|Canadian Disclosure Guidelines||2335||Guide;Publication||4/18/2011 4:05:57 PM|| The Canadian Disclosure Guidelines build on various patient safety initiatives currently under way across Canada and assist and support healthcare providers, inter-professional teams, organizations, and regulators. These guidelines symbolize a commitment to patients’ right to be informed if they are involved in a patient safety incident by promoting a clear and consistent approach to disclosure, emphasizing the importance of inter-professional teamwork, and supporting learning from patient safety incidents. The development of the Canadian Disclosure Guidelines is a significant achievement in healthcare in Canada.
Canadian Disclosure Guidelines (November 2011)
Backgrounder Development of the Canadian Disclosure Guidelines (2006)
The Impact of Disclosure on Litigation (2007)||Canadian Disclosure Guidelines: Being open with patients and families||The Canadian Disclosure Guidelines build on various patient safety initiatives currently under way across Canada and assist and support healthcare||6/20/2016 8:35:25 PM||11163||http://www.patientsafetyinstitute.ca/en/toolsResources||html||True||aspx|
|STOP! Clean Your Hands Day||2398||Events||6/3/2015 4:46:05 PM||May 5, 2017 It's time for patients and providers to come together for clean hands – STOP! Clean Your Hands Day returns Friday, May 5, 2017. The theme for STOP! Clean Your Hands Day is
Ask Yourself… Making a change to your behaviour can be as simple as asking yourself a question and understanding that change doesn’t need to be a burden. Small, incremental changes can lead to big things. Not only can you improve your own practices, you’re setting a great, easy to follow example for everyone around you! Whether you’re a patient, provider, or work in a healthcare setting – if you’re involved in the healthcare system, take the time to have a conversation with yourself and ask what you can change today to improve for tomorrow. Here's a run down of what we've got planned for STOP! Clean Your Hands Day 2017Video Competition This year, we're getting back into show business with the STOP! Clean Your Hands Day Video Competition. The theme for this competition is the same as the day itself
Ask Yourself... What are the questions you can ask yourself to improve hand hygiene? Start storyboarding your big idea for a video and get those cameras rolling. We can't wait to see what you come up with!
Click here to learn more about the video competitionWebinar We're hosting a webinar May 5, 2017 at 10 am MT / 12 pm ET. Watch for additional details and registration coming soon!
Sponsored by ||STOP! Clean Your Hands Day|| May 5, 2017 It's time for patients and providers to come together for clean hands – STOP! Clean Your Hands Day returns Friday, May 5, 2017. The||3/3/2017 3:52:56 PM||18613||http://www.patientsafetyinstitute.ca/en/Events||html||True||aspx|
|Five Questions to Ask about your Medications||2328||Patient and Family Resource;Checklists;Toolkits||2/25/2016 8:39:10 PM||
Ask the Right Questions about Your Medications For patients who require multiple medications or who are transitioning between treatments, safety can become a concern. You or your loved one may be at risk of fragmented care, adverse drug reactions, and medication errors. To be an active partner in your health, you need the right information to use your medications safely.
Download CPSI has teamed up with the Institute for Safe Medication Practices Canada, Patients for Patient Safety Canada, the Canadian Pharmacists Association, and the Canadian Society for Hospital Pharmacists to create a list of top questions to help patients and their caregivers have a conversation about medications with their healthcare provider. Use these five questions when you're Attending a doctor's appointment (e.g., family physician or specialist, dentist, optometrist)Interacting with a community pharmacistLeaving the hospital to go homeVisited by home care services
Are you a provider? Please share this valuable resource with your patients! Visit ISMP Canada for additional resources and endorsementsClick here for Additional resourcesClick here to endorse and add your organizations logo For more information, contact
email@example.com.||Five Questions to Ask about your Medications ||Ask the Right Questions about Your Medications For patients who require multiple medications or who are transitioning between treatments, safety can||11/4/2016 10:01:23 PM||8114||http://www.patientsafetyinstitute.ca/en/toolsResources||html||True||aspx|
|Measure Patient Safety, Quality Improvement and Leadership||2327||Metrics||7/12/2016 5:25:21 PM||
Use Real-Time Data to Make Patient Safety Improvements To improve your organization's patient safety quality, you need reliable, up-to-date data that helps you implement positive changes. The Framework for Measuring and Monitoring Safety, created by Professor Charles Vincent and colleagues from the Health Foundation, consists of five dimensions that organizations, units, or individuals can use to understand the safety of their services. This new approach assesses and evaluates safety from "ward to board" by providing a rounded and accurate real-time view of patient safety, while identifying the greatest opportunities for improving safety. The Framework shifts away from past cases of harm towards current performance, and measures future risks and organization resiliency.
Armed with a series of valuable questions, you can make better decisions about the safety of the care you provide. The primary questions are Has patient care been safe in the past?Are our clinical systems and processes reliable?Is our care safe now? Will our care be safe in the future? Are we responding and improving? The Framework will be foundational to CPSI's new measurement coaching services offered by its Central Measurement Team. Stay tuned for additional details on how to access these coaching services. For more information, contact us at
firstname.lastname@example.org. "The Framework helps us think differently, and have different conversations at different levels, whether it be at ward level through safety huddles and safety briefs in the morning, the hospital safety brief, or through other scheduled meetings. By doing this we can ensure everything we do every day for our patients and for our staff is focused on the same thing. We consider different components to determine if it's affected by system, process, or human factor and determine what we should do differently." —Charlie Sinclair, Associate Director, Nursing NHS Borders||Measure Patient Safety, Quality Improvement and Leadership||Use Real-Time Data to Make Patient Safety Improvements To improve your organization's patient safety quality, you need reliable, up-to-date data||3/3/2017 6:29:17 PM||2037||http://www.patientsafetyinstitute.ca/en/toolsResources||html||True||aspx|
|Patient Stories||2339||7/27/2015 12:39:48 PM|| ||Patient Stories||5/19/2016 4:22:33 AM||13241||http://www.patientsafetyinstitute.ca/en/toolsResources||html||True||aspx|
|The Safety Competencies Framework||2314||Publication;Framework||4/14/2009 11:53:32 PM|| Achieve safe patient care by incorporating our framework The Safety Competencies into your healthcare organization’s educational programs and professional development activities. Patient safety, defined as the reduction and mitigation of unsafe acts within the healthcare system, and the use of best practices shown to lead to optimal patient outcomes, is a critical aspect of quality healthcare.
Educating healthcare providers about patient safety and enabling them to use the tools and knowledge to build and maintain a safe system is critical to creating one of the safest health systems in the world. The Safety Competencies is a highly relevant, clear, and practical framework designed for all healthcare professionals. Created by the Canadian Patient Safety Institute (CPSI), The Safety Competencies has six core competency domains
Domain 1 Contribute to a Culture of Patient Safety – A commitment to applying core patient safety knowledge, skills, and attitudes to everyday work.
Domain 2 Work in Teams for Patient Safety – Working within interprofessional teams to optimize patient safety and quality of care..
Domain 3 Communicate Effectively for Patient Safety – Promoting patient safety through effective healthcare communication..
Domain 4 Manage Safety Risks – Anticipating, recognizing, and managing situations that place patients at risk..
Domain 5 Optimize Human and Environmental Factors – Managing the relationship between individual and environmental characteristics in order to optimize patient safety..
Domain 6 Recognize, Respond to, and Disclose Adverse Events – Recognizing the occurrence of an adverse event or close call and responding effectively to mitigate harm to the patient, ensure disclosure, and prevent recurrence.. This valuable framework includes 20 key competencies, 140 enabling competencies, 37 knowledge elements, 34 practical skills, and 23 essential attitudes that can lead to safer patient care and quality improvement. CPSI encourages its stakeholders, national, provincial, and territorial health organizations, associations, and governments; and universities and colleges to play a role in engaging stakeholders and spreading the word about this program so that healthcare professionals recognize the knowledge, skills, and attitudes needed to enhance patient safety across the spectrum of care. For further information, please email
email@example.com.||The Safety Competencies||The Safety Competencies: Message from the CEO||11/9/2016 8:49:19 PM||35226||http://www.patientsafetyinstitute.ca/en/toolsResources||html||True||aspx|
|Canadian Patient Safety Week (CPSW)||2396||Events||12/8/2009 9:50:43 PM||On behalf of all CPSI staff members, we would like to send out a big thank you to everyone who has made Canadian Patient Safety Week a huge success, on social media and at your own organizations. Thank you for helping us shine a spotlight on asking life-saving questions in healthcare! We couldn't have done it without you. We hope everyone had fun celebrating CPSW by participating in our social media campaign, Twitter Talk event and playing our new patient safety quiz. Next year's Canadian Patient Safety Week will be on October 30th – November 3rd, 2017 where we will make #asklistentalk trending again on Twitter! We look forward to celebrating with you next year. In the meantime, remember to ask lots of questions to help us promote safer care.
Take the patient safety provider or patient quiz!
About Canadian Patient Safety Week is a national, annual campaign that started in 2005 to inspire extraordinary improvement in patient safety and quality. As the momentum for promoting best practices in patient safety has grown, so has the participation in Canadian Patient Safety Week. Canadian Patient Safety week is relevant to anyone who engages with our healthcare system providers, patients, and citizens. Working together, thousands help spread the message to Ask. Listen. Talk. If your organization is interested in sponsoring a portion of CPSW 2016, please contact
firstname.lastname@example.org. We have many sponsorship opportunities available.
Do you have any questions or suggestions? Contact CPSI CommunicationsPhone (780) 409-8090Toll free 1-866-421-6933
CPSW@cpsi-icsp.caJoin the conversation at #asklistentalk
Sponsored by GOJO Industries, Inc. ||Canadian Patient Safety Week||Canadian Patient Safety Week (CPSW)||11/29/2016 4:03:58 PM||68333||http://www.patientsafetyinstitute.ca/en/Events||html||True||aspx|
|Guidelines for Informing The Media After an Adverse Event||2345||Guide||9/18/2015 5:00:21 PM|| These guidelines were developed by the Canadian Patient Safety Institute in conjunction with CPSI's Communication Advisory Committee to assist you and your organization throughout the process of informing the media and the public after adverse event occurs. Effective and timely communication will serve to enhance public trust, protect public safety and serve to educate the public in a way that empowers them to be self-advocates. In 2008, CPSI took a leading role in developing the Canadian Disclosure Guidelines, located at
www.patientsafetyinstitute.ca created to ensure a consistent process is in place for healthcare providers communicating adverse events to patients and their families.
||Guidelines for Informing The Media After an Adverse Event|| These guidelines were developed by the Canadian Patient Safety Institute in conjunction with CPSI's Communication Advisory Committee to assist you||6/29/2016 7:47:30 PM||1769||http://www.patientsafetyinstitute.ca/en/toolsResources||html||True||aspx|
|Patient Safety and Incident Management Toolkit||2311||Toolkits||12/18/2014 8:28:40 PM||Prevent Patient Safety Incidents and Minimize Harm When They Do Occur When a patient's safety is compromised, or even if someone just comes close to having an incident, you need to know you are taking the right measures to address it, now and in the future. CPSI provides you with practical strategies and resources to manage incidents effectively and keep your patients safe. This integrated toolkit considers the needs and concerns of patients and their families, and how to properly engage them throughout the process. Drawn from the best available evidence and expert advice, this newly designed toolkit is for those responsible for managing patient safety, quality improvement, risk management, and staff training in any healthcare setting.
Patient Safety Management
System Factors For more information, contact us at
email@example.com.Toolkit Focus and Components The toolkit focuses on patient safety and incident management; it touches on ideas and resources for exploring the broader aspects of quality improvement and risk management. There are three sections to the toolkit Incident management—the actions that follow patient safety incidents (including near misses)Patient safety management—the actions that help to proactively anticipate patient safety incidents and prevent them from occurring System factors—the factors that shape and are shaped by patient safety and incident management (legislation, policies, culture, people, processes and resources).
Visual representation of the toolkit.
Incident management Resources to guide the immediate and ongoing actions following a patient safety incident (including near misses). We emphasize immediate response, disclosure, how to prepare for analysis, the analysis process, follow-through, how to close the loop and share learning.
Patient safety management Resources to guide action before the incident (e.g., plan, anticipate, and monitor to respond to expected and unexpected safety issues) so care is safer today and in the future. We promote a patient safety culture and reporting and learning system.
System factors Understanding the factors that shape both patient safety and incident management and identify actions to respond, align, and leverage them is crucial to patient safety. The factors come from different system levels (inside and outside the organization) and include legislation, policies, culture, people, processes and resources.Implementing Patient Safety and Incident Management Processes Consider the following guiding principles when applying the practical strategies and resources.
Patient- and family-centred care. The patient and family are at the centre of all patient safety and incident management activities. Engage with patients and families throughout their care processes, as they are an equal partner and essential to the design, implementation, and evaluation of care and services.
Safety culture. Culture refers to shared values (what is important) and beliefs (what is held to be true) that interact with a system's structures and control mechanisms to produce behavioural norms. An organization with a safety culture avoids, prevents, and mitigates patient safety risks at all levels. This includes a reporting and learning culture.
System perspective. Keep patients safe by understanding and addressing the factors that contribute to an incident at all system levels, redesigning systems, and applying human factor principles. Develop the capability and capacity for effectively assessing the complex system to accurately identify weaknesses and strengths for preventing future incidents.
Shared responsibilities. Teamwork is necessary for safe patient care, particularly at transitions in care. It is the best defence against system failures and should be actively fostered by all team members, including patients and families. In a functional teamwork environment, everyone is valued, empowered, and responsible for taking action to prevent patient safety incidents, including speaking up when they see practices that endanger safety.Resources to Support Patient Safety and Incident Management CPSI's
toolkit resources are practical tools for patient safety and incident management, compiled with input from experts and contributing organizations. You may not require all of them when managing an incident, so please use your discretion in selecting the tools most appropriate for your needs.Toolkit Development and Maintenance CPSI accessed a variety of qualified experts and organizations to compile this practical and evidence-based toolkit. The process includedAssigning a CPSI team with support from a writer with experience in the fieldSeeking advice from an expert faculty that included patient and family representativesBasing the content on the Canadian Incident Analysis FrameworkEngaging key stakeholders via focus groups and collecting evidence from peer-reviewed journals and publicly available literature The toolkit will be updated every year to keep it relevant. We welcome feedback on what is helpful, what can be improved, and content enhancements at firstname.lastname@example.org.||Patient Safety and Incident Management Toolkit||Prevent Patient Safety Incidents and Minimize Harm When They Do Occur When a patient's safety is compromised, or even if someone just comes close to||7/20/2016 9:54:17 PM||18101||http://www.patientsafetyinstitute.ca/en/toolsResources||html||True||aspx|
|Healthcare Provider Stories||2343||10/19/2015 4:42:11 PM||||Healthcare Provider Stories||10/26/2015 3:41:32 PM||2000||http://www.patientsafetyinstitute.ca/en/toolsResources||html||True||aspx|
|Incident Analysis||2326||Framework;Publication||4/19/2011 9:12:41 PM||
Analyze, manage, and learn from patient safety incidents in any healthcare setting with the Canadian Incident Analysis Framework.
Incident analysis is a structured process for identifying what happened, how and why it happened, what can be done to reduce the risk of recurrence and make care safer, and what was learned. It is an integral activity in the incident management continuum, which represents the activities and processes that surround a patient safety incident.
The framework was developed collaboratively by CPSI, the
Institute for Safe Medication Practices Canada,
Patients for Patient Safety Canada (a patient-led program of CPSI), Paula Beard, Carolyn Hoffman, and Micheline Ste-Marie and is based on the 2006 Canadian Root Cause Analysis Framework.
To learn more about the framework and the resources available, you can
click here to watch the information webinars recorded.
following resources have been carefully selected to support you in implementing the Canadian Incident Analysis Framework.
To contribute a resource or to provide feedback, please email
To learn more about the framework and the learning opportunities available
||Incident Analysis||Root Cause Analysis (RCA)||6/20/2016 3:47:55 PM||14985||http://www.patientsafetyinstitute.ca/en/toolsResources||html||True||aspx|
|Hospital Harm Improvement Resource||2692||4/14/2015 5:37:10 PM||Introduction Patients expect hospital care to be safe and for most people it is. However, a small proportion of patients experience some type of unintended harm as a result of the care they receive. The Canadian Institute for Health Information (CIHI) and the Canadian Patient Safety Institute (CPSI) have collaborated on a body of work to address gaps in measuring harm and to support patient safety improvement efforts in Canadian hospitals. The Hospital Harm Improvement Resource was developed by the Canadian Patient Safety Institute to complement the Hospital Harm measure developed by CIHI. It links measurement and improvement by providing evidence-informed practices that will support patient safety improvement efforts. The purpose of measuring quality and safety is to improve patient care and optimize patient outcomes. The Hospital Harm measure should be used in conjunction with other sources of information about patient safety, including patient safety reporting and learning systems, chart reviews or audits, Accreditation Canada survey results, patient concerns and clinical quality improvement process measures. Together, this information can inform and optimize improvement initiatives. The Improvement Resource is a compilation of evidence-informed practices linked to each of the clinical groups within the Hospital Harm measure to help drive changes that will make care safer. Through extensive research and consultation with clinicians, experts and leaders in quality improvement (QI) and patient safety, the Improvement Resource is intended to make information on improving patient safety easily available, so teams spend less time researching and more time optimizing patient care. The Improvement Resource is a dynamic tool that the Canadian Patient Safety Institute will continue to develop and review every two years, or as new evidence emerge. If you have any suggestions for the Improvement Resource, please send your ideas to
email@example.com. The layout of the Improvement Resource reflects the framework of the Hospital Harm measure (Figure 1) and focuses on actions that can be taken to decrease the likelihood of harm. The measure includes four major categories of harm and within each category is a series of individual clinical groups, or types of harm, each of which connects to evidence-informed practices for improvement. For each clinical group, the Improvement Resource provides the followingAn overview of the clinical group and goal for improvement.Implications for patients experiencing the type of harm and their importance to patients and family.Evidence-informed practices to reduce the likelihood of harm. Outcome and process improvement measures. Associated Accreditation Canada standards and Required Organizational Practices and Global Patient Safety Alerts recommended search terms.Success stories from organizations.References and key resources, including guidelines and select research articles.Definitions As patient safety terminology evolves it is important to be clear on the meaning and differences of specific words. For the purposes of the Hospital Harm measure, the following definitions apply
Harm – An unintended outcome of care that may be prevented with evidence-informed practices and is identified and treated in the same hospital stay.
Occurrence of harm – Harmful event is synonymous with occurrence of harm.
Patient Safety – The reduction of risk of unnecessary harm associated with healthcare to an acceptable minimum. An acceptable minimum takes into consideration current knowledge, resources available and the context in which care was delivered weighed against the risk of non-treatment or other treatment.
Hospital Harm Measure – Acute care hospitalizations with at least one unintended occurrence of harm that could be potentially prevented by implementing known evidence-informed practices. For harm to be included in the measure, it must meet the following three criteria It is identified as having occurred after admission and within the same hospital stay.It requires treatment or prolongs the patient's hospital stay.It is one of the conditions from the 31 clinical groups in the Hospital Harm Framework.
Back to Hospital Harm Measure||Hospital Harm Improvement Resource ||Introduction Patients expect hospital care to be safe and for most people it is. However, a small proportion of patients experience some type of||10/25/2016 7:23:53 PM||4027||http://www.patientsafetyinstitute.ca/en/toolsResources/Hospital-Harm-Measure||html||True||aspx|
|Effective Governance for Quality and Patient Safety||2324||Toolkits||2/23/2010 10:49:46 PM||
Effective Governance for Quality and Patient Safety A Toolkit for Healthcare Board Members and Senior Leaders Safe patient care happens when healthcare service delivery organizations are functioning at the highest levels. Governing boards and senior leaders of healthcare organizations can ensure effective governance and meet their legal responsibilities with the Effective Governance for Quality and Patient Safety Toolkit.
Order Now This toolkit teaches healthcare board members, senior executives, and physician leaders across Canada about the tools available to support organizational efforts in improving quality and patient safety. Commissioned research led by Dr. G. Ross Baker (2010), Effective Governance for Quality and Patient Safety in Canadian Healthcare Organizations, identified a number of interdependent drivers that enable boards to fulfill their responsibilities for quality and patient safety.
The resources in this toolkit are organized around each of the key drivers and includePrinciples of each driver Tools and recommended reading Stories and examples from healthcare organizations
Use this toolkit to strengthen your organization’s performance and to promote and advance safer care.
This symbol, used throughout the toolkit, denotes Canadian references and examples.||Effective Governance for Quality and Patient Safety||Effective Governance for Quality and Patient Safety: A Toolkit for Healthcare Board Members and Senior Leaders||6/23/2016 3:37:52 PM||11282||http://www.patientsafetyinstitute.ca/en/toolsResources||html||True||aspx|
|Patient Engagement Resources||2337||Guide;Toolkits;Patient and Family Resource||8/17/2016 3:27:12 PM|| Effective partnerships with patients/ families to accelerate patient safety, quality and health service planning are being recognized as a best practice and in response to this, new initiatives, standards, policies, evidence and resources are being routinely developed across Canada and internationally. However, this is still an evolving field within healthcare, requiring much learning and collaboration to advance. The Canadian Patient Safety Institute (CPSI) is acutely aware of both the needs and challenges because of the decade-long partnership with patients/families, through Patients for Patient Safety Canada (PFPSC). The volunteer PFPSC members are partners in the design, development, delivery or evaluation of most of CPSI's programs as well as collaborating with external partners in their efforts. In addition, PFPSC volunteers are part of patient advisory groups at local levels allowing for a good understanding of needs at all system levels. PFPSC is also part of a global patient community through the World Health Organizations' Patients for Patient Safety Programme and through that global network is aware of needs, opportunities and challenges from around the world. The challenge of accelerating engagement practices across Canada presents a unique opportunity to coordinate and align efforts and resources that better support those working to improve patient safety through patient engagement. The National Patient Safety Consortium, a partnership among over 50 organizations has established a shared action plan for safer healthcare. One of the key themes in the Action Plan is the patient voice, and one of the shared actions is to develop a comprehensive guide for patient engagementbased on evidence and best practices. CPSI in collaboration with partners (see Action Team membership below) began the development of several resources, includingA Canadian Patient Engagement Guide (PE Guide) This practical guide will be based on evidence and best practices, applicable to various system levels, aligned with and complementary to existing resources, and the content will be generated from and targeted to both patients/families and providers/organizations. The topics covered will focus on patient/family engagement in incident management and improving patient safety and quality, as well as developing or sustaining structures and processes to support patient/family engagement. The Canadian Patient Safety Institute, the Atlantic Health Patient Safety and Quality Collaborative, and Health Quality Ontario provide leadership and financial contribution for the PE Guide development. One World Inc has been contracted to conduct the evidence scan and consultations with users and write the guide for the action team. The expected launch date is June 2017. Contact us at firstname.lastname@example.org to tell us what you would like to see in a guide like this or to share resources, evidence or best practices.The Canadian Patient Engagement Network (PE Network) A public, open, and safe space for anyone passionate about patient engagement or patient-centred care to learn, help and get help. Patients, families, patient advisors as well as healthcare providers and leaders can participate in this moderated network. Click on the following links to join the LinkedIn or Facebook network.The Canadian Foundation for Healthcare Improvement's Patient Engagement Resource Hub (CFHI's PE Hub) CFHI's growing collection of over 200 open source tools has been expanded to better support patients, families, caregivers and patient advisors as well as healthcare providers to advance patient engagement and patient safety. The Canadian Patient Safety Institute is one of several organizations that support CFHI's PE Hub through financial and ongoing in‑kind support. Click on the following link to access the Patient Engagement Resource Hub.Action Team The Canadian Patient Safety Institute, in partnership with representatives from the organizations listed below (the Action Team), is conducting the work related to the patient engagement resources described above.Canadian Patient Safety Institute Atlantic Patient Safety and Quality Council Health Quality Ontario Patients for Patient Safety Canada Imagine Citizens Collaborating for Health (Alberta) Accreditation Canada Alberta Health ServicesBC Patient Safety and Quality Council Canadian Foundation for Healthcare Improvement Centre of Excellence on Partnership with Patients and the PublicHealthCareCANHealth Quality Council of Alberta Manitoba Institute for Patient Safety Manitoba Health, Seniors and Active LivingOntario Ministry of Health and Long Term CareOntario Hospital AssociationSaskatchewan Health Quality Council University Health NetworkUniversity of Montreal||Patient Engagement Resources||Effective partnerships with patients/ families to accelerate patient safety, quality and health service planning are being recognized as a best||2/28/2017 10:34:29 PM||997||http://www.patientsafetyinstitute.ca/en/toolsResources||html||True||aspx|
|Introduction of the Measuring and Monitoring of Safety (Vincent) Framework to Canada||4179||Events;Presentation;Metrics||1/4/2017 4:11:25 PM||
ArchiveMonday, January 30, 2017 at 1000 am MST / 1200 pm EST
Purpose of the Call
"…if I apply
this [framework] conceptually to any problem I've got in safety I can make it work, and it orders my thinking" – Neil Prentice, Assistant Medical Director Mental Health, Tayside Trust, Scotland In Canada, as in the UK and US the focus of governments on assessing both quality and safety has increased over the past 10 years., A very large number of quality outcomes have been specified but the approach to safety has been much narrower, leaving many aspects of safety unexplored. The measurement of harm, so important in the evolution of patient safety, has been largely neglected and there have been prominent calls for improved measures. There is a critical need for patient safety measurement at the front lines, so that clinical teams can focus on key problems. Don Berwick has stated that 'most health care organisations at present have very little capacity to analyse, monitor, or learn from safety and quality information. This gap is costly and should be closed. Early warning signals can be valued and should be maintained and heeded'.5, In 2013 Professors Charles Vincent, Susan Burnett and Jane Carthey published their report
The Measuring and Monitoring of Safety which describes their framework to be implemented in practice to close the gap identified by Berwick. The framework provides a broader view of the information needed to create and sustain safer care.
ObjectivesIntroduce the Measuring and Monitoring of Safety Framework to a Canadian healthcare audienceDescribe how the framework would work in Canada
Presentation A framework for measuring and monitoring safety A practical guide to using a new framework for measuring and monitoring safety in the NHS (2014) -
Download the guide from The Health FoundationThe measurement and monitoring of safety Drawing together academic evidence and practical experience to produce a framework for safety measurement and monitoring (2013) –
Download the full report from The Health Foundation Speaker Biographies
Professor Charles Vincent Professor Charles Vincent is trained as a clinical psychologist and has worked in the British NHS for several years. Since 1985 he has focused on conducting research on the causes of harm to patients, the consequences for patients and staff and methods of improving the safety of healthcare. He established the Clinical Risk Unit at the Department of Psychology, University College London where he was Professor of Psychology. In 2002 he moved to become Professor of Clinical Safety Research in the Department of Surgery and Cancer at Imperial College in 2002. From 1999 to 2003 he was a Commissioner on the UK Commission for Health Improvement. He has acted as an advisor on patient safety in many inquiries and committees including the Bristol Inquiry, the Parliamentary Health Select Committee, the Francis Inquiry and the Berwick Review. From 2007 to 2013 he was the Director of the National Institute of Health Research Centre for Patient Safety & Service Quality at Imperial College. He moved to the Department of Experimental Psychology in January 2014 with the support of the Health Foundation to continue his work on safety in healthcare.
G. Ross Baker, Ph.D. G. Ross Baker, Ph.D., is a professor in the Institute of Health Policy, Management and Evaluation at the University of Toronto and Director of the MSc. Program in Quality Improvement and Patient Safety. Ross is co-lead for a large quality improvement-training program in Ontario, IDEAS (improving and Driving Excellence Across Sectors). Recent research projects include a review and synthesis of evidence on factors linked to high performing healthcare systems, an analysis of why progress on patient safety has been slower than expected and an edited book of case studies on patient engagement strategies.
Chris Power What began as a desire to help those in need 30 years ago has evolved into a mission to improve the quality of healthcare for all Canadians. Chris Power's journey in healthcare began at the bedside as a front-line nurse. Since then, she has grown into one of the preeminent healthcare executives in Canada. Her experiences, her success, and her values have led her to the position of CEO of the Canadian Patient Safety Institute. Previously, Chris served for eight years as president and CEO of Capital Health, Nova Scotia, with an annual operating budget of approximately $900 million, and 12,000 staff. Under Chris’s leadership Capital Health achieved Accreditation with Exemplary Status in 2014 with recognition for 10 Leading Practices.
SHIFT to Safety Ensuring patients are safe remains a major challenge for Canadian healthcare organisations and systems. The Canadian Patient Safety Institute's (CPSI) new initiative,
SHIFT to Safety, has been launched to address these challenges, including helping providers and leaders improve their measurement efforts.
References  Baker, G Ross,
Beyond the quick fix – Strategies for improving patient safety. Institute of Health Policy Management and Evaluation. Nov.9.2015  Darzi A. High quality care for all. London Department of Health, 2009.  Quality and Outcomes Framework 2013/14. London Department of Health, 2013.  Vincent CA, Aylin P, Franklin BD, et al.
Is health care getting safer? BMJ 2008;3371205–07.  Francis R.
Independent Inquiry into care provided by Mid Staffordshire NHS Foundation Trust January 2005–March 2009. London Department of Health, 2013.  Jha A, Pronovost P.
Toward a safer health care system The critical need to improve measurement. JAMA. 2016.  Berwick DM.
A promise to learn—a commitment to act. Improving the safety of patients in England. London Department of Health, 2013  Vincent CA, Burnett S, Carthey C.
The measurement and monitoring of safety in healthcare. London Health Foundation, 2013||Archive: Monday, January 30, 2017 at 10:00 am MST / 12:00 pm EST
Purpose of the Call:
"…if I apply
this||2/16/2017 11:08:48 PM||2632||http://www.patientsafetyinstitute.ca/en/toolsResources/Pages/Forms/NewDefaultView.aspx||html||False||aspx|
|Canadian Patient Engagement Network||2341||Guide;News;Patient and Family Resource;Publication||7/12/2016 10:02:15 PM||
Share, learn and help others about patient engagement Achieving safe healthcare for all Canadians requires everyone's involvement. CPSI offers patients and families, patient advisors, healthcare providers, leaders, and organizations a place to connect in real time so they can share, learn and help others. The Canadian Patient Engagement Network is an open, public, and safe space; a community for anyone passionate about patient engagement or patient-centred care. It helps build individual and system capacity for effective patient engagement towards one common goal safe healthcare for all Canadians. Participate in this network through
Facebook Group The Canadian Patient Engagement Network emerged when several partners and patient advisors from across Canada began to discuss the needs and opportunities around a comprehensive guide for patient engagement based on evidence and best practices, as part of the
National Patient Safety Consortium's Integrated Patient Safety Action Plan. For more information, contact us at
email@example.com.||Canadian Patient Engagement Network||Share, learn and help others about patient engagement Achieving safe healthcare for all Canadians requires everyone's involvement. CPSI offers||2/16/2017 9:25:57 PM||1668||http://www.patientsafetyinstitute.ca/en/toolsResources||html||True||aspx|
|Enhanced Recovery after Surgery||2347||Video||7/13/2016 2:57:58 AM||
When it comes to surgical care best practices, there is always room for improvement. ERAS -
Surgery is a program highlighting surgical best practices. This introductory interview with international ERAS expert Dr. Henrik Kehlet is one in a 6 part series. We trust this will whet your appetite. Stay tuned for additional interview segments and other ERAS related tools and resources to support optimal recovery after surgery.
Dr. Kehlet is currently Professor of Perioperative Therapy at Rigshospitalet, Copenhagen University, Denmark. He has published more than 900 scientific articles and is also an Honorary Fellow of the Royal College of Anaesthetists in the U.K., the American College of Surgeons, the American Surgical Association, the German Surgical Society, and the German Anaesthesiological Society. For more information, contact us at
firstname.lastname@example.org.||Enhanced Recovery after Surgery||When it comes to surgical care best practices, there is al ways room for improvement. ERAS -
S||7/18/2016 9:18:45 PM||338||http://www.patientsafetyinstitute.ca/en/toolsResources||html||True||aspx|
|Events||446||Events||6/4/2015 6:09:31 AM|| ||Events||2/28/2017 9:38:45 PM||25274||http://www.patientsafetyinstitute.ca/en||html||True||aspx|
|Patient Safety Metrics||2342||Metrics||7/9/2015 6:19:21 AM||
The Patient Safety Metrics system is no longer available. This decision is the result of a shift in our measurement approach as we focus more on expert measurement consultation and coaching. To access and transfer your data from Patient Safety Metrics, to a location of your choice, please email the Central Measurement Team at email@example.com for information. For more information, please refer to a recording of our webinar held on this subject Measurement Now and Into the Future If you have any questions or require support, please feel free to contact us via email at firstname.lastname@example.org We would like to thank all of the teams who have contributed to Patient Safety Metrics and taken part in our quality improvement audits over the years.
Frequently Asked Questions
||Patient Safety Metrics ||Safer Healthcare Now! Enrolment & Measurement||2/16/2017 6:51:41 PM||10813||http://www.patientsafetyinstitute.ca/en/toolsResources||html||True||aspx|
|Tools & Resources||441||3/25/2009 3:33:37 PM||||Tools & Resources||Tools & Resources||8/25/2016 8:34:20 PM||65550||http://www.patientsafetyinstitute.ca/en||html||True||aspx|
|Reducing Falls and Injury from Falls (Falls): Getting Started Kit||4165||Getting Started Kit||7/1/2015 8:52:44 AM|| Getting Started Kit This free resource is designed to help you successfully implement interventions in your organization. The Getting Started Kit contains clinical information, information on the science of improvement, and everything you need to know to start using the intervention. Click here to download the Getting Started Kit. One-Pager The One-Pager is a summary of the Getting Started Kit that you can use to promote the intervention to your organization.Click here to download the One-Pager for reducing falls and Injury from falls. Framework for Spread (Appendix N from Falls Getting Started Kit) This appendix contains a description of the seven components of a spread framework along with elements of spread readiness.Click here to download the Spread Framework What’s New in Falls Best Practice in 2013The one page summary of the changes in the 2013 Reducing Falls and injury from Falls Getting Started Kit. Click here to download the one page summary of “what’s new in 2013” Icons Intervention IconsUse these intervention icons on presentations, reports, flyers, and other material to promote the intervention throughout your organization.Click here to download the full-colour intervention icon.Click here to download the black and white intervention icon. Intervention Icons With Text Click here to download the full-colour intervention icon with text. Click here to download the black and white intervention icon with text.
|| Getting Started Kit This free resource is designed to help you successfully implement interventions in your organization. The Getting||11/24/2016 10:03:47 PM||6914||http://www.patientsafetyinstitute.ca/en/toolsResources/Pages/Forms/NewDefaultView.aspx||html||False||aspx|
|Implementing the Vincent Framework at the Frontline||31210||Events;Presentation||2/6/2017 5:34:40 PM||
Archive February 23, 2017
Purpose of the Call Hear firsthand from Healthcare Improvement Scotland and one of their teams that participated in the U.K. Health Foundation collaborative about their experience in applying the Vincent Framework at the frontline. The related challenges and benefits and how it has impacted their work.
"…if I apply this [framework] conceptually to any problem I've got in safety I can make it work, and it orders my thinking" – Neil Prentice, Assistant Medical Director Mental Health, Tayside Trust, Scotland
ObjectivesLearn how the Vincent Framework was implemented in Scotland at the frontlineLearn how Healthcare Improvement Scotland is spreading the FrameworkLearn how their experience applies to Canada
Speakers Jo Thomson – Senior Programme Manager, Measurement and Monitoring of Safety Programme, Healthcare Improvement Scotland Alison McGurk, Clinical Team Manager (RMN), Angus Health and Social Care Partnership Morag MacRae – Patient Safety Development Manager, NHS Tayside Dr. Jonathan Kirk – National Clinical Lead, Measuring and Monitoring Safety Programme, Healthcare Improvement Scotland
Dr. G. Ross Baker – Institute of Health Policy, Management and Evaluation, University of Toronto
SHIFT to Safety Ensuring patients are safe remains a major challenge for Canadian healthcare organisations and systems. The Canadian Patient Safety Institute's (CPSI) new initiative,
SHIFT to Safety, has been launched to address these challenges, including helping providers and leaders improve their measurement efforts.
ResourcesA framework for measuring and monitoring safety A practical guide to using a new framework for measuring and monitoring safety in the NHS (2014) –
Download the guide from The Health FoundationThe measurement and monitoring of safety Drawing together academic evidence and practical experience to produce a framework for safety measurement and monitoring (2013) –
Download the full report from The Health FoundationIntroduction of the Measuring and Monitoring of Safety (Vincent) Framework to Canada –
January 30, 2017 National Call||Archive: February 23, 2017
Purpose of the Call: Hear firsthand from Healthcare Improvement Scotland and one of their teams that||3/1/2017 10:04:13 PM||395||http://www.patientsafetyinstitute.ca/en/toolsResources/Pages/Forms/NewDefaultView.aspx||html||False||aspx|
|Venous Thromboembolism Prevention (VTE): Getting Started Kit Components||2334||Getting Started Kit;Toolkits||2/9/2017 6:41:38 PM||
Venous thromboembolism comprises both
deep vein thrombosis (DVT) and
pulmonary embolism (PE) and is one of the most common and preventable complications of hospitalization.1 Many risk factors for developing VTE have been identified (see Table 1), but the most common risk factor in hospitalized patients is reduced mobility. Almost every hospitalized patient has at least one of these risk factors for VTE and most have multiple risk factors.2 The VTE Getting Started Kit provides you with evidence-based resources to assist you in increasing the use of appropriate thromboprophylaxis in acute care hospitalized patients and aligns with Accreditation Canada's Required Organizational Practices on VTE prevention. This free resource contains clinical information, information on the science of improvement, and everything you need to know to optimize the appropriate use of thromboprophylaxis.
Getting Started Kit The Venous Thromboembolism Prevention Getting Started Kit is divided into eight sections
Section 1 Rationale for VTE Prophylaxis
Section 2 Evidence-Based Appropriate VTE Prophylaxis
Section 3 Adherence to VTE Prophylaxis
Section 4 A Formal Process to VTE Prophylaxis Quality Improvement The 10 Steps
Section 5 VTE Prophylaxis Improvement Guide
Section 6 Measurement and the VTE Improvement Program
Section 7 Measurement - Technical Descriptions and Worksheets
Section 8 Appendices
Want to learn more?
Download the complete Venous Thromboembolism Prevention Getting Started Kit
This document was updated in January 2017 For more information, email
email@example.com or call 1-866-421-6933||Venous Thromboembolism Prevention (VTE): Getting Started Kit Components ||Venous thromboembolism comprises both
deep vein thrombosis (DVT) and
pulmonary embolism (PE) and is one of the most common and||2/10/2017 9:01:24 PM||438||http://www.patientsafetyinstitute.ca/en/toolsResources||html||True||aspx|
|Technology helps to reduce medication errors across the United States||20290||News||10/19/2016 5:17:23 PM||10/19/2016 6:00:00 AM|| In the United States, great advances have been made in medication safety where strategies have been put in place for preventing errors, like not using dangerous abbreviations and identifying high alert drugs that are most likely to injure someone when they are used in error. More than 90 per cent of hospitals are barcoded and are using computerized prescribing and bedside barcode scanning, where the doctor's orders are computerized. When the pharmacy dispenses the drug, it is labelled with a barcode. If the incorrect drug is scanned, there is an alert. The nurse or pharmacist on dispensing, and the nurse when administering get notified that there is something wrong, specifically, it is the wrong drug or dose for that patient. The use of bedside barcode scanning ensures that the right drug is being given to the right patient, at the right time. "We have had very positive outcomes with manufacturers and regulators in terms of understanding that drug naming, labelling, and packaging is important," says Michael Cohen, President, Institute for Safe Medication Practices (ISMP). "Going forward we need to improve upon the availability of ready-to-use pharmaceuticals, like syringes or pre-mixed IV solutions, for institutional use in acute care hospitals. That in itself would address a lot of the errors we are seeing in our reporting programs in the United States, Canada and other places as well." Technology is at the forefront across the United States, where infusion pumps are smart pumps used by and large in almost all hospitals. The smart pumps contain a library of drugs and the concentrations that are available for use in the hospital. When a patient needs an infusion, the nurse will look at the label to confirm it is the right drug, then put the IV tubing into it, hang it on an IV pole, attach the IV to a pump and push a button to start the infusion; the rate of the infusion is selected. Based on the concentration of the solution, the library knows how much drug is in each ml of solution. If a tenfold increase or decrease is accidentally ordered as an example, an alert is generated. In some cases it is a hard stop and you can't undo, or infuse anything without checking it out. ISMP has been funded by the US Food Drug Administration (FDA) to develop a self-assessment tool for high alert drugs. The tool includes prevention strategies for each pharmaceutical that will allow hospitals to assess where they are in implementing each of the strategies. They will be able to compare themselves to each of the participating hospitals in a variety of demographic categories across the country. "There are a lot of different things that can go wrong with medications, but we have done a good job with identifying them and applying prevention strategies," says Michael Cohen. "We are not perfect. Sometimes the system fails and they get through." Michael Cohen, along with David U and Dr. Michael Hamilton from ISMP Canada, are members of the World Health Organization (WHO) Global Patient Safety Challenge on Medication Safety, Medicines Working Group. They are proposing solutions that address many of the obstacles the world faces today to ensure the safety of medication practices. The work will be launched in the first quarter of 2017.||In the United States, great advances have been made in medication safety where strategies have been put in place for preventing errors, like not||10/19/2016 5:25:25 PM||424||http://www.patientsafetyinstitute.ca/en/NewsAlerts/News/Pages/Forms/AllItems.aspx||html||False||aspx|
|Patient Safety Champion Awards||2399||Events||7/24/2015 10:09:51 AM||
Recognizing the people and the organizations who are making care safer through partnership. Safe care must include patient and family engagement. HealthCareCAN and the Canadian Patient Safety Institute strongly believe this and are working together to foster spread and sustainability of patient and family partnerships in healthcare delivery and patient safety. We are once again partnering to present the Patient Safety Champion Awards to recognize volunteers and organizations that are taking a leadership role in ensuring that patients and families are at the centre of patient safety initiatives. In 2017 and beyond, the Patient Safety Champions Awards will be presented at the annual
National Health Leadership Conference, to highlight the important leadership required to steward effective partnerships and improve patient safety. Are you a Patient Safety Champion? If you or someone you know sounds like a deserving recipient of the 2017 Patient Safety Champion Award, in either the volunteer or organizational category, submit your nomination today! The deadline for nominations is April 1, 2017, and the Awards will be presented at the National Health Leadership Conference, June 12 to 13, 2017 in Vancouver, BC.
Award winners will receive an all-expense paid trip and attendance to the conference.
See the award criteria
Submit your volunteer nomination
Submit your organizational nomination Last Year's Winners Volunteer Award
Johanna Trimble won the 2016 Patient Safety Champion Award for her ongoing passion and commitment to changing the healthcare system by raising awareness around the overmedication of seniors. Organizational Award
Michael Garron Hospital, which also took home a 2016 Patient Champion Safety Award last year, was recognized for their outstanding work in engaging patients and families as partners in continuous improvement. Read more here These are just two examples of some of the exceptional work the Patient Champion Safety Awards have featured in that past couple years. Use the menu on the right to explore the stories of past winners and honorable mentions. For questions about the 2017 Patient Safety Champion Awards, please contact us at
||2017 Patient Safety Champion Awards||2016 Champion Awards||2/22/2017 5:30:29 PM||7119||http://www.patientsafetyinstitute.ca/en/Events||html||True||aspx|
|Canada's Virtual Forum||2394||Events||7/12/2011 8:55:44 PM||
Thank you to the more than 1,100 viewers from the nearly 600 sites in Canada and 6 countries around the world that made Canada's Virtual Forum on Patient Safety & Quality Improvement a huge success! If you weren't able to watch live, or if you want to watch anything again,
click here to access the archives and watch recordings of each of our sessions. Make use of these recordings during your in-services and as part of your local education sessions.
We would like to hear from you To help us plan for future events, we'd like to have your feedback. Please tell us what went well or what we could do better by
completing our survey. Questions or comments? Contact CPSI Communications at
firstname.lastname@example.org.||Canada’s Virtual Forum on Patient Safety and Quality Improvement||
Thank you to the more than 1,100 viewers from the nearly 600 sites in Canada and 6 countries around the world that made Canada's Virtual||5/25/2016 4:28:18 PM||23409||http://www.patientsafetyinstitute.ca/en/Events||html||True||aspx|
|Surgical Site Infection (SSI): Getting Started Kit||4200||Getting Started Kit||7/1/2015 8:55:00 AM||Getting Started KitThis free resource is designed to help you successfully implement interventions in your organization. The Getting Started Kit contains clinical information, information on the science of improvement, and everything you need to know to start using the intervention.. Click here to download the Getting Started Kit. Click here to download the summary of changes to the Getting Started Kit One-PagerThe One-Pager is a summary of the Getting Started Kit that you can use to promote the intervention to your organization. Click here to download the One-Pager. IconsIntervention IconsUse these intervention icons on presentations, reports, flyers, and other material to promote the intervention throughout your organization.Click here to download the full-colour intervention icon.Click here to download the black and white intervention icon.Intervention Icons With TextClick here to download the full-colour intervention icon with text. Click here to download the black and white intervention icon with text.
||SSI: Getting Started Kit||11/28/2016 5:52:16 PM||8182||http://www.patientsafetyinstitute.ca/en/toolsResources/Pages/Forms/NewDefaultView.aspx||html||False||aspx|
|Hand Hygiene Observation Tools||4168||Guide;Toolkits||6/3/2015 4:47:24 PM||Measurement is a vital part of the quality improvement process. Auditing hand hygiene compliance by health care providers provides a benchmark for improvement. The results of observation audits will help identify the most appropriate interventions for hand hygiene education, training and promotion. Results should be shared with front-line healthcare providers, management and hospital boards.
To support organizations in doing direct observation, CPSI has an observation tool based on the 4 Moments for Hand Hygiene. This tool is available in electronic (link to content below) and paper (link to content below) format.
CPSI has also adapted a Patient Family Observation Tool that will allow patient and family partners to observe and share information about how healthcare workers participate in optimal hand hygiene. (link to content below)
Direct observation of hand hygiene practices should be performed by trained observers using a standardized and validated audit tool. Need training on how to conduct Hand Hygiene observations? Here are some training resources to help you. (link to content below)
CPSI Hand Hygiene Observation Tool (Paper Tool)
This paper tool is for Acute Care only.
CPSI Hand Hygiene Observation Tool
Instructions for Using the Observation Analysis Tool
Observation Analysis Tool - Excel workbook (ZIP)
Training on how to conduct Hand Hygiene observations
Hand Hygiene Education
Monitoring and Observation (Auditing) for ACUTE
Monitoring and Observation (Auditing) for LTC
Hand Hygiene Measurement within Patient Safety Metrics (National Call Websinar)||Measurement is a vital part of the quality improvement process. Auditing hand hygiene compliance by health care providers provides a benchmark for||8/9/2016 7:43:28 PM||7467||http://www.patientsafetyinstitute.ca/en/toolsResources/Pages/Forms/NewDefaultView.aspx||html||False||aspx|
|Home Care Safety||2309||Report;Research;Toolkits||6/5/2014 8:48:12 PM||
With the release of the Safety at Home A Pan- Canadian Home Care Study (2013), the Canadian Patient Safety Institute (CPSI) and the Canadian Home Care Association (CHCA) worked with the research team to translate the knowledge acquired from the study into tools, resources and programs for the field. Click on the following links to access resources available to home care providers, clients and families, and policy makers.
Resources for home care providers
Resources for family caregivers and clients
Resources for policy makers and academics
||Home Care Safety||With the release of the Safety at Home: A Pan- Canadian Home Care Study (2013) , the Canadian Patient Safety Institute (CPSI) and the||6/29/2016 8:24:53 PM||4310||http://www.patientsafetyinstitute.ca/en/toolsResources||html||True||aspx|
|Medication Bar Code System Implementation Planning – a Resource Guide||2329||Guide;Publication||2/5/2014 9:27:38 PM||This comprehensive resource document has been written for use by senior practice leaders involved with medication management and system development, and by their executive leadership colleagues responsible for strategic funding and system acquisition. The purpose of this document is to review the need for automated identification (e.g., bar coding) of medications within both community‐based (e.g., nursing homes) and institutional (e.g., hospital and ambulatory) care. It is hoped that a better understanding of relevant issues will accelerate the adoption of innovative and safer medication processes within the Canadian healthcare system thus creating a medication system that protects Canadian patients from preventable and potentially serious harm. Its release represents the final phase of the
Canadian Pharmaceutical Bar Coding Project, co‐led by the
Institute for Safe Medication Practices Canada and the Canadian Patient Safety Institute. Its development has incorporated input and received support from major Canadian healthcare practice organizations, such as the Canadian Nurses Association and the Canadian Society of Hospital Pharmacists.
The guide has four sectionsA Bar Code Primer for LeadersBuilding the Case for Automated Identification of MedicationsImplementation Considerations
References||Medication Bar Code System Implementation Planning – a Resource Guide|| This comprehensive resource document has been written for use by senior practice leaders involved with medication management and system||8/22/2016 8:18:37 PM||2113||http://www.patientsafetyinstitute.ca/en/toolsResources||html||True||aspx|