Resources for Organizational Learning

NOTE: The resources included here do not constitute an endorsement by the Center for Patient Safety (CPS). CPS does not attest to the accuracy of information provided by linked sites.

Root cause analysis is widely used to identify the underlying causes of medical errors. Exclusive reliance on root cause analyses, however, can result in a lengthy list of action items (too many to be addressed) and failure to get an accurate view of the “big picture” - common themes and issues affecting safety.

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The Improvement Capability Self-Assessment Tool from IHI is designed to assist organizations in assessing their capability in six key areas that support improvement:

• Leadership for Improvement
• Results
• Resources
• Workforce and Human Resources
• Data Infrastructure and Management
• Improvement Knowledge and Competence

A useful guide for EMS system leaders to use to improve quality within their organizations, using the Malcomb Baldrige Quality Program as a model.

This AHRQ primer provides background information on debriefing for clinical learning, including components of debriefing, tools available, special considerations, and a framework for clinical event debriefing. 

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The Plan-Do-Study-Act (PDSA) cycle is shorthand for testing a change by developing a plan to test the change (Plan), carrying out the test (Do), observing and learning from the results (Study), and determining needed modifications (Act). The first website listed provides the steps in the PDSA cycle and the second website listed provides a PDSA Worksheet, a useful tool for documenting a test of change.

The AHRQ Quality Indicators (QIs) are measures of hospital quality and safety drawn from readily available hospital inpatient administrative data. This toolkit supports hospitals that want to improve performance on QIs and patient safety indicators by guiding them through the process, from the first stage of self-assessment to the final stage of ongoing monitoring. The tools are practical, easy to use, and designed to meet a variety of needs, including those of senior leaders, quality staff, and multistakeholder improvement teams.

The goal of this guide is to promote evidence-based decision-making and help decision-makers determine whether an innovation would be a good fit or an appropriate stretch for their healthcare organization.

The National Center for Patient Safety uses a multidisciplinary team approach, known as root cause analysis (RCA) to study healthcare-related adverse events and close calls. The goal of the RCA process is to find out what happened, why it happened, and how to prevent it from happening again. Because the Center’s Culture of Safety is based on prevention, not punishment, RCA teams investigate how well patient care systems function. The focus is on the “how” and the “why,” not on the “who.” 

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With a grant from The Doctors Company Foundation, the National Patient Safety Foundation convened a panel of subject matter experts and stakeholders to examine best practices around RCAs. The panel developed guidelines to help health professionals standardize the process and improve the way they investigate medical errors, adverse events, and near-misses. With the objective of preventing future harm, this updated process focuses on actions to be taken: Root Cause Analyses and Actions, or RCA2 (RCA “squared”). 

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This manual is designed to help community pharmacy personnel identify potential medication safety risks and prevent errors. Pharmacists can use the materials and tools in this manual to pinpoint specific areas of weakness in their medication delivery systems and to provide a starting point for successful organizational improvements.

The goals of this manual are to:

• Raise awareness of error-prone processes in the medication delivery system.
• Build awareness of risk-identification opportunities in the community pharmacy setting.
• Maximize the appropriate application of system strategies to reduce organizational risk.

The National Patient Safety Agency has developed the Incident Decision Tree to help National Health Service managers in the United Kingdom determine a fair and consistent course of action toward staff involved in patient safety incidents. Staff can use this decision tree when analyzing an error or adverse event in an organization to help identify how human factors and systemic issues contributed to the event. The Incident Decision Tree supports the aim of creating an open culture, where employees feel able to report patient safety incidents without undue fear of the consequences.

This change package is intended for nursing homes participating in the National Nursing Home Quality Care Collaborative, led by the Centers for Medicare & Medicaid Services (CMS) and the Medicare Quality Improvement Organizations (QIOs), to improve care for the millions of nursing home residents across the country. The change package is focused on the successful practices of high performing nursing homes. It was developed from a series of ten site visits to nursing homes across the country, and the themes that emerged regarding how they approached quality and carried out their work. The practices in the change package reflect how the nursing homes leaders and direct care staff at these sites shared and described their efforts. The change package is a menu of strategies, change concepts, and specific actionable items that any nursing home can choose from to begin testing for purposes of improving residents’ quality of life and care.

The decision tree for unsafe acts culpability is a tool available for download from the Institute for Healthcare Improvement (IHI) website. Staff can use this decision tree when analyzing an error or adverse event in an organization to help identify how human factors and systems issues contributed to the event. This decision tree is particularly helpful when working toward a nonpunitive approach in an organization.

Supported by the Commonwealth Fund, the Health Research & Educational Trust (HRET) and its partners at the Institute for Safe Medication Practices and the Medical Group Management Association Center for Research developed patient safety tools for physician practices. Pathways for Patient Safety™ is a three-part toolkit to help outpatient care settings improve safety in three areas: working as a team, assessing where you stand, and creating medication safety.

This toolkit from IHI includes the tools and templates you need to launch and manage a successful improvement project. Each of the nine tools in the toolkit includes a short description, instructions, an example, 
and a blank template.