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  • National Coordinating Council (NCC) for Medication Error Reporting and Prevention (MERP)
    Improvement Capability Person Family Centered Care Patient Safety Quality Cost and Value Triple Aim for Populations Education Education Overview Conferences In Person Training Virtual Training Audio and Video Programs Passport to IHI Training IHI Open School Resources Resources Overview How to Improve Measures Changes Improvement Stories Tools Publications IHI White Papers Case Studies Audio and Video Presentations Posterboards Other Websites Regions Regions Overview Africa Asia Pacific Europe Latin America Middle East North America Engage with IHI Engage with IHI Overview Collaboratives Initiatives Membership Programs Fellowship Programs Strategic Partnerships Customized Services Blogs and User Groups Home Resources Other Websites National Coordinating Council NCC for Medication Error Reporting and Prevention MERP Other Websites Resources Resources How to Improve Measures Changes Improvement Stories Tools Publications IHI White Papers Case Studies Audio and Video Presentations Posterboards Other Websites IHI LR Wide National Coordinating Council NCC for Medication Error Reporting and Prevention MERP Page Content The National Coordinating Council NCC is an independent body of 27 national organizations whose aim is to maximize the safe use of medications and increase awareness of medication errors through open communication increased reporting and promotion of medication error prevention strategies The NCC also publishes incident driven medication alerts NAN Alerts on its website The NCC MERP Index classifies an error according to the severity of the outcome the aim of the index is to help health care practitioners and institutions track medication errors in a consistent systematic manner The IHI Global Trigger Tool uses the NCC MERP Index to categorize errors View website Average Content Rating 0 user Your comments were submitted successfully Please enter a comment Please login to rate or comment on this content User Comments Show More Comments Loading You are about to report a violation of our Terms of Use All reports are strictly confidential

    Original URL path: http://www.ihi.org/resources/Pages/OtherWebsites/NCCMERP.aspx (2016-02-01)
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  • Signal and Noise: Applying a Laboratory Trigger Tool to Identify Adverse Drug Events among Primary Care Patients
    Centered Care Patient Safety Quality Cost and Value Triple Aim for Populations Education Education Overview Conferences In Person Training Virtual Training Audio and Video Programs Passport to IHI Training IHI Open School Resources Resources Overview How to Improve Measures Changes Improvement Stories Tools Publications IHI White Papers Case Studies Audio and Video Presentations Posterboards Other Websites Regions Regions Overview Africa Asia Pacific Europe Latin America Middle East North America Engage with IHI Engage with IHI Overview Collaboratives Initiatives Membership Programs Fellowship Programs Strategic Partnerships Customized Services Blogs and User Groups Home Resources Publications Signal and Noise Applying a Laboratory Trigger Tool to Identify Adverse Drug Events among Primary Care Patients Publications Resources Resources How to Improve Measures Changes Improvement Stories Tools Publications IHI White Papers Case Studies Audio and Video Presentations Posterboards Other Websites IHI LR Wide Signal and Noise Applying a Laboratory Trigger Tool to Identify Adverse Drug Events among Primary Care Patients Page Content Brenner S Detz A López A Horton C Sarkar U Signal and noise Applying a laboratory trigger tool to identify adverse drug events among primary care patients BMJ Quality and Safety 2012 21 670 675 The extent of outpatient adverse drug events ADEs remains unclear and the value of using trigger tools to identify ADEs in outpatient populations particularly chronically ill adults is largley untested The authors used six abnormal laboratory triggers for detecting ADEs among adults in outpatient care They found that the trigger tool identified 91 15 percent ADEs View article Average Content Rating 0 user Your comments were submitted successfully Please enter a comment Please login to rate or comment on this content User Comments Show More Comments Loading You are about to report a violation of our Terms of Use All reports are strictly confidential Reason Select One Contains profanity

    Original URL path: http://www.ihi.org/resources/Pages/Publications/SignalandNoiseApplyingaLaboratoryTriggerTool.aspx (2016-02-01)
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  • Deciphering Harm Measurement
    My IHI Home About Us Vision Mission Values History Science of Improvement Innovation People How to Get Involved Finances In the News Supporters Careers Contact FAQs Topics All Topics A Z Improvement Capability Person Family Centered Care Patient Safety Quality Cost and Value Triple Aim for Populations Education Education Overview Conferences In Person Training Virtual Training Audio and Video Programs Passport to IHI Training IHI Open School Resources Resources Overview How to Improve Measures Changes Improvement Stories Tools Publications IHI White Papers Case Studies Audio and Video Presentations Posterboards Other Websites Regions Regions Overview Africa Asia Pacific Europe Latin America Middle East North America Engage with IHI Engage with IHI Overview Collaboratives Initiatives Membership Programs Fellowship Programs Strategic Partnerships Customized Services Blogs and User Groups Home Resources Publications Deciphering Harm Measurement Publications Resources Resources How to Improve Measures Changes Improvement Stories Tools Publications IHI White Papers Case Studies Audio and Video Presentations Posterboards Other Websites IHI LR Wide Deciphering Harm Measurement Page Content Parry G Cline A Goldmann D Deciphering harm measurement Journal of the American Medical Association 2012 May 23 307 20 2155 2156 This article looks at several current approaches to measuring harm including the Center for Medicare Medicaid Services Medicare Patient Safety Monitoring System AHRQ s Patient Safety Indicators and the IHI Global Trigger Tool The authors conclude that until a national consensus is reached the Office of the Inspector General s approach an adaption of the IHI Global Trigger Tool that estimates national harm rates based on review of a random sample of Medicare patient records may be the best available method for determining national harm trends View article Average Content Rating 0 user Your comments were submitted successfully Please enter a comment Please login to rate or comment on this content User Comments Show More

    Original URL path: http://www.ihi.org/resources/Pages/Publications/DecipheringHarmMeasurement.aspx (2016-02-01)
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  • All
    How does the front line nurse engage her team foster communication and improve teamwork the three requirements for effective use of a checklist Passport Exclusive Improvement Skills to Empower Front Line Nurses I This recording discusses Developing a Sensitivity to Risk including many tools that can help uncover and reduce risk and patient harm Saving lives by studying deaths Using standardized mortality reviews to improve inpatient safety Substantial variation existed in hospital standardized mortality ratios HSMRs across hospitals in the Kaiser Permanente system In 2008 multidisciplinary teams at KP used the IHI Global Trigger Tool along with other tools to investigate hospital level mortality in order to identify patterns of potential harm and focus improvement efforts WIHI The Power to Detect and Improve Revisiting the IHI Global Trigger Tool and Adverse Events April 14 2011 The authors discuss a new study in Health Affairs that finds that the IHI Global Trigger Tool identified at least ten times more confirmed serious events than other methods WIHI The Power to Detect and Reduce Harm IHI s Global Trigger Tool and Adverse Events in the US October 21 2010 This WIHI provides a window into research findings from a series of reports from the Office of Inspector General and their significance for patient safety harm detection improvement work and policy reform going forward The IHI Global Trigger Tool for identifying adverse events is also a focus of the discussion Global Trigger Tool shows that adverse events in hospitals may be ten times greater than previously measured This study finds that the IHI Global Trigger Tool identifies at least ten times more confirmed serious events than voluntary reporting and Patient Safety Indicators Temporal trends in rates of patient harm resulting from medical care A retrospective study of a stratified random sample of 10 hospitals in North Carolina Introduction to Trigger Tools for Identifying Adverse Events The use of triggers or clues to identify adverse events is an effective method for measuring the overall level of harm from medical care in a health care organization Pediatric ADE Patient Record Review Sheet Included in Trigger Tool for Measuring Adverse Drug Events A one page form that can be used to register information obtained from individual pediatric patient records during a review for adverse drug events ADEs included in the Trigger Tool for Measuring Adverse Drug Events IHI Trigger Tool for Measuring Adverse Drug Events A method for using triggers or clues in patient records to identify ADEs that may not have been reported through traditional mechanisms Pediatric Trigger Toolkit Measuring Adverse Drug Events in the Children s Hospital This tool provides a powerful yet simple method to detect medication related harm in pediatric inpatients Estimating hospital deaths due to medical errors preventability is in the eye of the reviewer Studies using physician implicit review have suggested that the number of deaths due to medical errors in US hospitals is extremely high However some have questioned the validity of these estimates The reliability of medical record review

    Original URL path: http://www.ihi.org/resources/pages/ViewAll.aspx?FilterField2=IHI_x0020_Topic&FilterValue2=6596896b-d6a6-48cc-81fc-b8fc21990ac4&Filter2ChainingOperator=Or&TargetWebPath=/resources&orb=Created (2016-02-01)
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  • Create My Profile
    Measures Changes Improvement Stories Tools Publications IHI White Papers Case Studies Audio and Video Presentations Posterboards Other Websites Regions Regions Overview Africa Asia Pacific Europe Latin America Middle East North America Engage with IHI Engage with IHI Overview Collaboratives Initiatives Membership Programs Fellowship Programs Strategic Partnerships Customized Services Blogs and User Groups Register with ihi org it s free and easy Register with ihi org it s free and easy To register with ihi org please complete the profile information below required field Login Information Your email address will be your login for ihi org IHI will never share your email address without your permission Email Email is required Please enter a valid email address Email Password Passwords are case sensitive and must be between 6 and 12 characters Confirm Password Public Profile Information This information will be visible to the public if you participate in certain site features like commenting on blogs or contributing content First Name Last Name Email Services Sign up for IHI s email services You ll receive IHI s weekly e newsletter This Week IHI and other key program announcements at your email address You can return to your profile and change your selection at

    Original URL path: https://www.ihi.org/_layouts/ihi/userregistration/basicregistration.aspx (2016-02-01)
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  • Improvement Blog
    of deliveries in private hospitals are C sections and nearly 50 percent in public hospitals We asked Paulo Borem MD about his project to improve the rates in the IHI Improvement Advisor Program IHI Why are C section rates so high in Brazil Paulo Borem The main factor is the way we organize care delivery In the private sector obstetricians exclusively attend their own patients for prenatal car read full post Tag s Patient Safety Maternal and Child Health Culture of Safety Quality Improvement Latin America Obstetrics Community Based Adaptations of the IHI Breakthrough Series Model Posted by Kimberly Mitchell on Tuesday Jul 21 2015 A new article co authored by Dr Pierre Barker IHI Senior Vice President provides examples of how the IHI Breakthrough Series model was adapted in four community based quality improvement projects in South Africa Malawi and Mozambique to support community volunteer health workers in improving HIV care The IHI Breakthrough Series model typically brings together clinical and leadership teams from health facilities sometimes including community members A report published this month in an AIDS read full post Tag s Collaboratives IHI Breakthrough Series model Improvement Capability Preventing Mother to Child Transmission of HIV HIV AIDS Maternal and Child Health Africa Data Use in Large Scale Improvement Projects The Experience of Project Fives Alive Posted by Kimberly Mitchell on Friday Apr 17 2015 Sodzi Sodzi Tettey MD MPH is the Institute for Healthcare Improvement s Senior Technical Director Africa Region and Director of Project Fives Alive in Ghana In this post he talks about some challenges and lessons learned from using data to support the project s work across Ghana to reduce mortality of children under five years of age In March 2015 I presented aspects of Project Fives Alive s work at the Consortium of Universities in Global Health meeting in Boston A curious colleague read full post Tag s Improvement Capability Quality Improvement Data and Measurement Data Reporting and Analysis Large Scale Improvement Maternal and Child Health Mortality Reduction Project Fives Alive in Ghana Ghana Africa Africa Take a Clear Look at the US Infant Mortality Rate Posted by Caitlin Littlefield on Wednesday Aug 14 2013 By Nigel Deen Research Assistant Innovation When our health care system fails those who are most vulnerable bear the brunt of the burden This is especially true for the young and old As a general measure of population health the infant mortality rate IMR can be used to track the health status of a population over time or to compare populations at a single point in time The IMR is also useful because of the association between the causes of infant mortality and socioeconomic determinan read full post Tag s Perinatal Care Maternal and Child Health Population Health Follow Me Subscribe Blog Archive 2016 9 January 9 2015 64 December 7 November 6 October 5 September 3 August 10 July 8 June 1 May 6 April 4 March 7 February 4 January 3 2014 50 December 9 November

    Original URL path: http://www.ihi.org/communities/blogs/_layouts/ihi/community/blog/viewblog.aspx?List=7d1126ec-8f63-4a3b-9926-c44ea3036813&filter=byTags:df1bc341-21e4-4d47-88c2-acd9f84c4f97 (2016-02-01)
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  • Improvement Blog
    In many parts of Latin America the quality improvement and patient safety movement is just getting started A hierarchical health care system has made it difficult to promote quality and teamwork But one project known as Adios Bacteriemias has made remarkable progress 111 intensive care units ICUs in 40 participating hospitals in seven countries have reduced central line associated bloodstream infections CLABSIs by 43 percent improving patient safety in ICUs across Latin America Eve read full post Tag s Patient Safety Ventilator Associated Pneumonia VAP Central Line Infection Latin America Changing Culture Changing Care Reducing Elective C Sections in Brazil Posted by Joelle Baehrend on Thursday Dec 03 2015 In Brazil C section deliveries are the norm rather than the exception more than 80 percent of deliveries in private hospitals are C sections and nearly 50 percent in public hospitals We asked Paulo Borem MD about his project to improve the rates in the IHI Improvement Advisor Program IHI Why are C section rates so high in Brazil Paulo Borem The main factor is the way we organize care delivery In the private sector obstetricians exclusively attend their own patients for prenatal car read full post Tag s Patient Safety Maternal and Child Health Culture of Safety Quality Improvement Latin America Obstetrics Lessons Learned about the Role of Government in Improving Health Care and Population Health Posted by Kimberly Mitchell on Tuesday Nov 17 2015 One individual has been pioneering quality improvement in Mexico for more than 20 years IHI board member Enrique Ruelas the former Vice Minister of Innovation and Quality for the Mexican Ministry of Health led the development of the country s first quality strategy in 2000 which earned him the 2005 Transparency Award by the Mexican government and helped foster a movement for quality and safety in Latin America He is now advising the Ministry on a new National Quality Strategy that builds on read full post Tag s Patient Safety Culture of Safety Quality Improvement Latin America Improvement Capability Building a Culture of Safety and Improvement in Brazil Posted by Kimberly Mitchell on Tuesday Sep 22 2015 Antonio Capone Neto MD PhD FCCM a 2014 2015 Hospital Israelita Albert Einstein Fellow at IHI was the first person from Latin America selected for IHI s year long fellowship program for mid career health professionals In this blog post by IHI project assistant Santiago Narino Dr Capone Neto describes his improvement journey Antonio Capone NetoBefore starting his fellowship year at IHI Dr Capone Neto was Medical Coordinator Director of Critical Care Medicine at Hospital Israelita Albe read full post Tag s Patient Safety Culture of Safety Quality Improvement Fellowships Latin America Improvement Capability Follow Me Subscribe Blog Archive 2016 9 January 9 2015 64 December 7 November 6 October 5 September 3 August 10 July 8 June 1 May 6 April 4 March 7 February 4 January 3 2014 50 December 9 November 3 October 3 September 4 August 3 July 9 May 2 April 2 March

    Original URL path: http://www.ihi.org/communities/blogs/_layouts/ihi/community/blog/viewblog.aspx?List=7d1126ec-8f63-4a3b-9926-c44ea3036813&filter=byTags:174f685b-96d8-4666-9504-dbafac4deadb (2016-02-01)
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  • Improvement Blog
    Initiatives Membership Programs Fellowship Programs Strategic Partnerships Customized Services Blogs and User Groups Home User Communities Blogs Improvement Blog Improvement Blog Improvement Blog IHI staff faculty and colleagues offer diverse examples and perspectives on improving health and health care building improvement capability and the science of improvement Improvement Blog Blog Home processing Changing Culture Changing Care Reducing Elective C Sections in Brazil Posted by Joelle Baehrend on Thursday Dec 03 2015 In Brazil C section deliveries are the norm rather than the exception more than 80 percent of deliveries in private hospitals are C sections and nearly 50 percent in public hospitals We asked Paulo Borem MD about his project to improve the rates in the IHI Improvement Advisor Program IHI Why are C section rates so high in Brazil Paulo Borem The main factor is the way we organize care delivery In the private sector obstetricians exclusively attend their own patients for prenatal car read full post Tag s Patient Safety Maternal and Child Health Culture of Safety Quality Improvement Latin America Obstetrics Follow Me Subscribe Blog Archive 2016 9 January 9 2015 64 December 7 November 6 October 5 September 3 August 10 July 8 June 1 May 6 April 4 March 7 February 4 January 3 2014 50 December 9 November 3 October 3 September 4 August 3 July 9 May 2 April 2 March 12 February 2 January 1 2013 34 October 3 September 2 August 4 July 3 June 4 May 4 April 2 March 6 February 3 January 3 2012 10 December 1 November 2 October 1 September 2 August 4 Most Popular Blog Tags Quality Improvement 44 Improvement Capability 33 Person and Family Centered Care 29 Triple Aim for Populations 26 Patient Safety 19 Improvement Methods and Tools 18 Equitable Care Delivery 17

    Original URL path: http://www.ihi.org/communities/blogs/_layouts/ihi/community/blog/viewblog.aspx?List=7d1126ec-8f63-4a3b-9926-c44ea3036813&filter=byTags:9f6760d1-fc22-4a57-80fd-365cb391de17 (2016-02-01)
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