Busy hospital, doctors

Preventable harm in healthcare is a public health crisis, with estimates placing it as a leading cause of death in the United States.1-4 Many adverse events leading to patient harm could have been prevented if appropriate safety protocols and clinical guidelines were followed.

The Institute for Healthcare Improvement (IHI) recently released a Patient Safety Essentials Toolkit to help organizations deliver safe, reliable care every time, for every patient. The Toolkit includes documents on improving teamwork and communication, tools to understand underlying issues that can cause errors, and valuable guidance about how to create and maintain reliable systems.

Inside the Toolkit, you’ll find:

  • The SBAR (Situation-Background-Assessment-Recommendation) technique, which provides a framework for communication between members of the health care team about a patient’s condition.
  • Action Hierarchy, a component of RCA2 that will assist teams in identifying which actions will have the strongest effect for successful and sustained system improvement.
    A daily huddle agenda, which gives teams a way to proactively manage quality and safety.
  • Failure Modes and Effects Analysis (FEMA): Also used in LEAN management and Six Sigma, FMEA is a systematic, proactive method for identifying potential risks and their impact.

Reducing the occurrence of adverse events and harm can reduce waste and create more efficient and effective health systems.



1. Institute of Medicine (IOM). Committee on Quality of Health Care in America; Kohn LT, Corrigan JM, Donaldson MS, eds. To Err Is Human: Building a Safer Health System. Washington, DC: National Academy Press; 2000.
2. Centers for Disease Control and Prevention (CDC). Leading Causes of Death Website. National Center for Health Statistics. 2016. http://www.cdc.gov/nchs/fastats/leading-causes-of-death.htm
3. James JT. A new, evidence-based estimate of patient harms associated with hospital care. J Patient Saf. 2013(Sep); 9(3):122–128. http://www.ncbi.nlm.nih.gov/pubmed/23860193
4. Makary M, Daniel M. Medical error – the third leading cause of death in the US. BMJ. 2016; 353:i2139. http://www.bmj.com/content/353/bmj.i2139