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Tools & Resources28909/18/2020 4:40:20 AMTools & ResourcesTools & Resources9/21/2020 9:19:04 AM82793https://www.patientsafetyinstitute.ca/enhtmlTrueaspx
Glossary of Terms122602/24/2010 6:21:45 PM Adverse event An event that results in unintended harm to the patient, and is related to the care and/or services provided to the patient rather than to the patient’s underlying medical condition. Close call An event that did not reach the patient because of timely intervention or good fortune. (The term is often equated to a near miss or near hit.) Disclosure The process by which an adverse event is communicated to the patient by healthcare providers. Initial disclosure The first communication made with the patient as soon as reasonably possible after an adverse event, focusing on the known facts and the provision of further clinical care. Post-analysis disclosure Subsequent communications with the patient about known facts related to the reasons for the harm after an appropriate analysis of the adverse event. Harm An outcome that negatively affects the patient’s health and/or quality of life. Just culture of safety A healthcare approach in which the provision of safe care is a core value of the organization. The culture encourages and develops the knowledge, skills, and commitment of all leaders, management, healthcare providers, staff, and patients for the provision of safe patient care. Opportunities to proactively improve the safety of care are constantly identified and acted on. Providers and patients are appropriately and adequately supported in the pursuit of safe care. The culture encourages learning from adverse events and close calls to strengthen the system, and where appropriate, supports and educates healthcare providers and patients to help prevent similar events in the future. There is a shared commitment across the organization to implement improvements and to share the lessons learned. Justice is an important element. All are aware of what is expected, and when analyzing adverse events, any professional accountability of health care providers is determined fairly. The interests of both patients and providers are protected. Patient safety The pursuit of the reduction and mitigation of unsafe acts within the healthcare system, as well as the use of best practices shown to lead to optimal patient outcomes. Patient safety is the reduction of risk of unnecessary harm associated with healthcare to an acceptable minimum. An acceptable minimum refers to the collective notions of given current knowledge, resources available, and the context in which care was delivered weighed against the risk of non-treatment or other treatment. Quality The degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge. Quality Improvement Review The analysis by healthcare organizations (usually by a quality improvement committee) of patient outcomes, clinical practices, and systems of care in order to recommend improvements. Quality improvement committees, as part of an ongoing program to improve patient care, should be structured under the relevant provincial/territorial legislation and include formal terms of reference. Quality improvement committees, depending on the province or territory, may have different titles, for example, Quality of Care, Critical Incident Review, or Risk Management. Reporting The communication of information about an adverse event or close call by healthcare providers through appropriate channels inside or outside of healthcare organizations for the purpose of reducing the risk of adverse events in the future. Root cause analysis An analytic tool that can be used to perform a comprehensive, system-based review of critical incidents. It includes the identification of the root and contributory factors, identification of risk reduction strategies, and development of action plans along with measurement strategies, to evaluate the effectiveness of the plans. This glossary is not intended to be an exhaustive list of terms, but rather a concise list of key terms used throughout the tool kit. For more information, use these references World Health Organization’s (WHO) International Classification for Patient Safety Key Concepts and Preferred Terms Canadian Disclosure Guidelines The Safety Competencies Learning from adverse events Fostering a just culture of safety in Canadian hospitals and health care institutionsGlossary of Terms7/7/2015 4:01:16 PM6836https://www.patientsafetyinstitute.ca/en/toolsResources/GovernancePatientSafety/Pages/Forms/AllItems.aspxhtmlFalseaspx
Atlantic Learning Exchange3228General Patient SafetyEvents9/20/2016 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! Program Partners Sponsors 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 gpeck@cpsi-icsp.ca to receive more information on sponsorship and exhibiting at the conference. Atlantic Quality and Patient Safety Learning ExchangeDiscover innovative and emerging trends in patient safety & quality improvement October 8 – 9, 2019 St. John's, NL, The Atlantic Health10/29/2020 9:25:42 PM14508https://www.patientsafetyinstitute.ca/en/EventshtmlTrueaspx
Education to support mandatory ADR and MDI reporting (Vanessa’s Law)3110General Patient Safety;Government Relations;Healthcare HarmReports & Publications;Patient and Family Resource;Toolkits & Guides3/4/2019 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 info@ismpcanada.ca HSO https//healthstandards.org/ CPSI info@cpsi-icsp.ca ​If you have questions about Vanessa's Law and the mandatory reporting requirements, please contact hc.canada.vigilance.sc@canada.ca. 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 HospitalsThe Protecting Canadians from Unsafe Drugs Act, also known as Vanessa's Law, is intended to9/24/2020 8:13:31 AM169480https://www.patientsafetyinstitute.ca/en/toolsResourceshtmlTrueaspx
Advocacy and support for use of a Surgical Safety Checklist3070Surgical Care SafetyPosition Statements2/5/2019 7:55:32 PMPosition 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. Download Advocacy and support for use of a Surgical Safety ChecklistPosition Statement A Surgical Safety Checklist is smart for patients and smart for providers. It's use in Canadian healthcare facilities9/24/2020 8:13:01 AM3060https://www.patientsafetyinstitute.ca/en/toolsResourceshtmlTrueaspx
Hand Hygiene Fact Sheets3120Infection Prevention & Control (IPAC)Toolkits & Guides;Tip Sheets4/1/2020 2:15:32 PMVisit the new home for hand hygiene resources on the Healthcare Excellence Canada website. Check it out Hand Hygiene Fact SheetsVisit the new home for hand hygiene resources on the Healthcare Excellence Canada website. Check it out5/14/2021 3:21:23 PM20213https://www.patientsafetyinstitute.ca/en/toolsResourceshtmlTrueaspx
Patient engagement in medication safety at the point of care – roles, responsibilities6751Improving Medication Safety;General Patient SafetyEvents;Patient and Family Resource;Webinars;Social Media/Social Share8/26/2016 6:43:53 PM ​​​ ​Archive September 15, 2016 Objective At the end of the session patient/ family/ advisors/ champions as well as health providers/ leaders/ authorities will leave with at least one practical idea to advance patient engagement in medication safety as a result of their increased understanding of the role and responsibilities of patients/ families in medication safety different approaches to patient engagement in medication safety influencing factors (e.g. health literacy, culture, organizational and public policy) supporting resources and leading practices Resources Download (Available in English only) Speakers and moderator Helen Haskell – President, Mothers Against Medical Error and Consumers Advancing Patient Safety; Steering Group, World Health Organization Global Patient Safety Challenge on Medication Safety Johanna Trimble – Patient Champion, Patients for Patient Safety Canada and Patient Voices Network British Columbia Maryann Murray –Patient Champion, Patients for Patient Safety Canada; Patients and Public Workgroup, WHO Global Patient Safety Challenge on Medication Safety ​Theresa Malloy-Miller (moderator) - Patient Champion, Patients for Patient Safety Canada Designed by patient/family champions for champions this interactive webinar is offered by the World Health Organization Patients for Patient Safety Programme in partnership with Patients for Patient Safety Canada. For this session the term patient safety champion includes any individual that volunteers as a patient/family representative in programs, groups, networks and/or organizations working to improve quality and safety in healthcare. The session is designed to allow for conversation among participants, so be prepared to contribute to the dialogue verbally or via chat. The slides, recording and a summary of ideas presented will be publicly available after the session he​re. For more information contact patients@cpsi-icsp.ca.   Archive: September 15, 2016 Objective: At the end of the session patient/ family/ advisors/ champions as well as9/24/2020 8:12:32 AM3978https://www.patientsafetyinstitute.ca/en/toolsResources/Pages/Forms/NewDefaultView.aspxhtmlFalseaspx
Home Care Safety3067Community Based Care;General Patient Safety;Improving Medication Safety;Healthcare HarmReports & Publications;Toolkits & Guides6/5/2014 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 SafetyWith the release of the Safety at Home: A Pan- Canadian Home Care Study (2013) , the Canadian Patient Safety Institute (CPSI) and the9/24/2020 8:14:05 AM7089https://www.patientsafetyinstitute.ca/en/toolsResourceshtmlTrueaspx
Improvement Frameworks Getting Started Kit3068General Patient Safety;Healthcare HarmToolkits & Guides;Frameworks11/24/2011 4:21:24 PM12/2/2015 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 KitThe Improvement Frameworks Getting Started Kit is intended to serve as a common document appended to the Safer Healthcare Now! Getting Started9/24/2020 8:14:36 AM11812https://www.patientsafetyinstitute.ca/en/toolsResourceshtmlTrueaspx
Patient Safety and Incident Management Toolkit3069General Patient Safety;Improving Medication Safety;Healthcare HarmToolkits & Guides12/18/2014 8:28:40 PMIn March 2021, Healthcare Excellence Canada launched, bringing together the Canadian Foundation for Healthcare Improvement and Canadian Patient Safety Institute. This content can now be found on HEC’s new website. Check it out Patient Safety and Incident Management ToolkitIn March 2021, Healthcare Excellence Canada launched, bringing together the Canadian Foundation for Healthcare Improvement and Canadian Patient6/22/2022 2:51:42 PM26173https://www.patientsafetyinstitute.ca/en/toolsResourceshtmlTrueaspx
The Canadian Surgical Site Infection Prevention Audit - Results 3071Surgical Care Safety;Infection Prevention & Control (IPAC)Events;Webinars;Reports & Publications8/31/2015 5:35:10 PM Surgical site infection is the most common healthcare associated infection among surgical patients, with 77 per cent of patient deaths reported to be related to infection. In February 2016, the Canadian Patient Safety Institute (CPSI) along with our partners Alberta Health Services-Surgery Strategic Clinical Network, Atlantic Health Quality & Patient Safety Collaborative, BC Patient Safety & Quality Council, Health Quality Ontario, and Saskatchewan Ministry of Health- Patient Safety Unit, conducted the Canadian Surgical Site Infection (SSI) Prevention Audit. Download Auditing helps to identify both areas of excellence and areas for improvement. During the month of February, all acute care organizations providing surgical services were challenged to audit their established processes for preventing surgical site infections (SSI). 52 service areas participated in the Surgical Site Infection Prevention Audit with 1.998 patient charts audited. Audit highlights noted that 91% of patients received appropriate prophylactic antibiotics and 96% of patients received the appropriate method of pre-operative hair removal whereas post-operative glucose control was identified as an area requiring improvement. To learn more about the Canadian Surgical Site Infection Prevention Audit and Results Click here for information regarding Audit Methodology Access the National Call Results from Canadian SSI Prevention Audit; March 24th, 2016 View the Canadian Surgical Site Infection Prevention Audit Recap Report Audit Recap Report The Canadian Surgical Site Infection Prevention Audit - Results Surgical site infection is the most common healthcare associated infection among surgical patients, with 77 per cent of patient deaths reported to be9/24/2020 8:16:44 AM3254https://www.patientsafetyinstitute.ca/en/toolsResourceshtmlTrueaspx
The Safety Competencies Framework3072General Patient Safety;Healthcare HarmReports & Publications;Frameworks4/14/2009 11:53:32 PMSafety 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 CompetenciesThe Safety Competencies: Message from the CEO12/3/2020 4:19:06 PM58061https://www.patientsafetyinstitute.ca/en/toolsResourceshtmlTrueaspx
Suicide Risk3073Mental Health;Healthcare HarmToolkits & Guides;Reports & Publications4/21/2011 4:02:20 AMThe 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 GuideThe Canadian Patient Safety Institute (CPSI) has partnered with the Mental Health Commission of Canada (MHCC) to help healthcare workers and2/4/2021 5:47:10 PM16850https://www.patientsafetyinstitute.ca/en/toolsResourceshtmlTrueaspx
The Canadian Nosocomial Infection Surveillance Program (CNISP) Publications3074Infection Prevention & Control (IPAC)Reports & Publications12/3/2019 4:30:08 PM In March 2021, Healthcare Excellence Canada launched, bringing together the Canadian Foundation for Healthcare Improvement and Canadian Patient Safety Institute. This content can now be found on HEC’s new website. Check it out The Canadian Nosocomial Infection Surveillance Program (CNISP) PublicationsIn March 2021, Healthcare Excellence Canada launched, bringing together the Canadian Foundation for Healthcare Improvement and Canadian Patient11/17/2022 6:30:35 PM5219https://www.patientsafetyinstitute.ca/en/toolsResourceshtmlTrueaspx
Report on the Integration of the Safety Competencies Framework3075General Patient Safety;Healthcare Harm;Improving CultureFrameworks;Reports & Publications9/12/2017 7:58:51 PM CPSI is pleased to present a comprehensive new report on the integration and impact of the Safety Competencies Framework (SCF) originally launched in 2008 in partnership with the Royal College of Physicians and Surgeons of Canada. The framework has been one of the most downloaded documents on the CPSI website, consistently since its launch. Almost 10 years after the launch, this report examines the historical background of the SCF while providing a rationale for the development of the competencies, mapping of the competencies to integrate patient safety content in training programs. The report outlines the successes and challenges in the uptake of the competencies and includes a provocative call to action for educators. Several key findings were determined through interviews done with a select group of stakeholders familiar with the SCF and this feedback provided better understanding of the value of the competencies to organizations and professional bodies. As we look towards renewing the SCF to address feedback received, it is clear that despite the successes and challenges, we must shift our attention away from the "what" to focus on the "how" of integrating safety competencies in the curricula of health professionals on a more consistent basis. Download Report on the Integration of the Safety Competencies FrameworkCPSI is pleased to present a comprehensive new report on the integration and impact of the Safety Competencies Framework (SCF)9/24/2020 8:15:57 AM4586https://www.patientsafetyinstitute.ca/en/toolsResourceshtmlTrueaspx
Results of 2018 Public Survey Related to the Labelling of Non-Prescription Health Products3076Improving Medication Safety;Government RelationsReports & Publications;Patient and Family Resource2/21/2019 3:31:22 PM As part of a Health Canada committee developing Plain Language Labelling regulations for non-prescription health products, Patients for Patient Safety Canada led a joint PFPSC and CPSI initiative to survey the public on the issue. Have people had problems with the labelling of non-prescription health products? The survey results indicate that consumers are often confused when purchasing self-care products. This raises concerns of harm are people choosing the wrong product because of this confusion? Our survey found that 29% of respondents said that they had wrongly purchased a natural health or homeopathic product, or over-the-counter drug; Another 29.5% said that they were not sure if they had wrongly purchased one of these products. The most cited reasons for the wrong purchase were Mixed it up with another product, Information about the product on the label was too small to read, or They were confused by, or did not understand, the information on the label. Some examples of comments on the survey include "I looked for Gravol on the drugstore shelf and all of the types of Gravol were together. When I saw Gravol ginger I thought it was Gravol with an added boost of ginger. When I got home and read the ingredients, I realized that there was not active ingredient in it. I feel I am a very health literate person, but I did not know the difference." "I did not realize the ingredients until I arrived home. Printing is so tiny on labels." "I bought a product for a yeast infection thinking it was for a Urinary Tract Infection" PFPSC represented members at the Health Canada table to ensure that "just like food products, all labels should be written in plain language, list all ingredients, and be printed in legible size." The results of this survey confirm that consumers want to know what's in the products they are taking. To protect Canadians from preventable harm, PFPSC and CPSI are calling for clear information and larger size lettering on the labels for non-prescription health products. Results of 2018 Public Survey Related to the Labelling of Non-Prescription Health Products  As part of a Health Canada committee developing Plain Language Labelling regulations for non-prescription health products, Patients for9/24/2020 8:16:23 AM2941https://www.patientsafetyinstitute.ca/en/toolsResourceshtmlTrueaspx
Engaging Patients in Patient Safety – a Canadian Guide3078General Patient SafetyToolkits & Guides;Reports & Publications4/25/2017 3:01:50 PMIn March 2021, Healthcare Excellence Canada launched, bringing together the Canadian Foundation for Healthcare Improvement and Canadian Patient Safety Institute. This content can now be found on HEC’s new website. Check it out Engaging Patients in Patient Safety – a Canadian GuideIn March 2021, Healthcare Excellence Canada launched, bringing together the Canadian Foundation for Healthcare Improvement and Canadian Patient6/29/2022 2:55:24 PM30000https://www.patientsafetyinstitute.ca/en/toolsResourceshtmlTrueaspx
Deteriorating Patient Condition3079General Patient Safety;Infection Prevention & Control (IPAC);Healthcare HarmToolkits & Guides3/30/2017 5:19:46 PM Early warning signs of deteriorating condition are often unrecognized, leading to devastating results. Research shows that virtually all critical inpatient events are preceded by warning signs that occur approximately six-and-a-half hours in advance. In this section, you'll find information, tools and resources to not only help you recognize deteriorating patient condition, but what you can do to act on it as a member of the public, a healthcare provider or leader. Click any of the icons below to get started! (updated in February 2020) Deteriorating Patient ConditionEarly warning signs of deteriorating condition are often unrecognized, leading to devastating results. Research shows that virtually all critical12/23/2020 8:11:28 PM4209https://www.patientsafetyinstitute.ca/en/toolsResourceshtmlTrueaspx
Learn how to use and store methadone safely3081Improving Medication SafetyTip Sheets;Toolkits & Guides3/24/2021 8:07:00 PM Methadone is an opioid used to help people with opioid dependence. Unlike other opioids, it stays in the body a long time, preventing cravings and the discomfort of withdrawal. Like all other medications, methadone must be taken safely. Seeking help for your opioid dependence is a wise and important step in your road to recovery. Click here to learn how to use and store methadone safely. This information is brought to you in partnership between ISMP Canada and the Saskatchewan Ministry of Health, the College of Physicians and Surgeons of Saskatchewan's Opioid Agonist Therapy Program, Canadian Agency for Drugs and Technologies in Health (CADTH), the Saskatchewan Health Authority, Patients for Patient Safety Canada along with support from Canadian Patient Safety Institute. It has been reviewed by Canadian Society of Hospital Pharmacists (CSHP), the Nurse Practitioner Association of Canada (NPAC), The College of Family Physicians of Canada (CFPC), the Canadian Pharmacists Association (CPhA), and the Canadian Centre on Substance Use and Addiction (CCSA). Visit ISMP Canada for additional resources. Learn how to use and store methadone safelyMethadone is an opioid used to help people with opioid dependence. Unlike other opioids, it stays in the body a long time, preventing cravings and3/24/2021 8:10:17 PM313https://www.patientsafetyinstitute.ca/en/toolsResourceshtmlTrueaspx
MedError.ca3082Partnering with Patients;Patient & Family Resources;Improving Medication Safety;General Patient SafetyPatient and Family Resource10/26/2020 4:10:45 PM Medication errors cause harm to Canadians. Preventing such harm requires an understanding of where and why the medication safety system has failed, and the perspective of consumers is needed to advance this understanding. By sharing the learning from medication errors, consumers and providers can meaningfully work together to improve medication safety in Canada. Developed by the Institute for Safe Medication Practices Canada (ISMP Canada) and CPSI, www.mederror.ca is a new website for the public to submit reports of medication errors for analysis, learning, and action. It builds on the work and success of SafeMedicationUse.ca, to create a more user-friendly portal to share their medication error experiences with the goal to improve the quality and quantity of incident reporting in Canada. Anyone can report and with the growing numbers of Canadians who take prescription and non-prescription medications in the community, it is important to understand and learn from the public. Whether it is a suspected medication error or medication reaction, the website provides a quick and easy way to provide valuable insight that contributes to patient safety improvement. Access Now Mederror.caMedication errors cause harm to Canadians. Preventing such harm requires an understanding of where and why the medication safety system has failed,11/3/2020 3:46:35 PM1982https://www.patientsafetyinstitute.ca/en/toolsResourceshtmlTrueaspx
Medication Safety at Care Transitions Safety Improvement Project Learning Collaborative3083Improving Medication SafetyToolkits & Guides1/15/2019 9:35:30 PMWhat 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. Medication Safety at Care Transitions Safety Improvement Project – An 18-month learning collaborative The Canadian Patient Safety Institute launched its Medication Safety- Safety Improvement Project in April 2019. This learning collaborative approach was delivered by expert faculty and coaches, with mentoring provided over 18 months. Participating teams learned and applied strategies to decrease readmissions related to medication safety issues at discharge among frail patients. Participant Learned To identify Frail clients who are at risk for medication safety issues, How to apply new processes for medication management at discharge, How to utilize Knowledge Translation and Implementation Science techniques to successfully implement and sustain new evidence-based practices for medication safety at transitions, To share 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. If you didn't have an opportunity to participate in the implementation collaborative, you can still access free resources below Get Started Kit 5 Questions to Ask About Your Medications Medication Reconciliation Measures Medication Reconciliation ResourcesMedication Safety at Care Transitions: Safety Improvement ProjectWhat is Medication Safety? Medications are the most common treatment intervention used in healthcare around the world. When used safely and2/10/2021 8:16:16 PM5973https://www.patientsafetyinstitute.ca/en/toolsResourceshtmlTrueaspx
Safety Improvement Projects3084General Patient Safety;Improving Medication Safety;Community Based Care;Healthcare HarmFrameworks9/14/2018 2:50:29 PM The Canadian Patient Safety Institute (CPSI) held 4 Safety Improvement Projects in 2018/2019. Thirty teams from across Canada participated in the Safety Improvement Project Learning Collaborative with a lifecycle of 18 months. A brief description of each project is provided below Teamwork and Communication focused on improving patient safety culture and positive patient outcomes. Medication Safety at Care Transitions focused on improving medication safety at discharge for frail, elderly patients with poly-morbidity. Enhanced Recovery Canada focused on improving outcomes and system efficiencies for colorectal surgery patients. Measurement and Monitoring of Safety focused on creating a culture of safety and reducing harm in organizations. The Safety Improvement Projects concluded with a virtual congress on October 28th and 29th 2020. Please see the short Highlights video (422). If you have any questions, please email SafetyImprovementProjects@cpsi-icsp.ca Safety Improvement Projects The Canadian Patient Safety Institute (CPSI) held 4 Safety Improvement Projects in 2018/2019. Thirty teams from across Canada participated in the2/11/2021 5:55:44 PM7850https://www.patientsafetyinstitute.ca/en/toolsResourceshtmlTrueaspx
Awareness of the Patient Safety Crisis in Canada3085General Patient Safety;Healthcare HarmPatient and Family Resource;Reports & Publications4/23/2019 2:52:28 PM4/23/2019 3:00:00 PMAwareness of the Patient Safety Crisis in Canada THE ISSUES We are facing a patient harm crisis of epidemic proportions. The Canadian public knows almost nothing about it. As soon as they learn, the public urgently prioritizes safer healthcare. Canadians should have an expectation that their healthcare is safe, and in most cases it is.However, every resident of Canada must learn that there are risks in our healthcare system, despite the efforts of thousands of dedicated healthcare providers across Canada. In our healthcare system, there is a death from patient harm every 13 minutes and 14 seconds. It is the third leading cause of death in Canada. One out of 18 hospital visits results in preventable harm. These incidents generate an additional $2.75 billion in healthcare treatment costs every year.This level of harm is simply unacceptable. Patient Safety Survey THE SURVEY In 2018, the Canadian Patient Safety Institute (CPSI) commissioned Ipsos Public Affairs to survey Canadians about their awareness of the rates of patient harm in our healthcare system. We sought a baseline read of Canadians' understanding of patient safety, with the main objectives of Assessing knowledge of patient safety and patient safety incidents in Canada; Understanding how Canadians prioritize patient safety; Determining how Canadians would like to receive information about patient safety, if at all; and, Assessing experience with patient safety incidents. Ipsos Public Affairs surveyed 1003 Canadian adults, weighted by gender, age, region and income. The credibility interval was +/- 3.5%. Ipsos found that while 44% of respondents identified as caregivers at some point in their lives, 30% stated they had a chronic disease or illness themselves. Out of the 199 respondents who identified as parents, 13% said that they have a child with a chronic illness. KEY FINDINGS Canadians show limited knowledge of patient harm. One third of Canadians rank patient safety in their top three healthcare priorities, with just under one in ten ranking it first. About one in ten correctly say that patient safety incidents are the third leading cause of death in Canada. Only one in ten Canadians believe that someone dies from a patient safety incident every 15 minutes in Canada. Six in ten say the $2.75 billion cost of patient safety incidents in Canada is higher than they expected. Despite the limited knowledge of the patient safety crisis in Canada, one in three Canadians has experienced a patient safety incident. One in three Canadians stated that they either personally experienced a patient safety incident (12%) or have a loved one who did (24%). Misdiagnosis, falls, infections and mistakes during treatment are the most common types of patient safety incidents. Those who have experienced a patient safety incident most commonly cite distracted or overworked health care providers as the largest contributing factors that led to the incident. Once informed about the scale of the problem, Canadians demonstrated far more concern about patient harm and wanted more information. Three‐quarters of Canadians are concerned about experiencing a patient safety incident, ranking it in their top three (compared to originally 1 in 3), including 1 in 4 ranking patient safety incidents as their top priority. Three in four Canadians are interested in learning how to keep safe in healthcare, Eighty per cent say they'd like to receive this information delivered via (in order of preference) healthcare provider; print, digital and in-person. This knowledge should be provided in real time (when patients go to the hospital for surgery and upon a new diagnosis of a serious health problem), but some also believe it should be general knowledge. CONCLUSIONS We are facing a patient harm crisis of epidemic proportions. The Canadian public knows almost nothing about it. As soon as they learn, the public urgently prioritizes safer healthcare. Canadians should have an expectation that their healthcare is safe, and in most cases it is. Every resident of Canada must learn that there are risks in our healthcare system, despite the efforts of thousands of dedicated healthcare providers across Canada.Healthcare providers, healthcare systems, and the Canadian Patient Safety Institute must empower residents of Canada with information and tools to ask good questions, connect with the right people, and learn as much as they can to keep them or a family member safe while receiving healthcare. Patient experience in the healthcare system should be characterized by clear, honest, two-way communication.WHAT CAN YOU DO?Ask us about patient experiences of harm in Canada's healthcare system. We invite you to read some of the stories shared by members of Patients for Patient Safety Canada, and the changes they have championed in our healthcare system to keep patients safer.Ask us what you can do to keep yourself and your loved ones safe in the healthcare system. The Canadian Patient Safety Institute designs and collects resources designed to help patients navigate the healthcare system by asking questions and being informed. Five Questions to Ask About Your Medications Tips and Tools for Talking to your Healthcare Team Tips to identify Deteriorating Patient Condition Shift to Safety tools and resource to keep you safe Share what you have learned. We have discovered that, as soon as we learn about the scale of the public healthcare crisis, we become far more concerned. Post your experiences on social media and use the hashtag #PatientSafetyRightNow – with your help, we will inform anyone who uses our healthcare system about the crisis and teach them how to keep themselves and their loved ones safe.ABOUT USThe Canadian Patient Safety Institute (CPSI) is the only national organization solely dedicated to reducing preventable harm, improving the safety of the healthcare system, and engaging patients and families as partners in safe care. Patients for Patient Safety Canada (PFPSC) is the patient-led program of CPSI and the Canadian arm of the World Health Organization's PFPS program. As patient partners, these volunteer members harmed by healthcare contribute to patient safety improvements at all system levels. CPSI and PFPSC are committed to working together with the public, patients, healthcare providers, and healthcare leaders to make Canadian healthcare safer. BACKGROUND INFORMATION 2018 Ipsos Patient Safety Survey Risk Analytica 2017 The Case for Investing in Patient Safety in Canada Ipsos 2016 National Health Leadership Conference Survey Canadian Patient Engagement Guide Awareness of the Patient Safety Crisis in CanadaAwareness of the Patient Safety Crisis in Canada THE ISSUES: We are facing a patient harm crisis of epidemic proportions. 9/24/2020 8:13:06 AM5520https://www.patientsafetyinstitute.ca/en/toolsResourceshtmlTrueaspx
Effective Governance for Quality and Patient Safety3087General Patient Safety;PolicyToolkits & Guides2/23/2010 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. The Effective Governance for Quality and Patient Safety Toolkit was revised in 2015. Effective Governance for Quality and Patient SafetyEffective Governance for Quality and Patient Safety: A Toolkit for Healthcare Board Members and Senior Leaders1/13/2022 9:10:10 PM18393https://www.patientsafetyinstitute.ca/en/toolsResourceshtmlTrueaspx
A Policy Framework for Patient Safety in Canada3088General Patient Safety;Government Relations;PolicyFrameworks;Reports & Publications11/29/2019 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. Policy Levers 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. Download Executive Summary A Policy Framework for Patient Safety in CanadaPatient Safety Right Now, the Canadian Patient Safety Institute’s (CPSI) 2018-2023 strategy defines a vision that “Canada has the safest healthcare9/29/2020 6:20:02 PM5533https://www.patientsafetyinstitute.ca/en/toolsResourceshtmlTrueaspx
Incident Analysis3089Healthcare HarmFrameworks;Reports & Publications4/19/2011 9:12:41 PMIn March 2021, Healthcare Excellence Canada launched, bringing together the Canadian Foundation for Healthcare Improvement and Canadian Patient Safety Institute. This content can now be found on HEC’s new website. Check it out Incident AnalysisRoot Cause Analysis (RCA)6/28/2022 8:33:39 PM32518https://www.patientsafetyinstitute.ca/en/toolsResourceshtmlTrueaspx
The Measurement and Monitoring of Safety3090General Patient Safety;Healthcare Harm;Improving CultureToolkits & Guides;Reports & Publications;Frameworks7/12/2016 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 Download 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 info@cpsi-icsp.ca. "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 SafetyRewiring your thinking on measuring and monitoring of patient safety.  Patient safety refers to more than just looking at harm that has11/17/2020 6:52:38 PM14665https://www.patientsafetyinstitute.ca/en/toolsResourceshtmlTrueaspx
Fall Prevention Tip Sheets3091Community Based Care;Healthcare HarmTip Sheets;Patient and Family Resource2/3/2020 6:40:35 PMFalls 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. https//www.patientsafetyinstitute.ca/en/toolsResources/Documents/Interventions/Reducing%20Falls%20and%20Injury%20from%20Falls/FallsJointReport_2014_EN.pdf 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 SheetsFalls and injuries from falls are significant health concerns in Canada and critical issues in healthcare safety. 1   Falls account for up9/24/2020 2:49:48 PM2196https://www.patientsafetyinstitute.ca/en/toolsResourceshtmlTrueaspx
Five Questions to Ask about your Medications3092Improving Medication Safety;General Patient Safety;Community Based Care;Mental HealthPatient and Family Resource;Toolkits & Guides2/25/2016 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 medrec@ismp-canada.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 can9/24/2020 8:13:47 AM26368https://www.patientsafetyinstitute.ca/en/toolsResourceshtmlTrueaspx
Never Events for Hospital Care in Canada3093General Patient Safety;Healthcare HarmReports & Publications7/25/2015 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 outcomes9/24/2020 8:14:53 AM15379https://www.patientsafetyinstitute.ca/en/toolsResourceshtmlTrueaspx