and health care across the world.

What are the six aims?

The document recommends “six aims for improvement.” The aims are safety, effectiveness, equity, timeliness, patient-centeredness, and ef- ficiency. These aims are intended to iden- tify the fundamental domains that need to be addressed to improve the health care services delivered to individuals and populations.

What are the 6 domains of quality?

Six domains of quality exist within health care (safety, timeliness, effectiveness, efficiency, equitability, patient-centeredness), and quality improvement projects should seek to improve the patient experience in at least one of these domains.

What is the IHI model?

​​​IHI uses the Model for Improvement as the framework to guide improvement work. The Model for Improvement,* developed by Associates in Process Improvement, is a simple, yet powerful tool for accelerating improvement.

Why is the IHI Certificate important?

WHY certification is important. This professional certification program establishes core standards for the field of patient safety, benchmarks requirements necessary for health care professionals, and sets an expected proficiency level.

What are the 3 components of quality health care?

Effective – providing evidence-based healthcare services to those who need them; Safe – avoiding harm to people for whom the care is intended; and. People-centred – providing care that responds to individual preferences, needs and values.

What are the 6 dimensions of quality in healthcare?

Don Berwick describes six dimensions of quality in health care: safety, effectiveness, patient-centeredness, timeliness, efficiency, and equity.

What are 5 factors that identify quality healthcare?

He identified 182 attributes of quality healthcare and grouped them into five categories: environment, empathy, efficiency, effectiveness and efficacy.

What are the six priorities for high quality care?

A set of six quality priorities for fast-tracking improvement have been identified, these include safety and security, long waiting times, drug availability, nursing attitude, infection prevention and control and values of staff.

What are the four levels of the healthcare system?

Primary, secondary, tertiary and quaternary care refer to the complexity and severity of health challenges that are addressed, as well as the nature of the patient-provider relationship.

What are the six aims for improvement in healthcare?

In this chapter, the committee puts forth six specific aims for improvement: health care should be safe, effective, patient-centered, timely, efficient, and equitable.

What is IHI's goal?

​​​​​​​​​​​Our goal: To advance a total systems approach to safety around the world. Together with like-minded health care leaders, organizations, practitioners, and patients, IHI drives innovative thinking and bold leaps forward that none of us could achieve on our own. More >>

Who is the CEO of IHI?

At the IHI Forum in early December, IHI CEO Kedar Mate made a case for patient safety solutions that help marginalized populations and also benefit the greater public.

When is the IHI 2022?

IHI Patient Safety Congress 2022. May 16-18, 2022. The IHI Patient Safety Congress, brings together people who are passionate about ensuring safe care equitably for all across the globe.

When was "Err is human" released?

In 1999, the Institute of Medicine (IOM) in Washington, DC, USA, released To Err Is Human: Building a Safer Health System, an alarming report that brought tremendous public attention to the crisis of patient safety in the United States. In 2001, IOM followed up with Crossing the Quality Chasm: A New Health System for the 21st Century, ...

What does "first do no harm" mean?

This means much more than the ancient maxim "First, do no harm," which makes it the individual caregiver’s responsibility to somehow try extra hard to be more careful (a requirement modern human factors theory has shown to be unproductive). Instead, the aim means that safety must be a property of the system.

Is the health care system lagging behind the ideal?

Not only is the current health care system lagging behind the ideal in large and numerous ways, but the system is fundamentally and incurably unable to reach the ideal. In order to begin achieving real improvement in health care, the whole system has to change. Let’s look at the other side of the chasm — at the ideal health care outlined by ...

What is the significance of the report "To Err Is Human"?

Fifteen years after the Institute of Medicine published the report, To Err Is Human, which brought public attention to the issue of medical errors and adverse events, patient safety concerns remain a serious public health issue that must be tackled with a more pervasive response.

When was the NPSF panel?

The National Patient Safety Foundation (NPSF) convened an expert panel in February 2015 to assess the state of the patient safety field and set the stage for the next 15 years of work.

Why is safety considered a non-event?

Safety has been called a "dynamic non-event" because when humans are in a potentially hazardous environment: (A) It is natural to establish and follow safe practices. (B) It requires the same kind of thinking that causes problems to set them right. (C) It takes significant work to ensure nothing bad happens.

Who is Janet from the orthopedic surgery unit?

Janet is a new physical therapist on the orthopedic surgery unit. Although learning a new position has been exhausting and somewhat stressful, she remains excited about the opportunity, and two weeks into her new job she has already volunteered to take on extra patients while a colleague is away.

Who created the psychological safety concept?

This concept originated with James Reason’s book, Managing the Risks of Organizational Accidents,5 and was popularized by Amy Edmondson in her early writings and in her book, Teaming.6 Although thought of colloquially as “I can speak up about concerns,” the specific elements of psychological safety are much more nuanced and entail the following four attributes:6

What is systematic improvement?

Once defects are identified, a systematic improvement approach like the Model for Improvement17 enables teams to redesign processes and achieve outcomes that matter to patients, families, and staff.

What is reliability in healthcare?

Reliability is the ability of a system to successfully produce a product to specification repeatedly. In the case of health care, that product is safe, efficient, person-centered care. The challenge in achieving reliability in health care is the complexity of the processes, which heavily depend on human beings and their interactions with each other. Vigilance and exhortation are inadequate to counter human foibles, and sometimes good people err and the consequences can be dire. Great organizations design systems that take advantage of people’s intrinsic strengths and support their inherent weaknesses, and in doing so increase the likelihood of reliable performance. Mediocre organizations, by comparison, assume that vigilance and intrinsic strengths overcome human fallibility and inherent personal and organizational weaknesses.

How to achieve psychological safety?

Achieving psychological safety requires a flat hierarchy and a solid learning system that create an environment in which people can comfortably make suggestions, even somewhat outlandish ideas that might not fit at the time, but that others can mold to be useful. Leaders, in a coaching role, must be role models for applying learning judiciously and judgment sparingly, and admitting to their own failures and mistakes. These types of coaching and feedback are the primary mechanisms for achieving psychological safety. Regular one-on-one meetings with staff offer a prime setting for this work. Managers should meet individually with the people who report to them — at least 10 minutes per month — and ask pointed questions, such as the following:

What is the responsibility of health care organizations?

Health care organizations have an absolute responsibility to deliver safe, reliable, and effective care to patients. Yet consistently meeting this obligation can be daunting, and organizations are often challenged to design a balanced portfolio of improvement projects that will enable them to meet system-level quality and safety goals. They may have stand-alone safety improvement projects underway, or regularly conduct staff surveys to better understand the organization’s current safety culture, but it remains unclear how these various efforts interweave and interact to provide safer, more reliable care. Diverse data streams are difficult to combine, making it challenging to develop sustainable, system-wide programs focused on all-cause harms and errors.

What is the framework for safe, reliable, and effective care?

The Framework for Safe, Reliable, and Effective Care is designed to guide organizations on their journey. The two overarching domains and nine components — with patients and families at the core — reinforce the idea that all parts of the framework are interconnected and interdependent, and success in one area is predicated on success in another.

What is the engagement of patients and families?

Engagement of patients and families resides at the core of the framework — that is, all the effort involved in executing the framework should be in the service of engaging patients and families, and realizing the best outcomes for them across the continuum of care.