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.
The healthcare system is comprised of many sub-systems operating at different levels (e.g. outside of the organization, organization and/or program level, point of care) each with specific goals, resources (human, financial, equipment) and processes (formal and informal.) Maintaining a system perspective and regularly assessing the sub-systems and their connectivity is critical in identifying how they influence each other which in turn can inform actions to strengthen patient safety and incident management.
Assess key system factors and understand how they relate to patient safety and incident management.
Identify actions to strengthen patient safety and incident management
Respond – Monitor and anticipate system factors that influence and impact patient safety (e.g., changes in regulations, workforce shortages, changes to health funding), ensure patient safety remains at the forefront of decision making (e.g., regular updates at key meetings, assigning responsibility to stay informed to key leaders) and take action to respond as appropriate.
Align – Use internal and external system factors in assessing priority of patient safety and incident management initiatives. Initiatives that align at different system levels create multiple wins, which will accelerate uptake and spread, and promote best practices known to reduce harm.
Leverage – Take advantage of system factors to improve patient safety and incident management (e.g., use Accreditation Canada’s Required Organizational Practices as a lever to implement best practices known to improve patient safety.)
Partner/collaborate – Work with others to make changes that can positively impact healthcare in your setting; support or endorse the work and successes of others.
Advocate – Promote learning from patient safety incident management to shape system factors for the benefit of your healthcare organization and providers, as well as others (e.g. work with advocacy groups to change public policy, engage funders in addressing known safety issues.)