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CPSI Share                                                    
5/31/2015 6:00 PM

​​The Canadian Patient Safety Institute (CPSI) has launched a new online Patient Safety and Incident Management Toolkit (Toolkit) that brings together evidence, resources and leading practices from Canada and around the world in a practical and easy-to-use format. It was developed in collaboration with an Expert Faculty which included Accreditation Canada, and aligns with 2016 Required Organizational Practices (ROPs) and standards related to incident management and disclosure.  

The online Toolkit provides those responsible for patient safety and incident management with an integrated set of practical strategies and resources for recognizing, responding to and learning from patient safety incidents which ultimately aims to improve the safety of patient care. This practical, yet comprehensive resource provides tools that can be used to help strengthen quality, risk management and patient safety endeavours.

CPSI Incident Management Diagram - Web.jpg 

Visual representation of the Toolkit.

“To effectively prepare for, prevent and manage patient safety incidents, you really need multiple pieces working together,” says Heather Howley, Health Services Research Specialist, Accreditation Canada. “The Toolkit illustrates that it is not just about having a reporting system. It is about laying down the foundational pieces around culture and a safe system, and then where the reporting system fits into that.”

“The Toolkit will be a great resource for organizations who are struggling with reporting, or not sure how to implement a particular test for compliance within the ROPs,” adds Heather Howley. “The Toolkit provides context behind what we are asking, while linking to practical tools. For example, if you do not yet have a reporting policy, you can find one in the Toolkit.  It is that link to resources that organizations are looking for.”

The Toolkit provides an inventory of relevant information in one place, including the Canadian Incident Management Framework, the Canadian Disclosure Guidelines, the Guidelines for Informing the Media after an Adverse Event, and Global Patient Safety Alerts. The Incident Management Continuum from the Canadian Incident Analysis Framework formed the foundation for the Toolkit. New content, guidance and resources were added to better support actions to understand and prevent incidents as well as to understand and leverage system factors. The World Health Organization (WHO) classification language has also been adopted throughout the Toolkit.

The content for the Toolkit was informed by key stakeholders via focus groups, evidence from peer-reviewed journals and publicly available literature, and was shaped by advice from an Expert Faculty that included patient/family representatives. Partner organizations and front-line professionals have generously shared tools, templates, policies and stories to augment the Toolkit.

Dr. Amir Ginzburg, Medical Director, Quality and Performance, Trillium Health Partners was one of the Expert Faculty members involved in the development of the Toolkit.  “We spent a long time thinking about the main focus and it is all about culture -- how do we foster a just culture at all levels of an organization? That is the core foundation that a patient safety management program is based on.”

“The Toolkit takes into account the entire life cycle of a patient safety incident from end-to-end and provides organizations with different tools and considerations to look at as they improve their processes around patient safety,” says Dr. Ginzburg. “It includes the environment before an incident actually happens – looking at the safety culture, reporting culture, leadership support – all the way through to the identification of an incident, bringing teams together, analyzing the incident, generating recommendations for improvement, implementation and closing the loop by sharing the learning with key stakeholders to eliminate the risk of future occurrences. At a click of a button, you can translate principles and philosophies into practical tools that can be customized and implemented into an organization very quickly.”

“The Toolkit spans the continuum of care and will be a tremendous resource for the establishment of a patient safety culture in primary care units and family practices in analyzing patient safety incidents as they may occur,” says Dr. John Maxted, an Expert Faculty member and Assistant Professor of Family Medicine, Markham Family Medicine Teaching Unit, University of Toronto. “The document is knowledgeable and user-friendly and will gain in value as you use it. It should be reviewed in its entirety before implementing the opportunities that it presents.”

“One of the biggest challenges in patient safety is establishing a safe culture,” adds Dr. Maxted. “The web page on the culture of patient safety encompasses valuable information that will help us all, particularly in primary care, to identify, talk about and ultimately improve our systems to overcome the patient safety incidents that we experience.”

Every healthcare organization is at a different point in their patient safety journey. The Toolkit helps address questions like:  Are there things we can do better? How can we integrate our patient safety efforts? Are there new tools, evidence or leading practices? The Toolkit helps organizations to reflect on how they are performing against best practice standards, identify the one or two key areas where improvement can be accomplished, and ensure that patients and families are engaged and an active part of the process. 

“When there has been harm or an unexpected outcome, it is essential that patients and families are part of a process that is open, transparent and respectful, that guides us through these incident reviews and leads to improvements,” says Sharon Nettleton, Co-Chair, Patients for Patient Safety Canada. “Often there is an invisible wall that goes up where little information is shared. Having patients and families participate in the development of the Toolkit and in incident management processes is helping to break down these barriers so there is greater understanding of what everyone needs to make the system safer at all levels.”

“Information sharing goes both ways,” adds Sharon Nettleton. “There is much that the system can learn from patients and families who have been involved in incidents. Communication is vital. Patients and families need to be included in the incident management process. After all it is the safety of our care that we are talking about here.”

The Toolkit will be updated annually. To provide feedback on what can be improved or to share resources to enhance the content, send an email to: For more information on the Toolkit, visit