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Five Questions to Ask about your Medications2338Patient and Family Resource;Checklists;Toolkits2/25/2016 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 medrec@ismp-canada.org.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 can4/5/2017 7:26:26 PM9944http://www.patientsafetyinstitute.ca/en/toolsResourceshtmlTrueaspx
Patient Safety and Incident Management Toolkit2319Toolkits12/18/2014 8:28:40 PMPrevent 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 Incident Management System Factors For more information, contact us at info@cpsi-icsp.ca.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 info@cpsi-icsp.ca.Patient Safety and Incident Management ToolkitPrevent Patient Safety Incidents and Minimize Harm When They Do Occur When a patient's safety is compromised, or even if someone just comes close to6/19/2017 4:19:43 PM20071http://www.patientsafetyinstitute.ca/en/toolsResourceshtmlTrueaspx
Canadian Patient Safety Week (CPSW)2445Events12/8/2009 9:50:43 PM Welcome to asklistentalk.ca – your home for Canadian Patient Safety Week!Mark your calendars and register today! Canadian Patient Safety Week 2017 will be held October 30th – November 3rd, 2017 and registration is now open! Register Now Join us as we focus on medication safety and the 5 Questions to Ask About Your Medications. There is important health advice we all hear from a young age. Eat healthy. Exercise regularly. Get a good night's sleep. But there is other important health advice that we sometimes don't hear. This year, we are making it our mission to encourage patients and remind healthcare professionals what lifesaving questions we should all ask about our medications. Introducing Take With Questions. Our mission. Your life-saving reminder. Order your FREE CPSW package today! The package will contain notepads, planning materials, and plenty of goodies to help you plan a successful CPSW event in your organization! Packages will be shipped out mid-September, so you will have your materials in time for your event. Register Now Check back at as more details are unveiled.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 sponsorshipsmail@cpsi-icsp.ca. We have many sponsorship opportunities available. Do you have any questions or suggestions? Contact CPSI CommunicationsPhone (780) 409-8090Toll free 1-866-421-6933 Email CPSW@cpsi-icsp.caJoin the conversation at #asklistentalkCanadian Patient Safety WeekCanadian Patient Safety Week (CPSW)6/19/2017 8:20:40 PM74148http://www.patientsafetyinstitute.ca/en/EventshtmlTrueaspx
Engaging Patients in Patient Safety – a Canadian Guide2327Guide4/25/2017 3:01:50 PM During the past decade, we have seen evidence that when healthcare providers work closely with patients and their families, we can achieve great things. The healthcare system will be safer, and patients will have better experiences and health outcomes when patients, families, and the public are fully engaged in program and service design and delivery. Patient involvement is also important in monitoring, evaluating, setting policy and priorities, and governance. This work is not easy and may even be uncomfortable at first. Providers may need to let go of control, change behaviours to listen and understand patients more effectively, brainstorm ideas together, build trust, and incorporate many different perspectives. Patients may need to participate more actively in decisions about their care. Leaders must support all this work by revising practices to embed patient engagement in their procedures, policies, and structures. But finding different and innovative ways to work together, even when it's challenging, benefits everyone. When patients and healthcare providers partner effectively, the results are powerful. We invite you to join us in advancing this work. We welcome diverse perspectives and beliefs to challenge the status quo. Let's explore ways to shape new behaviours, using everyone's unique perspectives and courage to make healthcare a safe and positive experience. A deep belief in the power of partnership inspired the Engaging Patients in Patient Safety - a Canadian Guide. Written by patients and providers for patients and providers, the information demonstrates our joint commitment to achieving safe and quality healthcare in Canada. Download Who is this guide for? The guide is for anyone involved with patient engagement, includingPatients and families interested in how to partner in their own care to ensure safetyPatient partners interested in how to help improve patient safetyProviders interested in creating collaborative care relationships with patients and familiesManagers and leaders responsible for patient engagement, patient safety, and/or quality improvementAnyone else interested in partnering with patients to develop care programs and systems While the guide focuses primarily on patient safety, many engagement practices apply to other areas, including quality, research, and education. The guide is designed to support patient engagement in any healthcare sector. What is the purpose of the guide? This extensive resource, based on evidence and leading practices, helps patients and families, patient partners, providers, and leaders work together more effectively to improve patient safety. Working collaboratively, we can more proactively identify risks, better support those involved in an incident, and help prevent similar incidents from occurring in the future. Together we can shape safe, high-quality care delivery, co-design safer care systems, and continuously improve to keep patients safe.What is included in the guide?Evidence-based guidancePractical patient engagement practicesConsolidated information, resources, and toolsSupporting evidence and examples from across CanadaExperiences from patients and families, providers, and leadersOutstanding questions about how to strengthen current approachesStrategies and policies to meet standards and organizational practice requirementsChapter summariesEngaging patients as partnersWhy partner on patient safety and qualityCurrent state of patient engagement across CanadaEvidence of patient engagement benefits and impactChallenges and enablers to patient engagementEmbedding and sustaining patient engagement Read More Partners at the point of carePartnering in patient safety Partnering in incident management Read More Partners at organizational and system levelsPreparing to partnerPartnering in patient safety Partnering in incident management Read More Evaluating patient engagementIntroduction to evaluating patient engagementEvaluating patient engagement at the point of careEvaluating patient engagement at the organizational levelEvaluating patient engagement integration Read More Click here to learn how and why was the guide developed. ​ ​​ Engaging Patients in Patient Safety – a Canadian GuideDuring the past decade, we have seen evidence that when healthcare providers work closely with patients and their families, we can achieve great6/19/2017 5:27:43 PM5680http://www.patientsafetyinstitute.ca/en/toolsResourceshtmlTrueaspx
Atlantic Learning Exchange2448Events9/20/2016 6:01:00 PM The Atlantic Learning Exchange 2017 was an opportunity to join leaders and patient safety champions who gathered for a two-day quality and patient safety knowledge exchange. Participants took in engaging presentations on quality improvement from the system, provider, and patient experiences, as well, rapid fire presentations that showcased local initiatives and the differences they have made. This year's theme was Advancing patient safety culture to improve the patient experience.Be sure to check out the ALE 2017 Program. Program​ ​ MAINTENANCE OF CERTIFICATION Attendance at this program entitles certified Canadian College of Health Leaders members (CHE / Fellow) to 5.75 Category II credits towards their maintenance of certification requirement.Atlantic Health Quality & Patient Safety Learning Exchange 2017The Atlantic Learning Exchange 2017 was an opportunity to join leaders and patient safety champions who  gathered for a two-day quality and6/12/2017 2:28:54 PM5348http://www.patientsafetyinstitute.ca/en/EventshtmlTrueaspx
Canadian Disclosure Guidelines2345Guide;Publication4/18/2011 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.​ Download 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 familiesThe Canadian Disclosure Guidelines build on various patient safety initiatives currently under way across Canada and assist and support healthcare6/20/2016 8:35:25 PM12943http://www.patientsafetyinstitute.ca/en/toolsResourceshtmlTrueaspx
Patient Stories23497/27/2015 12:39:48 PM ​​​​​​​​​​​​​​​​​​​​​​​​​​​Patient Stories5/19/2016 4:22:33 AM15341http://www.patientsafetyinstitute.ca/en/toolsResourceshtmlTrueaspx
Deteriorating Patient Condition2329Toolkits3/30/2017 5:19:46 PM Early warning signs of deteriorating condition are often unrecognized, leading to devastating results. Research shows that virtually all critical inpatient events are preceded by warning signs that occur approximately six-and-a-half hours in advance. In this section, you'll find information, tools and resources to not only help you recognize deteriorating patient condition, but what you can do to act on it as a member of the public, a healthcare provider or leader. Click any of the icons below to get started! Deteriorating Patient ConditionEarly warning signs of deteriorating condition are often unrecognized, leading to devastating results. Research shows that virtually all critical4/21/2017 4:50:50 PM608http://www.patientsafetyinstitute.ca/en/toolsResourceshtmlTrueaspx
Measure Patient Safety, Quality Improvement and Leadership2337Metrics7/12/2016 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. Download 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 info@cpsi-icsp.ca. "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 BordersMeasure Patient Safety, Quality Improvement and LeadershipUse Real-Time Data to Make Patient Safety Improvements To improve your organization's patient safety quality, you need reliable, up-to-date data6/22/2017 8:27:31 PM2799http://www.patientsafetyinstitute.ca/en/toolsResourceshtmlTrueaspx
Tools & Resources4513/25/2009 3:33:37 PM​​​​​​​​​Tools & ResourcesTools & Resources5/31/2017 4:33:46 PM74029http://www.patientsafetyinstitute.ca/enhtmlTrueaspx
The Safety Competencies Framework2322Publication;Framework4/14/2009 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. Download Flyer 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 safetycomp@cpsi-icsp.ca.The Safety CompetenciesThe Safety Competencies: Message from the CEO11/9/2016 8:49:19 PM37518http://www.patientsafetyinstitute.ca/en/toolsResourceshtmlTrueaspx
Enhanced Recovery after Surgery2357Video7/13/2016 2:57:58 AM When it comes to surgical care best practices, there is always room for improvement. ERAS - Enhanced Recovery After 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 info@cpsi-icsp.ca.Enhanced Recovery after SurgeryWhen it comes to surgical care best practices, there is al ways room for improvement. ERAS - E nhanced R ecovery A fter S4/5/2017 7:33:55 PM486http://www.patientsafetyinstitute.ca/en/toolsResourceshtmlTrueaspx
Patient Safety Champion Awards2447Events7/24/2015 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. 2017 Champion Awards North York General Hospital is the 2017 recipient of the Patient Safety Champion Award for organizations. Presented annually by the Canadian Patient Safety Institute, HealthCareCAN, and Patients for Patient Safety Canada, the Patient Safety Champion Award recognizes volunteers and organizations that are taking a leadership role in ensuring that patients and families are at the centre of patient safety initiatives. The prominent Award was presented at the National Health Leadership Conference in Vancouver, on June 12, 2017. Read More For questions about the 2017 Patient Safety Champion Awards, please contact us at info@cpsi-icsp.ca. ​2017 Patient Safety Champion Awards2016 Champion Awards6/12/2017 8:22:30 PM8622http://www.patientsafetyinstitute.ca/en/EventshtmlTrueaspx
Patient Concern Resolution Process2342Guide;Patient and Family Resource;Toolkits4/19/2011 6:12:38 PM​​​Every patient experience should be safe. Patients, residents, clients, and their families can be active partners in safe care. Help ensure a safe patient experience with information, tools, tips, and resources for patients and their families. Patient Concern Resolution Process If you have a question or a concern about the healthcare services you have received, there are several options that may be available. You may be able to resolve the problem simply by talking to your healthcare provider—a physician, a nurse, someone else directly involved in your care, or the appropriate supervisor. Your healthcare provider is in the best position to address your questions and concerns. If your questions or concerns are still not fully addressed, you can Talk to the healthcare organization or regional health authority that provided the care. Some have a patient relations officer, client representative, or patient advocate to assist you with the process. If you have specific concerns about the conduct of a healthcare provider, comments should be directed to the appropriate professional regulatory body, such as the College of Physicians and Surgeons, the Registered Nurses Association, or other health professions’ regulatory authorities. Regulatory bodies generally have their own concern-handling bylaws, policies, or procedures, and they can assist you. You may be asked to put your concern in writing and identify yourself so that the issue can be thoroughly investigated. If none of the above options results in the resolution of your question or concern, you may wish to contact the ministry of health in the province where you received your care. If your concerns are still not addressed, you may be able to appeal through various mechanisms including the provincial/territorial ombudsman or a similar advocacy body. For more information Alberta British Columbia Manitoba New Brunswick Newfoundland and Labrador Nova Scotia Nunavut Ontario Prince Edward Island Quebec Saskatchewan The Northwest Territories Yukon Please note If you received healthcare services in the Province of Quebec and have a question or concern about those services, please refer to the following website for information regarding resolution of your concern msss.gouv.qc.ca/reseau/plaintes.php As it is recognized that the patient's family or another advocate may be included in the concern resolution process, the term "patient" includes family members or advocates.Patient Concern Resolution ProcessEvery patient experience should be safe. Patients, residents, clients, and their families can be active partners in safe care. Help ensure a safe6/13/2017 7:42:45 PM2996http://www.patientsafetyinstitute.ca/en/toolsResourceshtmlTrueaspx
Hospital Harm Improvement Resource26904/14/2015 5:37:10 PMIntroduction 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 info@cpsi-icsp.ca. 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. Download Back to Hospital Harm MeasureHospital 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 of10/25/2016 7:23:53 PM4744http://www.patientsafetyinstitute.ca/en/toolsResources/Hospital-Harm-MeasurehtmlTrueaspx
Reducing Falls and Injury from Falls (Falls): Getting Started Kit4354Getting Started Kit7/1/2015 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 h​ere 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 Getting11/24/2016 10:03:47 PM7856http://www.patientsafetyinstitute.ca/en/toolsResources/Pages/Forms/NewDefaultView.aspxhtmlFalseaspx
Incident Analysis2336Framework;Publication4/19/2011 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, Saskatchewan Health, 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. Download To learn more about the framework and the resources available, you can click here to watch the information webinars recorded. The 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 analysis@cpsi-icsp.ca. To learn more about the framework and the learning opportunities available click here. Incident AnalysisRoot Cause Analysis (RCA)6/20/2016 3:47:55 PM17171http://www.patientsafetyinstitute.ca/en/toolsResourceshtmlTrueaspx
Improvement Frameworks Getting Started Kit2318Toolkits;Getting Started Kit;Framework11/24/2011 4:21:24 PM12/2/2015 7:00:00 AM​​​​The Improvement Frameworks Getting Started Kit is intended to serve as a common document appended to the Safer Healthcare Now! Getting Started Kits. The goal is to help provide a consistent way for teams and individuals to approach the challenge of making changes that result in improvements. Download Improvement Frameworks Getting Started KitThe Improvement Frameworks Getting Started Kit is intended to serve as a common document appended to the Safer Healthcare Now! Getting Started1/5/2016 6:18:07 PM7251http://www.patientsafetyinstitute.ca/en/toolsResourceshtmlTrueaspx
Events456Events6/4/2015 6:09:31 AM ​​Events6/5/2017 8:44:57 PM27696http://www.patientsafetyinstitute.ca/enhtmlTrueaspx
Guidelines for Informing The Media After an Adverse Event2355Guide9/18/2015 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. Download 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 you6/29/2016 7:47:30 PM2187http://www.patientsafetyinstitute.ca/en/toolsResourceshtmlTrueaspx
STOP! Clean Your Hands Day2446Events6/3/2015 4:46:05 PM​​​​​​May 5, 2017 Join the conversation #STOPCleanyourhandsday 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 2017Webinar We're hosting a webinar May 4, 2017 at 10 am MT / 12 pm ET. Learn More How Clean Are Your Hands? Take the Quiz Video Competition Thank you to everyone who submitted a video, they look great! View Videos Winners will be announced May 4, 2017 during our STOP! Clean Your Hands Day webinar. Sponsored by ​Partners STOP! Clean Your Hands Day May 5, 2017 Join the conversation #STOPCleanyourhandsday It's time for patients and providers to come together for clean hands –4/21/2017 9:31:19 PM26447http://www.patientsafetyinstitute.ca/en/EventshtmlTrueaspx
Introduction of the Measuring and Monitoring of Safety (Vincent) Framework to Canada4370Events;Presentation;Metrics1/4/2017 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.[1],[2] 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.[3] The measurement of harm, so important in the evolution of patient safety, has been largely neglected[4] and there have been prominent calls for improved measures.[5] 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,[7] In 2013 Professors Charles Vincent, Susan Burnett and Jane Carthey published their report The Measuring and Monitoring of Safety[8] 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 Resources Video 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 [1] Baker, G Ross, Beyond the quick fix – Strategies for improving patient safety. Institute of Health Policy Management and Evaluation. Nov.9.2015 [2] Darzi A. High quality care for all. London Department of Health, 2009. [3] Quality and Outcomes Framework 2013/14. London Department of Health, 2013. [4] Vincent CA, Aylin P, Franklin BD, et al. Is health care getting safer? BMJ 2008;3371205–07. [5] Francis R. Independent Inquiry into care provided by Mid Staffordshire NHS Foundation Trust January 2005–March 2009. London Department of Health, 2013. [6] Jha A, Pronovost P. Toward a safer health care system The critical need to improve measurement. JAMA. 2016. [7] Berwick DM. A promise to learn—a commitment to act. Improving the safety of patients in England. London Department of Health, 2013 [8] Vincent CA, Burnett S, Carthey C. The measurement and monitoring of safety in healthcare. London Health Foundation, 2013Archive: Monday, January 30, 2017 at 10:00 am MST / 12:00 pm EST Purpose of the Call: "…if I apply this4/5/2017 7:29:00 PM3418http://www.patientsafetyinstitute.ca/en/toolsResources/Pages/Forms/NewDefaultView.aspxhtmlFalseaspx
Falls Prevention & Management: A New Tool To Help With Process Improvement (ACUTE & LONG TERM CARE)25105Presentation6/3/2015 3:41:41 PM​​​Intervention Reducing Falls and Injury from Falls InterventionDate Wednesday, February 4thSponsor Canadian Patient Safety InstituteSafer Healthcare Now! Registered Nurses’ Association of OntarioSpeakersRosalie Freund-Heritage, Project Manager AHS Falls Risk Management StrategyVirginia Flintoft, Safer Healthcare Now! Central Measurement TeamFacilitatorsSusan McNeill, Registered Nurses’ Association of OntarioMaryanne D’Arpino, Canadian Patient Safety InstituteHélène Riverin, French Language Support, Canadian Patient Safety InstitutePurpose of the CallTo briefly describe the need for improved quality of admission falls prevention processes.To introduce the use of a tool which allow teams to collect patient level data on specific admission falls quality determinants.To demonstrate how this data can be easily submitted and analyzed through the Patient Safety Metrics system.Resources Video Presentation Intervention: Reducing Falls and Injury from Falls Intervention Date: Wednesday, February 4th Sponsor: Canadian Patient Safety9/13/2016 5:12:30 PM3430http://www.patientsafetyinstitute.ca/en/toolsResources/Presentations/2015Webinars/Pages/Forms/AllItems.aspxhtmlFalseaspx
Surgical Site Infection (SSI): Getting Started Kit4391Getting Started Kit7/1/2015 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. ​​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 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 Kit11/28/2016 5:52:16 PM9160http://www.patientsafetyinstitute.ca/en/toolsResources/Pages/Forms/NewDefaultView.aspxhtmlFalseaspx
Hand Hygiene Toolkit4360Guide;Toolkits6/3/2015 4:47:25 PM​​​​​​​​​​​​​​​​This comprehensive Hand Hygiene Toolkit allows you to start improving hand hygiene in your organization. You can buy this toolkit here. Additional copies of some of the tools available in the Hand Hygiene Toolkit can be found below. Hand Hygiene Toolkit resource links to scholarly literature and fact sheets can also be found in the Resources section. Copies of the hand hygiene education PowerPoint presentations can be found in Hand Hygiene Education. Looking for the Patient and Family Guide? You can find it plus other resources in the Patients & Their Families section. Hand Hygiene Observation Tool WRHA Hand Hygiene Observation Tool WRHA Hand Hygiene Audit Instructions On-the-Spot Feedback Tool Hand Hygiene Surveillance Instrument Guidebook for Use of Hand Hygiene Surveillance Instrument Instructions for Using the Hand Hygiene Surveillance Instrument A Simple Framework and tools for Establishing Accountability in Hand Hygiene Programs How to Handrub How to Handwash 4 Moments for Hand Hygiene (poster) WHO Facility-Level Situation Analysis WHO Template Action Plan This comprehensive Hand Hygiene Toolkit allows you to start improving hand hygiene in your organization. You can buy this  toolkit here .11/28/2016 6:03:38 PM8350http://www.patientsafetyinstitute.ca/en/toolsResources/Pages/Forms/NewDefaultView.aspxhtmlFalseaspx
Implementing the Vincent Framework at the Frontline4365Events;Presentation2/6/2017 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 Presentation 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 that3/1/2017 10:04:13 PM809http://www.patientsafetyinstitute.ca/en/toolsResources/Pages/Forms/NewDefaultView.aspxhtmlFalseaspx
SHIFT to teamwork, communication and patient safety culture2324Guide;Toolkits7/13/2016 5:21:38 PM Ensuring patient safety remains a major challenge for Canadian healthcare organisations and systems. The Canadian Patient Safety Institute (CPSI) has been at the forefront of efforts to promote safety in Canadian Healthcare settings and has achieved substantial improvements with the implementation of patient safety bundles. However, there remain substantial challenges to implementing patient safety practices. SHIFT to Safety is excited to announce a new partnership with Dr. Jeremy Grimshaw and the Ottawa Hospital Research Institute and provide new resources in the field of behavior change and implementation science to address this issue! Please join us on October 6th as Dr. Jeremy Grimshaw and Dr. Kathy Suh discuss how to take your improvement efforts to the next level by focusing on behaviour change and implementation science. To register for this session, Click hereSHIFT to teamwork, communication and patient safety cultureEnsuring patient safety remains a major challenge for Canadian healthcare organisations and systems. The Canadian Patient Safety Institute (CPSI) has4/5/2017 7:32:59 PM1181http://www.patientsafetyinstitute.ca/en/toolsResourceshtmlTrueaspx
Teamwork and Communication2320Publication;Framework7/22/2009 8:44:35 PM ​​​Effective teamwork and communication are critical for ensuring high reliability and the safe delivery of care. Teamwork and communication techniques can improve quality and safety, decrease patient harm, promote cross-professional collaboration and the development of common goals, decrease workload issues, and improve staff and patient satisfaction. Building effective teams and improving communication through standardized tools will move effective teamwork forward in Canada and contribute to a culture of patient safety. CPSI is developing a Canadian Framework for Teamwork and Communication to help healthcare providers and organizations integrate tools and resources into practice. Canadian Framework for Teamwork and CommunicationAppendix A Teamwork and Communication in Healthcare A Literature ReviewAppendix B Consultation with Health Professionals and Administrators Regarding Teamwork and CommunicationAppendix C Report on Summary of Team Training Programs Download Canadian Framework for Teamwork and CommunicationEffective Teamwork and Communication to Enhance Patient Safety11/9/2016 8:44:39 PM9410http://www.patientsafetyinstitute.ca/en/toolsResourceshtmlTrueaspx
Patient Safety Metrics2352Metrics7/9/2015 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 info@cpsi-icsp.ca 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 info@cpsi-icsp.ca 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 & Measurement2/16/2017 6:51:41 PM12160http://www.patientsafetyinstitute.ca/en/toolsResourceshtmlTrueaspx
Central Line-Associated Bloodstream Infection (CLABSI): Getting Started Kit4348Getting Started Kit7/1/2015 8:51:29 AM​​​These free resources are designed to help you successfully implement interventions in your organization. Getting Started ​Getting Started Kit 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. ​​Icons ​Intervention Icons Use 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. CLI: Getting Started Kit11/24/2016 10:07:46 PM5501http://www.patientsafetyinstitute.ca/en/toolsResources/Pages/Forms/NewDefaultView.aspxhtmlFalseaspx