Iowa Healthcare Collaborative

Patient safety and the delivery of quality care go hand in hand.  Each individual has a right to safety while in any healthcare organization.  The process to ensuring patient safety can be complicated. Though challenging, patient safety should be a serious goal for all hospitals and health care establishments.

Programs for patient safety should be comprehensive and steered by qualified personnel.  This page will provide program implementation tools, assessment and educational materials, and additional resources for leadership engagement for a culture of safety.

Provider Educational Resources

AHRQ Patient Safety Network
Providers and healthcare facilities can use this site to access current journal articles and patient safety resources from the Agency for Healthcare Research and Quality.

Develop a Culture of Safety
Providers and healthcare facilities can use this webpage from the Institute for Healthcare Improvement to access current tools that can help to accelerate existing work to improve patient safety and develop a culture of safety.

Johns Hopkins Medicine - Culture of Safety
Providers and healthcare facilities can use this website from the Center for Innovation in Quality Patient Care at Johns Hopkins to review current culture of safety tools to improve patient safety.

National Patient Safety Foundation
Providers can use this website to review current patient safety resources, online educational resources, and upcoming events from the National Patient Safety Foundation.

Rural Organizational Safety Culture Change (PDF)
This PDF document contains a compilation of tools and information gathered from a variety of sources from the Health Services Advisory Group. The tools can be used to assist hospitals that are participating in the Rural Organizational Safety Culture Change participant group.

Surveillance Reporting for Enrolled Facilities
This website from the National Healthcare Safety Network (NHSN) and the Centers for Disease Control and Prevention (CDC), contains numerous links and documents on patient safety and surveillance reporting.


Just Culture

A Just Culture is a method used to create a positive culture for patient safety. Created by David Marx, a system safety engineer, the original intent of the concept was to develop a system to fairly define culpability for potential or actual harm due to medication errors. For approximately ten years, the Just Culture Community has been working to develop open, fair, and just cultures that support open communication and development of systems for accountability. One goal of a Just Culture is to assign consequences for an unsafe act in a fair way.

Four key categories of a Just Culture to assign fault include:

  1. Human error: unintended mistake

  2. Negligence Conduct: failure to exercise care

  3. Reckless Conduct: conscious disregard for a known risk

  4. Knowing Violations: conscious disregard for known rules

The Just Culture Community – Online Courses
Providers interested in online education about The Just Culture Community can visit this website to sign up for online courses.


Leadership Engagement Resources

ASP: Best Practices in Care - Guidelines and Standards
Providers and healthcare facilities can access current guidelines and standards on this ASP website from different professional organizations including: APIC, CDC, OSHA, and DHHS.

Executive Walkrounds Toolkit – Kaiser Permanente
**This toolkit from Kaiser Permanente is only available through the Patient Safety Department at Kaiser Permanente. To request a copy, please contact the Patient Safety Department at (510) 987-2820, as this material is copyright protected. "California's Patient Safety Program Manual"

IHI - Patient Safety
Providers and hospital leadership can use these culture of safety tools from the Institute for Healthcare Improvement (IHI) to help guide current or create new patient safety activities.

Leadership Guide to Patient Safety White Paper
This paper presents eight steps that are recommended for leaders to follow to achieve patient safety and high reliability in their organizations.

Seven Leadership Leverage Points for Organization-Level Improvement in Health Care (Second Edition)
This white paper presents what IHI believes to be some important leverage points for leaders who want to achieve dramatic, system-level performance improvement.


Implementation Resources

A Framework for Spread: From Local Improvements to System-Wide Changes
This IHI white paper provides a snapshot of IHI's latest developments and work on spread.

Communication and Teamwork Toolkit
**This toolkit from Kaiser Permanente is only available through the Patient Safety Department at Kaiser Permanente. To request a copy, please contact the Patient Safety Department at (510) 987-2820, as this material is copyright protected.

Hospital Survey on Patient Safety Culture
Providers and healthcare facilities can use this Agency for Healthcare Research and Quality database report to review comparative patient safety data from hospitals across the United States.

The SBAR Technique for Communication: A Situational Briefing Model
The SBAR (Situation-Background- Assessment Recommendation) provides a framework for communication between members of the healthcare team about a patient's condition.  Providers can use this situational briefing model to help to improve communication between other providers, to improve the quality of care, and to create a culture of patient safety.

Science of Safety Toolkit for Intensive Care Units
Providers working in Intensive Care Units can use this toolkit to improve the safety and quality of patient care within the ICU.

TeamSTEPPS®: National Implementation
The United States Department of Health and Human Services and the Agency for Healthcare Research and Quality provide resources and tools to improve patient safety on this website.


Additional Materials   

National Patient Safety Goals
The Joint Commission creates new national patient safety goals for each year. The safety goals can be found on this website as well as links to patient safety organizations and programs. 

Fact Sheet: 30 Safe Practices for Better Health Care
NQF and AHRQ identify 30 safe evidence-based practices that can work to reduce or prevent adverse events and medical errors.

ISMP Medication Safety Alert
This is a printable safety survey from Allina Hospitals and Clinics. This survey was created to solicit information about the culture of reporting.

LifeWings ® Patient Safety System
This comprehensive program helps your facility adopt and sustain a culture of safety for better patient and financial outcomes.

National EMS Culture of Safety
This website contains information on the EMS culture of safety.

VA National Center for Patient Safety
This website contains information on the VA's experiences with changing the culture of safety.


Articles

6 Elements of a True Patient Safety Culture
This article from Becker’s Clinical Quality and Infection reviews elements of a patient safety culture including information on leadership and a vision of a culture of safety for your organization.

Journal of Patient Safety
This website contains current articles on patient safety.

Strategies For Improving Patient Safety Culture In Hospitals: A Systematic Review
To view this article, you must purchase the article or login.

Use Of The Hospital Survey On Patient Safety Culture In Critical Access Hospitals (PDF)
This policy brief from the Flex Monitoring Team reviews information on creating and promoting a patient safety culture in Rural Hospitals.


Created: November 2009
Updated: April 2014

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