Patient Safety Tools: Their Benefits and Limitations

Why It Matters

Designed and tested by IHI’s world-renowned safety experts, the Patient Safety Essentials Toolkit can help you improve teamwork and communication, understand the underlying issues that can cause errors, and create and maintain reliable systems. IHI Vice President Frank Federico helped develop the contents of the new toolkit. In the following interview, he provides an overview of how to put the toolkit to good use.

What’s in IHI’s Patient Safety Essentials Toolkit?

The Patient Safety Essentials Toolkit contains a number of different interventions that IHI has found very useful over the years. They’re tools that any organization can use to understand and improve safety in their system. “How do we change our safety culture?” “What should we fix to make care better?” “How do you make changes reliable and sustainable over time?” Here are the tools included in the toolkit that you may find helpful:

• Action Hierarchy (part of RCA2)
• Ask Me 3
• Cause and Effect Diagram
• Developing Reliable Processes
• 5 Whys: Finding the Root Cause of a Problem
• Flowchart
• Failure Modes and Effects Analysis (FMEA)
• Huddles
• SBAR (Situation-Background-Assessment-Recommendation)

Each tool has a description, instructions, a template, and examples of how to put the tool into practice.

Is the Patient Safety Essentials Toolkit useful for a beginner or someone with more safety experience?

There’s something for everybody. For example, if you’re beginning your patient safety journey, SBAR is used by many people around the world as a communication tool. It helps you hand off necessary information in a concise manner. Huddles are also important. They can give teams a way to proactively manage their most pressing safety issues. Some of the other tools require more background and training.

The 5 Whys is one of the most popular tools on the IHI website. Would you describe a scenario to illustrate how it can be used?

You should use it when you’re trying to solve a problem. Let’s say we’re finding that people are not completing a checklist appropriately. We want to dig a little bit to understand why. It may be that the checklist is too complex. Why is the checklist too complex? We didn’t test it before it was implemented. Why didn’t we test it first? We took it from another organization. Why did we take it from another organization? We didn’t know what to include. And you keep going from there.

It’s important to deeply understand a problem before you decide on a solution. We too often think we can train our way out of problems. In this checklist example, if the checklist is too complicated, it doesn’t matter how much training you do. People won’t use it appropriately until you simplify it.

There are many elements that are part of RCA², so we decided to include only one in the Toolkit. Would you describe the purpose of the Action Hierarchy?

The Action Hierarchy is useful because oftentimes when people get together to complete an RCA², we fall back on what we’re most familiar with to solve the problem. “We have to be more vigilant.” “We need to work harder.” Yes, being more vigilant and working harder are important. But the Action Hierarchy helps you think about human factors or how our brains process information and how they function in real situations. What does it take to design a system so that it becomes the most powerful way to help you do the right thing? It helps us think more carefully about the best actions that will be most effective for successful and sustained system improvement.

People often gravitate toward tools. What are the pitfalls of that?

It’s important to remember that we cannot improve patient safety without improving culture. Creating a safety culture means influencing people’s attitudes and behaviors. There are no tools that can magically do that.

Tools can, however, be part of creating a safety culture if, for example, we use RCA² because we want greater transparency, more psychological safety, and to create a culture that encourages people to speak up and contribute. If we want good teamwork, using huddles can be helpful. If we want better communication, we can use tools like SBAR. Tools can be great, but without a vision and a mission, and a supportive culture, tools can’t get you where you want to go on their own.

Frank Federico, RPh, is a Vice President at IHI. He is faculty for IHI’s Patient Safety Executive Development Program (PSE) program.

Editor’s note: This interview has been edited for length and clarity.