|Measures: Ventilator-Associated Pneumonia (VAP)||13001||Infection Prevention ＆ Control (IPAC)||Toolkits ＆ Guides||7/1/2015 8:57:33 AM|| Measurement is essential to monitoring success and helps guide your team towards your specific intervention goal. Measurement also tells us what's working and what's not, and provides evidence to inspire other healthcare providers to improve the quality of patient safety. The measurement methodology and recommendations regarding sampling size referenced in this GSK, is based on The Model for Improvement and is designed to accelerate the pace of improvement using the PDSA cycle; a "trial and learn" approach to improvement based on the scientific method. Langley, G., Nolan, K., Nolan, T., Norman, C., Provost, L. The Improvement Guide A Practical Approach to Enhancing Organizational Performance. San Francisco, Second Edition, CA. Jossey-Bass Publishers. 2009. It is not intended to provide the same rigor that might be applied in a research study, but rather offers an efficient way to help a team understand how a system is performing. When choosing a sample size for your intervention, it is important to consider the purposes and uses of the data and to acknowledge when reporting that the findings are based on an "x" sample as determined by the team. The scope or scale (amount of sampling, testing, or time required) of a test should be decided according to The team's degree of belief that the change will result in improvement The risks from a failed test Readiness of those who will have to make the change Provost, Lloyd P; Murray, Sandra (2011-08-26). The Health Care Data Guide Learning from Data for Improvement (Kindle Locations 1906-1909). Wiley. Kindle Edition. Please refer to the
Improvement Frameworks GSK (2015) for additional information.VAP Measures
Type VAP 1 - VAP Rate in ICU per 1000 Ventilator Days Decrease 50% Outcome VAP 2 - VAP Bundle Compliance 95% Process VAP 3 - Paediatric VAP Bundle Compliance 95% Process
Measures and definitions Types of Measures
Safer Healthcare Now! (SHN) has two types of measures for each of the interventions process measures and outcome measures. Some interventions also have balancing measures and information measures. Below are examples of each.
Outcome measures - answers whether the team is achieving what it is trying to accomplish and articulates the picture of success. For example, if the team wants to reduce falls it should measure the number of falls.
Process measures - Processes which directly affect the outcome are measured to ensure that all key changes are being implemented to impact the outcome measure. For example, the delivery of timely prophylactic antibiotics to reduce surgical site infection.
Balancing measures - answer the question whether improvements in one part of the system were made at the expense of other processes in other parts of the system. For example, in a project to reduce the average length of stay for a group of patients, the team should also monitor the percent of readmissions within 30 days for the same group.
Information measures - collect general details relative to the intervention.||VAP: Measurement Worksheets||9/24/2020 8:15:22 AM||14152||https://www.patientsafetyinstitute.ca/en/toolsResources/psm/Pages/Forms/UpdateData.aspx||html||False||aspx|
|Tools & Resources||2890||9/18/2020 4:40:20 AM||Tools & Resources||Tools & Resources||9/21/2020 9:19:04 AM||82793||https://www.patientsafetyinstitute.ca/en||html||True||aspx|
|Canadian Patient Safety Week (CPSW)||3223||General Patient Safety||Events||12/8/2009 9:50:43 PM|| The theme for this year’s Canadian Patient Safety Week will be announced soon. The campaign will be hosted on the new Healthcare Excellence Canada website.
Check it out
||Canadian Patient Safety Week||Canadian Patient Safety Week (CPSW)||2/23/2022 5:50:44 PM||129660||https://www.patientsafetyinstitute.ca/en/Events||html||True||aspx|
|Clean Your Hands Day||3225||Infection Prevention ＆ Control (IPAC)||Events||6/3/2015 4:46:05 PM|| Visit Clean Your Hands Day new home page on the Healthcare Excellence Canada website.
Check it out
||Clean Your Hands Day||Visit Clean Your Hands Day new home page on the Healthcare Excellence Canada website.
Check it out||5/14/2021 3:20:35 PM||97408||https://www.patientsafetyinstitute.ca/en/Events||html||True||aspx|
|Advocacy and support for use of a Surgical Safety Checklist||3070||Surgical Care Safety||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||9/24/2020 8:13:01 AM||3060||https://www.patientsafetyinstitute.ca/en/toolsResources||html||True||aspx|
|Atlantic Learning Exchange||3228||General Patient Safety||Events||9/20/2016 6:01:00 PM||
Discover innovative and emerging trends in patient safety & quality improvement
October 8 – 9, 2019 St. John's, NL, The Atlantic Health Quality and Patient Safety Collaborative (AHQPSC), through partnership support of the Canadian Patient Safety Institute (CPSI), welcomes you to attend this year's Atlantic Health Quality & Patient Safety Learning Exchange (ALE 2019) which will take place at the Sheraton Hotel Newfoundland, St. John's, NL,
October 8 – 9, 2019.
Program Who should attend? We look forward to welcoming innovative and engaged care providers, managers, health leaders, academics and students from university and college setting, as well as government representatives from the four Atlantic Provinces in attendance this year. Tickets are limited! Through this conference, you will be given an opportunity to Mobilize energy and enthusiasm for a new era of patient safety and quality improvement; Understand the role innovation and technology play in healthcare improvement; Stimulate change through the power of the patient voice; and Develop the skills for leading transformational change!
Do you want to support this event? Do you want exclusive access to the front line of healthcare in the Atlantic provinces? We are looking for Sponsors and Exhibitors contact Gina Peck at 902-481-5034 or
firstname.lastname@example.org to receive more information on sponsorship and exhibiting at the conference. ||Atlantic Quality and Patient Safety Learning Exchange||Discover innovative and emerging trends in patient safety & quality improvement
October 8 – 9, 2019 St. John's, NL, The Atlantic Health||10/29/2020 9:25:42 PM||14508||https://www.patientsafetyinstitute.ca/en/Events||html||True||aspx|
|Education to support mandatory ADR and MDI reporting (Vanessa’s Law)||3110||General Patient Safety;Government Relations;Healthcare Harm||Reports ＆ Publications;Patient and Family Resource;Toolkits ＆ Guides||3/4/2019 9:27:01 PM||
The Protecting Canadians from Unsafe Drugs Act, also known as Vanessa's Law, is intended to increase drug and medical device safety in Canada by strengthening Health Canada's ability to collect information and to take quick and appropriate action when a serious health risk is identified. As of December 16, 2019, it became mandatory for hospitals to report serious adverse drug reactions (serious ADRs) and medical device incidents (MDIs) to Health Canada. Downloadable from this
webpage are 4 PowerPoint modules developed in collaboration with
Health Canada. These modules contain core content intended for use by hospitals, health care
professionals, patients and their families, and educators, to explain,
describe, or promote the reporting of serious ADRs and MDIs. Module 1 – Overview of Vanessa's Law and Reporting Requirements
PowerPoint - Module 1
Module 2 – Reporting Processes to Health Canada
PowerPoint - Module 2
Module 3 – Strategies to Promote and Support Mandatory Reporting
PowerPoint - Module 3
Module 4 – Health Canada's Review and Communication of Safety Findings
PowerPoint - Module 4 These materials (as entire modules or as individual slides or selected content) can be used for individual learning or incorporated into presentations, orientation, continuing education, and other information-sharing activities. The materials can be used in the following ways to support and raise awareness of mandatory reporting requirements
Hospitals can include some or all of the content in their local, regional, and/or provincial information-sharing activities (e.g., "Lunch and Learn" sessions, presentations, orientation programs for new staff).
Educators in the health care sector can use the content in presentations or as part of a curriculum.
Professional associations, societies, and regulatory colleges, as well as other training institutions for health care workers, may incorporate the content of the modules into accredited courses or continuing education certification programs.
Patient and consumer organizations can help disseminate some or all of the information in the modules to increase awareness and knowledge among their members.
If you have questions about how to use these educational materials for your specific audience (e.g., selecting slides or content from several modules to create a customized presentation), please contact
ISMP Canada email@example.com
https//healthstandards.org/ CPSI firstname.lastname@example.org
If you have questions about Vanessa's Law and the mandatory reporting requirements, please contact
This conceptual model of serious ADR and MDI reporting by hospitals depicts the information provided in the 4 PowerPoint modules mandatory reporting requirements, reporting processes to Health Canada, strategies to promote and support reporting, and Health Canada’s review and communication of safety findings. ACKNOWLEDGEMENTS Health Canada, ISMP Canada, HSO, and CPSI gratefully acknowledge input received from the Advisory Panel (listed in alphabetical order)
Glenn Cox, Senior Director Pharmacy Services NSHA, Director Pharmacy Services, Cape Breton/Antigonish/Guysborough, Cape Breton Regional Hospital, Sydney, NS ;
Michael Gaucher, Director Pharmaceuticals & Health Workforce Information Services, Canadian Institute for Health Information, Ottawa, ON ;
Andrew Ibey – Clinical Engineer, Children's Hospital of Eastern Ontario, Ottawa, ON ;
Denis Lebel – Pharmacien, adjoint aux soins, enseignement et recherche, Département de pharmacie, CHU Sainte-Justine, QC ;
Dr. Joel Lexchin, Professor Emeritus, School of Health Policy & Management, York University, Toronto, ON ;
Faith Louis, Regional Manager, Quality Improvement & Support Services, Pharmacy Services, Horizon Health Network, NB;
Holly Meyer, Provincial Director, Product Quality & Safety, Alberta Health Services, AB ;
Maryann V. Murray, Patients for Patient Safety Canada;
Tolu Oyebode, Government of Saskatchewan, Senior Project Manager, Patient Safety Unit, Strategic Priorities Branch, Ministry of Health, SK ;
Sheryl Peterson, Associate Director, Lecturer, Faculty of Pharmaceutical Sciences, The University of British Columbia (Vancouver Campus);
Michelle Rossi, Director, Policy and Strategy, Health Quality Ontario, Toronto, ON ;
Myrella Roy, Executive Director, and
Cathy Lyder, Director Professional Practice, Canadian Society of Hospital Pharmacists, Ottawa, ON ;
Christelle Sessua, Quality Assurance-Risk Management Coordinator, Iqaluit Health Services, Department of Health, Government of Nunavut ;
Robyn Tamblyn, James McGill Chair, Professor, Department of Medicine, Department of Epidemiology & Biostatistics, McGill University, Scientific Director, Institute of Health Services and Policy Research, Canadian Institutes of Health Research, Montreal, QC ;
Annemarie Taylor, Executive Director, Patient Safety & Learning System, Vancouver, British Columbia ;
Terence Young, Chair of Drug Safety Canada and father of Vanessa Young. ||Educational Support for Mandatory Reporting of Serious ADRs and MDIs by Hospitals||The Protecting Canadians from Unsafe Drugs Act, also known as Vanessa's Law, is intended to||9/24/2020 8:13:31 AM||169480||https://www.patientsafetyinstitute.ca/en/toolsResources||html||True||aspx|
|A Guide to Patient Safety Improvement||3077||General Patient Safety||Toolkits ＆ Guides||7/29/2020 5:15:14 PM||
When it comes to patient safety, a substantial body of evidence exists to demonstrate interventions (leading practices and processes) that lead to improved patient outcomes for numerous healthcare conditions. Despite available evidence, practice changes are not implemented consistently and effectively to support organizations and teams to address patient safety challenges. This resource has been designed to support teams across all healthcare sectors in using a Knowledge Translation and Quality Improvement integrated approach to change that will impact patient safety outcomes. This Guide for Patient Safety Improvement is intended to accompany current best available evidence change ideas, and tools and resources for your specific project. It includes ideal practice changes “the what” and strategies “the how” that creates the evidence-based intervention. Adaptations are expected and important considerations for implementation will be provided in this guide.
||A Guide to Patient Safety Improvement||When it comes to patient safety, a substantial body of evidence exists to demonstrate interventions (leading practices and processes) that lead to||10/15/2020 7:33:09 PM||10195||https://www.patientsafetyinstitute.ca/en/toolsResources||html||True||aspx|
|Canadian Quality and Patient Safety Framework for Health Services||3103||General Patient Safety;Policy;Government Relations;Improving Culture;Partnering with Patients;Patient ＆ Family Resources||Frameworks;Patient and Family Resource;Position Statements;Reports ＆ Publications||3/27/2019 7:47:40 PM||
The need for a national patient safety and quality framework Health services across Canada are comprehensive, complex, and at times complicated. Every person in Canada deserves safe, high-quality healthcare when and where they need it. For the most part, this is our experience. But we don't always get it right. People may be inadvertently harmed by the services intended to help them. The reality is that unintended harm occurs in a Canadian hospital or home care setting every 1 minute and 18 seconds Every 13 minutes and 14 seconds, someone dies Patient safety incidents are the third leading cause of death in Canada Even more, there are significant variations in care by age, gender, race/ethnicity, geography and socio-economic status. Access to quality health services is more challenging for Indigenous peoples, (including First Nations, Inuit and Métis), Black people, LQBTQ2S+ identities (including Lesbian, Gay, Bisexual, Transgender, Queer or Questioning and Two-Spirit), immigrants, visible minorities, and many more diverse peoples that comprise our country. While some jurisdictions have quality and safety plans or frameworks in place, people continue to experience healthcare differently across the country. These considerations, when added to the heightened need for consistency and coordination in healthcare due to the COVID-19 pandemic, prompt us to ask How can we focus and align quality and safety improvement throughout the country, regardless of jurisdiction?
The Canadian Quality and Patient Safety Framework for Health Services is the first of its kind in Canada. We can all work together to accelerate quality and patient safety across Canadian health systems by focusing all stakeholders across Canada on five goals for safe, quality care. This people-centred
framework defines five goal areas designed to drive improvement and to align Canadian legislation, regulations, standards, organizational policies, and public engagement on patient safety and quality improvement. It includes action guides and resources customized for each stakeholder group to support you in putting the goals into practice.
Download the Framework
How to use the Framework
Be sure to take full advantage of all the
communications tools and resources in this package
Download the Communication Toolkit Leading Practice How have you used the Canadian Quality and Patient Safety Framework to drive quality and safety improvements? Please email
email@example.com and share your experience with us for an opportunity to be profiled as a Leading Practice or a case study.Evaluation Survey How is the Canadian Quality and Patient Safety Framework helping you align with Canada on five goals for quality, safe care? Heathcare Excellence Canada and Health Standards Organization welcome your feedback (10 min survey)
Mapping Tool A mapping tool was developed to help you map your organization's current quality and patient safety improvement initiatives to the goals, objectives, and outcomes of the Framework. This exercise will help demonstrate your organization's strengths in aligning with the Framework and uncover opportunities to work toward these key goals for safe, high-quality care.
Framework Mapping Tool
For any questions, comments or to share your experience using the Framework, please contact firstname.lastname@example.org.
Contact us || Why does Canada need a National Quality and Patient Safety Framework for Health Services?||The need for a national patient safety and quality framework Health services across Canada are comprehensive, complex, and at times complicated.||6/21/2021 7:31:24 PM||32673||https://www.patientsafetyinstitute.ca/en/toolsResources||html||True||aspx|
|Creating a Safe Space: Addressing the Psychological Safety of Healthcare Workers||3086||General Patient Safety;Psychological Safety for Healthcare Workers||Toolkits ＆ Guides;Healthcare provider stories;Reports ＆ Publications||1/6/2020 4:59:11 PM||In March 2021, Healthcare Excellence Canada launched, bringing together the Canadian Foundation for Healthcare Improvement and Canadian Patient Safety Institute. This content can now be found on HEC’s new website.
Check it out ||Creating a Safe Space: Psychological Safety of Healthcare Workers (Peer to Peer Support and Other Support Models)||In March 2021, Healthcare Excellence Canada launched, bringing together the Canadian Foundation for Healthcare Improvement and Canadian Patient||6/21/2022 5:44:59 PM||13178||https://www.patientsafetyinstitute.ca/en/toolsResources||html||True||aspx|
|Hand Hygiene Fact Sheets||3120||Infection Prevention ＆ Control (IPAC)||Toolkits ＆ Guides;Tip Sheets||4/1/2020 2:15:32 PM||Visit the new home for hand hygiene resources on the Healthcare Excellence Canada website.
Check it out
||Hand Hygiene Fact Sheets||Visit the new home for hand hygiene resources on the Healthcare Excellence Canada website.
Check it out||5/14/2021 3:21:23 PM||20213||https://www.patientsafetyinstitute.ca/en/toolsResources||html||True||aspx|
|Home Care Safety||3067||Community Based Care;General Patient Safety;Improving Medication Safety;Healthcare Harm||Reports ＆ Publications;Toolkits ＆ Guides||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||9/24/2020 8:14:05 AM||7089||https://www.patientsafetyinstitute.ca/en/toolsResources||html||True||aspx|
|Improvement Frameworks Getting Started Kit||3068||General Patient Safety;Healthcare Harm||Toolkits ＆ Guides;Frameworks||11/24/2011 4:21:24 PM||12/2/2015 7:00:00 AM||The Improvement Frameworks Getting Started Kit is intended to serve as a common document appended to the Safer Healthcare Now! Getting Started Kits. The goal is to help provide a consistent way for teams and individuals to approach the challenge of making changes that result in improvements.
Download ||Improvement Frameworks Getting Started Kit||The Improvement Frameworks Getting Started Kit is intended to serve as a common document appended to the Safer Healthcare Now! Getting Started||9/24/2020 8:14:36 AM||11812||https://www.patientsafetyinstitute.ca/en/toolsResources||html||True||aspx|
|Patient Safety and Incident Management Toolkit||3069||General Patient Safety;Improving Medication Safety;Healthcare Harm||Toolkits ＆ Guides||12/18/2014 8:28:40 PM||In March 2021, Healthcare Excellence Canada launched, bringing together the Canadian Foundation for Healthcare Improvement and Canadian Patient Safety Institute. This content can now be found on HEC’s new website.
Check it out
||Patient Safety and Incident Management Toolkit||In March 2021, Healthcare Excellence Canada launched, bringing together the Canadian Foundation for Healthcare Improvement and Canadian Patient||6/22/2022 2:51:42 PM||26173||https://www.patientsafetyinstitute.ca/en/toolsResources||html||True||aspx|
|The Canadian Surgical Site Infection Prevention Audit - Results ||3071||Surgical Care Safety;Infection Prevention ＆ Control (IPAC)||Events;Webinars;Reports ＆ Publications||8/31/2015 5:35:10 PM||
Surgical site infection is the most common healthcare associated infection among surgical patients, with 77 per cent of patient deaths reported to be related to infection. In February 2016, the Canadian Patient Safety Institute (CPSI) along with our partners Alberta Health Services-Surgery Strategic Clinical Network, Atlantic Health Quality & Patient Safety Collaborative, BC Patient Safety & Quality Council, Health Quality Ontario, and Saskatchewan Ministry of Health- Patient Safety Unit, conducted the Canadian Surgical Site Infection (SSI) Prevention Audit.
Download Auditing helps to identify both areas of excellence and areas for improvement. During the month of February, all acute care organizations providing surgical services were challenged to audit their established processes for preventing surgical site infections (SSI). 52 service areas participated in the Surgical Site Infection Prevention Audit with 1.998 patient charts audited. Audit highlights noted that 91% of patients received appropriate prophylactic antibiotics and 96% of patients received the appropriate method of pre-operative hair removal whereas post-operative glucose control was identified as an area requiring improvement. To learn more about the Canadian Surgical Site Infection Prevention Audit and Results
Click here for information regarding Audit Methodology Access the National Call
Results from Canadian SSI Prevention Audit; March 24th, 2016
View the Canadian Surgical Site Infection Prevention Audit Recap Report
Audit Recap Report ||The Canadian Surgical Site Infection Prevention Audit - Results ||Surgical site infection is the most common healthcare associated infection among surgical patients, with 77 per cent of patient deaths reported to be||9/24/2020 8:16:44 AM||3254||https://www.patientsafetyinstitute.ca/en/toolsResources||html||True||aspx|
|The Safety Competencies Framework||3072||General Patient Safety;Healthcare Harm||Reports ＆ Publications;Frameworks||4/14/2009 11:53:32 PM||Safety Competencies Framework Educating healthcare providers about patient safety and enabling them to use the tools and knowledge to build and maintain a safe system is fundamental to creating a culture of safety across the spectrum of care. The 2020 Safety Competencies Framework (2nd Edition) is a simple, powerful and flexible framework that includes enabling competencies that can be adopted and adapted by diverse healthcare programs to design curricula to teach safety and quality for any sector or healthcare program. It can also be a valuable resource to policy makers, regulators and accreditors to guide system change. The Six Domains support moving patient safety evidence into action and has strengthened its content with advancements in collective knowledge that include patient/family partnership, leadership, quality improvement and cultural competency concepts. Safety Competencies Framework Domains Domain 1 Patient Safety Culture Patient safety culture improvement involves recognizing the importance of ongoing collaboration and the commitment to advocate for change. Domain 2 Teamwork High-performing interprofessional teams demonstrate capabilities and competencies that are essential to efficient, effective, and safe collaborative practice. Domain 3 Communication Effective communication is beneficial to patients and healthcare providers, builds trust, and is a precondition of obtaining patient consent. Domain 4 Safety, Risk, and Quality Improvement Healthcare providers collect and monitor performance data to assess risk and improve outcomes. Domain 5 Optimize Human and System Factors Optimizing the human and environmental factors that support the achievement of best human performance is an essential safety competency for all healthcare providers. Domain 6 Recognize, Respond to and Disclose Patient Safety Incidents Open, honest, and empathetic disclosure and appropriate apologies benefit patients and families, health providers, and their organizations. ||The Safety Competencies||The Safety Competencies: Message from the CEO||12/3/2020 4:19:06 PM||58061||https://www.patientsafetyinstitute.ca/en/toolsResources||html||True||aspx|
|Suicide Risk||3073||Mental Health;Healthcare Harm||Toolkits ＆ Guides;Reports ＆ Publications||4/21/2011 4:02:20 AM||The Canadian Patient Safety Institute (CPSI) has partnered with the Mental Health Commission of Canada (MHCC) to help healthcare workers and organizations select and compare available suicide risk assessment tools in Canada. For every death by suicide, 15-30 people are profoundly affected - this toolkit can help inform and strengthen the suicide risk assessment process. The Suicide Risk Assessment Toolkit seeks to provide a high-level overview of what to consider when using suicide risk assessment tools, along with a non-exhaustive list of available Canadian and international tools, and their characteristics. It is designed to be a quick, informative guide for healthcare workers and organizations interested in selecting and comparing such tools. The process of assessing suicide risk is complex. While assessment tools play an important role, they should be used to inform, not replace, clinical judgment. Use this toolkit, developed by CPSI and MHCC, to help you select/compare tools to complement the suicide risk assessment process.
Download Toolkit (publication January 26, 2021) For a more comprehensive guide to suicide risk assessment, including the role of healthcare workers and organizations, see
Suicide Risk Assessment Guide A Resource for Health Care Organizations.
Download Guide (publication 2011) We acknowledge the need to have suicide risk assessment tools that are truly inclusive and are based on principles of equity and diversity. We encourage you to seek out opportunities to engage with diverse peoples, including First Nations, Inuit, Métis, people who identify as 2SLQBTQ+, and immigrant, refugee, ethnocultural and racialized groups in order to understand and respond to their specific needs. Sponsored by The Canadian Patient Safety Institute and the Mental Health Commission of Canada. Production of this toolkit has been made possible through a financial contribution from Health Canada. ||Suicide Risk Assessment - Toolkit and Guide||The Canadian Patient Safety Institute (CPSI) has partnered with the Mental Health Commission of Canada (MHCC) to help healthcare workers and||2/4/2021 5:47:10 PM||16850||https://www.patientsafetyinstitute.ca/en/toolsResources||html||True||aspx|
|The Canadian Nosocomial Infection Surveillance Program (CNISP) Publications||3074||Infection Prevention ＆ Control (IPAC)||Reports ＆ Publications||12/3/2019 4:30:08 PM|| The Canadian Nosocomial Infection Surveillance Program (CNISP) is a collaborative effort between the Public Health Agency of Canada's Centre for Communicable Diseases and Infection Control (CCDIC) and the National Microbiology Laboratory (NML), and sentinel hospitals across Canada who participate as members of the Canadian Hospital Epidemiology Committee (CHEC), a standing committee of the Association of Medical Microbiology and Infectious Disease (AMMI) Canada. Established in 1994, the objectives of CNISP are to provide national and regional rates and trends on selected healthcare-associated infections (HAIs) and antimicrobial resistant organisms (AROs), as well as provide key information that informs the development of federal, provincial and territorial infection prevention and control programs and policies. At present, 70 sentinel hospitals from 10 provinces and 1 territory participate in the CNISP network. Below are the definitions and protocols for the healthcare associated infections currently under surveillance by the CNISP. For protocols or documents not appearing below, contact CNISP email@example.com Surveillance Definitions HAI Surveillance Case Definitions (2021) CNISP Surveillance Protocols Surveillance for COVID-19 and other viral respiratory infections among inpatients in CNISP hospitals (2021) Hospital Antibiogram Protocol (2022) Antimicrobial Utilization (AMU) Protocol (2022) Surveillance for Candida auris (2022) Surveillance Protocol for Carbapenemase-Producing Organisms (CPO) in CNISP Hospitals (2022) Surveillance for Clostridioides difficile infection, CDI (2022) Surveillance for Central Line Associated Blood Stream Infections (CLABSI) in Intensive Care Units, ICUs (2022) Surveillance of Cerebrospinal Fluid (CSF) Shunt Associated Surgical Site Infections (SSIs) Surveillance Protocol (2022) Surveillance Protocol for Methicillin-Resistant (MRSA) and Methicillin-Susceptible Staphylococcus aureus (MSSA) Bloodstream Infections in CNISP Hospitals (2021) Surveillance of Surgical Sites Infections Following Pediatric Cardiac Surgery (2020) Surveillance of Surgical Sites Infections (SSIs) Following Hip and Knee Arthroplasty (2022) Surveillance Protocol for Vancomycin Resistant Enterococci (VRE) Bloodstream Infections in CNISP Hospitals (2022) Other Documents Canada Communicable Disease Report Nosocomial Infection Surveillance May 2020 CNISP Infographic Healthcare-associated infection rates in Canadian hospitals (2020) Summary Report of Healthcare Associated Infection (HAI), Antimicrobial Resistance (AMR) and Antimicrobial Use (AMU) Surveillance Data from January 1, 2013 to December 31, 2017 Laboratory Surveillance 2019 Device-associated infections in Canadian acute-care hospitals from 2009 to 2018 ||The Canadian Nosocomial Infection Surveillance Program (CNISP) Publications||The Canadian Nosocomial Infection Surveillance Program (CNISP) is a collaborative effort between the Public Health Agency of Canada's Centre for||2/22/2022 2:55:27 PM||5219||https://www.patientsafetyinstitute.ca/en/toolsResources||html||True||aspx|
|Report on the Integration of the Safety Competencies Framework||3075||General Patient Safety;Healthcare Harm;Improving Culture||Frameworks;Reports ＆ Publications||9/12/2017 7:58:51 PM|| CPSI is pleased to present a comprehensive new report on the integration and impact of the
Safety Competencies Framework (SCF) originally launched in 2008 in partnership with the Royal College of Physicians and Surgeons of Canada. The framework has been one of the most downloaded documents on the CPSI website, consistently since its launch. Almost 10 years after the launch, this report examines the historical background of the SCF while providing a rationale for the development of the competencies, mapping of the competencies to integrate patient safety content in training programs. The report outlines the successes and challenges in the uptake of the competencies and includes a provocative call to action for educators. Several key findings were determined through interviews done with a select group of stakeholders familiar with the SCF and this feedback provided better understanding of the value of the competencies to organizations and professional bodies. As we look towards renewing the SCF to address feedback received, it is clear that despite the successes and challenges, we must shift our attention away from the "what" to focus on the "how" of integrating safety competencies in the curricula of health professionals on a more consistent basis.
||Report on the Integration of the Safety Competencies Framework||CPSI is pleased to present a comprehensive new report on the integration and impact of the
Safety Competencies Framework (SCF)||9/24/2020 8:15:57 AM||4586||https://www.patientsafetyinstitute.ca/en/toolsResources||html||True||aspx|
|Results of 2018 Public Survey Related to the Labelling of Non-Prescription Health Products||3076||Improving Medication Safety;Government Relations||Reports ＆ Publications;Patient and Family Resource||2/21/2019 3:31:22 PM||
As part of a Health Canada committee developing Plain
Language Labelling regulations for non-prescription health products, Patients for Patient Safety Canada led a joint PFPSC and
CPSI initiative to survey the public on the issue. Have people had problems
with the labelling of non-prescription health products?
The survey results indicate that consumers are often confused when purchasing self-care products. This raises concerns of harm are people choosing the wrong product because of this confusion? Our survey found that
29% of respondents said that they had wrongly purchased a natural health or homeopathic product, or over-the-counter drug; Another 29.5% said that they were not sure if they had wrongly purchased one of these products. The most cited reasons for the wrong purchase were Mixed it up with another product, Information about the product on the label was too small to read, or They were confused by, or did not understand, the information on the label. Some examples of comments on the survey include "I looked for Gravol on the drugstore shelf and all of the types of Gravol were together. When I saw Gravol ginger I thought it was Gravol with an added boost of ginger. When I got home and read the ingredients, I realized that there was not active ingredient in it. I feel I am a very health literate person, but I did not know the difference." "I did not realize the ingredients until I arrived home. Printing is so tiny on labels." "I bought a product for a yeast infection thinking it was for a Urinary Tract Infection" PFPSC
represented members at the Health Canada table to ensure that "just like
food products, all labels should be written in plain language, list all
ingredients, and be printed in legible size."
The results of this survey confirm that consumers want to know what's in the products they are taking. To protect Canadians from preventable harm, PFPSC and CPSI are calling for clear information and larger size lettering on the labels for non-prescription health products. ||Results of 2018 Public Survey Related to the Labelling of Non-Prescription Health Products|| As part of a Health Canada committee developing Plain
Language Labelling regulations for non-prescription health products, Patients for||9/24/2020 8:16:23 AM||2941||https://www.patientsafetyinstitute.ca/en/toolsResources||html||True||aspx|
|Engaging Patients in Patient Safety – a Canadian Guide||3078||General Patient Safety||Toolkits ＆ Guides;Reports ＆ Publications||4/25/2017 3:01:50 PM||In March 2021, Healthcare Excellence Canada launched, bringing together the Canadian Foundation for Healthcare Improvement and Canadian Patient Safety Institute. This content can now be found on HEC’s new website.
Check it out
||Engaging Patients in Patient Safety – a Canadian Guide||In March 2021, Healthcare Excellence Canada launched, bringing together the Canadian Foundation for Healthcare Improvement and Canadian Patient||6/29/2022 2:55:24 PM||30000||https://www.patientsafetyinstitute.ca/en/toolsResources||html||True||aspx|
|Deteriorating Patient Condition||3079||General Patient Safety;Infection Prevention ＆ Control (IPAC);Healthcare Harm||Toolkits ＆ Guides||3/30/2017 5:19:46 PM|| Early warning signs of deteriorating condition are often unrecognized, leading to devastating results. Research shows that virtually all critical inpatient events are preceded by warning signs that occur approximately six-and-a-half hours in advance. In this section, you'll find information, tools and resources to not only help you recognize deteriorating patient condition, but what you can do to act on it as a member of the public, a healthcare provider or leader. Click any of the icons below to get started! (updated
in February 2020)
||Deteriorating Patient Condition||Early warning signs of deteriorating condition are often unrecognized, leading to devastating results. Research shows that virtually all critical||12/23/2020 8:11:28 PM||4209||https://www.patientsafetyinstitute.ca/en/toolsResources||html||True||aspx|
|Learn how to use and store methadone safely||3081||Improving Medication Safety||Tip Sheets;Toolkits ＆ Guides||3/24/2021 8:07:00 PM|| Methadone is an opioid used to help people with opioid dependence. Unlike other opioids, it stays in the body a long time, preventing cravings and the discomfort of withdrawal. Like all other medications, methadone must be taken safely. Seeking help for your opioid dependence is a wise and important step in your road to recovery. Click here to learn how to use and store methadone safely. This information is brought to you in partnership between ISMP Canada and the Saskatchewan Ministry of Health, the College of Physicians and Surgeons of Saskatchewan's Opioid Agonist Therapy Program, Canadian Agency for Drugs and Technologies in Health (CADTH), the Saskatchewan Health Authority, Patients for Patient Safety Canada along with support from Canadian Patient Safety Institute. It has been reviewed by Canadian Society of Hospital Pharmacists (CSHP), the Nurse Practitioner Association of Canada (NPAC), The College of Family Physicians of Canada (CFPC), the Canadian Pharmacists Association (CPhA), and the Canadian Centre on Substance Use and Addiction (CCSA). Visit ISMP Canada for additional resources. ||Learn how to use and store methadone safely||Methadone is an opioid used to help people with opioid dependence. Unlike other opioids, it stays in the body a long time, preventing cravings and||3/24/2021 8:10:17 PM||313||https://www.patientsafetyinstitute.ca/en/toolsResources||html||True||aspx|
|MedError.ca||3082||Partnering with Patients;Patient ＆ Family Resources;Improving Medication Safety;General Patient Safety||Patient and Family Resource||10/26/2020 4:10:45 PM|| Medication errors cause harm to Canadians. Preventing such harm requires an understanding of where and why the medication safety system has failed, and the perspective of consumers is needed to advance this understanding. By sharing the learning from medication errors, consumers and providers can meaningfully work together to improve medication safety in Canada. Developed by the Institute for Safe Medication Practices Canada (ISMP Canada) and CPSI,
www.mederror.ca is a new website for the public to submit reports of medication errors for analysis, learning, and action. It builds on the work and success of
SafeMedicationUse.ca, to create a more user-friendly portal to share their medication error experiences with the goal to improve the quality and quantity of incident reporting in Canada. Anyone can report and with the growing numbers of Canadians who take prescription and non-prescription medications in the community, it is important to understand and learn from the public. Whether it is a suspected medication error or medication reaction, the website provides a quick and easy way to provide valuable insight that contributes to patient safety improvement.
||Mederror.ca||Medication errors cause harm to Canadians. Preventing such harm requires an understanding of where and why the medication safety system has failed,||11/3/2020 3:46:35 PM||1982||https://www.patientsafetyinstitute.ca/en/toolsResources||html||True||aspx|
|Medication Safety at Care Transitions Safety Improvement Project Learning Collaborative||3083||Improving Medication Safety||Toolkits ＆ Guides||1/15/2019 9:35:30 PM||What is Medication Safety? Medications are the most common treatment intervention used in healthcare around the world. When used safely and appropriately, they contribute to significant improvements in the health and well-being of patients. Medication safety is defined as freedom from preventable harm with medication use (ISMP Canada, 2007). Medication safety issues can impact health outcomes, length of stay in a healthcare facility, readmission rates, and overall costs to Canada's healthcare system. Medication Safety at Care Transitions Safety Improvement Project – An 18-month learning collaborative The Canadian Patient Safety Institute launched its Medication Safety- Safety Improvement Project in April 2019. This learning collaborative approach was delivered by expert faculty and coaches, with mentoring provided over 18 months. Participating teams learned and applied strategies to decrease readmissions related to medication safety issues at discharge among frail patients. Participant Learned To identify Frail clients who are at risk for medication safety issues, How to apply new processes for medication management at discharge, How to utilize Knowledge Translation and Implementation Science techniques to successfully implement and sustain new evidence-based practices for medication safety at transitions, To share key learnings and challenges, and networking with colleagues across Canada, Accessing, sharing and adopting advanced patient safety knowledge, tools, and resources within a learning network, Improving the team's approach to patient safety while taking action to deliver safer care. If you didn't have an opportunity to participate in the implementation collaborative, you can still access free resources below Get Started Kit 5 Questions to Ask About Your Medications Medication Reconciliation Measures Medication Reconciliation Resources||Medication Safety at Care Transitions: Safety Improvement Project||What is Medication Safety? Medications are the most common treatment intervention used in healthcare around the world. When used safely and||2/10/2021 8:16:16 PM||5973||https://www.patientsafetyinstitute.ca/en/toolsResources||html||True||aspx|
|Safety Improvement Projects||3084||General Patient Safety;Improving Medication Safety;Community Based Care;Healthcare Harm||Frameworks||9/14/2018 2:50:29 PM||
The Canadian Patient Safety Institute (CPSI) held 4 Safety Improvement Projects in 2018/2019. Thirty teams from across Canada participated in the Safety Improvement Project Learning Collaborative with a lifecycle of 18 months. A brief description of each project is provided below Teamwork and Communication focused on improving patient safety culture and positive patient outcomes. Medication Safety at Care Transitions focused on improving medication safety at discharge for frail, elderly patients with poly-morbidity. Enhanced Recovery Canada focused on improving outcomes and system efficiencies for colorectal surgery patients. Measurement and Monitoring of Safety focused on creating a culture of safety and reducing harm in organizations. The Safety Improvement Projects concluded with a virtual congress on October 28th and 29th 2020. Please see the short Highlights video (422). If you have any questions, please email SafetyImprovementProjects@cpsi-icsp.ca ||Safety Improvement Projects ||The Canadian Patient Safety Institute (CPSI) held 4 Safety Improvement Projects in 2018/2019. Thirty teams from across Canada participated in the||2/11/2021 5:55:44 PM||7850||https://www.patientsafetyinstitute.ca/en/toolsResources||html||True||aspx|
|Awareness of the Patient Safety Crisis in Canada||3085||General Patient Safety;Healthcare Harm||Patient and Family Resource;Reports ＆ Publications||4/23/2019 2:52:28 PM||4/23/2019 3:00:00 PM||Awareness of the Patient Safety Crisis in Canada
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.
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.
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 Canada||Awareness of the Patient Safety Crisis in Canada
We are facing a patient harm crisis of epidemic proportions.
||9/24/2020 8:13:06 AM||5520||https://www.patientsafetyinstitute.ca/en/toolsResources||html||True||aspx|
|Effective Governance for Quality and Patient Safety||3087||General Patient Safety;Policy||Toolkits ＆ Guides||2/23/2010 10:49:46 PM||
Effective Governance for Quality and Patient Safety A Toolkit for Healthcare Board Members and Senior Leaders Safe patient care happens when healthcare service delivery organizations are functioning at the highest levels. Governing boards and senior leaders of healthcare organizations can ensure effective governance and meet their legal responsibilities with the Effective Governance for Quality and Patient Safety Toolkit.
This toolkit teaches healthcare board members, senior executives, and physician leaders across Canada about the tools available to support organizational efforts in improving quality and patient safety. Commissioned research led by Dr. G. Ross Baker (2010), Effective Governance for Quality and Patient Safety in Canadian Healthcare Organizations, identified a number of interdependent drivers that enable boards to fulfill their responsibilities for quality and patient safety.
The resources in this toolkit are organized around each of the key drivers and include Principles of each driver Tools and recommended reading Stories and examples from healthcare organizations
Use this toolkit to strengthen your organization’s performance and to promote and advance safer care.
This symbol, used throughout the toolkit, denotes Canadian references and examples. The Effective Governance for Quality and Patient Safety Toolkit was revised in 2015. ||Effective Governance for Quality and Patient Safety||Effective Governance for Quality and Patient Safety: A Toolkit for Healthcare Board Members and Senior Leaders||1/13/2022 9:10:10 PM||18393||https://www.patientsafetyinstitute.ca/en/toolsResources||html||True||aspx|
|A Policy Framework for Patient Safety in Canada||3088||General Patient Safety;Government Relations;Policy||Frameworks;Reports ＆ Publications||11/29/2019 5:15:21 PM|| Patient Safety Right Now, the Canadian Patient Safety Institute’s (CPSI) 2018-2023 strategy defines a vision that “Canada has the safest healthcare in the world.” CPSI’s mission is “to inspire and advance a culture committed to sustained improvement for safer healthcare.” CPSI develops system-wide strategies to ensure safe healthcare in two ways by demonstrating what works to improve safe care in Canada, and by strengthening commitment to patient safety priorities among all healthcare stakeholders. It has, however, become clear that not only are more robust commitments required to advance patient safety in Canada, but health systems need additional evidence and support to complete end-to-end patient safety improvements and to measure and sustain results. To this end, CPSI drafted the Strengthening Commitment for Improvement Together A Policy Framework for Patient Safety (Figure 1) to stimulate conversation and action on the following policy levers
organizational policies and
Figure 1 Policy Framework for Patient Safety in Canada Moving the needle on patient safety in Canada requires an overall shift in culture, values and expectations at all levels of the health system and the active engagement of various policy actors. CPSI recommends that the Policy Framework be used as a conceptual guide to implement and evaluate the policy levers and to systematically share what we have learned with others. The next steps in Canada are clear. People in Canada need policies that support patient safety, be it at the level of health care organizations, or by governments. These policies must incorporate patient safety competencies and adhere to accreditation standards that promote safe care. Whether you are a policy maker, healthcare leader, administrator, provider, or member of the public, you can help us achieve our goal.
Download Executive Summary
||A Policy Framework for Patient Safety in Canada||Patient Safety Right Now, the Canadian Patient Safety Institute’s (CPSI) 2018-2023 strategy defines a vision that “Canada has the safest healthcare||9/29/2020 6:20:02 PM||5533||https://www.patientsafetyinstitute.ca/en/toolsResources||html||True||aspx|
|Incident Analysis||3089||Healthcare Harm||Frameworks;Reports ＆ Publications||4/19/2011 9:12:41 PM||In March 2021, Healthcare Excellence Canada launched, bringing together the Canadian Foundation for Healthcare Improvement and Canadian Patient Safety Institute. This content can now be found on HEC’s new website.
Check it out
||Incident Analysis||Root Cause Analysis (RCA)||6/28/2022 8:33:39 PM||32518||https://www.patientsafetyinstitute.ca/en/toolsResources||html||True||aspx|