|Measures: Ventilator-Associated Pneumonia (VAP)||10529||Infection Prevention ＆ Control (IPAC)||Toolkits ＆ Guides||7/1/2015 8:57:33 AM|| Measurement is essential to monitoring success and helps guide your team towards your specific intervention goal. Measurement also tells us what's working and what's not, and provides evidence to inspire other healthcare providers to improve the quality of patient safety. The measurement methodology and recommendations regarding sampling size referenced in this GSK, is based on The Model for Improvement and is designed to accelerate the pace of improvement using the PDSA cycle; a "trial and learn" approach to improvement based on the scientific method. Langley, G., Nolan, K., Nolan, T., Norman, C., Provost, L. The Improvement Guide A Practical Approach to Enhancing Organizational Performance. San Francisco, Second Edition, CA. Jossey-Bass Publishers. 2009. It is not intended to provide the same rigor that might be applied in a research study, but rather offers an efficient way to help a team understand how a system is performing. When choosing a sample size for your intervention, it is important to consider the purposes and uses of the data and to acknowledge when reporting that the findings are based on an "x" sample as determined by the team. The scope or scale (amount of sampling, testing, or time required) of a test should be decided according to The team's degree of belief that the change will result in improvement The risks from a failed test Readiness of those who will have to make the change Provost, Lloyd P; Murray, Sandra (2011-08-26). The Health Care Data Guide Learning from Data for Improvement (Kindle Locations 1906-1909). Wiley. Kindle Edition. Please refer to the
Improvement Frameworks GSK (2015) for additional information.VAP Measures
Type VAP 1 - VAP Rate in ICU per 1000 Ventilator Days Decrease 50% Outcome VAP 2 - VAP Bundle Compliance 95% Process VAP 3 - Paediatric VAP Bundle Compliance 95% Process
Measures and definitions Types of Measures
Safer Healthcare Now! (SHN) has two types of measures for each of the interventions process measures and outcome measures. Some interventions also have balancing measures and information measures. Below are examples of each.
Outcome measures - answers whether the team is achieving what it is trying to accomplish and articulates the picture of success. For example, if the team wants to reduce falls it should measure the number of falls.
Process measures - Processes which directly affect the outcome are measured to ensure that all key changes are being implemented to impact the outcome measure. For example, the delivery of timely prophylactic antibiotics to reduce surgical site infection.
Balancing measures - answer the question whether improvements in one part of the system were made at the expense of other processes in other parts of the system. For example, in a project to reduce the average length of stay for a group of patients, the team should also monitor the percent of readmissions within 30 days for the same group.
Information measures - collect general details relative to the intervention.||VAP: Measurement Worksheets||9/24/2020 8:15:22 AM||13141||https://www.patientsafetyinstitute.ca/en/toolsResources/psm/Pages/Forms/UpdateData.aspx||html||False||aspx|
|Hand Hygiene Fact Sheets||2654||Infection Prevention ＆ Control (IPAC)||Toolkits ＆ Guides;Tip Sheets||4/1/2020 2:15:32 PM||Visit the new home for hand hygiene resources on the Healthcare Excellence Canada website.
Check it out
||Hand Hygiene Fact Sheets||Visit the new home for hand hygiene resources on the Healthcare Excellence Canada website.
Check it out||5/14/2021 3:21:23 PM||19329||https://www.patientsafetyinstitute.ca/en/toolsResources||html||True||aspx|
|Tools & Resources||2502||9/18/2020 4:40:20 AM||Tools & Resources||Tools & Resources||9/21/2020 9:19:04 AM||79570||https://www.patientsafetyinstitute.ca/en||html||True||aspx|
|Surgical Site Infection (SSI): Getting Started Kit||6205||Surgical Care Safety;Infection Prevention ＆ Control (IPAC)||Toolkits ＆ Guides||7/1/2015 8:55:00 AM||Effective March 14 2019, the Canadian Patient Safety Institute has archived the Surgical Site Infection (SSI) 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 summary of changes to the Getting Started Kit
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. ||SSI: Getting Started Kit||9/24/2020 8:12:12 AM||13877||https://www.patientsafetyinstitute.ca/en/toolsResources/Pages/Forms/NewDefaultView.aspx||html||False||aspx|
|Canadian Quality and Patient Safety Framework for Health Services||2639||General Patient Safety;Policy;Government Relations;Improving Culture;Partnering with Patients;Patient ＆ Family Resources||Frameworks;Patient and Family Resource;Position Statements;Reports ＆ Publications||3/27/2019 7:47:40 PM||
The need for a national patient safety and quality framework Health services across Canada are comprehensive, complex, and at times complicated. Every person in Canada deserves safe, high-quality healthcare when and where they need it. For the most part, this is our experience. But we don't always get it right. People may be inadvertently harmed by the services intended to help them. The reality is that unintended harm occurs in a Canadian hospital or home care setting every 1 minute and 18 seconds Every 13 minutes and 14 seconds, someone dies Patient safety incidents are the third leading cause of death in Canada Even more, there are significant variations in care by age, gender, race/ethnicity, geography and socio-economic status. Access to quality health services is more challenging for Indigenous peoples, (including First Nations, Inuit and Métis), Black people, LQBTQ2S+ identities (including Lesbian, Gay, Bisexual, Transgender, Queer or Questioning and Two-Spirit), immigrants, visible minorities, and many more diverse peoples that comprise our country. While some jurisdictions have quality and safety plans or frameworks in place, people continue to experience healthcare differently across the country. These considerations, when added to the heightened need for consistency and coordination in healthcare due to the COVID-19 pandemic, prompt us to ask How can we focus and align quality and safety improvement throughout the country, regardless of jurisdiction?
The Canadian Quality and Patient Safety Framework for Health Services is the first of its kind in Canada. We can all work together to accelerate quality and patient safety across Canadian health systems by focusing all stakeholders across Canada on five goals for safe, quality care. This people-centred
framework defines five goal areas designed to drive improvement and to align Canadian legislation, regulations, standards, organizational policies, and public engagement on patient safety and quality improvement. It includes action guides and resources customized for each stakeholder group to support you in putting the goals into practice.
Download the Framework
How to use the Framework
Be sure to take full advantage of all the
communications tools and resources in this package
Download the Communication Toolkit Leading Practice How have you used the Canadian Quality and Patient Safety Framework to drive quality and safety improvements? Please email
email@example.com and share your experience with us for an opportunity to be profiled as a Leading Practice or a case study.Evaluation Survey How is the Canadian Quality and Patient Safety Framework helping you align with Canada on five goals for quality, safe care? Heathcare Excellence Canada and Health Standards Organization welcome your feedback (10 min survey)
Mapping Tool A mapping tool was developed to help you map your organization's current quality and patient safety improvement initiatives to the goals, objectives, and outcomes of the Framework. This exercise will help demonstrate your organization's strengths in aligning with the Framework and uncover opportunities to work toward these key goals for safe, high-quality care.
Framework Mapping Tool
For any questions, comments or to share your experience using the Framework, please contact firstname.lastname@example.org.
Contact us || Why does Canada need a National Quality and Patient Safety Framework for Health Services?||The need for a national patient safety and quality framework Health services across Canada are comprehensive, complex, and at times complicated.||6/21/2021 7:31:24 PM||29445||https://www.patientsafetyinstitute.ca/en/toolsResources||html||True||aspx|
|Surgical Safety Checklist: Download||6207||Surgical Care Safety;General Patient Safety||Toolkits ＆ Guides||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 information 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||9/24/2021 3:29:49 PM||20341||https://www.patientsafetyinstitute.ca/en/toolsResources/Pages/Forms/NewDefaultView.aspx||html||False||aspx|
|World Patient Safety Day||2588||General Patient Safety||Events||8/31/2020 8:43:30 PM||
Visit the World Patient Safety Day new home page on the Healthcare Excellence Canada website for the 2021 campaign.
Check it out
Below are details from the 2020 World Patient Safety Day campaign.
Premiere of Building a Safer System Thank you for joining us for World Patient Safety Day! Thank you for joining us for the live streaming of Building a Safer System, the documentary celebrating Canadian Patient Safety Institute's 17-year impact on Canada's healthcare system.
#BuildingaSaferSystem In case you missed it, the documentary is available on our
The CPSI Legacy Celebration On September 17th, former staff members, colleagues, and supporters of CPSI gathered to re-connect and celebrate the organization on the Remo conferences platform. A panel of CEOs discussed the future of patient safety, and Donna Davis of Patients for Patient Safety Canada powerfully represented the patient voice. Click below to view the recording of the panel discussion and the closing keynote remarks
World Health Organization The COVID-19 pandemic has unveiled the huge challenges and risks health workers are facing globally including health care associated infections, violence, stigma, psychological and emotional disturbances, illness and even death. Furthermore, working in stressful environments makes health workers more prone to errors which can lead to patient harm. Therefore, on World Patient Safety Day 2020
Theme Health Worker Safety A Priority for Patient Safety
Slogan Safe health workers, Safe patients
Call for action Speak up for health worker safety!
World Patient Safety Day information
Sponsored by With special thanks to our generous sponsors – together we are making positive and lasting change. Platinum Gold (in alphabetical order)
||World Patient Safety Day: September 17, 2021||Visit the World Patient Safety Day new home page on the Healthcare Excellence Canada website for the 2021 campaign.
Check it||9/15/2021 1:34:34 PM||18777||https://www.patientsafetyinstitute.ca/en/Events||html||True||aspx|
|Clean Your Hands Day||2592||Infection Prevention ＆ Control (IPAC)||Events||6/3/2015 4:46:05 PM|| Visit Clean Your Hands Day new home page on the Healthcare Excellence Canada website.
Check it out
||Clean Your Hands Day||Visit Clean Your Hands Day new home page on the Healthcare Excellence Canada website.
Check it out||5/14/2021 3:20:35 PM||96319||https://www.patientsafetyinstitute.ca/en/Events||html||True||aspx|
|Canadian Patient Safety Week (CPSW)||2590||General Patient Safety||Events||12/8/2009 9:50:43 PM|| The theme for this year’s Canadian Patient Safety Week will be announced soon. The campaign will be hosted on the new Healthcare Excellence Canada website.
Check it out
Below are details from the 2020 Canadian Patient Safety Week campaign.
Virtual Care is New to Us #ConquerSilence
Thank you to everyone who participated in Canadian Patient Safety Week from October 26 to 30, 2020. Let’s Keep the Momentum Going
The theme of Canadian Patient Safety Week 2020 was Virtual Care is New to Us. Only 10% of Canadians have experience with virtual care1, but 41% would like to have virtual visits with their healthcare providers2.
The way to ensure that healthcare providers and patients make the most of virtual appointments is to use tried and true basics – encourage patients to ask questions and to bring an advocate with them to appointments.
Although Canadian Patient Safety Week 2020 has passed, virtual care is here to stay! Please continue to access and share the virtual care resources below.Virtual Care Resources – ConquerSilence.ca
Access valuable resources for you, your colleagues, and your patients to improve virtual care appointments. We worked with the Canadian Medical Association to develop a WEBside manner infographic for healthcare providers, plus two virtual care checklists and a how to make the most of your virtual visit infographic for patients.
Access Now PATIENT Podcast Series Listen to season 4 of our award-winning PATIENT podcast!
Listen Here Are your patients ready for Virtual care? Share our free online quiz with your patients
Virtual care Quiz
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. Partners
If your organization is interested in sponsoring a portion of CPSW 2020, please contact
email@example.com. We have many opportunities available.
Virtual Care Definition Virtual care has been defined as any interaction between patients and/or members of their circle of care, occurring remotely, using any forms of communication or information technologies with the aim of facilitating or maximizing the quality and effectiveness of patient care. (CMA definition)
Do you have any questions or suggestions? Contact CPSI Communications Email
CPSW@cpsi-icsp.ca Join the conversation at
2https//www.cma.ca/sites/default/files/pdf/virtual-care/ReportoftheVirtualCareTaskForce.pdf; https//actt.albertadoctors.org/file/VirtualVisitsLitSummary2020.pdf ||Canadian Patient Safety Week||Canadian Patient Safety Week (CPSW)||9/10/2021 8:53:37 PM||126817||https://www.patientsafetyinstitute.ca/en/Events||html||True||aspx|
|Are you Prescribing Safely?||2636||Improving Medication Safety||Toolkits ＆ Guides||10/26/2018 7:49:02 PM|| Are you Prescribing Safely? Join the medication safety movement to assess your prescribing skills and help reduce medication errors. Building on the success of Prescribing Safely Canada pilot and participant feedback, the Royal College is pleased to offer new prescribing assessments in an engaging format for a limited time.
About Prescribing Safely Canada – New accredited modules Short, thematic, case-based modules that focus on a full range of prescribing competencies
Created for Canadian prescribers to address current hot topics
Frail Client, Opioid Prescribing and Antibiotic Stewardship
Available free of charge in both English and French, until April 2019 Participant can complete the online learning modules at a time of their choosing
Participant will receive a certificate of completion, and can claim 0.5 hours of Maintenance of Certification (MOC) Section 3 credits per module The Royal College is committed to supporting life-long learning and enhancement of skills and competencies. Authored and peer reviewed by clinicians, the Prescribing Safely Canada modules aim to address the everyday practice context. For a limited time only, take advantage of this accredited learning opportunity and
participate today! Questions? Please get in touch at
||Are you Prescribing Safely?||Are you Prescribing Safely? Join the medication safety movement to assess your prescribing skills and help reduce medication errors. Building on||9/24/2020 8:13:03 AM||1380||https://www.patientsafetyinstitute.ca/en/toolsResources||html||True||aspx|
|Leading Large Scale Change (Reference List)||2649||General Patient Safety;Improving Culture||Reports ＆ Publications||1/11/2016 10:57:34 PM||
Purpose The purpose of this document is to provide a summary of frameworks and strategies for leading large scale change. The intent is that this paper will provide the background for open discussion for the National Patient Safety Consortium. Research suggests that leaders who want wide scale change are more likely to be successful when an explicit model or theory of change is used.
Click here to access Leading Large Scan Change (Reference List)
||Leading Large Scale Change (Reference List)||
Purpose The purpose of this document is to provide a summary of frameworks and strategies for leading large scale change. The intent is||9/24/2020 8:14:49 AM||5467||https://www.patientsafetyinstitute.ca/en/toolsResources||html||True||aspx|
|The Canadian Human Factors in Healthcare Network||2651||General Patient Safety||Reports ＆ Publications;Toolkits ＆ Guides||9/12/2017 2:58:38 PM|| The Canadian Patient Safety Institute (CPSI), through the SHIFT to Safety program, has teamed up with the Canadian Human Factors in Healthcare Network to provide human factors information to healthcare organizations and the professionals who work there to add to their existing knowledge base related to quality and patient safety. Many healthcare professionals in Canada have, by now, heard about human factors engineering and psychology from other patient safety activities or venues, including the WHO human factors module and CPSI modules and presentations on human factors. The network's intent is to provide up to date information about human factors research and trends in Canada and around the world that go beyond the basics. As technology evolves and changes the way we do work, human factors specialists and researchers can help determine ways to improve the safety of the new ways of working. Use the links on the right hand side of the page to learn more about the Canadian Human Factors in Healthcare Network, its members and upcoming learning opportunities. SHIFT to Safety brings you the latest in advancements in human factors in healthcare. Shift your focus to what you do best — improving your practices for the benefit of your patients. The Canadian Human Factors in Healthcare Network is currently supported by the CPSI and in-kind funding by the member organizations. Objective of the Network Provide human factors expertise to healthcare organizations through consultation, knowledge transfer and exchange activities. Promote partnerships between healthcare organizations, industry, and academic institutions to promote the delivery of safer, more effective care to patients. If you have any questions for the members of the Healthcare Human Factors Network, please email HF-Network@cpsi-icsp.ca ||The Canadian Human Factors in Healthcare Network ||The Canadian Patient Safety Institute (CPSI), through the SHIFT to Safety program, has teamed up with the Canadian Human Factors in Healthcare||9/24/2020 8:16:31 AM||5168||https://www.patientsafetyinstitute.ca/en/toolsResources||html||True||aspx|
|Canada's Virtual Forum||2587||General Patient Safety||Events||7/12/2011 8:55:44 PM||
Thank you to the more than 1,100 viewers from the nearly 600 sites in Canada and 6 countries around the world that made Canada's Virtual Forum on Patient Safety & Quality Improvement a huge success! If you weren't able to watch live, or if you want to watch anything again,
click here to access the archives and watch recordings of each of our sessions. Make use of these recordings during your in-services and as part of your local education sessions.
We would like to hear from you To help us plan for future events, we'd like to have your feedback. Please tell us what went well or what we could do better by
completing our survey. Questions or comments? Contact CPSI Communications at
firstname.lastname@example.org.||Canada’s Virtual Forum on Patient Safety and Quality Improvement||
Thank you to the more than 1,100 viewers from the nearly 600 sites in Canada and 6 countries around the world that made Canada's Virtual||9/24/2020 8:05:32 AM||13344||https://www.patientsafetyinstitute.ca/en/Events||html||True||aspx|
|Atlantic Learning Exchange||2595||General Patient Safety||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!
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||10/29/2020 9:25:42 PM||14167||https://www.patientsafetyinstitute.ca/en/Events||html||True||aspx|
|Improvement Frameworks Getting Started Kit||2605||General Patient Safety;Healthcare Harm||Toolkits ＆ Guides;Frameworks||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||9/24/2020 8:14:36 AM||11204||https://www.patientsafetyinstitute.ca/en/toolsResources||html||True||aspx|
|Patient Safety and Incident Management Toolkit||2606||General Patient Safety;Improving Medication Safety;Healthcare Harm||Toolkits ＆ Guides||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||10/8/2020 7:03:53 PM||24932||https://www.patientsafetyinstitute.ca/en/toolsResources||html||True||aspx|
|The Safety Competencies Framework||2609||General Patient Safety;Healthcare Harm||Reports ＆ Publications;Frameworks||4/14/2009 11:53:32 PM||Safety Competencies Framework Educating healthcare providers about patient safety and enabling them to use the tools and knowledge to build and maintain a safe system is fundamental to creating a culture of safety across the spectrum of care. The 2020 Safety Competencies Framework (2nd Edition) is a simple, powerful and flexible framework that includes enabling competencies that can be adopted and adapted by diverse healthcare programs to design curricula to teach safety and quality for any sector or healthcare program. It can also be a valuable resource to policy makers, regulators and accreditors to guide system change. The Six Domains support moving patient safety evidence into action and has strengthened its content with advancements in collective knowledge that include patient/family partnership, leadership, quality improvement and cultural competency concepts. Safety Competencies Framework Domains Domain 1 Patient Safety Culture Patient safety culture improvement involves recognizing the importance of ongoing collaboration and the commitment to advocate for change. Domain 2 Teamwork High-performing interprofessional teams demonstrate capabilities and competencies that are essential to efficient, effective, and safe collaborative practice. Domain 3 Communication Effective communication is beneficial to patients and healthcare providers, builds trust, and is a precondition of obtaining patient consent. Domain 4 Safety, Risk, and Quality Improvement Healthcare providers collect and monitor performance data to assess risk and improve outcomes. Domain 5 Optimize Human and System Factors Optimizing the human and environmental factors that support the achievement of best human performance is an essential safety competency for all healthcare providers. Domain 6 Recognize, Respond to and Disclose Patient Safety Incidents Open, honest, and empathetic disclosure and appropriate apologies benefit patients and families, health providers, and their organizations. ||The Safety Competencies||The Safety Competencies: Message from the CEO||12/3/2020 4:19:06 PM||54195||https://www.patientsafetyinstitute.ca/en/toolsResources||html||True||aspx|
|Suicide Risk||2610||Mental Health;Healthcare Harm||Toolkits ＆ Guides;Reports ＆ Publications||4/21/2011 4:02:20 AM||The Canadian Patient Safety Institute (CPSI) has partnered with the Mental Health Commission of Canada (MHCC) to help healthcare workers and organizations select and compare available suicide risk assessment tools in Canada. For every death by suicide, 15-30 people are profoundly affected - this toolkit can help inform and strengthen the suicide risk assessment process. The Suicide Risk Assessment Toolkit seeks to provide a high-level overview of what to consider when using suicide risk assessment tools, along with a non-exhaustive list of available Canadian and international tools, and their characteristics. It is designed to be a quick, informative guide for healthcare workers and organizations interested in selecting and comparing such tools. The process of assessing suicide risk is complex. While assessment tools play an important role, they should be used to inform, not replace, clinical judgment. Use this toolkit, developed by CPSI and MHCC, to help you select/compare tools to complement the suicide risk assessment process.
Download Toolkit (publication January 26, 2021) For a more comprehensive guide to suicide risk assessment, including the role of healthcare workers and organizations, see
Suicide Risk Assessment Guide A Resource for Health Care Organizations.
Download Guide (publication 2011) We acknowledge the need to have suicide risk assessment tools that are truly inclusive and are based on principles of equity and diversity. We encourage you to seek out opportunities to engage with diverse peoples, including First Nations, Inuit, Métis, people who identify as 2SLQBTQ+, and immigrant, refugee, ethnocultural and racialized groups in order to understand and respond to their specific needs. Sponsored by The Canadian Patient Safety Institute and the Mental Health Commission of Canada. Production of this toolkit has been made possible through a financial contribution from Health Canada. ||Suicide Risk Assessment - Toolkit and Guide||The Canadian Patient Safety Institute (CPSI) has partnered with the Mental Health Commission of Canada (MHCC) to help healthcare workers and||2/4/2021 5:47:10 PM||16050||https://www.patientsafetyinstitute.ca/en/toolsResources||html||True||aspx|
|The Canadian Nosocomial Infection Surveillance Program (CNISP) Publications||2611||Infection Prevention ＆ Control (IPAC)||Reports ＆ Publications||12/3/2019 4:30:08 PM|| The Canadian Nosocomial Infection Surveillance Program (CNISP) is a collaborative effort between the Public Health Agency of Canada's Centre for Communicable Diseases and Infection Control (CCDIC) and the National Microbiology Laboratory (NML), and sentinel hospitals across Canada who participate as members of the Canadian Hospital Epidemiology Committee (CHEC), a standing committee of the Association of Medical Microbiology and Infectious Disease (AMMI) Canada. Established in 1994, the objectives of CNISP are to provide national and regional rates and trends on selected healthcare-associated infections (HAIs) and antimicrobial resistant organisms (AROs), as well as provide key information that informs the development of federal, provincial and territorial infection prevention and control programs and policies. At present, 70 sentinel hospitals from 10 provinces and 1 territory participate in the CNISP network. Below are the definitions and protocols for the healthcare associated infections currently under surveillance by the CNISP. For protocols or documents not appearing below, contact CNISP firstname.lastname@example.org Surveillance Definitions CNISP (Acute Care) HAI Surveillance Case definitions (2020) CNISP Surveillance Protocols COVID-19 and other viral respiratory infections (March 2021) Hospital Antibiogram Protocol (2020) Antimicrobial Utilization (AMU) Protocol (2020) Candida auris (C. auris) Protocol (2020) Carbapenemase-Producing Organisms (CPO) in CNISP Healthcare Facilities (2020) Clostridium difficile infection (CDI) Protocol (2020) Central Line Associated Blood Stream Infections (CLABSI) in Intensive Care Units (2020) Healthcare Acquired Cerebrospinal Fluid Shunt (CSF) Associated Infections (2020) Methicillin-Resistant and Methicillin-Susceptible Staphylococcus aureus (MRSA & MSSA) Bloodstream Infections in CNISP Hospitals (2020) Surgical Sites Infections Following Pediatric Cardiac Surgery (2020) Surgical Sites Infections Following Total Hip and Knee Arthroplasty (2020) Vancomycin Resistant Enterococci (VRE) Bloodstream Infections in CNISP Hospitals (2020) Other Documents Canada Communicable Disease Report (Nosocomial Infection Surveillance, May 2020) CNISP Infographic Healthcare-associated infection rates in Canadian hospitals (2013-2017) CNISP Summary Report of Healthcare Associated Infection (HAI), Antimicrobial Resistance (AMR) and Antimicrobial Use (AMU) Surveillance Data from January 1, 2013 to December 31, 2017 Laboratory Surveillance 2019 Device-associated infections in Canadian acute-care hospitals from 2009 to 2018 ||The Canadian Nosocomial Infection Surveillance Program (CNISP) Publications||The Canadian Nosocomial Infection Surveillance Program (CNISP) is a collaborative effort between the Public Health Agency of Canada's Centre for||5/11/2021 2:58:14 PM||4580||https://www.patientsafetyinstitute.ca/en/toolsResources||html||True||aspx|
|A Guide to Patient Safety Improvement||2614||General Patient Safety||Toolkits ＆ Guides||7/29/2020 5:15:14 PM||
When it comes to patient safety, a substantial body of evidence exists to demonstrate interventions (leading practices and processes) that lead to improved patient outcomes for numerous healthcare conditions. Despite available evidence, practice changes are not implemented consistently and effectively to support organizations and teams to address patient safety challenges. This resource has been designed to support teams across all healthcare sectors in using a Knowledge Translation and Quality Improvement integrated approach to change that will impact patient safety outcomes. This Guide for Patient Safety Improvement is intended to accompany current best available evidence change ideas, and tools and resources for your specific project. It includes ideal practice changes “the what” and strategies “the how” that creates the evidence-based intervention. Adaptations are expected and important considerations for implementation will be provided in this guide.
||A Guide to Patient Safety Improvement||When it comes to patient safety, a substantial body of evidence exists to demonstrate interventions (leading practices and processes) that lead to||10/15/2020 7:33:09 PM||9459||https://www.patientsafetyinstitute.ca/en/toolsResources||html||True||aspx|
|Engaging Patients in Patient Safety – a Canadian Guide||2615||General Patient Safety||Toolkits ＆ Guides;Reports ＆ Publications||4/25/2017 3:01:50 PM||
In recent decades, evidence has emerged that demonstrates when healthcare providers work closely with patients and their families, the healthcare system is safer, and patients have better experiences and health outcomes. Engagement with patients and families includes program and service design and delivery as well as monitoring, evaluating, policy and priority setting, and governance. Engagement work is not easy and often may be uncomfortable at first. Providers may need to let go of control, change behaviours to actively listen to what patients are saying, and take additional time to understand the patient perspective. It may require more effective ways to brainstorm ideas together, build trust, and incorporate many different perspectives. Patients may need to participate more actively in decisions about their care. Leaders must support all this work by revising practices to embed patient engagement in their procedures, policies, and structures. Finding innovative ways to work together will benefit everyone. We invite you to join us in advancing engagement by making healthcare safer. Our deep belief in the power of partnership is inspired by the publication, Engaging Patients in Patient Safety – a Canadian Guide. It is written by patients, providers and leaders for patients, providers and leaders. We trust that you will find the information in this guide useful. It demonstrates our joint commitment to achieving safe and quality healthcare in Canada.
Download Better yet, bookmark this page. This resource is updated regularly. To ensure you are accessing the most up-to-date version, we recommend that you bookmark this page for future reference. Who is this guide for? The guide is for anyone involved with patient safety and interested in engagement, including Patients and families interested in how to partner in their own care to ensure safety Patient partners interested in how to help improve patient safety Providers interested in creating collaborative care relationships with patients and families Managers and leaders responsible for patient engagement, patient safety, and/or quality improvement Anyone else interested in partnering with patients to develop care programs and systems While the guide focuses primarily on patient safety, many engagement practices apply to other areas, including quality, research, and education. The guide is designed to support patient engagement across the healthcare sector. What is the purpose of the guide? The purpose of the guide is to help patients and families, providers and leaders work more effectively together to improve patient safety. The guide is an extensive resource that is based on evidence and leading practices. What is included in the guide? Evidence-based guidance Practical patient engagement practices Consolidated information, resources, and tools Supporting evidence and examples from across Canada Experiences from patients and families, providers, and leaders Probing questions about how to strengthen current approaches Strategies and policies to meet standards and organizational practice requirements Click here to learn how and why was the guide developed.
CitationPatient Engagement Action Team. 2017.
Engaging Patients in Patient Safety – a Canadian Guide. Canadian Patient Safety Institute. Last modified December 2019. Available at
www.patientsafetyinstitute.ca/engagingpatients ||Engaging Patients in Patient Safety – a Canadian Guide||In recent decades, evidence has emerged that demonstrates when healthcare providers work closely with patients and their families, the healthcare||10/8/2020 8:27:08 PM||28656||https://www.patientsafetyinstitute.ca/en/toolsResources||html||True||aspx|
|Creating a Safe Space: Addressing the Psychological Safety of Healthcare Workers||2623||General Patient Safety;Psychological Safety for Healthcare Workers||Toolkits ＆ Guides;Healthcare provider stories;Reports ＆ Publications||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 and other support models 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 support healthcare workers by creating peer-to-peer support programs (PSPs) or other models of supports to improve the emotional well-being of healthcare workers and allow them to provide the best and safest care to their patients. The Creating a Safe Space Addressing the Psychological Safety of Healthcare Workers manuscript provides a comprehensive overview of what healthcare worker support models are 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.
Disclaimer 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 and Other Support Models)||Cumulative stress, compassion fatigue and trauma due to experiences with patient safety incidents impact the mental wellness of our healthcare||12/1/2020 4:47:37 PM||12370||https://www.patientsafetyinstitute.ca/en/toolsResources||html||True||aspx|
|Effective Governance for Quality and Patient Safety||2624||General Patient Safety;Policy||Toolkits ＆ Guides||2/23/2010 10:49:46 PM||
Effective Governance for Quality and Patient Safety A Toolkit for Healthcare Board Members and Senior Leaders Safe patient care happens when healthcare service delivery organizations are functioning at the highest levels. Governing boards and senior leaders of healthcare organizations can ensure effective governance and meet their legal responsibilities with the Effective Governance for Quality and Patient Safety Toolkit.
This toolkit teaches healthcare board members, senior executives, and physician leaders across Canada about the tools available to support organizational efforts in improving quality and patient safety. Commissioned research led by Dr. G. Ross Baker (2010), Effective Governance for Quality and Patient Safety in Canadian Healthcare Organizations, identified a number of interdependent drivers that enable boards to fulfill their responsibilities for quality and patient safety.
The resources in this toolkit are organized around each of the key drivers and include Principles of each driver Tools and recommended reading Stories and examples from healthcare organizations
Use this toolkit to strengthen your organization’s performance and to promote and advance safer care.
This symbol, used throughout the toolkit, denotes Canadian references and examples.||Effective Governance for Quality and Patient Safety||Effective Governance for Quality and Patient Safety: A Toolkit for Healthcare Board Members and Senior Leaders||9/24/2020 8:13:33 AM||17573||https://www.patientsafetyinstitute.ca/en/toolsResources||html||True||aspx|
|Incident Analysis||2626||Healthcare Harm||Frameworks;Reports ＆ Publications||4/19/2011 9:12:41 PM||
Analyze, manage, and learn from patient safety incidents in any healthcare setting with the Canadian Incident Analysis Framework.
Incident analysis is a structured process for identifying 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 an integral activity in the incident management continuum, which represents the activities and processes that surround a patient safety incident.
The framework was developed collaboratively by CPSI, the
Institute for Safe Medication Practices Canada,
Patients for Patient Safety Canada (a patient-led program of CPSI), Paula Beard, Carolyn Hoffman, and Micheline Ste-Marie and is based on the 2006 Canadian Root Cause Analysis Framework.
To learn more about the framework and the resources available, you can
click here to watch the information webinars recorded.
following resources have been carefully selected to support you in implementing the Canadian Incident Analysis Framework.
To contribute a resource or to provide feedback, please email
To learn more about the framework and the learning opportunities available
||Incident Analysis||Root Cause Analysis (RCA)||9/24/2020 8:14:38 AM||31107||https://www.patientsafetyinstitute.ca/en/toolsResources||html||True||aspx|
|The Measurement and Monitoring of Safety||2627||General Patient Safety;Healthcare Harm;Improving Culture||Toolkits ＆ Guides;Reports ＆ Publications;Frameworks||7/12/2016 5:25:21 PM||
Rewiring your thinking on measuring and monitoring of patient safety. Patient safety refers to more than just looking at harm that has occurred in the past. Understanding the difference between the absence of harm and the presence of safety is essential and requires a broader view of safety. The Measurement and Monitoring Safety Framework, created by Professor Charles Vincent and colleagues from the Health Foundation, consists of five dimensions that organizations, units, or individuals including leaders, providers, patients and families can use to understand, guide and improve patient safety. This new approach assesses and evaluates safety from "ward to board" by providing a comprehensive and accurate real-time view of patient safety. The Framework helps users move from "assurance" to "inquiry" by shifting away from a focus on past cases of harm towards current performance, future risks and organizational resiliency.
"The MMS Framework shifted safety for us from a policy perspective to a day-to-day care-provider and patient interaction. It led to ownership, engagement and passion." Dr. Jan Sommers, Nova Scotia Health Authority
Armed with a series of valuable questions, you can make better decisions about the safety of the care you provide. The primary questions are Has patient care been safe in the past? Are our clinical systems and processes reliable? Is our care safe now? Will our care be safe in the future? Are we responding and improving? For more information, contact us at
email@example.com. "We started out in the safety world really worrying about past harm and I think that was really important because it raised peoples' understanding about the magnitude of the safety issues. But it is insufficient because people don't go to work thinking about past incidents; they go to work thinking about the patients they are going to see today. So that is part of the shift now is that we are putting safety into a much more relevant context for the staff on their units doing their daily jobs. I think we can still build on that. We can build a broader sense of how units function and how units interact with other units." Dr. G. Ross Baker, PhD, Professor, Institute of Health Policy Management and Evaluation, University of Toronto Table of Contents Why Measurement and Monitoring of Safety Framework? Measurement and Monitoring of Safety in Canada Learning Collaborative Evaluation Research of Measurement and Monitoring of Safety Framework Collaborative Testimonials Learn more about MMSF in Canada "How Safe is Your Care?" Measurement and Monitoring of Safety Through the Eyes of Patients and their Caregivers - Research Project Other Resources ||The Measurement and Monitoring of Safety||Rewiring your thinking on measuring and monitoring of patient safety. Patient safety refers to more than just looking at harm that has||11/17/2020 6:52:38 PM||13910||https://www.patientsafetyinstitute.ca/en/toolsResources||html||True||aspx|
|Five Questions to Ask about your Medications||2629||Improving Medication Safety;General Patient Safety;Community Based Care;Mental Health||Patient and Family Resource;Toolkits ＆ Guides||2/25/2016 8:39:10 PM||
Ask the Right Questions about Your Medications For patients who require multiple medications or who are transitioning between treatments, safety can become a concern. You or your loved one may be at risk of fragmented care, adverse drug reactions, and medication errors. To be an active partner in your health, you need the right information to use your medications safely.
Download CPSI has teamed up with the
Institute for Safe Medication Practices Canada, Patients for Patient Safety Canada, the Canadian Pharmacists Association, and the Canadian Society for Hospital Pharmacists to create a list of top questions to help patients and their caregivers have a conversation about medications with their healthcare provider. Use these five questions when you're Attending a doctor's appointment (e.g., family physician or specialist, dentist, optometrist) Interacting with a community pharmacist Leaving the hospital to go home Visited by home care services
Are you a provider? Please share this valuable resource with your patients!
Visit ISMP Canada for additional resources and endorsements
Click here for Additional resources
Click here to endorse and add your organizations logo For more information, contact
firstname.lastname@example.org.||Five Questions to Ask about your Medications ||Ask the Right Questions about Your Medications For patients who require multiple medications or who are transitioning between treatments, safety can||9/24/2020 8:13:47 AM||25521||https://www.patientsafetyinstitute.ca/en/toolsResources||html||True||aspx|
|Never Events for Hospital Care in Canada||2630||General Patient Safety;Healthcare Harm||Reports ＆ Publications||7/25/2015 2:52:36 AM||
Patients rightfully expect safe care, and health care providers work to provide care that results in better health and safe outcomes for patients. Unfortunately, events that harm patients do occur while care is being provided or as a result of that care. Many of these events that cause harm are preventable using current knowledge and practices. "Never events" are patient safety incidents that result in serious patient harm or death, and are preventable using organizational checks and balances.
Download An Action Team from the
National Patient Safety Consortium has sought consensus on the top priorities for Canadian never events in health care. The current focus is on events that can occur while a patient is admitted in a health care facility, where care providers have a high amount of control over care. The Never Events Action Team includes the following experts, and patient representatives Atlantic Health Quality and Patient Safety Collaborative British Columbia Patient Safety and Quality Council Canadian Patient Safety Institute Health Quality Council of Alberta Health Quality Ontario Manitoba Institute for Patient Safety New Brunswick Health Council Newfoundland and Labrador Provincial Safety and Quality Committee
Patients for Patient Safety Canada (a patient led program of the Canadian Patient Safety Institute) Our work aims to provide some areas and targets for continually improving patient safety. We believe various strategies can be effective in identifying and reducing never events, including cultural changes, reporting and learning systems, identification of opportunities for improvement and continuous improvement supported by measurement and evaluation. The
Incident Management Toolkit is an available tool from the Canadian Patient Safety Institute and designed to help healthcare organizations prevent patient safety incidents and minimize harm when incidents do occur.
Click here to access the final report on Never Events for Hospital Care in Canada.||Never Events for Hospital Care in Canada||
Patients rightfully expect safe care, and health care providers work to provide care that results in better health and safe outcomes||9/24/2020 8:14:53 AM||14659||https://www.patientsafetyinstitute.ca/en/toolsResources||html||True||aspx|
|A Framework for Establishing a Patient Safety Culture||2631||General Patient Safety;Healthcare Harm;Improving Culture||Frameworks||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||9/24/2020 8:12:57 AM||16261||https://www.patientsafetyinstitute.ca/en/toolsResources||html||True||aspx|
|Patient Concern Resolution Process||2633||General Patient Safety;Partnering with Patients||Toolkits ＆ Guides;Patient and Family Resource||4/19/2011 6:12:38 PM||Every patient experience should be safe.
Patients, residents, clients, and their families can be active partners in safe care. Help ensure a safe patient experience with information, tools, tips, and resources for patients and their families.
Patient Concern Resolution Process
If you have a question or a concern about the healthcare services you have received, there are several options that may be available. You may be able to resolve the problem simply by talking to your healthcare provider—a physician, a nurse, someone else directly involved in your care, or the appropriate supervisor. Your healthcare provider is in the best position to address your questions and concerns.
If your questions or concerns are still not fully addressed, you can
Talk to the healthcare organization or regional health authority that provided the care. Some have a patient relations officer, client representative, or patient advocate to assist you with the process.
If you have specific concerns about the conduct of a healthcare provider, comments should be directed to the appropriate professional regulatory body, such as the College of Physicians and Surgeons, the Registered Nurses Association, or other health professions’ regulatory authorities. Regulatory bodies generally have their own concern-handling bylaws, policies, or procedures, and they can assist you. You may be asked to put your concern in writing and identify yourself so that the issue can be thoroughly investigated.
If none of the above options results in the resolution of your question or concern, you may wish to contact the ministry of health in the province where you received your care.
If your concerns are still not addressed, you may be able to appeal through various mechanisms including the provincial/territorial ombudsman or a similar advocacy body.
For more information
Newfoundland and Labrador
Prince Edward Island
The Northwest Territories
Please note If you received healthcare services in the Province of Quebec and have a question or concern about those services, please refer to the following website for information regarding resolution of your concern
As it is recognized that the patient's family or another advocate may be included in the concern resolution process, the term "patient" includes family members or advocates.||Patient Concern Resolution Process||Every patient experience should be safe.
Patients, residents, clients, and their families can be active partners in safe care. Help ensure a safe||9/24/2020 8:14:56 AM||8678||https://www.patientsafetyinstitute.ca/en/toolsResources||html||True||aspx|
|Canadian Disclosure Guidelines||2637||General Patient Safety||Toolkits ＆ Guides;Reports ＆ Publications||4/18/2011 4:05:57 PM|| The Canadian Disclosure Guidelines build on various patient safety initiatives currently under way across Canada and assist and support healthcare providers, inter-professional teams, organizations, and regulators. These guidelines symbolize a commitment to patients’ right to be informed if they are involved in a patient safety incident by promoting a clear and consistent approach to disclosure, emphasizing the importance of inter-professional teamwork, and supporting learning from patient safety incidents. The development of the Canadian Disclosure Guidelines is a significant achievement in healthcare in Canada.
Canadian Disclosure Guidelines (November 2011)
Backgrounder Development of the Canadian Disclosure Guidelines (2006)
The Impact of Disclosure on Litigation (2007)||Canadian Disclosure Guidelines: Being open with patients and families||The Canadian Disclosure Guidelines build on various patient safety initiatives currently under way across Canada and assist and support healthcare||9/24/2020 8:13:08 AM||23995||https://www.patientsafetyinstitute.ca/en/toolsResources||html||True||aspx|