Strategies Potential Tools and Resources for Learning

General tools - for reporting culture, just culture, teamwork, etc.

The Nebraska Center for Rural Health Research: includes tools, checklists, presentations, case studies, etc. for Reporting Culture, Just Culture, Flexible Culture and Learning Culture.

A brief overview of Lean, SixSigma

Overview of RCA, FMEA

AHRQ CUSP "Identifying Defects through Sense Making" presentation

AHRQ CUSP "Identifying your Unit's Safety Issues" video

AHRQ CUSP "Developing a Learning from Defects Action Plan" video

1) Develop a robust system of data-gathering that can improve patient safety and quality

Minnesota Department of Health State AHE Reporting

The Nebraska Center for Rural Health Research: includes tools specific to this section on:

  • Medication Safety Reporting Form
  • Near-Miss Reporting Form

Dana Farber Patient Safety Electronic Reporting Form

Dana Farber Patient Safety Rounds Toolkit

Report: Integrating reporting into EMR

Article: "Global Trigger Tool Shows that Adverse Events in Hospitals may be Ten Times Greater than Previously Measured," Health Affairs: [PDF]

2) Use evidence-based prospective analysis methods to identify potential failures in care.

The Basics of Healthcare Failure Mode and Effect Analysis – Videoconference Course presented by: VA National Center for Patient Safety: [PDF]

IHI FMEA Toolkit

Joint Commission FMEA tools: [PDF]

AHRQ article on assessing medication system failures in long-term care facilities: [PDF]

Joint Commission Journal on Quality and Patient Safety article: "A Practical Guide to Failure Mode and Effects Analysis": [PDF]

Journal of System Safety: "Reducing Patient Healthcare Safety Risks Through Fault Tree Analysis": [PDF]

"Failure Modes and Effects Analysis Based on In Situ Simulations: A Methodology to Improve Understanding of Risks and Failures": [PDF]

AHRQ CUSP Staff Safety Assessment - a tool to help identify defects or safety issues

3) Use evidence-based retrospective methods of analysis to identify root causes of problems or events.

Nebraska Medical College toolkit

Minnesota Department of Health RCA training

US Dept. of Veterans Affairs RCA tools

4) Develop solutions/action plans and monitor progress.

Macomb County Community Mental Health RCA Action plan: [PDF]

AHRQ CUSP Learn from Defects tool

5) Share what is learned

6) Share solutions/action plans