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 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:
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] 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 |
4) Develop solutions/action plans and monitor progress. |
Macomb County Community Mental Health RCA Action plan: [PDF] |
5) Share what is learned |
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6) Share solutions/action plans |
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