|Creating a Safe Space: Addressing the Psychological Safety of Healthcare Workers||69221||Toolkits;Healthcare provider stories;Report||1/6/2020 4:59:11 PM||
Cumulative stress, compassion fatigue and trauma due to experiences with patient safety incidents impact the mental wellness of our healthcare providers. These factors contribute to inadvertent patient care errors, mental health issues and attrition which compromise patient safety. A peer support program not only simply helps healthcare workers with their experiences with patient safety incidents but also improves the system and help make patient care safe. The
Creating a Safe Space Addressing the Psychological Safety of Healthcare Workers manuscript and the
Canadian Peer Support Network are intended to assist healthcare organizations create peer-to-peer support programs (PSPs) to improve the emotional well-being of healthcare workers and allow them to provide the best and safest care to their patients.
Download The Creating a Safe Space Addressing the Psychological Safety of Healthcare Workers manuscript provides a comprehensive overview of what peer support is available in Canada and internationally. The Manuscript outlines best practice guidelines, tools, and resources that policy makers, accreditation bodies, regulators and healthcare leaders can use to assess the support needs of healthcare workers. The
Canadian Peer Support Network is intended as a forum for healthcare organizations seeking guidance in the development of their Peer Support Programs to assist providers who have experienced a patient safety incident.
The Canadian Peer Support Network is not intended as therapeutic support between, or amongst, members It is for informational purposes only. ||Creating a Safe Space: Psychological Safety of Healthcare Workers (Peer to Peer Support)||Cumulative stress, compassion fatigue and trauma due to experiences with patient safety incidents impact the mental wellness of our healthcare||3/11/2020 9:25:46 PM||2271||https://www.patientsafetyinstitute.ca/en/toolsResources||html||True||aspx|
|Education to support mandatory ADR and MDI reporting (Vanessa’s Law)||614||Report;Patient and Family Resource;Guide||3/4/2019 9:27:01 PM||
The Protecting Canadians from Unsafe Drugs Act, also known as Vanessa's Law, is intended to increase drug and medical device safety in Canada by strengthening Health Canada's ability to collect information and to take quick and appropriate action when a serious health risk is identified. As of December 16, 2019, it became mandatory for hospitals to report serious adverse drug reactions (serious ADRs) and medical device incidents (MDIs) to Health Canada. Downloadable from this
webpage are 4 PowerPoint modules developed in collaboration with
Health Canada. These modules contain core content intended for use by hospitals, health care
professionals, patients and their families, and educators, to explain,
describe, or promote the reporting of serious ADRs and MDIs. Module 1 – Overview of Vanessa's Law and Reporting Requirements
PowerPoint - Module 1
Module 2 – Reporting Processes to Health Canada
PowerPoint - Module 2
Module 3 – Strategies to Promote and Support Mandatory Reporting
PowerPoint - Module 3
Module 4 – Health Canada's Review and Communication of Safety Findings
PowerPoint - Module 4 These materials (as entire modules or as individual slides or selected content) can be used for individual learning or incorporated into presentations, orientation, continuing education, and other information-sharing activities. The materials can be used in the following ways to support and raise awareness of mandatory reporting requirements
Hospitals can include some or all of the content in their local, regional, and/or provincial information-sharing activities (e.g., "Lunch and Learn" sessions, presentations, orientation programs for new staff).
Educators in the health care sector can use the content in presentations or as part of a curriculum.
Professional associations, societies, and regulatory colleges, as well as other training institutions for health care workers, may incorporate the content of the modules into accredited courses or continuing education certification programs.
Patient and consumer organizations can help disseminate some or all of the information in the modules to increase awareness and knowledge among their members.
If you have questions about how to use these educational materials for your specific audience (e.g., selecting slides or content from several modules to create a customized presentation), please contact
ISMP Canada email@example.com
https//healthstandards.org/ CPSI firstname.lastname@example.org
If you have questions about Vanessa's Law and the mandatory reporting requirements, please contact
This conceptual model of serious ADR and MDI reporting by hospitals depicts the information provided in the 4 PowerPoint modules mandatory reporting requirements, reporting processes to Health Canada, strategies to promote and support reporting, and Health Canada’s review and communication of safety findings. ACKNOWLEDGEMENTS Health Canada, ISMP Canada, HSO, and CPSI gratefully acknowledge input received from the Advisory Panel (listed in alphabetical order)
Glenn Cox, Senior Director Pharmacy Services NSHA, Director Pharmacy Services, Cape Breton/Antigonish/Guysborough, Cape Breton Regional Hospital, Sydney, NS ;
Michael Gaucher, Director Pharmaceuticals & Health Workforce Information Services, Canadian Institute for Health Information, Ottawa, ON ;
Andrew Ibey – Clinical Engineer, Children's Hospital of Eastern Ontario, Ottawa, ON ;
Denis Lebel – Pharmacien, adjoint aux soins, enseignement et recherche, Département de pharmacie, CHU Sainte-Justine, QC ;
Dr. Joel Lexchin, Professor Emeritus, School of Health Policy & Management, York University, Toronto, ON ;
Faith Louis, Regional Manager, Quality Improvement & Support Services, Pharmacy Services, Horizon Health Network, NB;
Holly Meyer, Provincial Director, Product Quality & Safety, Alberta Health Services, AB ;
Maryann V. Murray, Patients for Patient Safety Canada;
Tolu Oyebode, Government of Saskatchewan, Senior Project Manager, Patient Safety Unit, Strategic Priorities Branch, Ministry of Health, SK ;
Sheryl Peterson, Associate Director, Lecturer, Faculty of Pharmaceutical Sciences, The University of British Columbia (Vancouver Campus);
Michelle Rossi, Director, Policy and Strategy, Health Quality Ontario, Toronto, ON ;
Myrella Roy, Executive Director, and
Cathy Lyder, Director Professional Practice, Canadian Society of Hospital Pharmacists, Ottawa, ON ;
Christelle Sessua, Quality Assurance-Risk Management Coordinator, Iqaluit Health Services, Department of Health, Government of Nunavut ;
Robyn Tamblyn, James McGill Chair, Professor, Department of Medicine, Department of Epidemiology & Biostatistics, McGill University, Scientific Director, Institute of Health Services and Policy Research, Canadian Institutes of Health Research, Montreal, QC ;
Annemarie Taylor, Executive Director, Patient Safety & Learning System, Vancouver, British Columbia ;
Terence Young, Chair of Drug Safety Canada and father of Vanessa Young. ||Educational Support for Mandatory Reporting of Serious ADRs and MDIs by Hospitals||The Protecting Canadians from Unsafe Drugs Act, also known as Vanessa's Law, is intended to||2/5/2020 4:12:48 PM||29248||https://www.patientsafetyinstitute.ca/en/toolsResources||html||True||aspx|
|Hand Hygiene Fact Sheets||78206||4/1/2020 2:15:32 PM||
Hand Hygiene Resources for Healthcare Providers, Patients and Families Cleaning your hands, either with soap and water or with alcohol-based hand rub, is one of the most effective ways to contain the spread of infections. Please read, download, and share these resources to help yourself and others stay safe. The World Health Organization designated May 5 as the day to shine a spotlight on hand hygiene with their campaign,
SAVE LIVES Clean YourHands. CPSI hosts
STOP! Clean Your Hands Day on May 5 to remind everyone to clean their hands on May 5 and every day.
The Need for Better Hand Hygiene in Healthcare
If Healthcare Provider Hands Could Talk
Proper Hand Hygiene Technique in Healthcare
How to Hand Wash (PDF)
How to Hand Rub (PDF)
Hand, Skin and Nail Care for Healthcare Providers
Your 4 Moments (PDF) On-the-Spot Feedback (PDF)
Patient and Family Guide
Patient and Family FAQs
Clean Care Conversations (PDF tip sheet for public)
Clean Care Conversations (PDF tip sheet for healthcare providers)
Additional Resources ||Hand Hygiene Fact Sheets||Hand Hygiene Resources for Healthcare Providers, Patients and Families Cleaning your hands, either with soap and water or with alcohol-based hand||4/3/2020 8:48:58 PM||273||https://www.patientsafetyinstitute.ca/en/toolsResources||html||True||aspx|
|Near-fatal medication error leads nurse to make patient safety a priority||43300||Healthcare provider stories||10/26/2017 7:43:16 PM|| More than 30 years have passed since the near-fatal medication error but Michael Villeneuve recalls the moment with absolute clarity. The little man on his shoulder was telling him 'wait a second, something is not right here,' but Villeneuve, then a cocky young nurse eager to keep pace with his colleagues in an Ontario intensive care unit, went ahead and administered the medication. The instant he did so, he knew exactly what he'd done right drug, wrong patient. Now the chief executive officer at the Canadian Nurses Association, Villeneuve frequently draws upon that experience in his day-to-day work to promote better care, better health and better nursing across the country. As a youngster, Villeneuve always dreamed of becoming a surgeon. His grandmother was a director of nursing in a small rural hospital and used to take him by the hand and lead him, spellbound, along with her as she did her rounds. His ambitions shifted slightly in high school after a family friend helped him get a job as an orderly at an Ottawa hospital. He was there less than an hour before he realized he was far more fascinated by what the nurses were doing than the doctors. "There was something about the competence of those women," Villeneuve recalls. "If you've been in an emergency department with certain women running the place, there's a kind of swagger and an attitude that's quite intoxicating when you're young. I just thought, 'I want to be like that.' That's where I ended up working in emergency intensive care, neurosurgery and so on, and never looked back. To this day, I would never change a second of it. "Except I wouldn't make the mistake." The mistake happened back in 1985. Two years after graduating nursing school Villeneuve had moved from a ward setting into a neurosurgical intensive care unit. He'd only been there a few weeks. At that time in the profession a male nurse was still something of a novelty and Villeneuve was eager to prove his worth. In that setting, an open ward with 12 beds, the pace is fast. Villeneuve remembers being so impressed by the confident execution and rapid thinking of the nurses around him. "When I think back to what happened, I do think some of it was trying to be better, faster maybe than I was, if you know what I mean." On the day of the incident, Villeneuve had two patients in his care — one with high potassium levels, the other with low potassium. The charge nurse took a call from a doctor, directing potassium be administered to one of his patients. She transcribed the order, called Villeneuve over and holding up the order sheet, instructed him to give medication A to patient B. It is something in that chain of events, a partially obscured order sheet, the utterance of one patient's name rather than the other, that sent Villeneuve to the wrong bedside. "I took the medication, which I had drawn up, potassium, and was about to give it to the patient and — this was a big lesson for me in my entire career — I thought, something was wrong," Villeneuve says. "I thought something was triggering me, something's wrong with this. What I didn't do was stop. I pushed it in, slowly, but pushed it in. It wasn't two seconds after I finished that I thought, oh, it's the wrong patient; it's the guy with the high potassium that I just overdosed with a whole bunch more potassium. Literally I nearly collapsed. I thought, my career's over, I'm going to lose my license, he's going to die." Villeneuve owned up to the error immediately and nurses and doctors swept in to attend to the patient, whose heart went into immediate distress. To make matters even worse, the patient was a senior physician himself. Villeneuve was so upset that his colleagues basically parked him in an adjacent staff lounge for the remainder of the day. "It's 32 or 33 years ago that that happened and it is still cemented in my mind, everything about the lighting in that room that day, the look of people around me, how I felt, what I learned about when the little man on your shoulder says, 'Slow down,' you should slow down before you hurt somebody," Villeneuve says. He views his experience as a perfect example of what is confirmed so often in medicine and nursing, which is that errors most often happen at points of handoff in care. "We see it in handoffs even in home care from registered nurses who provide plans of care and delegate care to a licensed practical nurse who may delegate that to a nursing assistant or a personal support worker and, a point of great error, onto families," Villeneuve says. "Because families provide a lot of care. So it's not just a critical care unit issue or a hospital issue; it's across the healthcare system. Points of handoff, and the more of them there are, the more chances that there are for an error." Villeneuve spent an entire second shift in that staff lounge that fateful day, panic-stricken about his patient, worried about his future, wracked by that "terrible fear of error" that hangs over nursing from graduation day onwards. But as the hours passed it eventually became clear the patient would survive. It was only then that Villeneuve had a chance to talk things over with his head nurse, who was wonderfully supportive. "I was expecting when she came in that I might be disciplined, I might be sent home. Her comment was, 'What did you learn?' " Villeneuve recalls, choking up at the memory. "She said, 'slow down.' One of the nurses I really looked up to was a nurse named Jennifer who was so competent. And she said, 'You're not Jennifer yet. Settle down. Stop. Double check.' All the things I knew I should've done. And it helped me reduce my ego, which was quite constrained after that incident." It was a major life lesson for him. When that little man on your shoulder says stop, it's like encountering the yellow light at the intersection. You shouldn't speed up, you should slow it down. Even now in my administrative roles, my teaching roles, if I sense something's wrong, I just say to people, 'I need a day to think about that.' I try to not make snap decisions and I think my decisions are better."|| More than 30 years have passed since the near-fatal medication error but Michael Villeneuve recalls the moment with absolute clarity. The||10/30/2017 10:07:37 PM||10231||https://www.patientsafetyinstitute.ca/en/toolsResources/HealthcareProviderStories/Pages/Forms/AllItems.aspx||html||False||aspx|
|Advocacy and support for use of a Surgical Safety Checklist||68992||Position Statements||2/5/2019 7:55:32 PM||Position StatementA Surgical Safety Checklist is smart for patients and smart for providers. It's use in Canadian healthcare facilities is endorsed by a
Position Statement supported by many surgical interest groups. Healthcare professionals must make every reasonable effort to provide safe care to their patients. The purpose of this statement is to express the commitment of the undersigned organizations to prioritize perioperative patient safety by creating an environment conducive to the effective adoption and use of a Surgical Safety Checklist.
||Advocacy and support for use of a Surgical Safety Checklist||Position Statement A Surgical Safety Checklist is smart for patients and smart for providers. It's use in Canadian healthcare facilities||2/5/2019 8:17:32 PM||1107||https://www.patientsafetyinstitute.ca/en/toolsResources||html||True||aspx|
|Tools & Resources||35066||3/25/2009 3:33:37 PM|| ||Tools & Resources||Tools & Resources||2/7/2020 6:54:52 PM||42864||https://www.patientsafetyinstitute.ca/en||html||True||aspx|
|Events||35071||Events||6/4/2015 6:09:31 AM|| ||Events||2/7/2020 6:34:43 PM||11569||https://www.patientsafetyinstitute.ca/en||html||True||aspx|
|Hand Hygiene Toolkit||38911||Guide;Toolkits||6/3/2015 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 .||7/19/2017 8:04:47 PM||5472||https://www.patientsafetyinstitute.ca/en/toolsResources/Pages/Forms/NewDefaultView.aspx||html||False||aspx|
|Conquer Silence – Ask the right questions about your medications||2248||Checklists;Patient and Family Resource||10/25/2019 4:05:46 PM||
Thank you for listening to stories and advice on reducing healthcare harm from real people at
ConquerSilence.ca. When any changes are made to your or your loved one’s medications (starting, stopping or changing doses) - especially when on multiple medications - there may be a risk of adverse drug reactions or errors.
The Canadian Patient Safety Institute has teamed up with the Institute for Safe Medications Practices Canada, Patients for Patient Safety Canada, the Canadian Pharmacists Association, and the Canadian Society for Hospital Pharmacists to create this list of questions to help you start a conversation about medications with your healthcare provider.
Together with your doctor, homecare nurse, or pharmacist, you can help Conquer Silence and keep yourself and your loved ones safe.
Download Sign up to for the Conquer Silence mailing list to be notified when we feature different patient safety issues, add new resources, and ask you to help us evaluate the effectiveness of this campaign. ||Thank you for listening to stories and advice on reducing healthcare harm from real people at
ConquerSilence.ca . When any changes are made to||10/25/2019 5:44:28 PM||1798||https://www.patientsafetyinstitute.ca/en/toolsResources/5-Questions-to-Ask-about-your-Medications/Pages/Forms/AllItems.aspx||html||False||aspx|
|Suicide Risk||36602||Guide;Publication||4/21/2011 4:02:20 AM||
We are pleased to announce that Dr. Chris Perlman, associate director, Homewood Research Institute, and his team are the successful recipients of Ontario Hospital Association (OHA) and Canadian Patient Safety Institute (CPSI) funding to develop an inventory and resource guide for assessing and preventing suicide risk.
Among its many accomplishments, Homewood Research Institute, located in Guelph, Ontario, was a lead organization in the development of mental health assessment systems, such as the Resident Assessment Instrument – Mental Health (RAI-MH), the interRAI Community Mental Health, and the interRAI Emergency Screener for Psychiatry.
The five-member team—Dr. Chris Perlman, Dr. John Hirdes, Dr. Lynn Martin, Dr. Eva Neufeld, and Ms. Mary Goy—includes researchers, policy analysts, and clinicians with more than 20 years of experience conducting health and policy research at the regional, provincial, national, and international levels. All team members have tremendous expertise in mental health research.
Dr. Perlman and his team will be working closely with the Advisory Group and with members of the OHA and CPSI to develop the inventory and resource guide. The innovative guide will be available by fall 2011.
||Inventory and Resource Guide Development for the Assessment and Prevention of Suicide Risk||We are pleased to announce that Dr. Chris Perlman, associate director, Homewood Research Institute, and his team are the successful recipients of||11/9/2016 5:59:18 PM||5020||https://www.patientsafetyinstitute.ca/en/toolsResources||html||True||aspx|
|Medication Safety at Care Transitions Safety Improvement Project Learning Collaborative||36608||1/15/2019 9:35:30 PM||Medication Safety at Care Transitions Safety Improvement Project – An 18 month learning collaborative
What is happening? The Canadian Patient Safety Institute launched its Medication Safety- Safety Improvement Project in April 2019. This learning collaborative approach is being, delivered by expert faculty and coaches, with mentoring provided over 18 months. Participating teams will learn and apply strategies to decrease readmissions related to medication safety issues at discharge among frail patients.Participating teams are Learning to identify Frail clients who are at risk for medication safety issues, Learning and applying new processes for medication management at discharge, Learning and utilizing Knowledge Translation and Implementation Science techniques to successfully implement and sustain new evidence-based practices for medication safety at transitions, Sharing key learnings and challenges, and networking with colleagues across Canada, Accessing, sharing and adopting advanced patient safety knowledge, tools, and resources within a learning network, Improving the team's approach to patient safety while taking action to deliver safer care.What is Medication Safety? Medications are the most common treatment intervention used in healthcare around the world. When used safely and appropriately, they contribute to significant improvements in the health and well-being of patients. Medication safety is defined as freedom from preventable harm with medication use (ISMP Canada, 2007). Medication safety issues can impact health outcomes, length of stay in a healthcare facility, readmission rates, and overall costs to Canada's healthcare system. For more information, contact email@example.com. ||Medication Safety at Care Transitions: Safety Improvement Project||Medication Safety at Care Transitions: Safety Improvement Project – An 18 month learning collaborative
What is happening? The Canadian||7/18/2019 7:37:13 PM||4034||https://www.patientsafetyinstitute.ca/en/toolsResources||html||True||aspx|
|Surgical Safety Checklist: Download||38957||Checklists||7/1/2015 8:56:47 AM||Getting Ready for Implementation
Adapt the checklist to your organization using human factors principles Download
How-To Guide for implementing the Surgical Safety Checklist A
Detailed Explanation of the Checklist Items An
Information, Rationale, and Frequently Asked Questions document
Surgical Safety Checklist - Canadian Version
The checklists below are Word documents with identical content. They are provided in portrait and landscape versions for easier integration into patient files or postings. If your organization is interested in measuring compliance, use the versions with a scorecard. We encourage you to adapt them for use in your organization. Surgical Safety Checklists - Scorecard
Surgical Safety Checklists - No Scorecard
LinksWorld Health Organization Safe Surgery Saves Lives
WHO Patient Safety Safe Surgery Saves Lives - the second global patient safety challenge Instructional VideosThese videos are intended to teach potential users how to and how not to perform the checklist in a real-world environment.
How to use the checklist
How NOT to use the checklist
How to use the checklist, complex caseReference Articles
Impact of using the checklist at the eight WHO pilot sites
Haynes AB, Weiser TG, Berry WB, et al. A surgical safety checklist to reduce morbidity and mortality in a global population. New England Journal of Medicine. 2009 Jan 14; [Epub ahead of print]. Retrieved from
The Canadian Adverse Events Study Baker GR, Norton P, Flintoft V, et al. The Canadian adverse events study the incidence of adverse events among hospital patients in Canada. CMAJ. 2004; 170 (11) 1678 - 1686. Retrieved from
Team behavior (information sharing during preoperative phases, briefing and infomration sharing during handoff) impacts the rate of surgical complications and death.
Mazzocco K, Petitti D, Fong K, et al. Surgical team behaviors and patient outcomes. The American Journal of Surgery. 2009, Volume 197, Issue 5, Pages 678-685.
Preoperative briefings have the potential to increase OR efficiency and thereby improve quality of care and reduce cost.
Nundy S, Mukherjee A, Sexton BJ, et al. Impact of preoperative briefings on operating room delays a preliminary report . Arch Surg. 2008 Nov;143(11)1068-72.
Team debriefings best practices and tips Salas E, Klein C, King H, et al. Debriefing medical teams 12 evidence-based best practices and tips. The Joint Commission Journal on Quality and Patient Safety. 2008 Sep;34(9)518-27.
Adapting the surgical checklist – requirements and implementation tips Verdaasdonk EGG, Stassen LPS, Widhiasmara PP, Dankelman J. Requirements for the design and implementation of checklists for surgical processes. Surg Endosc. 2009, 23 715-726
Prototype surgical checklist development and validation (the Netherlands) De Vries EN, Hollmann MW, Smorenburg SM, et al. Development and validation of the SURgical Patient Safety Sustem (SURPASS) Checklist. Qual Saf Health Care. 2009, 18 121-126
Interprofessional checklist briefings reduce the number of communication failures, promote proactive and collaborative team communication, and identifies patient safety problems. Lingard L, Regehr G, Orser B, et al. Evaluation of a Preoperative Checklist and Team Briefing Among Surgeons, Nurses, and Anesthesiologists to Reduce Failures in Communication. Arch Surg. 2008;143(1)12-17.
Large and sustained reduction of the catheter-related infections through an intervention program using a checklist Pronovost P, Needham D, Berenholtz S, et al. An Intervention to Decrease Catheter-Related Bloodstream Infections in the ICU. N Engl J Med 2006 355 2725-2732.||Implementation Resources||11/21/2018 5:37:37 PM||7634||https://www.patientsafetyinstitute.ca/en/toolsResources/Pages/Forms/NewDefaultView.aspx||html||False||aspx|
|STOP! Clean Your Hands Day||36689||Events||6/3/2015 4:46:05 PM||
May 5, 2020 #STOPCleanYourHandsDay Register today to receive updates, tools and resources to promote hand hygiene.
Register Now Whether you're a patient, visitor, provider, or worker in a healthcare setting – cleaning your hands is one of the best ways to prevent infection. Clean care saves lives. In acute care settings, infections will be the biggest driver of patient safety incidents in Canada, accounting for roughly 70,000 patient safety incidents per year on average – generating an additional $480 million per year on average in healthcare costs.1 Healthcare-associated infections (HAIs), or infections acquired in a healthcare setting, are the most frequently reported adverse events in healthcare delivery worldwide. Each year, hundreds of millions of patients are affected by HAIs, leading to significant morbidity and mortality and financial cost to healthcare systems.2 This year’s activities and resources will be announced soon.
Register today to receive updates!
More information about infection prevention and control is available on the
World Health Organization’s website.
1 https//www.patientsafetyinstitute.ca/en/toolsResources/case-for-investing-in-patient-safety/Pages/default.aspx2 https//www.who.int/gpsc/country_work/gpsc_ccisc_fact_sheet_en.pdf ||STOP! Clean Your Hands Day||May 5, 2020 #STOPCleanYourHandsDay Register today to receive updates, tools and resources to promote hand hygiene.
||4/3/2020 2:11:57 PM||39286||https://www.patientsafetyinstitute.ca/en/Events||html||True||aspx|
|Ventilator-Associated Pneumonia (VAP): Getting Started Kit||38961||Getting Started Kit||7/1/2015 8:57:36 AM||Effective March 14 2019, the Canadian Patient Safety Institute has archived the Ventilator-Associated Pneumonia (VAP) intervention.
Though you may continue to access the Getting Started Kit online, it will no longer be updated. 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 Annotated Bibliography
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 Text
Click here to download the full-colour intervention icon with text.
Click here to download the black and white intervention icon with text. ||VAP: Getting Started Kit||3/25/2019 8:23:06 PM||4694||https://www.patientsafetyinstitute.ca/en/toolsResources/Pages/Forms/NewDefaultView.aspx||html||False||aspx|
|Glossary||42267||5/15/2015 4:19:56 PM||This glossary is not intended to be an exhaustive list of terms, but rather a concise list of key terms used throughout the toolkit.
Actions (taken to reduce risk of harm) Actions taken to reduce, manage, or control any future harm, or probability of harm.
Alerts or advisories An alert or advisory is a piece of information that has been produced and publicly posted that outlines a specific type of patient safety incident or series of incidents that did occur or could occur.
Apology A genuine expression of sympathy or regret, a statement that one is sorry for what has happened. An apology includes an acknowledgement of responsibility if such responsibility has been determined after the analysis of the adverse event.
Authority gradient Balance of decision-making power or the steepness of command and hierarchy in a given situation.
Contributing factors A circumstance, action or influence which is thought to have played a part in the origin or development of an incident or to increase the risk of an incident.
Culture, Patient Safety 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.
Disclosure The process by which a patient safety incident is communicated to the patient by health care providers.
Early warning system A systemic process for evaluating and measuring risks early in order to take pre-emptive steps to minimize their impact.
Governance The body having accountability and legal responsibility for the overall performance of an organization and oversight of decisions.
Harm Impairment of structure or function of the body and/or any deleterious effect arising therefrom. Harm includes disease, injury, suffering, disability and death.
Hazard Situations with the potential to cause harm.
Healthcare organization An organization that provides health services in any healthcare sector.
High Reliability Organizations (HROs) Organisations that have few accidents despite operating in highly dynamic, technologically rich and hazardous industries.
Human Factors A discipline addressing human behaviour, abilities, limitations, and relationship to the work environment (physical, organizational, cultural), with the goal to promote efficiency, safety and effectiveness by improving the design of technologies, processes and work systems..
Incident Analysis A structured process that aims to identify 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 also referred to as system based analysis.
Incident Management The various actions and process required to conduct the immediate and ongoing activities following an incident. Incident analysis is a component of incident management.
Patient safety incident An event or circumstance which could have resulted, or did result, in unnecessary harm to a patient. There are three types of patient safety incidents
Harmful incident A patient safety incident that resulted in harm to the patient. Replaces "preventable adverse event”
Near miss A patient safety incident that did not reach the patient and therefore no harm resulted.
No-harm incident A patient safety incident that reached the patient but no discernible harm resulted.
Patient safety The pursuit of the reduction and mitigation of unsafe acts within the health care system, as well as the use of best practices shown to lead to optimal patient outcomes.
Patient A person who is receiving, has received, or has requested health care.
Family A person(s) whom the patient wishes to be involved with them in care, and acting on behalf of and in the interest of the patient.
Prospective analysis An analytical tool to assess and mitigate harm or loss by analyzing a situation or process that carries with it some inherent risk. Its purpose is to identify the way in which a process might potentially fail, with the goal to eliminate or reduce the likelihood or outcome severity of such a failure.
Providers Refers to physicians, professional, unregulated staff, and others engaged in the delivery of health services.
Quality Improvement (QI) A formal approach to the analysis of performance and systematic efforts to improve it. There are numerous models used.
Reporting The communication of information about a patient safety incident through appropriate channels inside or outside of healthcare organizations, for the purpose of reducing the risk of occurrence of patient safety incidents in the future.
Resilience The degree to which a system continuously prevents, detects, mitigates or ameliorates hazards or incidents so that an organization can “bounce back” to its original ability to provide core functions.
Risk management An organized effort to identify, assess and reduce, where appropriate, risks to patients, visitors, staff and organizational assets. Activities are undertaken to identify, analyze and educate, and to structure processes to reduce the likelihood of adverse events.
Risk mitigation The process of identifying and implementing precautions or controls that will most effectively reduce the consequence or likelihood of occurrence of a risk.
Risk The probability that a specific adverse event will occur in a specific time period or as a result of a specific situation.
System Levels Systems are generally viewed from various levels because they are differences in goals, structures and ways of working in different parts of the system.
System A health system, or healthcare system, is the sum of all the organizations, institutions, and resources whose primary purpose is to deliver health care services to meet the health needs of a target population.
Systems Thinking An approach that centers on the dynamic interaction, synchronization and integration of system components and sub-components (e.g. people, processes, technology, incentives, decisions, culture).
Team Two or more people who interact dynamically, interdependently, and adaptively toward a common and valued goal/objective/ mission. Patients/families are part of the team.
Teamwork Team members working together to achieve a shared goal.
Note to Quebec Readers
The toolkit was developed by and for English and French speaking Canadians and the terms used throughout were chosen by consensus. However, given the provisions contained in the Act Respecting Health Services and Social Services (R.S.Q., chapter S-4.2) effective in Quebec, various terms have been adapted. During the toolkit development we also consulted with Accreditation Canada to maintain consistency with the revised Disclosure and Incident Management Required Organizational Practices (2014) and the patient safety terminology used therein. Please make the necessary conversions when reading this toolkit text.
Terms used in the toolkit
Terms used in Quebec
Patient safety incident
Patient safety incident resulting from the provision of healthcare or social services
Accident with consequences for the user
No harm incident
Accident without consequences but the user was affected
Incident or near miss
Harmful incident, no harm incident, and near miss
||This glossary is not intended to be an exhaustive list of terms, but rather a concise list of key terms used throughout the toolkit.
Actions||7/13/2015 1:30:51 PM||3639||https://www.patientsafetyinstitute.ca/en/toolsResources/PatientSafetyIncidentManagementToolkit/Pages/Forms/AllItems.aspx||html||False||aspx|
|Additional Hand Hygiene Materials||38892||Toolkits;Guide||6/3/2015 4:46:57 PM||Still curious? Watch hand hygiene videos, find education opportunities, and learn more about general leadership, patient advocacy, and support materials.
Videos and Miscellaneous Links
The New England Journal of Medicine hand hygiene video.
Vital Smarts Hyrum Grenny's "All Washed Up" Video
Dude! Wash Your Hands! Video
Hand Hygiene Education Materials for Kids
Premier Safety Tools
Appreciative Inquiry Commons
Canadian Community Leadership Network
Positive Deviance Institute
The Conference Board of Canada
The Stuff of Heroes
Ted Ideas Worth Spreading
Patient Advocacy and Support
Advocare Consumer Advocare Network
Canadian Patient Safety Institute Patients for Patient Safety Canada
International Alliance of Patient's Organizations||Still curious? Watch hand hygiene videos, find education opportunities, and learn more about general leadership, patient advocacy, and support||9/1/2015 9:38:14 PM||2994||https://www.patientsafetyinstitute.ca/en/toolsResources/Pages/Forms/NewDefaultView.aspx||html||False||aspx|
|Central Line-Associated Bloodstream Infection (CLABSI): Getting Started Kit||38897||Getting Started Kit||7/1/2015 8:51:29 AM|| Effective March 14 2019, the Canadian Patient Safety Institute has archived the Central Line-Associated Bloodstream Infection (CLABSI) intervention. Though you may continue to access the Getting Started Kit online, it will no longer be updated. 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 Kit||3/25/2019 8:12:35 PM||5116||https://www.patientsafetyinstitute.ca/en/toolsResources/Pages/Forms/NewDefaultView.aspx||html||False||aspx|
|Atlantic Learning Exchange||36691||Events||9/20/2016 6:01:00 PM||
Discover innovative and emerging trends in patient safety & quality improvement
October 8 – 9, 2019 St. John's, NL, The Atlantic Health Quality and Patient Safety Collaborative (AHQPSC), through partnership support of the Canadian Patient Safety Institute (CPSI), welcomes you to attend this year's Atlantic Health Quality & Patient Safety Learning Exchange (ALE 2019) which will take place at the Sheraton Hotel Newfoundland, St. John's, NL,
October 8 – 9, 2019.
Program Who should attend? We look forward to welcoming innovative and engaged care providers, managers, health leaders, academics and students from university and college setting, as well as government representatives from the four Atlantic Provinces in attendance this year. Tickets are limited! Through this conference, you will be given an opportunity to Mobilize energy and enthusiasm for a new era of patient safety and quality improvement; Understand the role innovation and technology play in healthcare improvement; Stimulate change through the power of the patient voice; and Develop the skills for leading transformational change!
Registration $275 Student Registration $199*
*Spaces are limited for student registration. Student ID is required. Conference fees include full conference with light breakfast and lunch provided.Venue & Hotel Accommodations
The conference will be taking place at the
Sheraton Hotel Newfoundland located at 115 Cavendish Square in St. Johns Newfoundland.
For guests that require accommodations, a room block has been reserved for attendees at the Sheraton Hotel Newfoundland starting at $164 a night for a standard room.
Guests can use the booking link below or can call/email to do reserve a room for the conference. When booking via phone or email use reference code “Atlantic Learning Exchange”.
firstname.lastname@example.org Call Local 709-726-4980 or Toll Free 1-888-870-3033
Book Hotel Room Now Partners
Do you want to support this event? Do you want exclusive access to the front line of healthcare in the Atlantic provinces? We are looking for Sponsors and Exhibitors contact Gina Peck at 902-481-5034 or
email@example.com to receive more information on sponsorship and exhibiting at the conference. ||Atlantic Quality and Patient Safety Learning Exchange||Discover innovative and emerging trends in patient safety & quality improvement
October 8 – 9, 2019 St. John's, NL, The Atlantic Health||10/2/2019 3:07:21 PM||9187||https://www.patientsafetyinstitute.ca/en/Events||html||True||aspx|
|A Policy Framework for Patient Safety in Canada||64701||Framework;Publication;Report||11/29/2019 5:15:21 PM|| Patient Safety Right Now, the Canadian Patient Safety Institute’s (CPSI) 2018-2023 strategy defines a vision that “Canada has the safest healthcare in the world.” CPSI’s mission is “to inspire and advance a culture committed to sustained improvement for safer healthcare.” CPSI develops system-wide strategies to ensure safe healthcare in two ways by demonstrating what works to improve safe care in Canada, and by strengthening commitment to patient safety priorities among all healthcare stakeholders. It has, however, become clear that not only are more robust commitments required to advance patient safety in Canada, but health systems need additional evidence and support to complete end-to-end patient safety improvements and to measure and sustain results. To this end, CPSI drafted the Strengthening Commitment for Improvement Together A Policy Framework for Patient Safety (Figure 1) to stimulate conversation and action on the following policy levers legislation, regulations, standards, organizational policies and public engagement.
Figure 1 Policy Framework for Patient Safety in Canada
Moving the needle on patient safety in Canada requires an overall shift in culture, values and expectations at all levels of the health system and the active engagement of various policy actors. CPSI recommends that the Policy Framework be used as a conceptual guide to implement and evaluate the policy levers and to systematically share what we have learned with others. The next steps in Canada are clear. People in Canada need policies that support patient safety, be it at the level of health care organizations, or by governments. These policies must incorporate patient safety competencies and adhere to accreditation standards that promote safe care. Whether you are a policy maker, healthcare leader, administrator, provider, or member of the public, you can help us achieve our goal.||A Policy Framework for Patient Safety in Canada||Patient Safety Right Now, the Canadian Patient Safety Institute’s (CPSI) 2018-2023 strategy defines a vision that “Canada has the safest healthcare||12/11/2019 10:35:18 PM||1341||https://www.patientsafetyinstitute.ca/en/toolsResources||html||True||aspx|
|A Framework for Establishing a Patient Safety Culture||36622||Framework||2/14/2018 4:54:19 PM||Patient Safety Culture "Bundle" for CEOs/Senior Leaders What is the Patient Safety Culture "Bundle"? Strengthening a safety culture necessitates interventions that simultaneously
enable, enact and elaborate in a way that is attuned to the existing culture. Through a literature review of more than 60 resources, a Patient Safety Culture Bundle has been created and validated through interviews with Canadian thought leaders. The Bundle is based on a set of evidence-based practices that must all be applied in order to deliver good care. All components are required to improve the patient safety culture. The
Patient Safety Culture "Bundle" for CEOs and Senior Leaders encompasses key concepts of safety science, implementation science, just culture, psychological safety, staff safety/health, patient and family engagement, disruptive behavior, high reliability/resilience, patient safety measurement, frontline leadership, physician leadership, staff engagement, teamwork/communication, and industry-wide standardization/alignment.
Download a one-pager of the Patient Safety Culture Bundle for CEOs/Senior Leaders
Why was this Bundle created? A patient safety culture is difficult to operationalize. Improving safety requires an organizational culture that enables and prioritizes patient safety. The importance of culture change needs to be brought to the forefront, rather than taking a backseat to other safety activities. The National Patient Safety Consortium Education Working Group verified the critical role senior leadership plays in ensuring patient safety is an organizational priority. A Working group of partners, led by the Canadian Patient Safety Institute, Canadian College of Health Leaders (CCHL), HealthCareCAN and the Healthcare Insurance Reciprocal of Canada (HIROC) were brought together to establish a framework and advance this work. How can I use the Patient Safety Culture Bundle? The key components required for a Patient Safety Culture are identified under three pillars
Within each pillar you will find links to valuable tools and resources to help your efforts in establishing and sustaining a patient safety culture.
(coming soon)Are you looking to establish and sustain a culture of safety? We are committed to providing a robust framework to advance a safety culture. The Bundle is a dynamic tool that will be continually updated. We invite you to check back often for more links and resources. We also need your participation and input to ensure the Bundle is current and relevant. Please forward any links or comments to
"Patient safety and healthcare quality are advanced when boards and senior leaders are committed to it and are able to show evidence of that commitment. Missing until now is a concise "how to" guide. The Patient Safety bundle for Leaders fills that gap."
Catherine Gaulton, CEO, HIROC
"Leadership is critical to developing a patient safety culture and building leadership capacity requires a vision of the knowledge, skills and behaviours necessary to achieve this. The Patient Safety Leadership Bundle provides this and will be a practical tool for health leaders across the healthcare continuum to assess their personal capabilities. It will also provide both organizations and the system, as a whole, a checklist for what's missing from our collective leadership education toolkits so that we can strategically respond to these needs. HealthCareCAN is committed to the spread of this tool across the country as part of a cultural shift to safety and a drive towards high-reliability culture."
Dale Schierbeck, Vice-President, Learning & Development, HealthCareCAN and Co-Chair, Patient Safety Education for Leaders Working ||A Framework for Establishing a Patient Safety Culture||Patient Safety Culture "Bundle" for CEOs/Senior Leaders What is the Patient Safety Culture "Bundle"? Strengthening a safety||4/4/2019 2:29:25 PM||8812||https://www.patientsafetyinstitute.ca/en/toolsResources||html||True||aspx|
|Patient Stories||36635||7/27/2015 12:39:48 PM|| ||Patient Stories||12/20/2019 8:49:01 PM||12976||https://www.patientsafetyinstitute.ca/en/toolsResources||html||True||aspx|
|Patient Safety Metrics||36638||Metrics||7/9/2015 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 firstname.lastname@example.org 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 email@example.com 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 & Measurement||3/31/2020 2:35:21 PM||7295||https://www.patientsafetyinstitute.ca/en/toolsResources||html||True||aspx|
|Canadian Patient Safety Week (CPSW)||36688||Events||12/8/2009 9:50:43 PM||Welcome to your home for Canadian Patient Safety Week! #ConquerSilence Canadian Patient Safety Week runs October 28 to November 1, 2019. The Canadian Patient Safety Institute invites all Canadians – the public, providers and leaders – to become involved in making patient safety a priority. Printed packages are available for order while supplies last and include posters, buttons, other promotional materials, plus tips and resources for running a terrific CPSW event at your organization! Quantities are limited – 500 English packages and 100 French packages. Click HERE to be directed to the online store.
Conquer Silence At some point, every one of us will be a patient in the healthcare system. What most Canadians don’t realize, is that 28,000 of us die from preventable harm when receiving care, every single year. This makes patient safety incidents the third leading cause of death in Canada, behind cancer and heart disease. One in three Canadians has had patient harm affect themselves or a loved one, yet the public is collectively unaware that the problem exists. This is a silent epidemic. If we do nothing, 1.2 million Canadians will die from preventable patient harm in the next 30 years. What we must battle in our collective efforts to reduce patient harm, is systemic silence. Silence between patients and providers, between colleagues in healthcare facilities, between administrators in different regions, and between the public and policymakers. If something looks wrong, feels wrong, or is wrong – we need people to speak up, in the moment. It is only by bringing these issues to light that we can begin to work together to solve them. During this year’s Canadian Patient Safety Week, join us in sharing your story and your advice on how to reduce patient harm at ConquerSilence.ca. Canadian Patient Safety Week EventsShare your patient safety story and your advice on how to reduce harm at conquersilence.ca New episode of our award winning PATIENT podcasts
Creating a Safe Space Webinar
Mandatory Reporting (Protecting Canadians from Unsafe Drugs Act) Webinar Please explore the Canadian Patient Safety Week links for Tools & Resources, including our upcoming communications toolkit and tools to improve patient safety. Discover stories of overcoming silence in our award-winning podcast series, PATIENT. We will continue to add new content. 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 Conquer Silence. Sponsors
Sponsorship The Canadian Patient Safety Institute invites you to join our network of Canadians – the public, healthcare providers and healthcare leaders – in making patient safety a priority. If your organization is interested in sponsoring CPSW 2019, please contact
Do you have any questions or suggestions? Contact CPSI CommunicationsPhone (780) 409-8090 Toll free 1-866-421-6933
CPSW@cpsi-icsp.ca Join the conversation at
#ConquerSilence ||Canadian Patient Safety Week||Canadian Patient Safety Week (CPSW)||1/31/2020 10:25:12 PM||60519||https://www.patientsafetyinstitute.ca/en/Events||html||True||aspx|
|Patient safety and the power of one||48762||News;Patient and Family Resource;Patient Stories||2/27/2017 4:22:29 PM||2/27/2017 7:00:00 AM|| Barb Farlow is living proof that a single, dedicated person can make a difference, as she champions positive change in a health care system that failed her family. When the day came that Barb Farlow decided she had to make a stand for patient rights in Canada, she initially balked at the challenge ahead of her. What could a single individual hope to do, she wondered, in the face of all that impenetrable hospital bureaucracy and unimpeachable medical expertise? But Farlow pressed ahead anyway, digging for information, demanding answers, and in October 2006, she proudly participated in the founding Vancouver conference of Patients for Patient Safety Canada. Ten years have passed since she came out of that conference as one of Canada's original patient safety champions, but Farlow remains just as committed today to advocacy work for patients and their families. Like so many others, her bond with patient safety was forged by a shattering experience at the hospital. In August 2005, Barb and her husband Tim were struggling to understand the circumstances surrounding the death of their infant daughter, Annie. Annie, was born with a genetic abnormality with a range of outcomesgenerally associated with medical complexity and significant disability, and , had died within 24 hours of being rushed to the children's hospital. "The doctors were not open with us about their perspective and plan of care," Farlow says, thinking back to that confusing, agonizing experience. "We were very clear about what we hoped for. We certainly didn't want to go to any point where our daughter would incur suffering without any benefits. We had a great relationship, or so we thought, with the doctors. We realized that at some point we would likely opt for palliative care but we would then be at peace to know that we had considered medical care and determined with the doctors that it wasn't in Annie's best interest. So I think we were quite balanced and rational. "Reflecting on the experience, we believe that Annie's doctors didn't appreciate that some children survive and live a happy, though disabled, life and automatically limited care options. Tragically, Annie died at the age of 80 days shortly after arrival for respiratory distress. We came to discover that a do-not-resuscitate order had been placed in her chart without our knowledge or consent. We're not really sure why Annie suddenly declined because some of her final records are missing." The coroner who reviewed the case, said the final care provided had been inappropriate, and the hospital apologized for poor communication. But the entire experience left the Mississauga couple still looking for answers. "I couldn't figure out what we'd done wrong and I realized the doctors just didn't see things from our perspective at all," Farlow recalls. "It wasn't just one misunderstanding by a single doctor, it was a system that didn't understand our perspective. I just felt it was wrong and couldn't walk away from it." The aim of Patients for Patient Safety is to establish a global network of patients and family members affected by health care errors to collaborate with health care organizations to improve the quality of patient care. Farlow acquired her champion credentials, but again, as just one person, the prospects of affecting change seemed daunting. She feared that her perspective and desire to improve communication might be dismissed as merely the ramblings of a bereaved mother.. What Farlow soon found, though, was that her affiliation with the Canadian Patient Safety Institute made all the difference in the world. "What I found, was that being associated with the Institute gave me confidence to believe I could make a difference. Also, because there is an application process and required patient safety education involved in becoming a member of Patients for Patient Safety Canada, I believe I was viewed as a more credible person by the health care community and one with whom they could partner. She started reaching out, networking, seeking some way to share her experiences so that other patients and their families might avoid the same ordeal. Eventually she was invited by the Canadian Paediatric Society to write a narrative about her family's experience and that paper was published in the society's journal. That big step enabled her to make another and another and soon she was attending patient safety conferences and speaking at ethics symposiums and contributing more to the medical literature on the issue of vulnerable babies being judged and dismissed within the health system. "One of the things it's caused me to realize is that when you take a rational, calm approach, people will listen to you and partner with you to make effective improvements." Farlow adds, "indeed, even a single person who is determined to make a difference can, with the right attitude, make that difference. "I've really been amazed at how many good people there are in the system. , I've come to forgive and appreciate the physicians involved in my daughter's care, and realize that they were well-meaning, but misguided. They didn't act in a malicious way. They thought they were doing the right thing but their actions were based on many assumptions that were not evidence-based. The research I partnered to undertake and publish has complemented the literature with this necessary evidence." Farlow has welcomed a gradual patient-centred shift in the health care culture in recent years, a change in attitudes that now sees patients regularly sitting on health committees and an expansion of hospital family advisory councils. She's also greatly encouraged by efforts from organizations like the Canadian Institute of Health Research in developing new patient-centred research. "This direction is all based on the realization that providers can't know everything and do everything to deliver optimal health care to people. They have to consider the end user and deliver care with patients." That remains her fundamental message to health care providers everywhere "Listen to the patient, learn from the patient, include the patient." Looking back at her time with Patients for Patient Safety Canada, Farlow says she has come to appreciate that there's an undeniable power derived from having experienced an adverse medical event. "Our group provides a patient's voice to many areas that often doesn't relate at all to our personal experience. But when you have a personal experience there's this added energy. When something happens that shouldn't have happened, you have enough energy to move a mountain. The ability to productively channel that energy and be an incredible catalyst for change."||Barb Farlow is living proof that a single, dedicated person can make a difference, as she champions positive change in a health care system that||4/19/2017 5:04:51 PM||413||https://www.patientsafetyinstitute.ca/en/NewsAlerts/News/Pages/Forms/AllItems.aspx||html||False||aspx|
|Fall Prevention Tip Sheets||306||2/3/2020 6:40:35 PM||Falls and injuries from falls are significant health concerns in Canada and critical issues in healthcare safety.1 Falls account for up to 40% of inpatient incidents.40 to 60% of residents in long-term care facilities fall at least once a year.2
Falls can result in longer lengths of stay, increased health care cost and staff workload, and staff and family distress. Approximately 50% of patients sustaining an in-hospital hip fracture die within one year of the fracture.3 Direct health care costs for falls in Canada are estimated at $2 billion annually.4
The Canadian Patient Safety Institute has a variety of tools to help healthcare providers deliver safer care and support members of the public to partner with their providers to create safer care.
1 Accreditation Canada, Canadian Institute of Health Information, & Canadian Patient Safety Institute. (2014). Preventing Falls From Evidence to Improvement in Canadian Health Care. Ottawa, ON Canadian Institute for Health Information.
2 Feldman, F., Flintoft, V., & Freund-Heritage, R. (2015, February 26). April 2015 is Falls Quality Audit Month What you Need to Know to Participate. Canadian Patient Safety Institute & Registered Nurses’ Association of Ontario.
3 Feldman, F., Flintoft, V., & Freund-Heritage, R. (2015, February 26). April 2015 is Falls Quality Audit Month What you Need to Know to Participate. Canadian Patient Safety Institute & Registered Nurses’ Association of Ontario.
4 Accreditation Canada, Canadian Institute of Health Information, & Canadian Patient Safety Institute. (2014). Preventing Falls From Evidence to Improvement in Canadian Health Care. Ottawa, ON Canadian Institute for Health Information.
https//www.patientsafetyinstitute.ca/en/toolsResources/Documents/Interventions/Reducing%20Falls%20and%20Injury%20from%20Falls/FallsJointReport_2014_EN.pdf ||Fall Prevention Tip Sheets||Falls and injuries from falls are significant health concerns in Canada and critical issues in healthcare safety. 1 Falls account for up||2/11/2020 8:30:04 PM||589||https://www.patientsafetyinstitute.ca/en/toolsResources||html||True||aspx|
|Home Care Safety||36594||Report;Research;Toolkits||6/5/2014 8:48:12 PM||
With the release of the Safety at Home A Pan- Canadian Home Care Study (2013), the Canadian Patient Safety Institute (CPSI) and the Canadian Home Care Association (CHCA) worked with the research team to translate the knowledge acquired from the study into tools, resources and programs for the field. Click on the following links to access resources available to home care providers, clients and families, and policy makers.
Resources for home care providers
Resources for family caregivers and clients
Resources for policy makers and academics
||Home Care Safety||With the release of the Safety at Home: A Pan- Canadian Home Care Study (2013) , the Canadian Patient Safety Institute (CPSI) and the||6/29/2016 8:24:53 PM||2755||https://www.patientsafetyinstitute.ca/en/toolsResources||html||True||aspx|
|Improvement Frameworks Getting Started Kit||36595||Toolkits;Getting Started Kit;Framework||11/24/2011 4:21:24 PM||12/2/2015 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 Kit||The Improvement Frameworks Getting Started Kit is intended to serve as a common document appended to the Safer Healthcare Now! Getting Started||1/5/2016 6:18:07 PM||4908||https://www.patientsafetyinstitute.ca/en/toolsResources||html||True||aspx|
|Patient Safety and Incident Management Toolkit||36596||Toolkits||12/18/2014 8:28:40 PM||Prevent 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
System Factors For more information, contact us at
firstname.lastname@example.org.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 included Assigning a CPSI team with support from a writer with experience in the field Seeking advice from an expert faculty that included patient and family representatives Basing the content on the Canadian Incident Analysis Framework Engaging 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 email@example.com.||Patient Safety and Incident Management Toolkit||Prevent 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||6/19/2017 4:19:43 PM||11072||https://www.patientsafetyinstitute.ca/en/toolsResources||html||True||aspx|
|Canadian Framework for Teamwork and Communication||36597||Publication;Framework||7/22/2009 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 Communication Appendix A
Teamwork and Communication in Healthcare A Literature Review Appendix B
Consultation with Health Professionals and Administrators Regarding Teamwork and Communication Appendix C Report on Summary of Team Training Programs
||Canadian Framework for Teamwork and Communication||Effective Teamwork and Communication to Enhance Patient Safety||11/9/2016 8:44:39 PM||7376||https://www.patientsafetyinstitute.ca/en/toolsResources||html||True||aspx|
|The Safety Competencies Framework||36599||Publication;Framework||4/14/2009 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.
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
firstname.lastname@example.org.||The Safety Competencies||The Safety Competencies: Message from the CEO||9/12/2017 8:43:40 PM||16814||https://www.patientsafetyinstitute.ca/en/toolsResources||html||True||aspx|