Sign In
CPSI Share               

The Canadian Patient Safety Institute is happy to offer free access to the proceedings from each module of the Incident Analysis Learning Program. Below is a list of all modules with links to the agenda, slides and recordings. Please note that in order to encourage participation during the module, the recording does not include the small group discussions or any dialogue among participants.

Session Recordings and Documents

​Information Call

​English Session

​Recording Click here to watch the video
​Slides Click here to download

​French Session

​Recording Click here to watch the video
​Slides ​​Click here to download

Module 1: ​Patient/Family Partnership

The focus of this module is to explore patient/family centered care and how it links to incident analysis and management to will help to make care safer. Guest speakers and patient representatives will highlight what the patient needs are at different points during the incident analysis and management process. During small group discussions, participants will tap in to their own experiences and apply the “Checklist for Effective Meetings with Patients/ Families”.

​English Session

Recording Click here to view
Slides Click here to download
​Presentation: Clarification from AQESSS for organisations in Québec Click here to download (In French only)

​French Session

​Slides Click here to download​

​Module 2: The essentials: Principles, concepts and leading practices

The essential components of effective, credible and reliable incident analysis and management will be explored during this module. A good understanding of the principles, concepts and leading practices is fundamental because organizations need to nurture and support their use on an ongoing basis. Practical examples and facilitated discussions will help participants bridge this knowledge with their practice.

​English Session

​Recording ​Click here to view
​Slides Click here to download

French Session

​Recording Click here to view​
​Slides Click here to download

​​Module 3: Incident analysis as part of the incident management continuum

To increase the effectiveness of the incident analysis in improving care, analysis can’t be addressed in isolation from incident management (the multitude of activities that take place before and after an incident). Three main topics will be covered in this module: the main steps in the incident management continuum; differentiating between incident analysis (focused on system improvement) and accountability reviews (focused on individual performance), and selecting an incident analysis method.

English Session

​Recording Click here to view​
​Slides Click here to download

​French Session

​Recording Click here to view​
​Slides Click here to download

​Module 4: Comprehensive analysis method

During this module, the key features and main steps to analyze an incident using the comprehensive method will be described, discussed and applied. In addition, the tools that facilitate a comprehensive analysis will be introduced: the timeline, human factors, diagramming contributing factors and their interconnection (using the constellation diagram), guiding questions and the statements of findings.

English Session

​Recording ​Click here to view
​Slides Click here to download

French Session

​Recording Click here to view
​Slides Click here to download​

​Module 5: Concise analysis method

The background, key features and main steps of the concise analysis method are described, discussed and applied in this module together with the main tools used during a concise analysis (timeline, guiding questions, constellation diagram, and statements of findings).

​English Session

​Recording Click here to view​
​Slides Click here to download

French Session

​Recording Click here to view
​Slides ​Click here to download

​Module 6: Multi-incident analyses

The background, examples and steps in conducting a multi-incident analysis are described, discussed and applied during this module. Practical examples and case studies will help link the knowledge to practice.

English Session

​Recording Click here to view
​Slides Click here to download​

French Session

​Recording Click here to view
​Slides Click here to download​

Module 7: Recommended Actions

Developing well thought out, high leverage recommended actions, prioritizing, validating, and delegating them for implementation can result in fewer and more effective actions that can better help reduce the risk of recurrence and make care safer. During this module, the main steps in the development and management of recommended actions are discussed and applied to real life examples. Tools to support the process, like the hierarchy of effectiveness, heat map, tables, and the Larsen scale, will also be introduced.

English Session

​Recording Click here to view​
​Slides Click here to download

French Session

​Recording ​Click here to view
​Slides Click here to download

Module 8: Follow-through and share what was learned

The focus of this module is on techniques and tools for implementing recommended actions, monitoring and assessing their effectiveness, and sharing lessons from the incident analysis internally and externally so that risk of harm recurrence is reduced across multiple organizations. Through examples and dialogue will add a very practical layer to this module.

English Session

​Recording Click here to view​
​Slides Click here to download

​French Session

​Recording Click here to view
​Slides ​Click here to download

The CONSTELLATION DIAGRAM – a deep dive

The diagramming step of the incident analysis process is focused on recognizing all system issues that may have contributed to the incident rather than just the factors that are apparent and closer to the point of incident occurrence. The Constellation Diagram can assist teams to better understand systemic factors and the inter-relationships between them, better visualize these relationships, and help avoid the trap of hindsight bias. Diagramming is one of the elements that can increase the credibility, reliability and effectiveness of analysis in making care safer.

Resources:

​English Session - August 29, 2013 ​practice_diagramming.xlsx

​Video Click here to watch the video​
​Presentation Click here to download​
​Constellation diagram Excel template ​Click here to download (.zip)
​Constellation diagram Excel template xlsx practice_diagramming.xlsx
​Constellation Map Template Click here to download​

​French Session - September 17, 2013 ​

​Video Click here to watch the video
​Presentation Click here to download
​Constellation diagram Excel template Click here to download (.zip)
​Constellation Map Template Click here to download​