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Reports and White Papers
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NPSF periodically publishes papers about patient safety issues or the status of the patient safety field, reports on NPSF programs, and guidelines for health professionals.

Click on the links below to read or download the reports in PDF format.



Released November 2017


Closing the Loop:
A Guide to Safer Ambulatory Referrals in the EHR Era


Patient referrals are on the rise in the US, but even with the advent of EHRs, steps are missed as clinicians and staff deal with an array of challenges. With support from CRICO/Risk Management Foundation of the Harvard Medical Institutions, IHI/NPSF convened an expert panel that identified nine steps in a closed-loop referral process. This report provides specific guidelines to help standardize the ways in which primary care practitioners activate referrals to specialists and then keep track of the information over time. Read more and download the report.


Released August 2017


Patient Safety in the Home:
Assessment of Issues, Challenges, and Opportunities


With support from the Gordon and Betty Moore Foundation, IHI/NPSF contracted with Westat to evaluate research on patient safety in the home and identify gaps. This report examines safety issues in the home, including challenges, funding mechanisms to support safe home care, and conceptual frameworks that seek to structure these disparate issues. It concludes with opportunities for research to advance the science of patient safety improvement in the home. Read more and download the report.



Released June 2017


Optimizing a Business Case for Safe Health Care:
An Integrated Approach to Safety and Finance


A resource toolkit from the IHI/NPSF Patient Safety Coalition to guide collaboration among health professionals and financial leaders to demonstrate the value and return on investment for safer, quality care.



Released December 2015


Free from Harm: Accelerating Patient Safety Improvement Fifteen Years after To Err Is Human


With a grant from AIG, the National Patient Safety Foundation convened an expert panel in February 2015 to assess the state of the patient safety field and set the stage for the next 15 years of work. Read more and download their report.


Released June 2015

RCA2: Improving Root Cause Analyses and Actions to Prevent Harm


RCA2 is a trademark of the National Patient Safety Foundation. NPSF does not endorse any software or training for the RCA2 process that is not directly provided by NPSF.


With a grant from The Doctors Company Foundation, NPSF convened a panel of subject matter experts and stakeholders to examine best practices around root cause analysis (RCA) and develop guidelines to help health professionals standardize the process and improve the way they investigate medical errors, adverse events, and near misses. Read more and download the report.


Reports & White Papers

Item Name Posted By Date Posted
Research Summary of Progress. 2012 PDF (1.58 MB)  more ] Administration 6/10/2015
Assessment for Improving Patient Safety. 2003 PDF (183.18 KB)  more ] Administration 6/10/2015
Nothing About Me Without Me. 2003 PDF (301.45 KB)  more ] Administration 6/10/2015
Agenda for R & D in Patient Safety. 2000 PDF (46.5 KB)  more ] Administration 6/10/2015
Leadership for ESRD Patient Safety. 2001 PDF (543.98 KB)  more ] Administration 6/10/2015
Public Opinion of Patient Safety Issues. 2000 PDF (198.91 KB)  more ] Administration 6/10/2015
Reporting to Improve Patient Safety. 2000 PDF (42.05 KB)  more ] Administration 6/10/2015
Safe Use of Pharmaceuticals. 1999 PDF (85.55 KB)  more ] Administration 6/10/2015
A Tale of Two Stories: Contrasting Views. 1998 PDF (848.89 KB)  more ] Administration 6/10/2015
Infusion Pumps with “Drug Libraries.” 2003 PDF (161.08 KB)  more ] Administration 7/15/2015
NPSF Congress Leadership Day Ex Sum. Quality. 2014 PDF (587.03 KB)  more ] Administration 7/29/2015
NPSF Congress Leadership Day Ex Sum. Transp. 2015 PDF (155.91 KB)  more ] Administration 10/20/2015
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