|Education to support mandatory ADR and MDI reporting (Vanessa’s Law)||614||Report;Patient and Family Resource;Guide||3/4/2019 9:27:01 PM|| The Protecting Canadians from Unsafe Drugs Act, also known as Vanessa's Law, is intended to increase drug and medical device safety in Canada by strengthening Health Canada's ability to collect information and to take quick and appropriate action when a serious health risk is identified. It will be mandatory for hospitals to report serious adverse drug reactions (serious ADRs) and medical device incidents (MDIs) to Health Canada, effective December 16, 2019. Downloadable from this webpage are 4 PowerPoint modules that 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 | PDF Module 2 – Reporting Processes to Health Canada PowerPoint | PDF Module 3 – Strategies to Promote and Support Mandatory Reporting PowerPoint | PDF
Module 4 – Health Canada's Review and Communication of Safety Findings PowerPoint | PDF 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 firstname.lastname@example.org HSO https//healthstandards.org/ CPSI email@example.com If you have questions about Vanessa's Law and the mandatory reporting requirements, please contact firstname.lastname@example.org. 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
ACKNOWLEDGEMENTS Health Canada, ISMP Canada, HSO, and CPSI gratefully acknowledge input received from the Advisory Panel (listed in alphabetical order) Glenn Cox, Senior Director Pharmacy Services NSHA, Director Pharmacy Services, Cape Breton/Antigonish/Guysborough, Cape Breton Regional Hospital, Sydney, NS ; Michael Gaucher, Director Pharmaceuticals & Health Workforce Information Services, Canadian Institute for Health Information, Ottawa, ON ; Andrew Ibey – Clinical Engineer, Children's Hospital of Eastern Ontario, Ottawa, ON ; Denis Lebel – Pharmacien, adjoint aux soins, enseignement et recherche, Département de pharmacie, CHU Sainte-Justine, QC ; Dr. Joel Lexchin, Professor Emeritus, School of Health Policy & Management, York University, Toronto, ON ; Faith Louis, Regional Manager, Quality Improvement & Support Services, Pharmacy Services, Horizon Health Network, NB; Holly Meyer, Provincial Director, Product Quality & Safety, Alberta Health Services, AB ; Maryann V. Murray, Patients for Patient Safety Canada; Tolu Oyebode, Government of Saskatchewan, Senior Project Manager, Patient Safety Unit, Strategic Priorities Branch, Ministry of Health, SK ; Sheryl Peterson, Associate Director, Lecturer, Faculty of Pharmaceutical Sciences, The University of British Columbia (Vancouver Campus); Michelle Rossi, Director, Policy and Strategy, Health Quality Ontario, Toronto, ON ; Myrella Roy, Executive Director, and Cathy Lyder, Director Professional Practice, Canadian Society of Hospital Pharmacists, Ottawa, ON ; Christelle Sessua, Quality Assurance-Risk Management Coordinator, Iqaluit Health Services, Department of Health, Government of Nunavut ; Robyn Tamblyn, James McGill Chair, Professor, Department of Medicine, Department of Epidemiology & Biostatistics, McGill University, Scientific Director, Institute of Health Services and Policy Research, Canadian Institutes of Health Research, Montreal, QC ; Annemarie Taylor, Executive Director, Patient Safety & Learning System, Vancouver, British Columbia ; Terence Young, Chair of Drug Safety Canada and father of Vanessa Young. ||Educational Support for Mandatory Reporting of Serious ADRs and MDIs by Hospitals||The Protecting Canadians from Unsafe Drugs Act , also known as Vanessa's Law, is intended to||9/30/2019 4:41:09 AM||19415||https://www.patientsafetyinstitute.ca/en/toolsResources||html||True||aspx|
|Creating a Safe Space – Toolkit||69221||Toolkits||8/29/2019 4:12:22 PM|| The Creating a Safe Space Toolkit is intended to support healthcare leaders and policy makers to develop, implement or improve a workplace peer support program for healthcare providers. It includes tools, resources and templates from organizations across the globe who have successfully implemented their own peer support programs for healthcare providers. This toolkit was developed in partnership with the Mental Health Commission of Canada. To learn more about the importance of peer support for healthcare providers, review the full Creating a Safe Space manuscript.The Creating a Safe Space Toolkit focus and components The Creating a Safe Space Toolkit focuses on documents and examples from existing peer support programs for healthcare providers. Resources are sorted in drop-down menus by category. Each resource is listed with its source organization, title and a short description. The categories include Background – Provides background context on the importance of psychological health and safety in healthcare and the value of peer support Program description - Overviews of existing peer support programs to be used as examples. Program development tool – These tools will be helpful during the development of a peer support program including checklists and templates to get started. Policy document – Sample policy documents from various peer support programs. Recruitment – Role descriptions, documents and templates that will be helpful in recruiting peer supporters for a program. Training Resources – Documentation from training programs and links to established external training on mental health and peer support for healthcare providers. Documentation template – Templates on documenting interactions between peer supporters and their peer. Promotional material – Examples of brochures and flyers used to promote peer support programs. Evaluation tool – Tools to evaluate satisfaction and impact of a peer support program. Testimonial – Videos and podcasts from healthcare providers and patients about the importance of psychological health and safety and peer support. CPSI's Creating a Safe Space Toolkit resources are practical tools for developing a peer support program, compiled with input from experts and contributing organizations. Please use your discretion in selecting which tools are most appropriate for your context. This toolkit is not a complete inventory of every peer support program/resource available. It will be updated annually to ensure relevance. We welcome feedback on what is helpful, what can be improved, and content enhancements at email@example.com.||Creating a Safe Space – Toolkit||The Creating a Safe Space T oolkit is intended to support healthcare leaders and policy makers to develop, implement or improve a workplace peer||11/19/2019 2:41:32 AM||509||https://www.patientsafetyinstitute.ca/en/toolsResources||html||True||aspx|
|Creating a Safe Space||36623||Report||11/9/2018 8:43:28 PM|| Peer-to-peer support programs, where health professionals can discuss their experience with a PSI in a nonjudgmental environment with colleagues who can relate to what they are going through, are now seen as a potentially useful approach to helping health professionals cope with the PSI. A number of support programs are emerging in the US, and Canadian organizations are beginning to recognize that this – along with other types of support such as Employee Assistance Programs and trauma crisis teams – is an appropriate and valuable service for their staff. It is also well recognized that such programs will improve patient safety since health professionals will be in a healthier emotional state to care for their patients safely and be able to more effectively participate in PSI reviews and disclosures.
One of the first challenges many organizations confront in exploring the feasibility of such a support program is the ambiguity surrounding what type of legal protections may be available against disclosure of these communications in legal proceedings like malpractice actions or professional disciplinary hearings, or in employment or college disciplinary proceedings. With these guidelines, the Canadian Patient Safety Institute (CPSI) endeavours to clarify the legal privilege and professional confidentiality considerations of implementing peer-to-peer support programs for health professionals who are emotionally affected by a PSI. We hope that this work will help healthcare organizations create psychologically safe support programs, assist health professionals who are seeking support to understand what is protected and what is not, enable patients to gain insight into health professionals’ experience, and encourage policy makers to consider what might need to change – including enhanced protections for these communications – to ensure health professionals are supported after a PSI. ||Creating a Safe Space|| Peer-to-peer support programs, where health professionals can discuss their experience with a PSI in a nonjudgmental environment with colleagues who||10/23/2019 7:57:45 PM||1276||https://www.patientsafetyinstitute.ca/en/toolsResources||html||True||aspx|
|Creating a Safe Space: Psychological Health and Safety of Healthcare Workers ||102||Events;Presentation||4/10/2019 8:02:20 PM||
Webinar Series From 1200-100pm ET on June 12, June 20, September 12 and October 29, 2019 Watch on DemandWebinar 1 Creating a Safe Space Confidentiality and Legal Privilege for Peer Support Programs
Download Webinar 2 Results of the Pan Canadian survey of Healthcare Workers' Views on the Second Victim Phenomenon
Webinar 3 Global environmental scan of Peer-to-Peer Support Programs
Download Webinar #4 Canadian Best Practices Guidelines for Peer-to-Peer Support Programs in Healthcare
Download Webinar #5 Creating a Safe Space Launch of the Toolkit for Peer-to-Peer Support Programs in Healthcare, the Expert Advisory Committee and Canadian Peer Support Network
Download ||Webinar Series: From 12:00-1:00pm ET on June 12, June 20, September 12 and October 29, 2019 Watch on Demand Webinar 1:||11/4/2019 6:46:29 PM||12267||https://www.patientsafetyinstitute.ca/en/Events/Pages/Forms/AllItems.aspx||html||False||aspx|
|What the public needs to know about Vanessa's Law||1046||Report||8/15/2019 8:37:49 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. It will be mandatory for hospitals to report serious adverse drug reactions (serious ADRs) and medical device incidents (MDIs) to Health Canada, effective December 16, 2019.
Patients for Patient Safety Canada (PFPSC) created a presentation to help patients and the public understand and promote the reporting of serious adverse drug reactions and medical device incidents.
Download the patient module
This module can be used in presentations and other information-sharing activities.
Please share the link to this page with anyone who you think needs to know about the new requirements for reporting to improve safety.
The presentation was adapted from 4 core PowerPoint modules developed in collaboration with Health Canada.
Access the core modules
If you have questions about how to use these educational materials for your specific audience please contact firstname.lastname@example.org
If you have questions about Vanessa's Law and the mandatory reporting requirements, please contact
email@example.com. Why we need Vanessa’s Law By Brendan Gribbons of Lower Mainland Biomedical Engineering Consistent voluntary reporting followed by a thorough multi-incident analysis identified quickly a defect in IV tubing that resulted in a voluntary global recall of over 100 million IV tubing sets. Numerous alerts were generated regarding the uncontrolled flow, including from Health Canada and the manufacturer. This success story from British Columbia shows how Vanessa’s law can prevent harm. (This blog is in English only.)||
The Protecting Canadians from Unsafe Drugs Act , also known as Vanessa's Law, is intended to increase drug and medical device safety in||9/12/2019 9:32:18 PM||3940||https://www.patientsafetyinstitute.ca/en/toolsResources/Vanessas-Law/Pages/Forms/AllItems.aspx||html||False||aspx|
|Advocacy and support for use of a Surgical Safety Checklist||68992||Position Statements||2/5/2019 7:55:32 PM||Position StatementA Surgical Safety Checklist is smart for patients and smart for providers. It's use in Canadian healthcare facilities is endorsed by a
Position Statement supported by many surgical interest groups. Healthcare professionals must make every reasonable effort to provide safe care to their patients. The purpose of this statement is to express the commitment of the undersigned organizations to prioritize perioperative patient safety by creating an environment conducive to the effective adoption and use of a Surgical Safety Checklist.
||Advocacy and support for use of a Surgical Safety Checklist||Position Statement A Surgical Safety Checklist is smart for patients and smart for providers. It's use in Canadian healthcare facilities||2/5/2019 8:17:32 PM||847||https://www.patientsafetyinstitute.ca/en/toolsResources||html||True||aspx|
|Tools & Resources||35066||3/25/2009 3:33:37 PM|| ||Tools & Resources||Tools & Resources||7/19/2019 9:14:54 PM||31167||https://www.patientsafetyinstitute.ca/en||html||True||aspx|
|Events||35071||Events||6/4/2015 6:09:31 AM|| ||Events||11/18/2019 8:17:17 PM||8209||https://www.patientsafetyinstitute.ca/en||html||True||aspx|
|Introduction of the Measuring and Monitoring of Safety (Vincent) Framework to Canada||38928||Events;Presentation;Metrics||1/4/2017 4:11:25 PM||
Archive Monday, January 30, 2017 at 1000 am MST / 1200 pm EST
Purpose of the Call
"…if I apply
this [framework] conceptually to any problem I've got in safety I can make it work, and it orders my thinking" – Neil Prentice, Assistant Medical Director Mental Health, Tayside Trust, Scotland In Canada, as in the UK and US the focus of governments on assessing both quality and safety has increased over the past 10 years., A very large number of quality outcomes have been specified but the approach to safety has been much narrower, leaving many aspects of safety unexplored. The measurement of harm, so important in the evolution of patient safety, has been largely neglected and there have been prominent calls for improved measures. There is a critical need for patient safety measurement at the front lines, so that clinical teams can focus on key problems. Don Berwick has stated that 'most health care organisations at present have very little capacity to analyse, monitor, or learn from safety and quality information. This gap is costly and should be closed. Early warning signals can be valued and should be maintained and heeded'.5, In 2013 Professors Charles Vincent, Susan Burnett and Jane Carthey published their report
The Measuring and Monitoring of Safety which describes their framework to be implemented in practice to close the gap identified by Berwick. The framework provides a broader view of the information needed to create and sustain safer care.
Objectives Introduce the Measuring and Monitoring of Safety Framework to a Canadian healthcare audience Describe how the framework would work in Canada
Presentation A framework for measuring and monitoring safety A practical guide to using a new framework for measuring and monitoring safety in the NHS (2014) -
Download the guide from The Health Foundation The measurement and monitoring of safety Drawing together academic evidence and practical experience to produce a framework for safety measurement and monitoring (2013) –
Download the full report from The Health Foundation Speaker Biographies
Professor Charles Vincent Professor Charles Vincent is trained as a clinical psychologist and has worked in the British NHS for several years. Since 1985 he has focused on conducting research on the causes of harm to patients, the consequences for patients and staff and methods of improving the safety of healthcare. He established the Clinical Risk Unit at the Department of Psychology, University College London where he was Professor of Psychology. In 2002 he moved to become Professor of Clinical Safety Research in the Department of Surgery and Cancer at Imperial College in 2002. From 1999 to 2003 he was a Commissioner on the UK Commission for Health Improvement. He has acted as an advisor on patient safety in many inquiries and committees including the Bristol Inquiry, the Parliamentary Health Select Committee, the Francis Inquiry and the Berwick Review. From 2007 to 2013 he was the Director of the National Institute of Health Research Centre for Patient Safety & Service Quality at Imperial College. He moved to the Department of Experimental Psychology in January 2014 with the support of the Health Foundation to continue his work on safety in healthcare.
G. Ross Baker, Ph.D. G. Ross Baker, Ph.D., is a professor in the Institute of Health Policy, Management and Evaluation at the University of Toronto and Director of the MSc. Program in Quality Improvement and Patient Safety. Ross is co-lead for a large quality improvement-training program in Ontario, IDEAS (improving and Driving Excellence Across Sectors). Recent research projects include a review and synthesis of evidence on factors linked to high performing healthcare systems, an analysis of why progress on patient safety has been slower than expected and an edited book of case studies on patient engagement strategies.
Chris Power What began as a desire to help those in need 30 years ago has evolved into a mission to improve the quality of healthcare for all Canadians. Chris Power's journey in healthcare began at the bedside as a front-line nurse. Since then, she has grown into one of the preeminent healthcare executives in Canada. Her experiences, her success, and her values have led her to the position of CEO of the Canadian Patient Safety Institute. Previously, Chris served for eight years as president and CEO of Capital Health, Nova Scotia, with an annual operating budget of approximately $900 million, and 12,000 staff. Under Chris’s leadership Capital Health achieved Accreditation with Exemplary Status in 2014 with recognition for 10 Leading Practices.
SHIFT to Safety Ensuring patients are safe remains a major challenge for Canadian healthcare organisations and systems. The Canadian Patient Safety Institute's (CPSI) new initiative,
SHIFT to Safety, has been launched to address these challenges, including helping providers and leaders improve their measurement efforts.
References  Baker, G Ross,
Beyond the quick fix – Strategies for improving patient safety. Institute of Health Policy Management and Evaluation. Nov.9.2015  Darzi A. High quality care for all. London Department of Health, 2009.  Quality and Outcomes Framework 2013/14. London Department of Health, 2013.  Vincent CA, Aylin P, Franklin BD, et al.
Is health care getting safer? BMJ 2008;3371205–07.  Francis R.
Independent Inquiry into care provided by Mid Staffordshire NHS Foundation Trust January 2005–March 2009. London Department of Health, 2013.  Jha A, Pronovost P.
Toward a safer health care system The critical need to improve measurement. JAMA. 2016.  Berwick DM.
A promise to learn—a commitment to act. Improving the safety of patients in England. London Department of Health, 2013  Vincent CA, Burnett S, Carthey C.
The measurement and monitoring of safety in healthcare. London Health Foundation, 2013||Archive: Monday, January 30, 2017 at 10:00 am MST / 12:00 pm EST
Purpose of the Call:
"…if I apply
this||3/11/2019 4:45:52 PM||2735||https://www.patientsafetyinstitute.ca/en/toolsResources/Pages/Forms/NewDefaultView.aspx||html||False||aspx|
|Glossary of Terms||42570||5/22/2018 7:52:41 PM|| This Glossary defines and describes the terms used in the Engaging Patients in Patient Safety – a Canadian Guide. When appropriate, use your organization's preferred or commonly used terms. Accreditation A self-assessment and external peer assessment process used by health and social service organizations to accurately assess performance levels against established standards, and to implement ways to continuously improve. Culture of safety Culture is "the way we do things around here." Culture refers to people's shared values (what is important) and beliefs (what is held to be true), which interact with an organization's structure or system to produce behavioural norms (what people do). Positive safety culture Communication is open and honest, there is mutual respect and trust among providers and patients, people are comfortable reporting safety concerns, and there are fair and just processes in place to examine, address, and learn from failures. Disclosure A formal process to openly discuss a patient safety incident with the patient, their family, and members of the healthcare organization. Engagement An approach to encourage the people most impacted to participate actively in defining their issues of concern, and help decide, plan, deliver, implement, evaluate, and improve initiatives, processes, and/or policies. Ongoing engagement involves developing and sustaining constructive relationships, building strong, active partnerships at various levels across the healthcare system, and holding a meaningful dialogue with partners. Types of engagement include surveys, consultations, and shared decision making, as described in the spectrum of engagement. Effective engagement is goal-focused, decision-oriented and values-based. Patient engagement An approach to involve patients and/or patient partners to participate actively in designing, delivering, and evaluating health services at all system levels, with the goal of improving the quality of care (also known as co-design). Public engagement involving the public/ citizens before or after they access the healthcare system (e.g. make healthy and informed decisions regarding care) Spectrum (continuum, levels) of engagement The range of ways patient engagement takes place. It can span from input and consultation to shared leadership, accountability, and decision making. Evaluation Collecting, analyzing, and using data and information to understand how a project, program, or policy is progressing and/or what is its impact on individuals, organizations, and/or society. Evaluation often measures success or importance in relation to goals, objectives, and needs. Incident analysis (or root cause analysis) Structured, rigorous, often legally-protected and confidential process to review a patient safety incident. It identifies what happened, how, why it happened, what can be done to reduce the risk of recurrence and make care safer, and what was learned. It examines the whole system of care to identify the factors that contributed to the patient safety incident. Incident management Various actions and processes required immediately and on an ongoing basis following a patient safety incident. It includes immediate response, disclosure, incident analysis, sharing and learning. Patient and family Patient Person who is receiving, has received, or has requested health services. It refers to all other terms for patient, including client, resident, person, and individual. Family Person(s) whom the patient wishes to be involved in their care, and act on their behalf or interests. Family is defined by the patient. This person speaks up on behalf of the patient with the patient's input. Note because of the inconsistent terminology some use the term "those most impacted" instead of patient. Patient partner (or advisor) An individual who experienced care in the healthcare system (as a patient, family member or caregiver) and who, as part of a patient group (e.g., patient/family council), engages in shaping decisions, policies, and/or practices at all system levels. Patient representative An employee working in a healthcare setting who helps patients and families with their specific concerns, and answers their questions while in a healthcare facility. This person is the link between patients/ families, and providers/ organization. Patient-centred care (or patient and family-centred care, client and family-centred care) An approach to healthcare planning, delivery, and evaluation, grounded in mutually-beneficial partnerships among health care providers, patients, and families. This approach helps ensure that care is respectful, compassionate, culturally safe, and competent, while being responsive to the patient's needs, values, cultural backgrounds and beliefs, and preferences. Providers share information openly with patients, listen to and respect their needs and expectations, and ensures patients are involved in their own healthcare decisions. The core concepts are dignity and respect, information sharing, participation, and collaboration. Patient empowerment (or activation) Helping patients gain control over their own lives and increase their capacity to act on issues that they themselves define as important. Aspects of empowerment include self-efficacy, self-awareness, confidence, coping skills, and health literacy. Patient experience The sum of all interactions, shaped by an organization's culture, that influence patient perceptions, across the continuum of care. Patient safety The pursuit of the reduction and mitigation of unsafe acts within the health care system, as well as the use of best practices shown to lead to optimal patient outcomes. Patient safety is one of the dimensions of quality. Patient safety incident An event or circumstance which could have resulted, or did result, in unnecessary harm to a patient. It includes Near miss A patient safety incident that did not reach the patient. Replaces "close call." No harm incident A patient safety incident that reached a patient, but no discernible harm resulted. Harmful incident A patient safety incident that resulted in harm to the patient. Other terms sometimes still used to describe a harmful incident are adverse event or critical incident. Patient safety science Methods to acquire and apply safety knowledge to create highly reliable systems that approach "fail-safe" conditions (i.e., those in which the operator cannot perform the function improperly). Past effort has been directed toward developing defenses, which are barriers that prevent an unsafe act from resulting in harm. Over the years, healthcare has developed many of these barriers, and usually several must be breached for patient harm to occur Measurement A process essential to monitoring success. It indicates what's working and what's not, and can provide evidence for others to improve the quality of patient safety. Measures (metrics) Standard for determining an organization or initiative's activities and performance. Performance measures Monitors, evaluates, and communicates the extent to which various activities of the organization or the healthcare system meet their key objectives. Process measures Assesses what is being done and how (e.g., engagement activities, strategies or methods which directly affect the outcome), what is working well, and what needs to be changed or improved (e.g., the delivery of timely prophylactic antibiotics to reduce surgical site infection). Outcome measures Determines what effects the engagement had, what it did or did not accomplish, and what success looks like (e.g., to reduce falls, teams should measure the number of falls). Balancing measures Determines if improvements in one part of the system were made at the expense of other processes in other parts of the system (e.g., 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). Providers (or clinicians) Includes physicians, nurses, and allied health care professionals who directly provide healthcare services to patients. The term does not include the family members providing care (family caregivers or care partners). Quality of care The degree to which healthcare services produce the desired health outcomes and measure up to current evidence and knowledge. The attributes most often used to describe quality care are safe, patient-centred, accessible, appropriate, effective, efficient, and equitable. Each province or organization may have their own quality frameworks. Quality Improvement A systematic approach to making changes that lead to better patient outcomes and stronger health system performance. It involves applying quality improvement science, which provides a robust structure, tools, and processes to assess and accelerate efforts for testing, implementing, and spreading good practices. Information Qualitative information Descriptive information, such as patient stories, notes from interviews or focus group discussions, and observation notes. Qualitative information can be systematically analyzed to identify issues of interest. Quantitative information Information that measures characteristics using a numeric value (e.g., gender, income, marital status, etc.). The numeric values can be statistically analyzed to identify issues of interest. Stakeholder A person who has a vested interest in engagement outcomes and who could be affected by any decisions taken or changes made. Stakeholders could include patients, families, caregivers, providers, administrative staff, suppliers, organizational partners, the community, the public and others. System levels The healthcare system is comprised of many sub-systems operating at different levels (e.g., outside of the organization, within the organization and/or program level, at point of care) each with specific goals, resources (e.g., human, financial, equipment), and formal or informal processes. Point of care direct care (patient and family receiving care and providers and others who deliver care and services) Organization program/ unit/service and facility/organization/ health region (service design and delivery, strategy, system planning, organizational design, governance) System the sum of all the organizations, institutions, and resources that deliver health care services to meet the health needs of a target population (policy, planning, resourcing, research, education, accreditation) Validated tool/survey/questionnaire A measurement tool that has been tested for reliability (produces consistent results) and validity (produces true results).References Canadian Patient Safety Institute. Patient Safety and Incident Management Toolkit. Glossary. 2015. Carman KL, Dardess P, Maurer M, Sofaer S, Adams K, Bechtel C, Sweeney J. Patient and family engagement a framework for understanding the elements and developing interventions and policies. Health Aff (Millwood). 2013 Feb;32(2)223-31 Charles Vincent, René Amalberti. Safer Healthcare. Strategies for the Real World. Springer, Cham. 2016. Emanuel LL, Taylor L, Hain A, Combes JR, Hatlie MJ, Karsh B, Lau DT, Shalowitz J, Shaw T, Walton M, eds. The Patient Safety Education Program – Canada (PSEP – Canada) Curriculum. © PSEP – Canada, 2016. European Patients Forum. Patient Empowerment http//www.eu-patient.eu/campaign/PatientsprescribE/ Health Quality Council of Alberta. The Alberta Quality Matrix for Health. Health Quality Ontario. Quality Matters Realizing Excellent Care for All. 2015. Institute for Patient- and Family-Centered Care. What is patient and family centred care. Safer Healthcare Now! Improvement Frameworks Getting Started Kit. 2015 The Beryl Institute. Defining Patient Experience. ||This Glossary defines and describes the terms used in the Engaging Patients in Patient Safety – a Canadian Guide . When appropriate, use your||5/22/2018 9:22:11 PM||296||https://www.patientsafetyinstitute.ca/en/toolsResources/Patient-Engagement-in-Patient-Safety-Guide/Pages/Forms/AllItems.aspx||html||False||aspx|
|Conquer Silence – Ask the right questions about your medications||2248||Checklists;Patient and Family Resource||10/25/2019 4:05:46 PM||
Thank you for listening to stories and advice on reducing healthcare harm from real people at
ConquerSilence.ca. When any changes are made to your or your loved one’s medications (starting, stopping or changing doses) - especially when on multiple medications - there may be a risk of adverse drug reactions or errors.
The Canadian Patient Safety Institute has teamed up with the Institute for Safe Medications Practices Canada, Patients for Patient Safety Canada, the Canadian Pharmacists Association, and the Canadian Society for Hospital Pharmacists to create this list of questions to help you start a conversation about medications with your healthcare provider.
Together with your doctor, homecare nurse, or pharmacist, you can help Conquer Silence and keep yourself and your loved ones safe.
Download Sign up to for the Conquer Silence mailing list to be notified when we feature different patient safety issues, add new resources, and ask you to help us evaluate the effectiveness of this campaign. ||Thank you for listening to stories and advice on reducing healthcare harm from real people at
ConquerSilence.ca . When any changes are made to||10/25/2019 5:44:28 PM||740||https://www.patientsafetyinstitute.ca/en/toolsResources/5-Questions-to-Ask-about-your-Medications/Pages/Forms/AllItems.aspx||html||False||aspx|
|Fact Sheets About Hand Hygiene||38903||Toolkits;Guide||6/3/2015 4:46:57 PM|| Get the information you need about hand hygiene quickly and conveniently. Please share this information with your colleagues.
The Need for Better Hand Hygiene
If Hands Could Talk
Antimicrobial Resistance and MRSA in Canada
Proper Hand Hygiene Technique
How to Handrub
How to Handwash
Hand, Skin, and Nail Care||Get the information you need about hand hygiene quickly and conveniently. Please share this information with your colleagues.
The Need for||11/28/2016 5:59:41 PM||5335||https://www.patientsafetyinstitute.ca/en/toolsResources/Pages/Forms/NewDefaultView.aspx||html||False||aspx|
|Breaking down the barriers indigenous people face in Canada’s health-care system||2185||Patient and Family Resource;Patient Stories||9/18/2019 8:26:34 PM||
At the age of 40, Samaria Cardinal found herself homeless and alone, living under a bridge in Calgary, calculating miseries endured and all the hopeless days ahead.
Her father had experienced extreme trauma growing up in Alberta’s residential schools and he’d passed that damage on to his daughter in many ways. Samaria had run away from home and lost herself in drug addiction. Years of interaction with the medical and mental health systems had failed her. She’d been diagnosed as bipolar and locked up in mental health wards. She’d been administered shock treatments and overmedicated on so many antipsychotic drugs she wound up with severe tardive dyskinesia, a condition that causes uncontrollable jerky movements of the face and body.
On that day, the sum of all those sad experiences brought her to a crossroads.
“I was sitting on a mattress, dirty and soaked with urine, and I had no coat, and it was freezing,” Cardinal recalls. “And I thought I’m not living
anymore, my life has been destroyed. Nobody can help me so I might as well end it right now.”
Cardinal hesitates there, drawing a
long ragged breath at the memory.
“But something gave me the strength to live. And I chose to live.”
Some 20 years later Cardinal seems a world away from that sorrowful half-life. She’s proud of her Metis heritage, happy and confident, back at university, with her own place and her own business. And she’s an outspoken advocate for breaking down the barriers indigenous people face in Canada’s health-care system.
“I really feel my indigenous heritage played a big part in how I was treated and misdiagnosed by the health care system,” Cardinal says. “Because we are not understood by mainstream society and we are not understood by many doctors and nurses and people involved in the health care system. They don’t understand what we’ve been through as a people, and they
don’t understand how it has affected us.
Plus there are judgements.”
Cardinal saw that again first-hand recently while riding on the C-train in Calgary when an indigenous man suffered a seizure and slid off his seat onto the floor. All around him the business commuters paid no heed, assuming it was just another drunk Indian. A furious Cardinal had to
more or less shame the people in that crowded car into action to get the man the medical help he needed.
“I personally believe many people have to connect more with indigenous people. Learn the real history of Canada and North America, learn what these people have gone through, and try and understand where they are at the current time. And as a non-indigenous person, look at the myths out there. Try to educate yourself and try to understand another culture.”
ago Cardinal picked herself up from beneath that bridge, went to a friend’s house and appealed for help. A man from her past, someone who loved her, re-entered her life and gave her some much-needed support. Her daughter stood by her as well. Gradually, Cardinal came to realize that her long-time pattern of care was simply not working for her. She started resisting the idea of simply taking more and more pills. She found support and improvement with other holistic approaches and counselling.
She eventually broke with her old medical team and started up with a new psychiatrist, who was far less quick to prescribe medications. Over two years, she weaned herself off all the drugs and came to see herself as something other than a lifelong victim.
“If I had not fired that medical
team I would still be living in Calgary housing. I would be taking so many medications that I wouldn’t be able to function. I would be living a life where I was a burden on society, unhappy, a victim, lost, not going anywhere, just basically existing.”
Asked what single piece of advice she’d like to give to health-care practitioners, Cardinal draws back on her own early diagnosis as bipolar, one she questions today.
“Be very careful with the label that you’re putting on an individual, especially a mental health care diagnosis. Because with that diagnosis, comes a lot. People are judging you wherever you go so be really careful when you’re dispensing that.”
Cardinal says she has been encouraged by recent moves toward more culturally appropriate care for indigenous patients in Canadian hospitals, including access to indigenous elders.
“Having elders involved in the health care system, working in hospitals in liaison with all the health-care professionals is very important, because they can be an advocate. They dispense wisdom, they dispense experience and they can be the intermediary between the health care system and the indigenous patient involved. It’s very important to have them there and I have started seeing instances of that in Calgary, which is really nice and it’s a real big step from the way things used to be,” Cardinal says.
“Also many indigenous people are not urban indigenous, they live on reserves.
So they’re coming far away to a place they’re not comfortable in, with a lot of people that don’t know them, so having somebody there like an elder makes them feel better, provides them with a sense of safety…”
As part of her healing odyssey, Cardinal has found great satisfaction in working through a difficult reconciliation with her father, Douglas Cardinal, one of Canada’s best-known architects.
“He was always very focused on his career and I stayed away from him because of the trauma that I experienced when I was quite young,” she says. “I’ve only got back with my father in the last couple of years when I was off all of the medications and I started doing a lot of personal work on myself to deal with my trauma that was involved."
“The reason why I connected back with my father is because many people have seen the growth that I’ve experienced in my life and that I’m actually almost a totally different person off of all of those drugs and now that I’ve found strength in myself. And I’m expecting people to not look at my past and judge me any more, to see me as I am sitting right here now in this moment, and I thought how can I expect people to do that for me when I cannot do that for my father…
ago I would not have had the strength to do that. I was still so affected and feeling the victim in my life but now I’m not a victim anymore. I’m an empowered, resilient and strong human being and after I made that connection
again I realized he wasn’t the person he was either.”
Cardinal joined Patients for Patient Safety Canada because she wanted an opportunity to tell her story. She sees the organization as a
people can give voice to experiences that many professionals in the health care system need to hear. ||
At the age of 40, Samaria Cardinal found herself homeless and alone, living under a bridge in Calgary, calculating miseries endured and||9/23/2019 4:35:31 PM||2004||https://www.patientsafetyinstitute.ca/en/toolsResources/Member-Videos-and-Stories/Pages/Forms/AllItems.aspx||html||False||aspx|
|Ventilator-Associated Pneumonia (VAP): Getting Started Kit||38961||Getting Started Kit||7/1/2015 8:57:36 AM||Effective March 14 2019, the Canadian Patient Safety Institute has archived the Ventilator-Associated Pneumonia (VAP) intervention.
Though you may continue to access the Getting Started Kit online, it will no longer be updated. Getting Started KitThis free resource is designed to help you successfully implement interventions in your organization. The Getting Started Kit contains clinical information, information on the science of improvement, and everything you need to know to start using the intervention.
Click here to download the Getting Started Kit.
Click here to download the Annotated Bibliography
One-PagerThe One-Pager is a summary of the Getting Started Kit that you can use to promote the intervention to your organization.
Click here to download the One-Pager. Icons
Intervention IconsUse these intervention icons on presentations, reports, flyers, and other material to promote the intervention throughout your organization.
Click here to download the full-colour intervention icon.
Click here to download the black and white intervention icon. Intervention Icons With Text
Click here to download the full-colour intervention icon with text.
Click here to download the black and white intervention icon with text. ||VAP: Getting Started Kit||3/25/2019 8:23:06 PM||3194||https://www.patientsafetyinstitute.ca/en/toolsResources/Pages/Forms/NewDefaultView.aspx||html||False||aspx|
|Peer-to-Peer Support (Second Victim Phenomenon)||59677||11/9/2018 9:04:39 PM|| Peer-to-Peer Support (Second Victim
Phenomenon) - An ever-growing body of evidence demonstrates that health
professionals feel emotionally distressed after a patient safety incident
(PSI), and there is an emerging recognition of the potential negative impact on
both the health professionals’ health and on patient safety. As a result of this recognition, healthcare
organizations are seeking ways to support health professionals who are
emotionally traumatized after a PSI. The Second
Victim Phenomenon is a real and serious consequence related to health care
roles. Different studies estimate that
the prevalence of the Second Victim Phenomenon ranges from 10.4% up to 43.3
%. Although there seems to be great
interest in the topic, there are very few comprehensive programs specifically
designed to address second victim phenomenon with even fewer and less developed
Canadian programs. The distress
caused by patient safety incidents, particularly harmful incidents can have
negative effects on the care providers health and well-being and the safety of
patient care. If not addressed, the
provider may suffer in silence, change their role, leave the profession and
some very unfortunately, will become victims of suicide. As a result, the Canadian Patient Safety
Institute (CPSI) has been working to increase awareness of the second victim
phenomenon and available resources. Recommended strategies While provider
support programs are mainly targeted at emotionally supporting health care
providers that have experienced a patient safety incident, CPSI’s commitment to
patient safety remains the same. As part
of a comprehensive program, there is a critical need to support patients and
families on their journey from harm to healing.
Providers, patients, families and leaders are part of the same system
and to do better we need to support and collaborate in a manner that allows us
to maximize learning and improvement. A
provider support program will enable healthcare professionals to re-establish
or improve their previous levels of work performance and improve patient
safety. Provider programs should not be
designed simply to help the provider but must be designed to improve the system
and help make patient care safe. The
walking wounded, the silent mistake, the loss of providers all contribute to
lost opportunities for, and potential liabilities to patient safety. Immediate care and support for
patient(s), family, providers and others. Peer-to-peer
support programs, where health professionals can discuss their experience with a PSI in a non-judgmental environment with colleagues who can relate to what they are going through, are now seen as a potentially useful approach to helping health professionals cope with the PSI. Creating a Safe Space Addressing Confidentialityfor Peer-to-Peer Support Programs for Health Professionals ||Peer-to-Peer Support (Second Victim
Phenomenon) - An ever-growing body of evidence demonstrates that health
professionals feel emotionally distressed||4/12/2019 2:50:46 PM||1866||https://www.patientsafetyinstitute.ca/en/toolsResources/PatientSafetyIncidentManagementToolkit/IncidentManagement/Pages/Forms/AllItems.aspx||html||False||aspx|
|Atlantic Learning Exchange||36691||Events||9/20/2016 6:01:00 PM||
Discover innovative and emerging trends in patient safety & quality improvement
October 8 – 9, 2019 St. John's, NL, The Atlantic Health Quality and Patient Safety Collaborative (AHQPSC), through partnership support of the Canadian Patient Safety Institute (CPSI), welcomes you to attend this year's Atlantic Health Quality & Patient Safety Learning Exchange (ALE 2019) which will take place at the Sheraton Hotel Newfoundland, St. John's, NL,
October 8 – 9, 2019.
Program Who should attend? We look forward to welcoming innovative and engaged care providers, managers, health leaders, academics and students from university and college setting, as well as government representatives from the four Atlantic Provinces in attendance this year. Tickets are limited! Through this conference, you will be given an opportunity to Mobilize energy and enthusiasm for a new era of patient safety and quality improvement; Understand the role innovation and technology play in healthcare improvement; Stimulate change through the power of the patient voice; and Develop the skills for leading transformational change!
Registration $275 Student Registration $199*
*Spaces are limited for student registration. Student ID is required. Conference fees include full conference with light breakfast and lunch provided.Venue & Hotel Accommodations
The conference will be taking place at the
Sheraton Hotel Newfoundland located at 115 Cavendish Square in St. Johns Newfoundland.
For guests that require accommodations, a room block has been reserved for attendees at the Sheraton Hotel Newfoundland starting at $164 a night for a standard room.
Guests can use the booking link below or can call/email to do reserve a room for the conference. When booking via phone or email use reference code “Atlantic Learning Exchange”.
firstname.lastname@example.org Call Local 709-726-4980 or Toll Free 1-888-870-3033
Book Hotel Room Now Partners
Do you want to support this event? Do you want exclusive access to the front line of healthcare in the Atlantic provinces? We are looking for Sponsors and Exhibitors contact Gina Peck at 902-481-5034 or
email@example.com to receive more information on sponsorship and exhibiting at the conference. ||Atlantic Quality and Patient Safety Learning Exchange||Discover innovative and emerging trends in patient safety & quality improvement
October 8 – 9, 2019 St. John's, NL, The Atlantic Health||10/2/2019 3:07:21 PM||7499||https://www.patientsafetyinstitute.ca/en/Events||html||True||aspx|
|Enhanced Recovery Canada™ - Enhanced Recovery After Surgery||36646||Video||7/13/2016 2:57:58 AM||
What is Enhanced Recovery After Surgery? Enhanced Recovery After Surgery - ERAS is a program highlighting surgical best practices and consists of a number of evidence-based principles that support better outcomes for surgical patients including an improved patient experience, reduced length of stay, decreased complication rates and fewer hospital readmissions. As part of CPSI's Integrated Patient Safety Action Plan for Surgical Care Safety and with support from 24 partner organizations from across the country, Enhanced Recovery Canada™ is leading the drive to improve surgical safety across the country and help disseminate these ERAS principles.
A number of Canadian surgical care teams have already embraced the ERAS principles Alberta Health Services, Eastern Health, McGill University Health Centre, University of Toronto's Best Practices in Surgery, the Winnipeg Regional Health Authority as well as BC's Patient Safety & Quality Council and the Doctors of British Columbia.
Resources for Colorectal Surgeries
Industry Partners Enhanced Recovery Canada™ gratefully acknowledges the support from the following industry partners in the development of ERC tools and resources and contributing to the dissemination and implementation of these surgical best practices. The ERC Pathways and other resources have been developed based exclusively on unbiased clinical evidence.
For more information, contact us at
firstname.lastname@example.org.||Enhanced Recovery Canada™||What is Enhanced Recovery After Surgery ? Enhanced Recovery After Surgery - ERAS is a program highlighting surgical best practices and consists of a||7/5/2019 5:36:05 PM||8998||https://www.patientsafetyinstitute.ca/en/toolsResources||html||True||aspx|
|A Framework for Establishing a Patient Safety Culture||36622||Framework||2/14/2018 4:54:19 PM||Patient Safety Culture "Bundle" for CEOs/Senior Leaders What is the Patient Safety Culture "Bundle"? Strengthening a safety culture necessitates interventions that simultaneously
enable, enact and elaborate in a way that is attuned to the existing culture. Through a literature review of more than 60 resources, a Patient Safety Culture Bundle has been created and validated through interviews with Canadian thought leaders. The Bundle is based on a set of evidence-based practices that must all be applied in order to deliver good care. All components are required to improve the patient safety culture. The
Patient Safety Culture "Bundle" for CEOs and Senior Leaders encompasses key concepts of safety science, implementation science, just culture, psychological safety, staff safety/health, patient and family engagement, disruptive behavior, high reliability/resilience, patient safety measurement, frontline leadership, physician leadership, staff engagement, teamwork/communication, and industry-wide standardization/alignment.
Download a one-pager of the Patient Safety Culture Bundle for CEOs/Senior Leaders
Why was this Bundle created? A patient safety culture is difficult to operationalize. Improving safety requires an organizational culture that enables and prioritizes patient safety. The importance of culture change needs to be brought to the forefront, rather than taking a backseat to other safety activities. The National Patient Safety Consortium Education Working Group verified the critical role senior leadership plays in ensuring patient safety is an organizational priority. A Working group of partners, led by the Canadian Patient Safety Institute, Canadian College of Health Leaders (CCHL), HealthCareCAN and the Healthcare Insurance Reciprocal of Canada (HIROC) were brought together to establish a framework and advance this work. How can I use the Patient Safety Culture Bundle? The key components required for a Patient Safety Culture are identified under three pillars
Within each pillar you will find links to valuable tools and resources to help your efforts in establishing and sustaining a patient safety culture.
(coming soon)Are you looking to establish and sustain a culture of safety? We are committed to providing a robust framework to advance a safety culture. The Bundle is a dynamic tool that will be continually updated. We invite you to check back often for more links and resources. We also need your participation and input to ensure the Bundle is current and relevant. Please forward any links or comments to
"Patient safety and healthcare quality are advanced when boards and senior leaders are committed to it and are able to show evidence of that commitment. Missing until now is a concise "how to" guide. The Patient Safety bundle for Leaders fills that gap."
Catherine Gaulton, CEO, HIROC
"Leadership is critical to developing a patient safety culture and building leadership capacity requires a vision of the knowledge, skills and behaviours necessary to achieve this. The Patient Safety Leadership Bundle provides this and will be a practical tool for health leaders across the healthcare continuum to assess their personal capabilities. It will also provide both organizations and the system, as a whole, a checklist for what's missing from our collective leadership education toolkits so that we can strategically respond to these needs. HealthCareCAN is committed to the spread of this tool across the country as part of a cultural shift to safety and a drive towards high-reliability culture."
Dale Schierbeck, Vice-President, Learning & Development, HealthCareCAN and Co-Chair, Patient Safety Education for Leaders Working ||A Framework for Establishing a Patient Safety Culture||Patient Safety Culture "Bundle" for CEOs/Senior Leaders What is the Patient Safety Culture "Bundle"? Strengthening a safety||4/4/2019 2:29:25 PM||6150||https://www.patientsafetyinstitute.ca/en/toolsResources||html||True||aspx|
|Canadian Patient Safety Week (CPSW)||36688||Events||12/8/2009 9:50:43 PM||Welcome to your home for Canadian Patient Safety Week! #ConquerSilence Canadian Patient Safety Week runs October 28 to November 1, 2019. The Canadian Patient Safety Institute invites all Canadians – the public, providers and leaders – to become involved in making patient safety a priority. Printed packages are available for order while supplies last and include posters, buttons, other promotional materials, plus tips and resources for running a terrific CPSW event at your organization! Quantities are limited – 500 English packages and 100 French packages. Click HERE to be directed to the online store.
Conquer Silence At some point, every one of us will be a patient in the healthcare system. What most Canadians don’t realize, is that 28,000 of us die from preventable harm when receiving care, every single year. This makes patient safety incidents the third leading cause of death in Canada, behind cancer and heart disease. One in three Canadians has had patient harm affect themselves or a loved one, yet the public is collectively unaware that the problem exists. This is a silent epidemic. If we do nothing, 1.2 million Canadians will die from preventable patient harm in the next 30 years. What we must battle in our collective efforts to reduce patient harm, is systemic silence. Silence between patients and providers, between colleagues in healthcare facilities, between administrators in different regions, and between the public and policymakers. If something looks wrong, feels wrong, or is wrong – we need people to speak up, in the moment. It is only by bringing these issues to light that we can begin to work together to solve them. During this year’s Canadian Patient Safety Week, join us in sharing your story and your advice on how to reduce patient harm at ConquerSilence.ca. Canadian Patient Safety Week EventsShare your patient safety story and your advice on how to reduce harm at conquersilence.ca New episode of our award winning PATIENT podcasts
Creating a Safe Space Webinar
Mandatory Reporting (Protecting Canadians from Unsafe Drugs Act) Webinar Please explore the Canadian Patient Safety Week links for Tools & Resources, including our upcoming communications toolkit and tools to improve patient safety. Discover stories of overcoming silence in our award-winning podcast series, PATIENT. We will continue to add new content. About Canadian Patient Safety Week is a national, annual campaign that started in 2005 to inspire extraordinary improvement in patient safety and quality. As the momentum for promoting best practices in patient safety has grown, so has the participation in Canadian Patient Safety Week. Canadian Patient Safety week is relevant to anyone who engages with our healthcare system providers, patients, and citizens. Working together, thousands help spread the message to Conquer Silence. Sponsors
Sponsorship The Canadian Patient Safety Institute invites you to join our network of Canadians – the public, healthcare providers and healthcare leaders – in making patient safety a priority. If your organization is interested in sponsoring CPSW 2019, please contact
Do you have any questions or suggestions? Contact CPSI CommunicationsPhone (780) 409-8090 Toll free 1-866-421-6933
CPSW@cpsi-icsp.ca Join the conversation at
#ConquerSilence ||Canadian Patient Safety Week||Canadian Patient Safety Week (CPSW)||11/6/2019 8:53:52 PM||48610||https://www.patientsafetyinstitute.ca/en/Events||html||True||aspx|
|Patient Safety and the Hidden Curriculum||36647||Report||11/12/2018 10:50:58 PM||
Have you reflected on, seen or felt the impact of unprofessional behavior on safe patient care?
In the complex health care environment within which we live today, safe health care demands constant active and collaborative efforts among healthcare providers, patients and families alike.
Download Learn more about the
Hidden Curriculum and what it takes to ensure the reliable delivery of safe healthcare What is the culture of patient safety? Shifting focus from reactionary measures to commitment and building a safe environment from get-go.
Why do healthcare professionals need to commit to life-long learning? The critical role of learning through informal interactions and its impact on quality care.
How does the workplace culture impact safe care? Strong leadership, teamwork and commitment to improvement play a pivotal part.
Brought to you by the Canadian Patient Safety Institute and the Royal College of Physicians and Surgeons of Canada. ||Patient Safety and the Hidden Curriculum ||Have you reflected on, seen or felt the impact of unprofessional behavior on safe patient care?
In the complex health care environment within||11/13/2018 3:59:12 PM||315||https://www.patientsafetyinstitute.ca/en/toolsResources||html||True||aspx|
|Am I Safe?||36645||Report||7/13/2016 9:39:51 PM||
It's time to have a conversation about safety in the home Choosing to receive care at home is an important decision to make. Being aware of and understanding potential risks to safety is a big part of receiving home care for patients, their families and care providers. Talking openly and honestly as a healthcare team is important —before, during, and after care appointments. In 2015, CPSI worked with the Canadian Home Care Association to find tools and resources to guide safety conversations between health care providers and patients when receiving home care services. The result was the
Am I Safe? report.
Am I Safe? helps healthcare providers, patients, and caregivers work together to evaluate and manage risk when receiving care at home. Understanding and accepting "what is safe" means balancing the patient's and family's understanding of risk with the healthcare provider's knowledge and perception of acceptable risk. If all parties involved can have the right conversations, establish trust, share information and knowledge, and support one another, they greatly increase their chances of successful, safe care in the home. The next phase of Am I Safe? begins now. We want to discover and test resources to support safety conversations in the home. If you are using a tool or are aware of a tool that could facilitate conversations around safety in the home, please contact us at
email@example.com.||Am I Safe?||It's time to have a conversation about safety in the home Choosing to receive care at home is an important decision to make. Being aware of and||4/5/2017 7:21:23 PM||1640||https://www.patientsafetyinstitute.ca/en/toolsResources||html||True||aspx|
|Home Care Safety||36594||Report;Research;Toolkits||6/5/2014 8:48:12 PM||
With the release of the Safety at Home A Pan- Canadian Home Care Study (2013), the Canadian Patient Safety Institute (CPSI) and the Canadian Home Care Association (CHCA) worked with the research team to translate the knowledge acquired from the study into tools, resources and programs for the field. Click on the following links to access resources available to home care providers, clients and families, and policy makers.
Resources for home care providers
Resources for family caregivers and clients
Resources for policy makers and academics
||Home Care Safety||With the release of the Safety at Home: A Pan- Canadian Home Care Study (2013) , the Canadian Patient Safety Institute (CPSI) and the||6/29/2016 8:24:53 PM||1773||https://www.patientsafetyinstitute.ca/en/toolsResources||html||True||aspx|
|Improvement Frameworks Getting Started Kit||36595||Toolkits;Getting Started Kit;Framework||11/24/2011 4:21:24 PM||12/2/2015 7:00:00 AM||The Improvement Frameworks Getting Started Kit is intended to serve as a common document appended to the Safer Healthcare Now! Getting Started Kits. The goal is to help provide a consistent way for teams and individuals to approach the challenge of making changes that result in improvements.
Download ||Improvement Frameworks Getting Started Kit||The Improvement Frameworks Getting Started Kit is intended to serve as a common document appended to the Safer Healthcare Now! Getting Started||1/5/2016 6:18:07 PM||3347||https://www.patientsafetyinstitute.ca/en/toolsResources||html||True||aspx|
|Patient Safety and Incident Management Toolkit||36596||Toolkits||12/18/2014 8:28:40 PM||Prevent Patient Safety Incidents and Minimize Harm When They Do Occur When a patient's safety is compromised, or even if someone just comes close to having an incident, you need to know you are taking the right measures to address it, now and in the future. CPSI provides you with practical strategies and resources to manage incidents effectively and keep your patients safe. This integrated toolkit considers the needs and concerns of patients and their families, and how to properly engage them throughout the process. Drawn from the best available evidence and expert advice, this newly designed toolkit is for those responsible for managing patient safety, quality improvement, risk management, and staff training in any healthcare setting.
Patient Safety Management
System Factors For more information, contact us at
firstname.lastname@example.org.Toolkit Focus and Components The toolkit focuses on patient safety and incident management; it touches on ideas and resources for exploring the broader aspects of quality improvement and risk management. There are three sections to the toolkit Incident management—the actions that follow patient safety incidents (including near misses) Patient safety management—the actions that help to proactively anticipate patient safety incidents and prevent them from occurring System factors—the factors that shape and are shaped by patient safety and incident management (legislation, policies, culture, people, processes and resources).
Visual representation of the toolkit.
Incident management Resources to guide the immediate and ongoing actions following a patient safety incident (including near misses). We emphasize immediate response, disclosure, how to prepare for analysis, the analysis process, follow-through, how to close the loop and share learning.
Patient safety management Resources to guide action before the incident (e.g., plan, anticipate, and monitor to respond to expected and unexpected safety issues) so care is safer today and in the future. We promote a patient safety culture and reporting and learning system.
System factors Understanding the factors that shape both patient safety and incident management and identify actions to respond, align, and leverage them is crucial to patient safety. The factors come from different system levels (inside and outside the organization) and include legislation, policies, culture, people, processes and resources.Implementing Patient Safety and Incident Management Processes Consider the following guiding principles when applying the practical strategies and resources.
Patient- and family-centred care. The patient and family are at the centre of all patient safety and incident management activities. Engage with patients and families throughout their care processes, as they are an equal partner and essential to the design, implementation, and evaluation of care and services.
Safety culture. Culture refers to shared values (what is important) and beliefs (what is held to be true) that interact with a system's structures and control mechanisms to produce behavioural norms. An organization with a safety culture avoids, prevents, and mitigates patient safety risks at all levels. This includes a reporting and learning culture.
System perspective. Keep patients safe by understanding and addressing the factors that contribute to an incident at all system levels, redesigning systems, and applying human factor principles. Develop the capability and capacity for effectively assessing the complex system to accurately identify weaknesses and strengths for preventing future incidents.
Shared responsibilities. Teamwork is necessary for safe patient care, particularly at transitions in care. It is the best defence against system failures and should be actively fostered by all team members, including patients and families. In a functional teamwork environment, everyone is valued, empowered, and responsible for taking action to prevent patient safety incidents, including speaking up when they see practices that endanger safety.Resources to Support Patient Safety and Incident Management CPSI's
toolkit resources are practical tools for patient safety and incident management, compiled with input from experts and contributing organizations. You may not require all of them when managing an incident, so please use your discretion in selecting the tools most appropriate for your needs.Toolkit Development and Maintenance CPSI accessed a variety of qualified experts and organizations to compile this practical and evidence-based toolkit. The process included Assigning a CPSI team with support from a writer with experience in the field Seeking advice from an expert faculty that included patient and family representatives Basing the content on the Canadian Incident Analysis Framework Engaging key stakeholders via focus groups and collecting evidence from peer-reviewed journals and publicly available literature The toolkit will be updated every year to keep it relevant. We welcome feedback on what is helpful, what can be improved, and content enhancements at email@example.com.||Patient Safety and Incident Management Toolkit||Prevent Patient Safety Incidents and Minimize Harm When They Do Occur When a patient's safety is compromised, or even if someone just comes close to||6/19/2017 4:19:43 PM||7655||https://www.patientsafetyinstitute.ca/en/toolsResources||html||True||aspx|
|Teamwork and Communication||36597||Publication;Framework||7/22/2009 8:44:35 PM||
Effective teamwork and communication are critical for ensuring high reliability and the safe delivery of care. Teamwork and communication techniques can improve quality and safety, decrease patient harm, promote cross-professional collaboration and the development of common goals, decrease workload issues, and improve staff and patient satisfaction.
Building effective teams and improving communication through standardized tools will move effective teamwork forward in Canada and contribute to a culture of patient safety. CPSI is developing a Canadian Framework for Teamwork and Communication to help healthcare providers and organizations integrate tools and resources into practice.
Canadian Framework for Teamwork and Communication Appendix A
Teamwork and Communication in Healthcare A Literature Review Appendix B
Consultation with Health Professionals and Administrators Regarding Teamwork and Communication Appendix C Report on Summary of Team Training Programs
||Canadian Framework for Teamwork and Communication||Effective Teamwork and Communication to Enhance Patient Safety||11/9/2016 8:44:39 PM||4830||https://www.patientsafetyinstitute.ca/en/toolsResources||html||True||aspx|
|The Safety Competencies Framework||36599||Publication;Framework||4/14/2009 11:53:32 PM|| Achieve safe patient care by incorporating our framework The Safety Competencies into your healthcare organization’s educational programs and professional development activities. Patient safety, defined as the reduction and mitigation of unsafe acts within the healthcare system, and the use of best practices shown to lead to optimal patient outcomes, is a critical aspect of quality healthcare.
Educating healthcare providers about patient safety and enabling them to use the tools and knowledge to build and maintain a safe system is critical to creating one of the safest health systems in the world. The Safety Competencies is a highly relevant, clear, and practical framework designed for all healthcare professionals. Created by the Canadian Patient Safety Institute (CPSI), The Safety Competencies has six core competency domains
Domain 1 Contribute to a Culture of Patient Safety – A commitment to applying core patient safety knowledge, skills, and attitudes to everyday work.
Domain 2 Work in Teams for Patient Safety – Working within interprofessional teams to optimize patient safety and quality of care..
Domain 3 Communicate Effectively for Patient Safety – Promoting patient safety through effective healthcare communication..
Domain 4 Manage Safety Risks – Anticipating, recognizing, and managing situations that place patients at risk..
Domain 5 Optimize Human and Environmental Factors – Managing the relationship between individual and environmental characteristics in order to optimize patient safety..
Domain 6 Recognize, Respond to, and Disclose Adverse Events – Recognizing the occurrence of an adverse event or close call and responding effectively to mitigate harm to the patient, ensure disclosure, and prevent recurrence.. This valuable framework includes 20 key competencies, 140 enabling competencies, 37 knowledge elements, 34 practical skills, and 23 essential attitudes that can lead to safer patient care and quality improvement. CPSI encourages its stakeholders, national, provincial, and territorial health organizations, associations, and governments; and universities and colleges to play a role in engaging stakeholders and spreading the word about this program so that healthcare professionals recognize the knowledge, skills, and attitudes needed to enhance patient safety across the spectrum of care. For further information, please email
firstname.lastname@example.org.||The Safety Competencies||The Safety Competencies: Message from the CEO||9/12/2017 8:43:40 PM||11324||https://www.patientsafetyinstitute.ca/en/toolsResources||html||True||aspx|
|Suicide Risk||36602||Guide;Publication||4/21/2011 4:02:20 AM||
We are pleased to announce that Dr. Chris Perlman, associate director, Homewood Research Institute, and his team are the successful recipients of Ontario Hospital Association (OHA) and Canadian Patient Safety Institute (CPSI) funding to develop an inventory and resource guide for assessing and preventing suicide risk.
Among its many accomplishments, Homewood Research Institute, located in Guelph, Ontario, was a lead organization in the development of mental health assessment systems, such as the Resident Assessment Instrument – Mental Health (RAI-MH), the interRAI Community Mental Health, and the interRAI Emergency Screener for Psychiatry.
The five-member team—Dr. Chris Perlman, Dr. John Hirdes, Dr. Lynn Martin, Dr. Eva Neufeld, and Ms. Mary Goy—includes researchers, policy analysts, and clinicians with more than 20 years of experience conducting health and policy research at the regional, provincial, national, and international levels. All team members have tremendous expertise in mental health research.
Dr. Perlman and his team will be working closely with the Advisory Group and with members of the OHA and CPSI to develop the inventory and resource guide. The innovative guide will be available by fall 2011.
||Inventory and Resource Guide Development for the Assessment and Prevention of Suicide Risk||We are pleased to announce that Dr. Chris Perlman, associate director, Homewood Research Institute, and his team are the successful recipients of||11/9/2016 5:59:18 PM||3537||https://www.patientsafetyinstitute.ca/en/toolsResources||html||True||aspx|
|Engaging Patients in Patient Safety – a Canadian Guide||36605||Guide||4/25/2017 3:01:50 PM|| During the past decade, we have seen evidence that when healthcare providers work closely with patients and their families, we can achieve great things. The healthcare system will be safer, and patients will have better experiences and health outcomes when patients, families, and the public are fully engaged in program and service design and delivery. Patient involvement is also important in monitoring, evaluating, setting policy and priorities, and governance. This work is not easy and may even be uncomfortable at first. Providers may need to let go of control, change behaviours to listen and understand patients more effectively, 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. But finding different and innovative ways to work together, even when it's challenging, benefits everyone. When patients and healthcare providers partner effectively, the results are powerful. We invite you to join us in advancing this work. We welcome diverse perspectives and beliefs to challenge the status quo. Let's explore ways to shape new behaviours, using everyone's unique perspectives and courage to make healthcare a safe and positive experience. A deep belief in the power of partnership inspired the Engaging Patients in Patient Safety - a Canadian Guide. Written by patients and providers
for patients and providers, the information 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 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 in any healthcare sector. What is the purpose of the guide? This extensive resource, based on evidence and leading practices, helps patients and families, patient partners, providers, and leaders work together more effectively to improve patient safety. Working collaboratively, we can more proactively identify risks, better support those involved in an incident, and help prevent similar incidents from occurring in the future. Together we can shape safe, high-quality care delivery, co-design safer care systems, and continuously improve to keep patients safe.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 Outstanding questions about how to strengthen current approaches Strategies and policies to meet standards and organizational practice requirementsChapter summariesEngaging patients as partners Why partner on patient safety and quality Current state of patient engagement across Canada Evidence of patient engagement benefits and impact Challenges and enablers to patient engagement Embedding and sustaining patient engagement
Read More Partners at the point of care Partnering in patient safety Partnering in incident management
Read More Partners at organizational and system levels Preparing to partner Partnering in patient safety Partnering in incident management
Read More Evaluating patient engagement Introduction to evaluating patient engagement Evaluating patient engagement at the point of care Evaluating patient engagement at the organizational level Evaluating patient engagement integration
Click here to learn how and why was the guide developed.
Citation Patient Engagement Action Team. 2017. Engaging Patients in Patient Safety – a Canadian Guide. Canadian Patient Safety Institute. Last modified February 2018. Available at www.patientsafetyinstitute.ca/engagingpatients ||Engaging Patients in Patient Safety – a Canadian Guide||During the past decade, we have seen evidence that when healthcare providers work closely with patients and their families, we can achieve great||8/19/2019 7:55:16 PM||9779||https://www.patientsafetyinstitute.ca/en/toolsResources||html||True||aspx|
|Questions Are the Answer||36606||Checklists;Patient and Family Resource||7/14/2016 9:07:34 PM||Tips and Tools for Talking to Your Healthcare Team Empower yourself with information and tools to help you ask good questions, connect with the right people, and learn as much as you can to keep you or a family member safe while receiving healthcare. Questions Are the Answer helps you effectively prepare for making decisions about medical treatment options by asking the right questions of your healthcare team. It considers topics for before, during, and after appointments, using past, present, and future medicines, medical tests, and surgeries. Always use these resources before you attend any healthcare appointment Questions to ask before an appointment Questions to ask during an appointment Questions to ask after an appointment Overall question checklist SHIFT to Safety helps you advocate for your healthcare safety. Shift your focus to what really matters—the patient. Are you a provider? Please share this valuable resource with your patients! For more information, contact us at email@example.com. Internet Citation Be More Involved in Your Health Care. September 2012. Agency for Healthcare Research and Quality, Rockville, MD.||Questions Are the Answer||Tips and Tools for Talking to Your Healthcare Team Empower yourself with information and tools to help you ask good questions, connect with the||4/5/2017 7:20:44 PM||4980||https://www.patientsafetyinstitute.ca/en/toolsResources||html||True||aspx|
|Safety Improvement Projects||36609||Framework||9/14/2018 2:50:29 PM||
Canadian Patient Safety Institute (CPSI) is offering new Safety Improvement Projects designed with a Quality Improvement/Knowledge Translation integrated learning design for accelerating Patient Safety in Canada.
CPSI is working with committed partners to implement and evaluate measurable and sustainable Safety Improvement Projects that align with pan-Canadian priorities. The new Safety Improvement Projects are as follows
Teamwork and Communication leads to improved patient safety culture and positive patient outcomes.
Medication Safety at Care Transitions improves medication safety at discharge for frail, elderly patients with poly-morbidity in your organization.
Enhanced Recovery Canada leads to improved outcomes and system efficiencies for colorectal surgery patients.
Measurement and Monitoring of Safety creates a culture of safety and reduces harm in your organization. (already in progress) Each Safety Improvement Project lasts 18 months and uses principles from the Institute for Healthcare Improvement Breakthrough Series and the Knowledge to Action Framework. The learning design is unique in that it is guided by a Quality Improvement/Knowledge Translation integrated learning design. By adopting these projects, you and your organization will step in to a leading role in healthcare delivery. Please
sign up to subscribe to our Safety Improvement Project mailing list for updates and to learn more about each of these projects. Consider introducing them in your organization with a goal of supporting higher patient safety standards within your organization and across the country.
Sign up Benefits to participating organizations Support of expert faculty and coaches who are knowledgeable about the best-known evidence as well as practical ideas, tips and tools for application.
Use of a collaborative virtual space for networking with other participating teams and faculty, and continual and ongoing support provided through in-person and virtual contact opportunities with coaches. Opportunity to demonstrate, showcase and share the practices that support meeting strategic and operational objectives at a congress event. If you have any questions, please email
SafetyImprovementProjects@cpsi-icsp.ca ||Safety Improvement Projects ||Canadian Patient Safety Institute (CPSI) is offering new Safety Improvement Projects designed with a Quality Improvement/Knowledge Translation||3/26/2019 7:09:08 PM||3163||https://www.patientsafetyinstitute.ca/en/toolsResources||html||True||aspx|