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Hand Hygiene Fact Sheets2654Infection Prevention & Control (IPAC)Toolkits & Guides;Tip Sheets4/1/2020 2:15:32 PM ​Hand Hygiene Resources for Healthcare Providers, Patients and Families Cleaning your hands, either with soap and water or with alcohol-based hand rub, is one of the most effective ways to contain the spread of infections. Please read, download, and share these resources to help yourself and others stay safe. Download the following Guidelines and Tip Sheets How to Hand Wash (PDF) How to Hand Rub (PDF)Your 4 Moments (PDF)On-the-Spot Feedback (PDF)Clean Care Conversations (PDF tip sheet for public)Clean Care Conversations (PDF tip sheet for healthcare providers) Browse the following Hand Hygiene Fact Sheets The Need for Better Hand Hygiene in Healthcare If Healthcare Provider Hands Could Talk Proper Hand Hygiene Technique in Healthcare Hand, Skin and Nail Care for Healthcare ProvidersPatient and Family Guide Patient and Family FAQsAdditional Resources Hand Hygiene Fact SheetsHand Hygiene Resources for Healthcare Providers, Patients and Families Cleaning your hands, either with soap and water or with alcohol-based hand9/24/2020 8:13:49 AM13484https://www.patientsafetyinstitute.ca/en/toolsResourceshtmlTrueaspx
Creating a Safe Space: Addressing the Psychological Safety of Healthcare Workers2623General Patient Safety;Psychological Safety for Healthcare WorkersToolkits & Guides;Healthcare provider stories;Reports & Publications1/6/2020 4:59:11 PM Cumulative stress, compassion fatigue and trauma due to experiences with patient safety incidents impact the mental wellness of our healthcare providers. These factors contribute to inadvertent patient care errors, mental health issues and attrition which compromise patient safety. A peer support program and other support models not only simply helps healthcare workers with their experiences with patient safety incidents but also improves the system and help make patient care safe. The Creating a Safe Space Addressing the Psychological Safety of Healthcare Workers manuscript and the Canadian Peer Support Network are intended to assist healthcare organizations support healthcare workers by creating peer-to-peer support programs (PSPs) or other models of supports to improve the emotional well-being of healthcare workers and allow them to provide the best and safest care to their patients. The Creating a Safe Space Addressing the Psychological Safety of Healthcare Workers manuscript provides a comprehensive overview of what healthcare worker support models are available in Canada and internationally. The Manuscript outlines best practice guidelines, tools, and resources that policy makers, accreditation bodies, regulators and healthcare leaders can use to assess the support needs of healthcare workers. The Canadian Peer Support Network is intended as a forum for healthcare organizations seeking guidance in the development of their Peer Support Programs to assist providers who have experienced a patient safety incident. Download Disclaimer The Canadian Peer Support Network is not intended as therapeutic support between, or amongst, members It is for informational purposes only. Creating a Safe Space: Psychological Safety of Healthcare Workers (Peer to Peer Support and Other Support Models)Cumulative stress, compassion fatigue and trauma due to experiences with patient safety incidents impact the mental wellness of our healthcare12/1/2020 4:47:37 PM8773https://www.patientsafetyinstitute.ca/en/toolsResourceshtmlTrueaspx
Measures: Ventilator-Associated Pneumonia (VAP)10529Infection Prevention & Control (IPAC)Toolkits & Guides7/1/2015 8:57:33 AM Measurement is essential to monitoring success and helps guide your team towards your specific intervention goal. Measurement also tells us what's working and what's not, and provides evidence to inspire other healthcare providers to improve the quality of patient safety. The measurement methodology and recommendations regarding sampling size referenced in this GSK, is based on The Model for Improvement and is designed to accelerate the pace of improvement using the PDSA cycle; a "trial and learn" approach to improvement based on the scientific method. Langley, G., Nolan, K., Nolan, T., Norman, C., Provost, L. The Improvement Guide A Practical Approach to Enhancing Organizational Performance. San Francisco, Second Edition, CA. Jossey-Bass Publishers. 2009. It is not intended to provide the same rigor that might be applied in a research study, but rather offers an efficient way to help a team understand how a system is performing. When choosing a sample size for your intervention, it is important to consider the purposes and uses of the data and to acknowledge when reporting that the findings are based on an "x" sample as determined by the team. The scope or scale (amount of sampling, testing, or time required) of a test should be decided according to The team's degree of belief that the change will result in improvement The risks from a failed test Readiness of those who will have to make the change Provost, Lloyd P; Murray, Sandra (2011-08-26). The Health Care Data Guide Learning from Data for Improvement (Kindle Locations 1906-1909). Wiley. Kindle Edition. Please refer to the Improvement Frameworks GSK (2015) for additional information.VAP Measures Measure Goal Type VAP 1 - VAP Rate in ICU per 1000 Ventilator Days Decrease 50% Outcome VAP 2 - VAP Bundle Compliance 95% Process VAP 3 - Paediatric VAP Bundle Compliance 95% Process Measures and definitions Types of Measures Safer Healthcare Now! (SHN) has two types of measures for each of the interventions process measures and outcome measures. Some interventions also have balancing measures and information measures. Below are examples of each. Outcome measures - answers whether the team is achieving what it is trying to accomplish and articulates the picture of success. For example, if the team wants to reduce falls it should measure the number of falls. Process measures - Processes which directly affect the outcome are measured to ensure that all key changes are being implemented to impact the outcome measure. For example, the delivery of timely prophylactic antibiotics to reduce surgical site infection. Balancing measures - answer the question whether improvements in one part of the system were made at the expense of other processes in other parts of the system. For example, in a project to reduce the average length of stay for a group of patients, the team should also monitor the percent of readmissions within 30 days for the same group. Information measures - collect general details relative to the intervention.VAP: Measurement Worksheets9/24/2020 8:15:22 AM8616https://www.patientsafetyinstitute.ca/en/toolsResources/psm/Pages/Forms/UpdateData.aspxhtmlFalseaspx
Medication Reconciliation (Med Rec): Getting Started Kit6185Improving Medication Safety;Surgical Care SafetyToolkits & Guides7/1/2015 8:53:35 AM​Effective March 14 2019, the Canadian Patient Safety Institute has archived the Medication Reconciliation (MedRec) intervention. Though you may continue to access the Getting Started Kit online, it will no longer be updated. ​​ Getting Started Kit This 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 Acute Care Getting Started Kit. Click here to download the Long Term Care Getting Started Kit. Click here to download the Home Care Getting Started Kit. One-Pager The One-Pager is a summary of the Getting Started Kit that you can use to promote the intervention to your organization. Click here to download the Acute Care One-Pager. Click here to download the Long Term Care One-Pager. Click here to download the Home Care One-Pager. Icons Intervention Icons Use these intervention icons on presentations, reports, flyers, and other material to promote the intervention throughout your organization. Click here to download the full-colour intervention icon. Click here to download the black and white intervention icon. Intervention Icons With Text Click here to download the full-colour Acute Care intervention icon with text. Click here to download the black and white Acute Care intervention icon with text. Click here to download the full-colour Long Term Care intervention icon with text. Click here to download the black and white Long Term Care intervention icon with text. Click here to download the full-colour Home Care intervention icon with text. Click here to download the black and white Home Care intervention icon with text Medication Reconciliation (Med Rec): Getting Started Kit9/24/2020 8:10:39 AM11550https://www.patientsafetyinstitute.ca/en/toolsResources/Pages/Forms/NewDefaultView.aspxhtmlFalseaspx
Surgical Site Infection (SSI): Getting Started Kit6205Surgical Care Safety;Infection Prevention & Control (IPAC)Toolkits & Guides7/1/2015 8:55:00 AMEffective March 14 2019, the Canadian Patient Safety Institute has archived the Surgical Site Infection (SSI) intervention. Though you may continue to access the Getting Started Kit online, it will no longer be updated. ​​​​ Getting Started KitThis free resource is designed to help you successfully implement interventions in your organization. The Getting Started Kit contains clinical information, information on the science of improvement, and everything you need to know to start using the intervention.. Click here to download the Getting Started Kit. Click here to download the summary of changes to the Getting Started Kit ​ ​ One-PagerThe One-Pager is a summary of the Getting Started Kit that you can use to promote the intervention to your organization. Click here to download the One-Pager. ​​ Icons​​ ​Intervention IconsUse these intervention icons on presentations, reports, flyers, and other material to promote the intervention throughout your organization. Click here to download the full-colour intervention icon. Click here to download the black and white intervention icon.​ ​Intervention Icons With Text Click here to download the full-colour intervention icon with text. Click here to download the black and white intervention icon with text.​ SSI: Getting Started Kit9/24/2020 8:12:12 AM10368https://www.patientsafetyinstitute.ca/en/toolsResources/Pages/Forms/NewDefaultView.aspxhtmlFalseaspx
About the Framework10413Government Relations;Improving Culture;Partnering with Patients;Patient & Family Resources;PolicyFrameworks;Patient and Family Resource;Position Statements;Reports & Publications10/22/2020 7:26:52 PM Why a Framework?  To truly align Canada's efforts toward better and safer care we must prioritize coordinated action. Collective action across Canadian jurisdictions is needed now more than ever before with the current pandemic. This Framework is the roadmap that can align the country as we work to safely enhance health services. It is already being used in many jurisdictions at different levels. Developed with Broad Consultation, Including Patients and Families  The Framework was developed in consultation with members of the public, health leaders, policy makers, board members, and health teams (including patients and families). The processes also included numerous committee meetings, international and national environmental scans, key stakeholder interviews, a national public consultation, and further targeted consultations with key stakeholder groups. This comprehensive approach was prioritized to ensure the Framework package reflects both current and emerging trends and the realities of health systems across Canada, regardless of jurisdiction. The accompanying action guides, resources, and indicators are curated implementation tools to support all stakeholders with using and implementing the Framework package, regardless of their role or care. Download the Framework Five Goals for Safe, Quality Care   Together, we can create positive change by working towards the Framework’s five overarching goals Goal 1 | People-Centred Care People using health services are equal partners in planning, developing, and monitoring care to make sure it meets their needs and to achieve the best outcomes. Goal 2 | Safe Care Health services are safe and free from preventable harm. Goal 3 | Accessible Care People have timely and equitable access to quality health services. Goal 4 | Appropriate Care Care is evidence-based and people-centred. Goal 5 | Integrated Care Health services are continuous and well-coordinated, promoting smooth transitions. For any questions, comments or to share your experience using the Framework, please contact qualityservicesforall@healthstandards.org. Contact us Wh y a Framework?  To truly align Canada's efforts toward better and safer care we must prioritize coordinated action. Collective11/3/2020 5:12:12 PM1062https://www.patientsafetyinstitute.ca/en/toolsResources/Canadian-Quality-and-Patient-Safety-Framework-for-Health-and-Social-Services/Pages/Forms/AllItems.aspxhtmlFalseaspx
Canadian Quality and Patient Safety Framework for Health Services2639General Patient Safety;Policy;Government Relations;Improving Culture;Partnering with Patients;Patient & Family ResourcesFrameworks;Patient and Family Resource;Position Statements;Reports & Publications3/27/2019 7:47:40 PM The need for a national patient safety and quality framework Health services across Canada are comprehensive, complex, and at times complicated. Every person in Canada deserves safe, high-quality healthcare when and where they need it. For the most part, this is our experience. But we don't always get it right. People may be inadvertently harmed by the services intended to help them. The reality is that unintended harm occurs in a Canadian hospital or home care setting every 1 minute and 18 seconds Every 13 minutes and 14 seconds, someone dies Patient safety incidents are the third leading cause of death in Canada Even more, there are significant variations in care by age, gender, race/ethnicity, geography and socio-economic status. Access to quality health services is more challenging for Indigenous peoples, (including First Nations, Inuit and Métis), Black people, LQBTQ2S+ identities (including Lesbian, Gay, Bisexual, Transgender, Queer or Questioning and Two-Spirit), immigrants, visible minorities, and many more diverse peoples that comprise our country. While some jurisdictions have quality and safety plans or frameworks in place, people continue to experience healthcare differently across the country. These considerations, when added to the heightened need for consistency and coordination in healthcare due to the COVID-19 pandemic, prompt us to ask How can we focus and align quality and safety improvement throughout the country, regardless of jurisdiction? The Canadian Quality and Patient Safety Framework for Health Services is the first of its kind in Canada. We can all work together to accelerate quality and patient safety across Canadian health systems by focusing all stakeholders across Canada on five goals for safe, quality care. This people-centred framework defines five goal areas designed to drive improvement and to align Canadian legislation, regulations, standards, organizational policies, and public engagement on patient safety and quality improvement. It includes action guides and resources customized for each stakeholder group to support you in putting the goals into practice. Download the Framework How to use the Framework Be sure to take full advantage of all the communications tools and resources in this package Download the Communication Toolkit Mapping Tool A mapping tool was developed to help you map your organization's current quality and patient safety improvement initiatives to the goals, objectives, and outcomes of the Framework. This exercise will help demonstrate your organization's strengths in aligning with the Framework and uncover opportunities to work toward these key goals for safe, high-quality care. Framework Mapping Tool For any questions, comments or to share your experience using the Framework, please contact qualityservicesforall@healthstandards.org. Contact us Why does Canada need a National Quality and Patient Safety Framework for Health Services?The need for a national patient safety and quality framework Health services across Canada are comprehensive, complex, and at times complicated.1/14/2021 5:58:58 PM15457https://www.patientsafetyinstitute.ca/en/toolsResourceshtmlTrueaspx
Education to support mandatory ADR and MDI reporting (Vanessa’s Law)2645General 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 AM162745https://www.patientsafetyinstitute.ca/en/toolsResourceshtmlTrueaspx
Tools & Resources25029/18/2020 4:40:20 AMTools & ResourcesTools & Resources9/21/2020 9:19:04 AM64567https://www.patientsafetyinstitute.ca/enhtmlTrueaspx
TeamSTEPPS Canada(TM) Essentials microlearning course launched through Canada’s Patient Safety Online Learning Centre14177Education;General Patient SafetyNews9/14/2020 3:34:10 PM9/14/2020 6:00:00 AM Are you looking for tools to instil a culture of safety among your teams? A free micro-learning course, TeamSTEPPS Canada™ Essentials, is now available to optimize team performance across the healthcare system. The course consists of six interactive microlearning sessions that demonstrate teamwork and communication tools that can be used to equip your team for improved team functioning. "Initially, the material was designed to support the Safety Improvement Project Collaborative participants," says Maureen Sullivan-Bentz, Senior Program Manager at the Canadian Patient Safety Institute. "TeamSTEPPS Essentials has since been adapted and designed to accommodate the changing needs of today's learners in an interactive and engaging format. Teams can now easily access the course online and learn at their own pace." The Essentials course is based on the five key principles encompassed in the evidence-based TeamSTEPPS CanadaTM framework. These principles are designed to optimize team performance Team Structure, Communication, Leading Teams, Situation Monitoring, and Mutual Support. Each session is five minutes long; at the end of the program teams are familiarized with the tools to use in different situations. Each of the sessions has been enhanced with simulation videos and has been contextualized for Canadian audiences. The Centre for Innovative Education and Simulation in Nursing at the University of Ottawa generously provided their simulation lab as the backdrop for filming; props were provided by the University of Ottawa; and the contributions of Ben Hrkach, both as Director and one of the actors, were invaluable in creating a fun and creative portrayal of the teamwork and communication tools. Canada's Patient Safety Online Learning Centre Canada's Patient Safety Online Learning Centre takes learning anywhere, anytime, at your own pace, on any electronic device. This free, open source learning centre will house a repository of e-courses from the Canadian Patient Safety Institute. It was designed to provide open access to healthcare leaders, managers, educators, and point-of-care providers to learn as efficiently as possible in a self-paced environment. "The world of technology has advanced, and learning needs have evolved," says Gina de Souza, Senior Program Manager at the Canadian Patient Safety Institute. "People want on-demand learning in short snippets. Canada's Patient Safety Online Learning Centre is learner-centric and accommodates the increasing demands and diversity of learners using new tools, technologies, and design strategies." Learners must register to gain access, and once registered, they can explore all of the available e-courses for free. There are no learning pre-requisites required. A certificate of completion is available to print after each course is completed. Click here to learn more about Canada's Patient Safety Online Learning Centre and register for the TeamSTEPPS Essentials course. Watch for the quick-start microlearning version of the Guide to Patient Safety Improvement publication, to be added this fall. Are you looking for tools to instil a culture of safety among your teams? A free micro-learning course, TeamSTEPPS Canada™ Essentials , is now9/24/2020 8:10:14 AM1158https://www.patientsafetyinstitute.ca/en/NewsAlerts/News/Pages/Forms/AllItems.aspxhtmlFalseaspx
Measures: Venous Thromboembolism (VTE)10530Surgical Care SafetyToolkits & Guides7/1/2015 8:58:09 AM Measurement is essential to monitoring success and helps guide your team towards your specific intervention goal. Measurement also tells us what's working and what's not, and provides evidence to inspire other healthcare providers to improve the quality of patient safety. The measurement methodology and recommendations regarding sampling size referenced in this GSK, is based on The Model for Improvement and is designed to accelerate the pace of improvement using the PDSA cycle; a "trial and learn" approach to improvement based on the scientific method. Langley, G., Nolan, K., Nolan, T., Norman, C., Provost, L. The Improvement Guide A Practical Approach to Enhancing Organizational Performance. San Francisco, Second Edition, CA. Jossey-Bass Publishers. 2009. It is not intended to provide the same rigor that might be applied in a research study, but rather offers an efficient way to help a team understand how a system is performing. When choosing a sample size for your intervention, it is important to consider the purposes and uses of the data and to acknowledge when reporting that the findings are based on an "x" sample as determined by the team. The scope or scale (amount of sampling, testing, or time required) of a test should be decided according to The team's degree of belief that the change will result in improvement The risks from a failed test Readiness of those who will have to make the change Provost, Lloyd P; Murray, Sandra (2011-08-26). The Health Care Data Guide Learning from Data for Improvement (Kindle Locations 1906-1909). Wiley. Kindle Edition. Please refer to the Improvement Frameworks GSK (2015) for additional information.Measurement Worksheets (Measures) and Data Collection Forms (DCF) Measures DCFs Aggregate data (monthly) De-identified Patient-level data (daily) Numerator and Denominator Multiple data elements ​ Roll-up to Measurement Worksheets VTE Audit The tool is designed for use in Acute Care, and was developed to allow organizations to assess the quality of their venous thromboembolism prevention practices and determine the areas requiring quality improvement(s). DCF (Audit) Question Roll-up to Measures A. Preprinted order used on admission or after surgery VTE 4 B. Type of thromboprophylaxis VTE 2 C. Receiving appropriate thromboprophylaxis VTE 1 D. Reason recommended thromboprophylaxis not used VTE 3 VTE Audit DCF VTE Audit Score Template VTE Measures Measure Goal Type VTE 1 - Percent of Patients Receiving Appropriate Venous Thromboembolism Prophylaxis 100% Outcome VTE 2 - Type of Thromboprophylaxis Delivered (Optional Measure) 100% Information VTE 3 - Reasons that Recommended Thromboprophylaxis was NOT Used (Optional Measure) 0% Information VTE 4 - Percent Appropriate Use of Order Sets for Thromboembolism Prophylaxis 100% Process Measures and definitions Types of Measures Safer Healthcare Now! (SHN) has two types of measures for each of the interventions process measures and outcome measures. Some interventions also have balancing measures and information measures. Below are examples of each. Outcome measures - answers whether the team is achieving what it is trying to accomplish and articulates the picture of success. For example, if the team wants to reduce falls it should measure the number of falls. Process measures - Processes which directly affect the outcome are measured to ensure that all key changes are being implemented to impact the outcome measure. For example, the delivery of timely prophylactic antibiotics to reduce surgical site infection. Balancing measures - answer the question whether improvements in one part of the system were made at the expense of other processes in other parts of the system. For example, in a project to reduce the average length of stay for a group of patients, the team should also monitor the percent of readmissions within 30 days for the same group. Information measures - collect general details relative to the intervention. VTE: Measurement Worksheets9/24/2020 8:15:21 AM5860https://www.patientsafetyinstitute.ca/en/toolsResources/psm/Pages/Forms/UpdateData.aspxhtmlFalseaspx
Hand Hygiene Observation Tools6158Infection Prevention & Control (IPAC)Toolkits & Guides6/3/2015 4:47:24 PMMeasurement is a vital part of the quality improvement process. Auditing hand hygiene compliance by health care providers provides a benchmark for improvement. The results of observation audits will help identify the most appropriate interventions for hand hygiene education, training and promotion. Results should be shared with front-line healthcare providers, management and hospital boards. To support organizations in doing direct observation, CPSI has an observation tool based on the 4 Moments for Hand Hygiene. CPSI has also adapted a Patient Family Observation Tool that will allow patient and family partners to observe and share information about how healthcare workers participate in optimal hand hygiene. Direct observation of hand hygiene practices should be performed by trained observers using a standardized and validated audit tool. Need training on how to conduct Hand Hygiene observations? Here are some training resources to help you. (link to content below) CPSI Hand Hygiene Observation Tool (Paper Tool) This paper tool is for Acute Care only. CPSI Hand Hygiene Observation Tool Instructions for Using the Observation Analysis Tool Observation Analysis Tool - Excel workbook (ZIP) Training on how to conduct Hand Hygiene observations Hand Hygiene Education Module (IPAC Canada) Monitoring and Observation (Auditing) for ACUTE Monitoring and Observation (Auditing) for LTC Measurement is a vital part of the quality improvement process. Auditing hand hygiene compliance by health care providers provides a benchmark for9/24/2020 8:12:25 AM15206https://www.patientsafetyinstitute.ca/en/toolsResources/Pages/Forms/NewDefaultView.aspxhtmlFalseaspx
Near-fatal medication error leads nurse to make patient safety a priority11016Improving Medication SafetyHealthcare provider stories10/26/2017 7:43:16 PM More than 30 years have passed since the near-fatal medication error but Michael Villeneuve recalls the moment with absolute clarity. The little man on his shoulder was telling him 'wait a second, something is not right here,' but Villeneuve, then a cocky young nurse eager to keep pace with his colleagues in an Ontario intensive care unit, went ahead and administered the medication. The instant he did so, he knew exactly what he'd done right drug, wrong patient. Now the chief executive officer at the Canadian Nurses Association, Villeneuve frequently draws upon that experience in his day-to-day work to promote better care, better health and better nursing across the country. As a youngster, Villeneuve always dreamed of becoming a surgeon. His grandmother was a director of nursing in a small rural hospital and used to take him by the hand and lead him, spellbound, along with her as she did her rounds. His ambitions shifted slightly in high school after a family friend helped him get a job as an orderly at an Ottawa hospital. He was there less than an hour before he realized he was far more fascinated by what the nurses were doing than the doctors. "There was something about the competence of those women," Villeneuve recalls. "If you've been in an emergency department with certain women running the place, there's a kind of swagger and an attitude that's quite intoxicating when you're young. I just thought, 'I want to be like that.' That's where I ended up working in emergency intensive care, neurosurgery and so on, and never looked back. To this day, I would never change a second of it. "Except I wouldn't make the mistake." The mistake happened back in 1985. Two years after graduating nursing school Villeneuve had moved from a ward setting into a neurosurgical intensive care unit. He'd only been there a few weeks. At that time in the profession a male nurse was still something of a novelty and Villeneuve was eager to prove his worth. In that setting, an open ward with 12 beds, the pace is fast. Villeneuve remembers being so impressed by the confident execution and rapid thinking of the nurses around him. "When I think back to what happened, I do think some of it was trying to be better, faster maybe than I was, if you know what I mean." On the day of the incident, Villeneuve had two patients in his care — one with high potassium levels, the other with low potassium. The charge nurse took a call from a doctor, directing potassium be administered to one of his patients. She transcribed the order, called Villeneuve over and holding up the order sheet, instructed him to give medication A to patient B. It is something in that chain of events, a partially obscured order sheet, the utterance of one patient's name rather than the other, that sent Villeneuve to the wrong bedside. "I took the medication, which I had drawn up, potassium, and was about to give it to the patient and — this was a big lesson for me in my entire career — I thought, something was wrong," Villeneuve says. "I thought something was triggering me, something's wrong with this. What I didn't do was stop. I pushed it in, slowly, but pushed it in. It wasn't two seconds after I finished that I thought, oh, it's the wrong patient; it's the guy with the high potassium that I just overdosed with a whole bunch more potassium. Literally I nearly collapsed. I thought, my career's over, I'm going to lose my license, he's going to die." Villeneuve owned up to the error immediately and nurses and doctors swept in to attend to the patient, whose heart went into immediate distress. To make matters even worse, the patient was a senior physician himself. Villeneuve was so upset that his colleagues basically parked him in an adjacent staff lounge for the remainder of the day. "It's 32 or 33 years ago that that happened and it is still cemented in my mind, everything about the lighting in that room that day, the look of people around me, how I felt, what I learned about when the little man on your shoulder says, 'Slow down,' you should slow down before you hurt somebody," Villeneuve says. He views his experience as a perfect example of what is confirmed so often in medicine and nursing, which is that errors most often happen at points of handoff in care. "We see it in handoffs even in home care from registered nurses who provide plans of care and delegate care to a licensed practical nurse who may delegate that to a nursing assistant or a personal support worker and, a point of great error, onto families," Villeneuve says. "Because families provide a lot of care. So it's not just a critical care unit issue or a hospital issue; it's across the healthcare system. Points of handoff, and the more of them there are, the more chances that there are for an error." Villeneuve spent an entire second shift in that staff lounge that fateful day, panic-stricken about his patient, worried about his future, wracked by that "terrible fear of error" that hangs over nursing from graduation day onwards. But as the hours passed it eventually became clear the patient would survive. It was only then that Villeneuve had a chance to talk things over with his head nurse, who was wonderfully supportive. "I was expecting when she came in that I might be disciplined, I might be sent home. Her comment was, 'What did you learn?' " Villeneuve recalls, choking up at the memory. "She said, 'slow down.' One of the nurses I really looked up to was a nurse named Jennifer who was so competent. And she said, 'You're not Jennifer yet. Settle down. Stop. Double check.' All the things I knew I should've done. And it helped me reduce my ego, which was quite constrained after that incident." It was a major life lesson for him. When that little man on your shoulder says stop, it's like encountering the yellow light at the intersection. You shouldn't speed up, you should slow it down. Even now in my administrative roles, my teaching roles, if I sense something's wrong, I just say to people, 'I need a day to think about that.' I try to not make snap decisions and I think my decisions are better."  More than 30 years have passed since the near-fatal medication error but Michael Villeneuve recalls the moment with absolute clarity. The9/24/2020 8:14:04 AM17007https://www.patientsafetyinstitute.ca/en/toolsResources/HealthcareProviderStories/Pages/Forms/AllItems.aspxhtmlFalseaspx
Advocacy and support for use of a Surgical Safety Checklist2607Surgical 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 AM2076https://www.patientsafetyinstitute.ca/en/toolsResourceshtmlTrueaspx
Medication Reconciliation (Med Rec): Presentations & Posters 6186Improving Medication SafetyWebinars7/1/2015 8:53:35 AM ​​​​​​​​​​​​​​​These free resources are designed to help you successfully implement interventions in your organization. Presentations & Posters ​ Medication Communicat​ion Failures Impact Everyone Click here to download Risk Points for MedRec in Home Care Click here to download The MedRec Process in Home Care Click here to download Top 10 Practical Tips - How to Obtain an Efficient Comprehensive and Accurate Best Possible Medication History (BPMH) Click here to download Medication Reconciliation In Home Care Pilot Project Click here to download Med Rec (Acute Care): Presentations & Posters 9/24/2020 8:10:41 AM5201https://www.patientsafetyinstitute.ca/en/toolsResources/Pages/Forms/NewDefaultView.aspxhtmlFalseaspx
S.A.F.E. Toolkit Video Series6202Community Based Care;General Patient Safety;Improving Medication Safety;Surgical Care SafetyReports & Publications;Toolkits & Guides;Social Media/Social Share8/2/2017 3:58:40 PM Understanding that the healthcare system is complex and intimidating, the Manitoba Institute for Patient Safety created the Self Advocacy For Everyone (S. A. F. E) Toolkit to provide tips and resources to ease the minds of those who want to properly speak up about how they feel when it comes to healthcare. To bolster the toolkit, the Manitoba Institute for Patient Safety has created and is pleased to share their new, leading-edge resource. Establishing new ways to encourage people to be more involved in discussions about healthcare is challenging. Therefore, MIPS has come up with the S.A.F.E Toolkit Video series. Based off topics covered in their S.A.F.E Toolkit, the DVD's are made up of eight short three to five minute videos that are supplement the toolkit, and will include the "5 Questions" resource in three of the videos. These videos can be viewed by going to the websites listed below or by accessing YouTube Learn More The S.A.F.E Toolkit Series Playlist We strongly encourage patients, their families and healthcare providers share these resources. Understanding that the healthcare system is complex and intimidating, the Manitoba Institute for Patient Safety created the Self9/24/2020 8:12:42 AM1937https://www.patientsafetyinstitute.ca/en/toolsResources/Pages/Forms/NewDefaultView.aspxhtmlFalseaspx
Central Line-Associated Bloodstream Infection (CLABSI): Getting Started Kit6149Infection Prevention & Control (IPAC);Surgical Care SafetyToolkits & Guides7/1/2015 8:51:29 AM ​​​Effective March 14 2019, the Canadian Patient Safety Institute has archived the Central Line-Associated Bloodstream Infection (CLABSI) intervention. Though you may continue to access the Getting Started Kit online, it will no longer be updated. These free resources are designed to help you successfully implement interventions in your organization. Getting Started ​Getting Started Kit The Getting Started Kit contains clinical information, information on the science of improvement, and everything you need to know to start using the intervention. Click here to download the Getting Started Kit. ​One-Pager The One-Pager is a summary of the Getting Started Kit that you can use to promote the intervention to your organization. Click here to download the One-Pager. ​​Icons ​Intervention Icons Use these intervention icons on presentations, reports, flyers, and other material to promote the intervention throughout your organization. Click here to download the full-colour intervention icon. Click here to download the black and white intervention icon. Intervention Icons With Text Click here to download the full-colour intervention icon with text. Click here to download the black and white intervention icon with text. CLI: Getting Started Kit9/24/2020 8:10:31 AM8555https://www.patientsafetyinstitute.ca/en/toolsResources/Pages/Forms/NewDefaultView.aspxhtmlFalseaspx
New Patient Safety Improvement Guide Integrates Knowledge Translation and Quality Improvement14011Improving Culture;General Patient Safety;PolicyNews9/14/2020 3:59:47 PM9/14/2020 6:00:00 AM The best way to improve patient safety outcomes is to apply the best research in the most effective way. A Guide to Patient Safety Improvement is a new resource that integrates knowledge translation and quality improvement approaches to guide you through the improvement process. Are there gaps in your patient safety performance? This Guide offers a simplified process to select strategies to effectively implement patient safety practices. Although originally designed to support National Canadian Safety Improvement Projects, it can be adapted to fit any healthcare context. "The Guide to Patient Safety Improvement is an integrated approach to practice change – change that can have a sustainable impact on patient safety outcomes," says Gina De Souza, Senior Program Manager at the Canadian Patient Safety Institute. "It shows how two bodies of knowledge, quality improvement and knowledge translation, can be used synergistically." Several models, theories, and frameworks contributed to the Guide, including the Knowledge Translation and Quality Improvement Integrated Learning Design, Model for Improvement, Knowledge to Action Cycle, and COM-B theory. It includes ideal practice changes ("the what") and strategies ("the how") that creates the evidence-based intervention as well as a section on engaging patients at all levels, not just the point-of-care. "Understanding context and what supports behaviour change is so important when choosing a strategy," adds Gina De Souza. "Knowledge translation goes beyond looking only at what the evidence says, to getting people to be a part of the change and selecting the right strategy to support and sustain the change." A five-minute, 'Quick Start' microlearning course has been designed to complement the Guide to Patient Safety Improvement publication and is now available through Canada's Patient Safety Online Learning Centre at https//learning.patientsafetyinstitute.ca/ The best way to improve patient safety outcomes is to apply the best research in the most effective way. A Guide to Patient Safety Improvement is9/24/2020 8:10:15 AM528https://www.patientsafetyinstitute.ca/en/NewsAlerts/News/Pages/Forms/AllItems.aspxhtmlFalseaspx
Rapid Response Teams (RRT): Getting Started Kit6200Patient Safety IncidentToolkits & Guides7/1/2015 8:54:43 AM ​​​​ 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. ​ RRT: Getting Started Kit9/21/2020 1:41:34 AM5090https://www.patientsafetyinstitute.ca/en/toolsResources/Pages/Forms/NewDefaultView.aspxhtmlFalseaspx
Measures: Surgical Site Infections (SSI)10528Surgical Care SafetyToolkits & Guides7/1/2015 8:54:58 AM Measurement is essential to monitoring success and helps guide your team towards your specific intervention goal. Measurement also tells us what's working and what's not, and provides evidence to inspire other healthcare providers to improve the quality of patient safety. The measurement methodology and recommendations regarding sampling size referenced in this GSK, is based on The Model for Improvement and is designed to accelerate the pace of improvement using the PDSA cycle; a "trial and learn" approach to improvement based on the scientific method. Langley, G., Nolan, K., Nolan, T., Norman, C., Provost, L. The Improvement Guide A Practical Approach to Enhancing Organizational Performance. San Francisco, Second Edition, CA. Jossey-Bass Publishers. 2009. It is not intended to provide the same rigor that might be applied in a research study, but rather offers an efficient way to help a team understand how a system is performing. When choosing a sample size for your intervention, it is important to consider the purposes and uses of the data and to acknowledge when reporting that the findings are based on an "x" sample as determined by the team. The scope or scale (amount of sampling, testing, or time required) of a test should be decided according to The team's degree of belief that the change will result in improvement The risks from a failed test Readiness of those who will have to make the change Provost, Lloyd P; Murray, Sandra (2011-08-26). The Health Care Data Guide Learning from Data for Improvement (Kindle Locations 1906-1909). Wiley. Kindle Edition. Please refer to the Improvement Frameworks GSK (2015) for additional information.Measurement Worksheets (Measures) and Data Collection Forms (DCF) Measures DCFs Aggregate data (monthly) De-identified Patient-level data (daily) Numerator and Denominator Multiple data elements ​ Roll-up to Measurement Worksheets SSI Prevention Audit The tool is designed for use in Acute Care, and was developed to allow organizations to assess the quality of their surgical site infection prevention practices and determine the areas requiring quality improvement(s). DCF (Audit) Question Roll-up to Measures A. Type of Surgery N/A B. Surgical Class N/A C. Pre-Op Shower or bath with soap or antiseptic agent SSI 9, 14, 17 D. Solution used for intra-operative intact skin cleansing SSI 10, 14, 17 E. Prophylactic antibiotic administration SSI 8, 15, 17 F. Dose of Cefazolin used as prophylactic antibiotic SSI 11, 15, 17 G. Appropriate prophylactic antibiotic redosing according to guidelines SSI 12, 15, 17 H. Discontinuation of prophylactic antibiotic SSI 2, 16, 17 I. Hair removal method SSI 4, 14, 17 J. Glucose was below 11.1 mmol/L on each of POD 0, 1, & 2 SSI 5, 16, 17 K. Temperature at end of surgery or on arrival in PACU was within range of 36.0-38.0 degrees C SSI 6, 15, 17 SSI Prevention Audit DCF SSI Prevention Audit Instructions SSI Prevention Audit Score Template SSI Measures Measure Goal Type SSI 1 - Percent of clean and clean-contaminated patients with timely prophylactic antibiotic administration 95% Process SSI 2 - Percent of clean and clean-contaminated patients with appropriate prophylactic antibiotic discontinuation 95% Process SSI 3 - Percent of clean and clean contaminated surgery patients with surgical infection Reduce by 50% Outcome SSI 4 - Percent of surgical patients with appropriate hair removal 95% Process SSI 5 - Percent of all diabetic or surgical patients at risk of high blood glucose with controlled post-operative serum glucose POD 0, 1, and 2 95% Process SSI 6 - Percent of all clean or clean-contaminated surgical Patients with normothermia within 15 minutes of end of surgery or on arrival in PACU 95% Process SSI 7 - Percentage of clean or clean-contaminated surgical patients with appropriate selection of prophylactic antibiotic 95% Process SSI 8 - Percent of clean and clean-contaminated caesarean section patients with timely prophylactic antibiotic administration for C-Section 95% Process SSI 9 - Percent of clean and clean-contaminated surgical patients with pre-op wash with soap or antiseptic agent 95% Process SSI 10 - Percent of clean and clean-contaminated surgical patients with appropriate intra-op skin cleansing on intact skin 95% Process SSI 11 - Percent of clean and clean-contaminated adult surgical patients receiving 2 grams of Cefazolin as prophylactic antibiotic 95% Process SSI 12 - Percent of clean and clean-contaminated surgical patients receiving appropriate prophylactic antibiotic re- dosing 95% Process SSI 13 - Percent of clean and clean contaminated surgery patients with evidence of surgical site infection at the time of, or prior to discharge Reduce by 50% Outcome SSI 14 - Surgical Site Infection Pre-operative (Pre-op) Score 95% or higher Outcome SSI 15 - Surgical Site Infection Perioperative Score 95% or higher Outcome SSI 16 - Surgical Site Infection Postoperative (Post-op) Score 95% or higher Outcome SSI 17 - Surgical Site Infection Score 95% or higher Outcome Measures and definitions Types of Measures Safer Healthcare Now! (SHN) has two types of measures for each of the interventions process measures and outcome measures. Some interventions also have balancing measures and information measures. Below are examples of each. Outcome measures - answers whether the team is achieving what it is trying to accomplish and articulates the picture of success. For example, if the team wants to reduce falls it should measure the number of falls. Process measures - Processes which directly affect the outcome are measured to ensure that all key changes are being implemented to impact the outcome measure. For example, the delivery of timely prophylactic antibiotics to reduce surgical site infection. Balancing measures - answer the question whether improvements in one part of the system were made at the expense of other processes in other parts of the system. For example, in a project to reduce the average length of stay for a group of patients, the team should also monitor the percent of readmissions within 30 days for the same group. Information measures - collect general details relative to the intervention. SSI: Measurement Worksheets9/24/2020 8:15:19 AM9404https://www.patientsafetyinstitute.ca/en/toolsResources/psm/Pages/Forms/UpdateData.aspxhtmlFalseaspx
Getting ahead of harm before it happens: A guide about proactive analysis for improving surgical care safety6156Surgical Care Safety;Healthcare HarmReports & Publications8/30/2017 6:59:45 PM The Surgical Care Safety Summit brought together over 30 individuals representing professional associations, quality councils, provincial ministries, health authorities and a patients' group. The subsequent Surgical Care Safety Action Plan identified a goal of preventing surgical harm through enhancing the use of both retrospective and proactive analyses. This guide is the culmination of the work of the Proactive Analysis for Surgical Care Safety Action Team. Surgical Safety in Canada A 10-year review of CMPA and HIROC medico-legal data, the retrospective analysis, is also available. In healthcare, when patients are harmed or nearly harmed, reactive investigations are conducted. While these are important, they usually focus only on one patient, although occasionally the care of a group of patients may be reviewed. In a way, these investigations are too late- some patients will have come to harm from hazards in the healthcare system. From a safety point of view, being able to find those hazards before patients are harmed is better for patients, their care providers and the entire healthcare system. This kind of investigation - proactive analysis - is rarely used in healthcare. This guide, although not a 'how to' document, will help you and your colleagues to learn more about proactive analyses and prepare to undertake them. Download The Surgical Care Safety Summit brought together over 30 individuals representing professional associations, quality councils, provincial ministries,9/24/2020 8:12:43 AM1528https://www.patientsafetyinstitute.ca/en/toolsResources/Pages/Forms/NewDefaultView.aspxhtmlFalseaspx
Measures: Medication Reconciliation (MedRec)10526Improving Medication SafetyToolkits & Guides7/1/2015 8:53:29 AM Measurement is essential to monitoring success and helps guide your team towards your specific intervention goal. Measurement also tells us what's working and what's not, and provides evidence to inspire other healthcare providers to improve the quality of patient safety. The measurement methodology and recommendations regarding sampling size referenced in this GSK, is based on The Model for Improvement and is designed to accelerate the pace of improvement using the PDSA cycle; a "trial and learn" approach to improvement based on the scientific method. Langley, G., Nolan, K., Nolan, T., Norman, C., Provost, L. The Improvement Guide A Practical Approach to Enhancing Organizational Performance. San Francisco, Second Edition, CA. Jossey-Bass Publishers. 2009. It is not intended to provide the same rigor that might be applied in a research study, but rather offers an efficient way to help a team understand how a system is performing. When choosing a sample size for your intervention, it is important to consider the purposes and uses of the data and to acknowledge when reporting that the findings are based on an "x" sample as determined by the team. The scope or scale (amount of sampling, testing, or time required) of a test should be decided according to The team's degree of belief that the change will result in improvement The risks from a failed test Readiness of those who will have to make the change Provost, Lloyd P; Murray, Sandra (2011-08-26). The Health Care Data Guide Learning from Data for Improvement (Kindle Locations 1906-1909). Wiley. Kindle Edition. Please refer to the Improvement Frameworks GSK (2015) for additional information.Measurement Worksheets (Measures) and Data Collection Forms (DCF) Measures DCFs Aggregate data (monthly) De-identified Patient-level data (daily) Numerator and Denominator Multiple data elements ​ Roll-up to Measurement Worksheets MedRec Quality Audit The MedRec Quality Audit tool can be used by acute care and long term care organizations to measure the quality of the basic elements of their MedRec process on admission. These data will be helpful in identifying specific elements in need of process improvement and potentially reducing the occurrence of preventable drug events.MedRec (Acute Care and Long Term Care) Quality Audit DCF (Audit) Question Roll-up to ACUTE Measures Roll-up to LTC Measures A. Admitted via N/A N/A B. Was MedRec Performed? MedRec-Acute 5 MedRec-LTC 4 C. BPMH based on >1 source MedRec-Acute 11, 12 MedRec-LTC 6, 7 D. Actual medication use verified by pt./caregiver interview MedRec-Acute 11, 12 MedRec-LTC 6, 7 E. Each medication has drug name, dose +/- strength, route, frequency on BPMH and Admission Orders MedRec-Acute 11, 12 MedRec-LTC 6, 7 F. Every medication in the BPMH is accounted for in the admission orders MedRec-Acute 7, 11, 12 MedRec-LTC 5, 6, 7 G. Prescriber has documented rationale for 'holds' and 'discontinued' medications MedRec-Acute 11, 12 MedRec-LTC 6, 7 H. Discrepancy is communicated, resolved and documented N/A N/A MedRec Quality Audit Tools - Admission MedRec-Acute Home Care Long Term Care MedRec-Acute DCF - [PDF] MedRec-HC DCF - [PDF] MedRec-LTC DCF - [PDF] MedRec-Acute Instructions - [PDF] MedRec-HC Score Template - [Excel] MedRec-LTC Instructions - [PDF] MedRec-Acute Score Template - [Excel] MedRec-LTC Score Template - [Excel] MedRec Quality Audit Tools – Discharge Acute Care and Rehab MedRec-Discharge DCF - [PDF] MedRec-Discharge Instructions - [PDF] MedRec (Acute Care) Measures Measure Goal Type MedRec-Acute 1 - Mean Number of Undocumented Intentional Discrepancies per Patient Decrease 75% Outcome MedRec-Acute 2 - Mean Number of Unintentional Discrepancies per Patient Decrease 75% Outcome MedRec-Acute 3 - Medication Reconciliation Success Index (Optional Measure) Set % Process MedRec-Acute 4 - Percentage of Patients Reconciled at Discharge 100% Process MedRec-Acute 5 - Percentage of Patients Reconciled at Admission 100% Process MedRec-Acute 6 - Percentage of Patients Reconciled at Transfer 100% Process MedRec-Acute 7 - Percentage of Patients with One or More Discrepancy at Admission No goal Outcome MedRec-Acute 8 - Percentage of Patients Discharged with a BPMDP Distributed to ALL Eligible Care Providers No goal Process MedRec-Acute 9 - Percentage of Patients with a Medication Calendar No goal MedRec-Acute 10 - Average Number of Discrepancies Identified per Patient at Discharge No goal Outcome MedRec-Acute 11 - Average MedRec Quality Score at Admission 100% Outcome MedRec-Acute 12 - Quality Audit Bundle Compliance at Admission 100% Process MedRec-Acute 13 - Percentage of Patients using more than one source for BPMH 100% Process MedRec-Acute 14 - Percentage of Patients for whom actual med use was verified by pt/caregiver 100% Process MedRec-Acute 15 - Percentage of Patients for whom BPMH and Admission Orders has drug name, dose, route, and frequency for each medication 100% Process MedRec-Acute 16 - Percentage of Patients for whom every medication in BPMH is accounted for in Admission Orders 100% Process MedRec-Acute 17 - Percentage of Patients for whom the prescriber has documented the rationale for Holds and Discontinued medications 100% Process MedRec-Acute 18 - Percentage of Patients for whom a Best Possible Medication History (BPMH) was Completed 100% Process Measures and definitions MedRec (Home Care) Measures Measure Goal Type MedRec-HC 1 - Percentage of eligible Home Care clients with a Best Possible Medication History (BPMH) 95% Process MedRec-HC 2 - The average time to complete a Best Possible Medication History (BPMH) Set Balancing MedRec-HC 3 - Percentage of eligible Home Care clients with at least one discrepancy Set % Process MedRec-HC 4 - Percentage of Medication Discrepancies Identified by Type 100% Information MedRec-HC 5 - Percentage of Home Care Clients for whom MedRec was initiated 95% Process MedRec-HC 6 - Percentage of Home Care Clients for whom the BPMH was based on more than one source for BPMH 100% Process MedRec-HC 7 - Percentage of Home Care Clients for whom actual medication use was verified by the client/caregiver 100% Process MedRec-HC 8 - Percentage of Home Care Clients for whom BPMH and Admission Orders has drug name, dose, route, and frequency for each medication 100% Process MedRec-HC 9 - Percentage of Home Care Clients for whom every medication in BPMH is accounted for in Admission Orders 95% Process MedRec-HC 10 - Percentage of Home Care Clients for whom Discrepancies were Resolved, and/or Communicated to the Most Responsible Provider, and Actions Documented 95% Process MedRec-HC 11 - Percentage of Home Care Clients for whom the reconciled medication list has been communicated to the client/caregiver and others in the client circle of care. 95% Process MedRec-HC 12 - Average MedRec Quality Score at Admission 100% Outcome MedRec-HC 13 - Home Care MedRec Quality Bundle Compliance at Admission 100% Process Measures and definitions MedRec (Long Term Care) Measures Measure Goal Type MedRec-LTC 1 - Mean Number of Undocumented Intentional Discrepancies per Resident in Long-Term Care Decrease 75% Information MedRec-LTC 2 - Mean Number of Unintentional Discrepancies per Resident in Long-Term Care Decrease 75% Outcome MedRec-LTC 3 - Percentage of Long-Term Care Residents Reconciled 100% Process MedRec-LTC 4 - Percentage of Residents Reconciled at Admission 100% Process MedRec-LTC 5 - Percentage of Residents with One or More Discrepancy at Admission No goal Outcome MedRec-LTC 6 - Average MedRec Quality Score at Admission 100% Outcome MedRec-LTC 7 - Quality Assessment Bundle Compliance at Admission 100% Process MedRec-LTC 8 - Percentage of Residents using more than one source for BPMH 100% Process MedRec-LTC 9 - Percentage of Residents for whom actual medication use was verified by the resident/caregiver 100% Process MedRec-LTC 10 - Percentage of Residents for whom BPMH and Admission Orders has drug name, dose, route, and frequency for each medication 100% Process MedRec-LTC 11 - Percentage of Residents for whom every medication in BPMH is accounted for in Admission Orders 100% Process MedRec-LTC 12 - Percentage of Residents for whom the prescriber has documented the rationale for Holds and Discontinued meds 100% Process MedRec-LTC 13 - Percentage of Patients for whom a Best Possible Medication History (BPMH) was Completed 100% Process Measures and definitions Types of Measures Safer Healthcare Now! (SHN) has two types of measures for each of the interventions process measures and outcome measures. Some interventions also have balancing measures and information measures. Below are examples of each. Outcome measures - answers whether the team is achieving what it is trying to accomplish and articulates the picture of success. For example, if the team wants to reduce falls it should measure the number of falls. Process measures - Processes which directly affect the outcome are measured to ensure that all key changes are being implemented to impact the outcome measure. For example, the delivery of timely prophylactic antibiotics to reduce surgical site infection. Balancing measures - answer the question whether improvements in one part of the system were made at the expense of other processes in other parts of the system. For example, in a project to reduce the average length of stay for a group of patients, the team should also monitor the percent of readmissions within 30 days for the same group. Information measures - collect general details relative to the intervention.Med Rec (Acute Care): Measurement Worksheets9/24/2020 8:15:23 AM8855https://www.patientsafetyinstitute.ca/en/toolsResources/psm/Pages/Forms/UpdateData.aspxhtmlFalseaspx
Surgical Safety Checklist: Download6207Surgical Care Safety;General Patient SafetyToolkits & Guides7/1/2015 8:56:47 AM​​Getting Ready for Implementation Adapt the checklist to your organization using human factors principles Download How-To Guide for implementing the Surgical Safety Checklist A Detailed Explanation of the Checklist Items An Information, Rationale, and Frequently Asked Questions document Surgical Safety Checklist - Canadian Version The checklists below are Word documents with identical content. They are provided in portrait and landscape versions for easier integration into patient files or postings. If your organization is interested in measuring compliance, use the versions with a scorecard. We encourage you to adapt them for use in your organization. Surgical Safety Checklists - Scorecard Portrait Version Landscape Version Surgical Safety Checklists - No Scorecard Portrait version Landscape version LinksWorld Health Organization Safe Surgery Saves Lives WHO Patient Safety Safe Surgery Saves Lives - the second global patient safety challenge Instructional VideosThese videos are intended to teach potential users how to and how not to perform the checklist in a real-world environment. How to use the checklist How NOT to use the checklist How to use the checklist, complex caseReference Articles Impact of using the checklist at the eight WHO pilot sites Haynes AB, Weiser TG, Berry WB, et al. A surgical safety checklist to reduce morbidity and mortality in a global population. New England Journal of Medicine. 2009 Jan 14; [Epub ahead of print]. Retrieved from http//content.nejm.org/cgi/content/full/NEJMsa0810119 The Canadian Adverse Events Study Baker GR, Norton P, Flintoft V, et al. The Canadian adverse events study the incidence of adverse events among hospital patients in Canada. CMAJ. 2004; 170 (11) 1678 - 1686. Retrieved from http//www.cmaj.ca/cgi/content/full/170/11/1678 Team behavior (information sharing during preoperative phases, briefing and information sharing during handoff) impacts the rate of surgical complications and death. Mazzocco K, Petitti D, Fong K, et al. Surgical team behaviors and patient outcomes. The American Journal of Surgery. 2009, Volume 197, Issue 5, Pages 678-685. Preoperative briefings have the potential to increase OR efficiency and thereby improve quality of care and reduce cost. Nundy S, Mukherjee A, Sexton BJ, et al. Impact of preoperative briefings on operating room delays a preliminary report . Arch Surg. 2008 Nov;143(11)1068-72. Team debriefings best practices and tips Salas E, Klein C, King H, et al. Debriefing medical teams 12 evidence-based best practices and tips. The Joint Commission Journal on Quality and Patient Safety. 2008 Sep;34(9)518-27. Adapting the surgical checklist – requirements and implementation tips Verdaasdonk EGG, Stassen LPS, Widhiasmara PP, Dankelman J. Requirements for the design and implementation of checklists for surgical processes. Surg Endosc. 2009, 23 715-726 Prototype surgical checklist development and validation (the Netherlands) De Vries EN, Hollmann MW, Smorenburg SM, et al. Development and validation of the SURgical Patient Safety Sustem (SURPASS) Checklist. Qual Saf Health Care. 2009, 18 121-126 Interprofessional checklist briefings reduce the number of communication failures, promote proactive and collaborative team communication, and identifies patient safety problems. Lingard L, Regehr G, Orser B, et al. Evaluation of a Preoperative Checklist and Team Briefing Among Surgeons, Nurses, and Anesthesiologists to Reduce Failures in Communication. Arch Surg. 2008;143(1)12-17. Large and sustained reduction of the catheter-related infections through an intervention program using a checklist Pronovost P, Needham D, Berenholtz S, et al. An Intervention to Decrease Catheter-Related Bloodstream Infections in the ICU. N Engl J Med 2006 355 2725-2732.​​​​Implementation Resources9/24/2020 8:10:32 AM13720https://www.patientsafetyinstitute.ca/en/toolsResources/Pages/Forms/NewDefaultView.aspxhtmlFalseaspx
What is Quality and Patient Safety?99122/23/2010 11:02:11 PM Accreditation Canada defines quality as “the degree of excellence; the extent to which an organization meets clients needs and exceeds their expectations”. Key attributes of high quality healthcare systems, as defined by the Institute of Medicine (U.S.) include safety, timeliness, effectiveness, efficiency, equity and patient centeredness. The Health Council of Canada Annual Report (2006) entitled Clearing the Road to Quality found that patient safety, information management, quality councils and performance reporting are four key strategies to improve the quality of healthcare. The Canadian Patient Safety Dictionary (2003) defines patient safety as “the reduction and mitigation of unsafe acts within the healthcare system, as well as through the use of best practices shown to lead to optimal patient outcomes”. International efforts are underway to standardized taxonomy of key patient safety concepts share learning across health systems; thus, the World Health Organization’s (WHO) International Classification for Patient Safety defines patient safety as, “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”. Patient safety is often considered a component of quality, thus, practices to improve patient safety improve the overall quality of care.What is Quality and Patient Safety?1/8/2020 7:38:31 PM14581https://www.patientsafetyinstitute.ca/en/toolsResources/GovernancePatientSafety/Pages/Forms/AllItems.aspxhtmlFalseaspx
Suicide Risk2610Mental Health;Healthcare HarmToolkits & Guides;Reports & Publications4/21/2011 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. Download Inventory and Resource Guide Development for the Assessment and Prevention of Suicide RiskThe Canadian Patient Safety Institute (CPSI) has partnered with the Mental Health Commission of Canada (MHCC) to help healthcare workers and9/24/2020 8:16:27 AM7549https://www.patientsafetyinstitute.ca/en/toolsResourceshtmlTrueaspx
Enhanced Recovery Canada™ - Enhanced Recovery After Surgery2656Surgical Care Safety;General Patient SafetySocial Media/Social Share7/13/2016 2:57:58 AM What is Enhanced Recovery After Surgery? Enhanced Recovery Canada is a project of the Canadian Patient Safety Institute leading the drive to improve surgical safety across the country and is based on Enhanced Recovery After Surgery – ERAS surgical best practices. These evidence-based principles support better outcomes for surgical patients including an improved patient experience, reduced length of stay, decreased complication rates and fewer hospital readmissions. In partnership with Enhanced Recovery Canada endorses six core ERAS principles to shift the surgical care paradigm Patient and family engagement Nutrition management Perioperative fluid and hydration management Multi-modal opioid sparing analgesia Perioperative best practices Mobilization 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. Gold Level Silver Level Bronze Level For more information, contact us at info@cpsi-icsp.ca. Enhanced Recovery Canada™What is Enhanced Recovery After Surgery ? Enhanced Recovery Canada is a project of the Canadian Patient Safety Institute leading the drive to12/24/2020 4:35:14 PM23501https://www.patientsafetyinstitute.ca/en/toolsResourceshtmlTrueaspx
Hand Hygiene Human Factors Toolkit6170Infection Prevention & Control (IPAC);Surgical Care SafetyToolkits & Guides6/3/2015 4:47:25 PM​​​​​Human Factors is the study of how humans interact with the world around them. Studying how people interact with equipment and materials allows us to change the environment in which we work to make the interaction more useful or helpful. A user-friendly hand hygiene environment is one where staff, patients, and visitors are supported in such a way that participating in optimal hand hygiene activities can take place in the right place and at the right time. Developed by the Canadian Patient Safety Institute in conjunction with 3M and the University Health Network, the Hand Hygiene Human Factors Toolkit is designed to help you conduct the assessments necessary to assure that hand hygiene products are located where they are needed, available in the right quantity, visible, within reach, fully stocked and functional, and in the best form. Click here to order the full-colour, spiral-bound toolkit. Extra copies of the assessment forms can be downloaded in PDF format Environment tool Product tool Process tool Ongoing assessment toolsHuman Factors is the study of how humans interact with the world around them. Studying how people interact with equipment and materials allows us to9/24/2020 8:12:26 AM6381https://www.patientsafetyinstitute.ca/en/toolsResources/Pages/Forms/NewDefaultView.aspxhtmlFalseaspx
Awareness of the Patient Safety Crisis in Canada2621General 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 AM3058https://www.patientsafetyinstitute.ca/en/toolsResourceshtmlTrueaspx
Communicating After Harm in Healthcare2652General Patient Safety;Healthcare Harm;Psychological Safety for Healthcare WorkersToolkits & Guides9/18/2015 5:00:21 PM ​​​Communicating After Harm in Healthcare was developed by the Canadian Patient Safety Institute to assist you and your organization throughout the process of communicating after patient safety incidents that resulted in harm. This document can help to guide organizations with strategies and tactics for communicating harm in healthcare with various audiences including social media. This document is intended to replace the Guidelines for Informing the Media After an Adverse Event. Since those guidelines were originally published in 2009, the communications landscape has changed significantly, and stakeholders are expecting more accountability and transparency from healthcare and health professional organizations. The purpose of this document is to provide support for healthcare and health professional organizations that need to share information about patient safety incidents that caused harm. When implementing this process, each patient safety incident is individual, and each response must be customized appropriat​​ely. If you have any questions or comments you'd like to share about the Communicating After Harm in Healthcare guidelines, please feel free to email us at in​fo@cpsi-icsp.ca​. Download Communicating After Harm in Healthcare C ommunicating After Harm in Healthcare was developed by the Canadian Patient Safety Institute to assist you and your organization throughout9/24/2020 8:13:18 AM5812https://www.patientsafetyinstitute.ca/en/toolsResourceshtmlTrueaspx
Patient Safety and Incident Management Toolkit2606General Patient Safety;Improving Medication Safety;Healthcare HarmToolkits & Guides12/18/2014 8:28:40 PMPrevent 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 Incident Management System Factors For more information, contact us at info@cpsi-icsp.ca.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 info@cpsi-icsp.ca.Patient Safety and Incident Management ToolkitPrevent Patient Safety Incidents and Minimize Harm When They Do Occur When a patient's safety is compromised, or even if someone just comes close to10/8/2020 7:03:53 PM18549https://www.patientsafetyinstitute.ca/en/toolsResourceshtmlTrueaspx