The purpose of this toolkit is to provide an integrated set of practical strategies and resources related to patient safety and incident management. The needs and concerns of patients and families and how they can be engaged at each stage in the process were considered in the development of the toolkit. The toolkit aims to help healthcare organizations prevent patient safety incidents and minimize harm when incidents do occur.
Drawn from the best available evidence and expert advice, and regularly updated, this toolkit is designed for those responsible for managing patient safety, quality improvement, risk management, and staff training in any healthcare setting.
Toolkit Focus and Components
With the main focus on patient safety and incident management, the broader aspects of quality improvement and risk management are not specifically discussed in the toolkit; however ideas and resources for exploring these topics are offered.
There are three sections to the toolkit: incident management, patient safety management and system factors. Incident management is the foundation, where the focus is placed on the actions that follow patient safety incidents (including near misses.) The focus of the patient safety management section is broader and upstream, on the actions that help proactively anticipate and prevent patient safety incidents from occurring. Encompassing everything are the system factors, consisting of the forces that shape and are shaped by patient safety and incident management. These three toolkit sections include components which provide practical strategies and resources for specific focus areas.
Visual representation of the toolkit.
Below is a description of the three sections and associated components: click on the hyperlinks to access them.
System factors: understand the factors that shape both patient safety and incident management and identify actions to respond to, align with, and lever them. The factors come from different system levels (inside and outside the organization) and include legislation, policies, culture, people, processes and resources.
Patient Safety Management:
access resources to guide action before the incident (e.g. plan, anticipate, monitor to respond to expected and unexpected safety issues) so care is safer today and in the future. Emphasis is placed on patient safety culture and
reporting and learning system.
access resources to guide the immediate and ongoing actions following a patient safety incident (including near misses.) Emphasis is placed on: immediate response, disclosure, how to prepare for analysis, analysis process, follow-through, and close the loop/ share learning.
Principles to Guide the Implementation of Patient Safety and Incident Management Processes
Consider the following guiding principles when applying the practical strategies and resources.
Patient/Family Centred Care. The patient/family is at the centre of all patient safety and incident management activities meaning that patients and families
are treated with respect and compassion at all times, are an equal partner and thus 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 is committed to the avoidance, prevention and mitigation of patient safety risks at all levels. It encompasses the just, reporting and learning culture.
System Perspective. Patients can be made safer by seeking to understand and address the factors that contribute to an incident at all system levels, redesigning systems and applying human factors principles. It is essential to develop the capability and capacity for effective assessment of the complex system in order 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/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
The resources included in this toolkit were selected to provide practical tools to support patient safety and incident management. Our experts and contributing organizations advised on and shared these tools generously, but because the select tools and resources may not be suited to all circumstances, we encourage the users to assess their appropriateness before implementation.
Click here to access the complete list of resources referred to in the toolkit.
Toolkit Development and Maintenance
CPSI undertook to develop a toolkit integrating patient safety and incident management to serve as a compendium of evidence and practical resources. The content development process was:
The toolkit will be updated every year to keep it relevant. We welcome feedback on what is helpful, what can be improved, as well as content enhancements at