Patient Safety Tools Newsletter

Patient Safety Tools is a quarterly newsletter that looks in-depth at one dimension of patient safety. Written for Senior Executives, Nursing and Medical Staff Leaders and Quality Improvement professionals, each issue looks at the need for change and the tools to make change happen. To be notified of new issues as they become available, please subscribe to our announcement list.

Current Issue

Issue #5 - Error Reporting Systems: Feedback and Communication - (PDF)

Findings from the American Healthcare Research and Quality (AHRQ) Hospital Survey on Patient Safety indicate that we don't provide enough communication and feedback about errors. How do we communicate the data provided by enhanced error reporting systems to make care delivery better and safer? In this issue we're going to examine and propose answers to the question, "Now that I have good data, how do I proceed?"

Previous Issues

#1: Communication: Handoffs & Transitions (PDF)

Communication, team culture, shift reports, sign outs and other forms of information exchange have been identified as potential weak links that increase the likelihood of hospital errors. Learn how to identify potential trouble spots, and how to apply proven techniques such as "SBAR" that will increase clarity and focus in your internal communications.

#2: The Case for Leadership Support (PDF)

When you need to get something done safely and well in a complex and risky environment there is no substitute for active, ongoing, heartfelt leadership. This issue deals with how to engage senior leadership, and a range of tools management can use to promote a culture of safety.

#3: Moving From A Culture of Blame (PDF)

Two-thirds of hospital staff believe their mistakes are held against them. This issue examines the prevailing, toxic environment of blame in hospitals, and how that environment interferes with careful error analysis. A host of carefully chosen resources will help you move from a culture of blame to one of learning and safety.

#4: Becoming Comfortable With Error Reporting - (PDF)

Following on from our previous issue on moving away from a culture of blame, this issue studies how to build an effective system of error-reporting, examines the benefits of transparency, and provides guidance on overcoming the barriers to change.