|Creating a Safe Space: Addressing the Psychological Safety of Healthcare Workers||71662||Toolkits;Healthcare provider stories;Report||1/6/2020 4:59:11 PM||
Cumulative stress, compassion fatigue and trauma due to experiences with patient safety incidents impact the mental wellness of our healthcare providers. These factors contribute to inadvertent patient care errors, mental health issues and attrition which compromise patient safety. A peer support program 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 create peer-to-peer support programs (PSPs) to improve the emotional well-being of healthcare workers and allow them to provide the best and safest care to their patients.
Download The Creating a Safe Space Addressing the Psychological Safety of Healthcare Workers manuscript provides a comprehensive overview of what peer support is 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.
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)||Cumulative stress, compassion fatigue and trauma due to experiences with patient safety incidents impact the mental wellness of our healthcare||3/11/2020 9:25:46 PM||4043||https://www.patientsafetyinstitute.ca/en/toolsResources||html||True||aspx|
|Advocacy and support for use of a Surgical Safety Checklist||71642||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||5/25/2020 3:21:51 PM||1462||https://www.patientsafetyinstitute.ca/en/toolsResources||html||True||aspx|
|Education to support mandatory ADR and MDI reporting (Vanessa’s Law)||71689||Report;Patient and Family Resource;Guide||3/4/2019 9:27:01 PM||
The Protecting Canadians from Unsafe Drugs Act, also known as Vanessa's Law, is intended to increase drug and medical device safety in Canada by strengthening Health Canada's ability to collect information and to take quick and appropriate action when a serious health risk is identified. 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 firstname.lastname@example.org
https//healthstandards.org/ CPSI email@example.com
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||2/5/2020 4:12:48 PM||31818||https://www.patientsafetyinstitute.ca/en/toolsResources||html||True||aspx|
|Events||78516||Events||6/4/2015 6:09:31 AM|| ||Events||2/7/2020 6:34:43 PM||19742||https://www.patientsafetyinstitute.ca/en||html||True||aspx|
|Tools & Resources||115841||3/25/2009 3:33:37 PM|| ||Tools & Resources||Tools & Resources||2/7/2020 6:54:52 PM||50034||https://www.patientsafetyinstitute.ca/en||html||True||aspx|
|Introduction of the Measuring and Monitoring of Safety (Vincent) Framework to Canada||82424||Events;Presentation;Metrics||1/4/2017 4:11:25 PM||
Archive Monday, January 30, 2017 at 1000 am MST / 1200 pm EST
Purpose of the Call
"…if I apply
this [framework] conceptually to any problem I've got in safety I can make it work, and it orders my thinking" – Neil Prentice, Assistant Medical Director Mental Health, Tayside Trust, Scotland In Canada, as in the UK and US the focus of governments on assessing both quality and safety has increased over the past 10 years., A very large number of quality outcomes have been specified but the approach to safety has been much narrower, leaving many aspects of safety unexplored. The measurement of harm, so important in the evolution of patient safety, has been largely neglected and there have been prominent calls for improved measures. There is a critical need for patient safety measurement at the front lines, so that clinical teams can focus on key problems. Don Berwick has stated that 'most health care organisations at present have very little capacity to analyse, monitor, or learn from safety and quality information. This gap is costly and should be closed. Early warning signals can be valued and should be maintained and heeded'.5, In 2013 Professors Charles Vincent, Susan Burnett and Jane Carthey published their report
The Measuring and Monitoring of Safety which describes their framework to be implemented in practice to close the gap identified by Berwick. The framework provides a broader view of the information needed to create and sustain safer care.
Objectives Introduce the Measuring and Monitoring of Safety Framework to a Canadian healthcare audience Describe how the framework would work in CanadaResources
A framework for measuring and monitoring safety A practical guide to using a new framework for measuring and monitoring safety in the NHS (2014) -
Download the guide from The Health Foundation The measurement and monitoring of safety Drawing together academic evidence and practical experience to produce a framework for safety measurement and monitoring (2013) –
Download the full report from The Health Foundation
Professor Charles Vincent Professor Charles Vincent is trained as a clinical psychologist and has worked in the British NHS for several years. Since 1985 he has focused on conducting research on the causes of harm to patients, the consequences for patients and staff and methods of improving the safety of healthcare. He established the Clinical Risk Unit at the Department of Psychology, University College London where he was Professor of Psychology. In 2002 he moved to become Professor of Clinical Safety Research in the Department of Surgery and Cancer at Imperial College in 2002. From 1999 to 2003 he was a Commissioner on the UK Commission for Health Improvement. He has acted as an advisor on patient safety in many inquiries and committees including the Bristol Inquiry, the Parliamentary Health Select Committee, the Francis Inquiry and the Berwick Review. From 2007 to 2013 he was the Director of the National Institute of Health Research Centre for Patient Safety & Service Quality at Imperial College. He moved to the Department of Experimental Psychology in January 2014 with the support of the Health Foundation to continue his work on safety in healthcare.
G. Ross Baker, Ph.D. G. Ross Baker, Ph.D., is a professor in the Institute of Health Policy, Management and Evaluation at the University of Toronto and Director of the MSc. Program in Quality Improvement and Patient Safety. Ross is co-lead for a large quality improvement-training program in Ontario, IDEAS (improving and Driving Excellence Across Sectors). Recent research projects include a review and synthesis of evidence on factors linked to high performing healthcare systems, an analysis of why progress on patient safety has been slower than expected and an edited book of case studies on patient engagement strategies.
Chris Power What began as a desire to help those in need 30 years ago has evolved into a mission to improve the quality of healthcare for all Canadians. Chris Power's journey in healthcare began at the bedside as a front-line nurse. Since then, she has grown into one of the preeminent healthcare executives in Canada. Her experiences, her success, and her values have led her to the position of CEO of the Canadian Patient Safety Institute. Previously, Chris served for eight years as president and CEO of Capital Health, Nova Scotia, with an annual operating budget of approximately $900 million, and 12,000 staff. Under Chris’s leadership Capital Health achieved Accreditation with Exemplary Status in 2014 with recognition for 10 Leading Practices.
SHIFT to Safety Ensuring patients are safe remains a major challenge for Canadian healthcare organisations and systems. The Canadian Patient Safety Institute's (CPSI) new initiative,
SHIFT to Safety, has been launched to address these challenges, including helping providers and leaders improve their measurement efforts.
References  Baker, G Ross,
Beyond the quick fix – Strategies for improving patient safety. Institute of Health Policy Management and Evaluation. Nov.9.2015  Darzi A. High quality care for all. London Department of Health, 2009.  Quality and Outcomes Framework 2013/14. London Department of Health, 2013.  Vincent CA, Aylin P, Franklin BD, et al.
Is health care getting safer? BMJ 2008;3371205–07.  Francis R.
Independent Inquiry into care provided by Mid Staffordshire NHS Foundation Trust January 2005–March 2009. London Department of Health, 2013.  Jha A, Pronovost P.
Toward a safer health care system The critical need to improve measurement. JAMA. 2016.  Berwick DM.
A promise to learn—a commitment to act. Improving the safety of patients in England. London Department of Health, 2013  Vincent CA, Burnett S, Carthey C.
The measurement and monitoring of safety in healthcare. London Health Foundation, 2013 ||Archive: Monday, January 30, 2017 at 10:00 am MST / 12:00 pm EST
Purpose of the Call:
"…if I apply
this||5/26/2020 4:56:33 PM||4640||https://www.patientsafetyinstitute.ca/en/toolsResources/Pages/Forms/NewDefaultView.aspx||html||False||aspx|
|What is Quality and Patient Safety?||90847||2/23/2010 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 PM||10925||https://www.patientsafetyinstitute.ca/en/toolsResources/GovernancePatientSafety/Pages/Forms/AllItems.aspx||html||False||aspx|
|Webinar Series - Creating a Safe Space: Psychological Health and Safety of Healthcare Workers ||88860||Events;Presentation||4/10/2019 8:02:20 PM||
Watch on DemandWebinar 1 Creating a Safe Space Confidentiality and Legal Privilege for Peer Support Programs
Download Webinar 2 Results of the Pan Canadian survey of Healthcare Workers' Views on the Second Victim Phenomenon
Webinar 3 Global environmental scan of Peer-to-Peer Support Programs
Download Webinar #4 Canadian Best Practices Guidelines for Peer-to-Peer Support Programs in Healthcare
Download Webinar #5 Creating a Safe Space Launch of the Toolkit for Peer-to-Peer Support Programs in Healthcare, the Expert Advisory Committee and Canadian Peer Support Network
Download || Watch on Demand Webinar 1: Creating a Safe Space: Confidentiality and Legal Privilege for Peer Support Programs
||1/6/2020 11:15:15 PM||1834||https://www.patientsafetyinstitute.ca/en/toolsResources/Creating-a-Safe-Space-Psychological-Safety-of-Healthcare-Workers/Pages/Forms/AllItems.aspx||html||False||aspx|
|Hand Hygiene Fact Sheets||71698||Guide||4/1/2020 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 Sheets||Hand Hygiene Resources for Healthcare Providers, Patients and Families Cleaning your hands, either with soap and water or with alcohol-based hand||4/15/2020 7:50:33 PM||7813||https://www.patientsafetyinstitute.ca/en/toolsResources||html||True||aspx|
|Suicide Risk||71648||Guide;Publication||4/21/2011 4:02:20 AM||
We are pleased to announce that Dr. Chris Perlman, associate director, Homewood Research Institute, and his team are the successful recipients of Ontario Hospital Association (OHA) and Canadian Patient Safety Institute (CPSI) funding to develop an inventory and resource guide for assessing and preventing suicide risk.
Among its many accomplishments, Homewood Research Institute, located in Guelph, Ontario, was a lead organization in the development of mental health assessment systems, such as the Resident Assessment Instrument – Mental Health (RAI-MH), the interRAI Community Mental Health, and the interRAI Emergency Screener for Psychiatry.
The five-member team—Dr. Chris Perlman, Dr. John Hirdes, Dr. Lynn Martin, Dr. Eva Neufeld, and Ms. Mary Goy—includes researchers, policy analysts, and clinicians with more than 20 years of experience conducting health and policy research at the regional, provincial, national, and international levels. All team members have tremendous expertise in mental health research.
Dr. Perlman and his team will be working closely with the Advisory Group and with members of the OHA and CPSI to develop the inventory and resource guide. The innovative guide will be available by fall 2011.
||Inventory and Resource Guide Development for the Assessment and Prevention of Suicide Risk||We are pleased to announce that Dr. Chris Perlman, associate director, Homewood Research Institute, and his team are the successful recipients of||5/25/2020 8:06:45 PM||5948||https://www.patientsafetyinstitute.ca/en/toolsResources||html||True||aspx|
|Medication Safety Self-Assessment: Focus on Never Events||82427||Report;Toolkits||1/21/2020 5:03:55 PM||
Join your colleagues in improving patient safety by understanding and preventing medication-related never events! National Snapshot - January to December 2020 Medication-related errors are a major cause of preventable harm to patients in hospital and long-term care residents every day across Canada. “Never events” are patient safety incidents that result in serious harm or death, and that can be prevented by using organizational checks and balances. ISMP Canada and the Canadian Patient Safety Institute collaborated with partners across the country over the past year to develop and successfully pilot a tool for health care leaders to use to prevent medication-related never events. The Medication Safety Self-Assessment Focus on Never Events has been updated based on feedback from the pilot and there are now 2 programs
MSSA-Never Events for Hospitals and Ambulatory Care Centres
MSSA-Never Events for Long-Term Care Home We’re looking for at least 100 teams (60 acute care and 40 long-term care) to complete the MSSA-Never Events for their practice site between January and December 2020. Why participate in this national snapshot? The MSSA provides a useful way to identify vulnerabilities in your practice setting, along with strategies for safer care It provides an immediate comparison of your results with those of your peers The recently released Auditor General report in Ontario included a focus on preventing Never Events. What else do I need to know? The MSSA-Never Events is available in English and French The assessment can be completed in one meeting (approximately 1 hour for long-term care and 2 hours for hospitals) There is no charge to participate If you participated in the pilot, your user name and password are still valid If you have questions about the MSSA-Never Events, please email firstname.lastname@example.org For more information about never events in health care, see the Never Events for Hospital Care in Canada Report Help us reach our goal of 100 facilities! Register now.
Hospitals and Ambulatory Care Centres
Long-Term Care Homes
||Join your colleagues in improving patient safety by understanding and preventing medication-related never events! National Snapshot - January||6/24/2020 2:58:39 PM||627||https://www.patientsafetyinstitute.ca/en/toolsResources/Pages/Forms/NewDefaultView.aspx||html||False||aspx|
|World Patient Safety Day: September 17, 2019 ||80374||Events||8/15/2019 6:16:55 PM|| Thank
you for joining us for the 1st World Patient Safety Day! The recording of the panel discussion is now available. The World Health Organization (WHO) has declared September 17, 2019 as the first World Patient Safety Day. Globally, 134 million adverse events contribute to 2.6 million deaths each year due to unsafe care. At 28,000 deaths per year in Canada, patient harm ranks third in mortality after cancer and heart disease.
The slogan for the day is
“Speak Up for Patient Safety”. This campaign will mobilize patients and their families, health workers, policy makers, academicians, researchers, professional networks and the healthcare industry to speak up!
Together, we will raise awareness of the need to formulate policies, create a safe work culture, and provide care where the safety of patients is a priority.
Join us in a global campaign as WHO spotlights patient safety to increase public awareness and engagement, enhance global understanding, and spur global action. Help patients be more aware and engaged in their own care.
World Patient Safety Day information
Communications Toolkit To help us make patient safety a priority in Canada, we need your support! There are many ways in which to help spread this campaign. To help you, we have put together communicaitons materials and ideas in this toolkit
Join the Event Watch the patient safety documentary,
To Err is Human, followed by a healthcare leader panel discussion. You can attend in person in Ottawa, or join online from anywhere in the world with an internet connection.
Participate on Social Media Share World Patient Safety Day messages on your social media channels – let's get #Patientsafety and #WorldPatientSafetyDay trending around the world!
Share the Story Copy the story in this toolkit into your newsletters, intranets, and social media channels.
Exclusive Screening of To Err is Human, a Patient Safety Documentary
Attend in person in Ottawa or live stream online.
To celebrate the first World Patient Safety Day, the Canadian Patient Safety Institute – in partnership with Patients for Patient Safety Canada, Health Standards Organization (HSO) and CAE Healthcare – is hosting an exclusive screening of To Err is Human on September 17, 2019 in Ottawa, Canada. Through interviews with leaders in healthcare, footage of real-world efforts leading to safer care, and one family’s compelling journey from victimhood to empowerment, the film provides a unique look at the healthcare system’s ongoing fight against preventable harm.
After the film, senior Canadian healthcare leaders will discuss important healthcare issues facing Canadians today. The discussion will continue at an informal reception in the lobby. || Thank
you for joining us for the 1st World Patient Safety Day! The recording of the panel discussion is now available. ||3/27/2020 8:04:21 PM||24079||https://www.patientsafetyinstitute.ca/en/Events/Pages/Forms/AllItems.aspx||html||False||aspx|
|STOP! Clean Your Hands||71600||Events||6/3/2015 4:46:05 PM||
Thank you to everyone who participated in STOP! Clean Your Hands Day on May 5, 2020.
This year we saw
the best social media engagement to date! The hashtag #stopcleanyourhands had
7.822 million Twitter
of people from across Canada took the Clean Hands Self-Assessment,
pledged clean hands, and
hand hygiene resources.
Keep the Momentum Going
Although STOP! Clean Your Hands Day has passed,
hands have never mattered more!
Please continue to access and share
our free hand hygiene resources. Hand Hygiene Fact Sheets
Access and share our free hand hygiene resources to keep yourself and others safe
Hand Hygiene Resources
Clean Hands Self-Assessments Are you cleaning your hands properly? Are you protecting yourself and your loved ones from infections? Take the
Clean Hands Self-Assessments to find out!
Learn More Pledge Clean Hands Clean hands have never mattered more. Cleaning your hands, either with soap and water or with alcohol-based hand rub, is one of the best ways to avoid getting sick and spreading infections to others. Hand hygiene is easy and effective.
Pledge Clean Hands to tell the world you commit to cleaning your hands. Let’s all work together to flatten the curve!
Take the Pledge
The Importance of Hand Hygiene Whether you're a patient, visitor, provider, or worker in a healthcare setting – cleaning your hands is one of the best ways to prevent infection. Clean care saves lives. It is estimated that over the next 30 years in Canada, infections will be the biggest driver of acute care patient safety incidents, accounting for roughly 70,000 patient safety incidents per year on average – generating an additional $480 million per year on average in healthcare costs.1 Healthcare-associated infections (HAIs), or infections acquired in a healthcare setting, are the most frequently reported adverse events in healthcare delivery worldwide. Each year, hundreds of millions of patients are affected by HAIs, leading to significant morbidity, mortality, and financial cost to healthcare systems.2 World Health Organization SAVE LIVES Clean Your Hands Our STOP! Clean Your Hands campaign is hosted in conjunction with the World Health Organization’s (WHO) SAVE LIVES Clean Your Hands campaign. More information about SAVE LIVES Clean Your Hands and infection prevention is available at the
World Health Organization’s website. Sponsored by As a company dedicated to protecting public health, our operating principle is to prioritize healthcare facilities and first responders that are on the front line. We will continue to help safeguard those working so hard to keep us all healthy and safe.
1Patient Safety in Canada. Ipsos Public Affairs, 2018.
2 World Health Organization (WHO). n.d.
Healthcare-Associated Infections Fact Sheet. Retrieved March 20, 2020. ||STOP! Clean Your Hands||#STOPCleanYourHands
Thank you to everyone who participated in STOP! Clean Your Hands Day on May 5, 2020.
||5/26/2020 4:41:29 PM||64364||https://www.patientsafetyinstitute.ca/en/Events||html||True||aspx|
|The Canadian Nosocomial Infection Surveillance Program (CNISP) Publications||71649||Publication;Report||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 CNISP (Acute Care) HAI Surveillance Case definitions (2020) CNISP Surveillance Protocols COVID-19 and other viral respiratory infections (April 2020) Hospital Antibiogram Protocol (2020) Antimicrobial Utilization (AMU) Protocol (2020) Candida auris (C. auris) Protocol (2020) Carbapenemase-Producing Organisms (CPO) in CNISP Healthcare Facilities (2020) Clostridium difficile infection (CDI) Protocol (2020) Central Line Associated Blood Stream Infections (CLABSI) in Intensive Care Units (2020) Healthcare Acquired Cerebrospinal Fluid Shunt (CSF) Associated Infections (2020) Methicillin-Resistant and Methicillin-Susceptible Staphylococcus aureus (MRSA & MSSA) Bloodstream Infections in CNISP Hospitals (2020) Surgical Sites Infections Following Pediatric Cardiac Surgery (2020) Surgical Sites Infections Following Total Hip and Knee Arthroplasty (2020) Vancomycin Resistant Enterococci (VRE) Bloodstream Infections in CNISP Hospitals (2020) Other Documents Canada Communicable Disease Report (Nosocomial Infection Surveillance, May 2020) CNISP Infographic Healthcare-associated infection rates in Canadian hospitals (2013-2017) CNISP Summary Report of Healthcare Associated Infection (HAI), Antimicrobial Resistance (AMR) and Antimicrobial Use (AMU) Surveillance Data from January 1, 2013 to December 31, 2017 Laboratory Surveillance 2019 ||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||7/2/2020 5:48:49 PM||1216||https://www.patientsafetyinstitute.ca/en/toolsResources||html||True||aspx|
|Home Care Safety Falls Prevention Virtual Improvement Collaborative||88352||News||11/4/2015 10:29:59 PM||11/4/2015 11:00:00 PM|| The Canadian Patient Safety Institute, Canadian Home Care Association and Canadian Foundation for Healthcare Improvement have launched a new pan-Canadian initiative to prevent falls in the home. More than one third of Canadians aged 65 or older experience a fall, with half of these falls resulting in hospitalization taking place in or around the home. Fall-related injuries are the leading cause of injury for seniors across all Canadian provinces and territories and account for over 85 percent of all injury-related hospitalizations. Direct health care costs from falls among seniors are estimated to be $1 billion every year. Teams from Winnipeg Regional Health Authority (MB), St. Elizabeth Health Care (ON), Canadian Red Cross, VHA Home HealthCare (ON) and Eastern Health (NL) have been accepted into the first wave of the Home Care Safety Falls Prevention Virtual Improvement Collaborative focused on fall prevention and injury reduction. Working with the three partner organizations, the teams from will work from November 2015 to mid-2016 to Identify client outcomes for home care clients at risk for falls; Adapt quality improvement approaches to the home care environment; Build quality improvement capacity - including measurement capacity - in the home care sector; Identify evidence, tools and resources for spread across Canada; and Engage patients and families in falls risk assessment and prevention. The work by the partner organizations and teams in the first wave of the collaborative could lead to an expanded collaborative - open to more organizations that provide home care services - later in 2016.||The Canadian Patient Safety Institute, Canadian Home Care Association and Canadian Foundation for Healthcare Improvement have launched a new||3/8/2016 4:23:00 PM||2421||https://www.patientsafetyinstitute.ca/en/NewsAlerts/News/Pages/Forms/AllItems.aspx||html||False||aspx|
|Near-fatal medication error leads nurse to make patient safety a priority||101775||Healthcare provider stories||10/26/2017 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. The||10/30/2017 10:07:37 PM||12365||https://www.patientsafetyinstitute.ca/en/toolsResources/HealthcareProviderStories/Pages/Forms/AllItems.aspx||html||False||aspx|
|Hand Hygiene Observation Tools||82403||Guide;Toolkits||6/3/2015 4:47:24 PM||Measurement 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 for||5/26/2020 8:35:51 PM||10898||https://www.patientsafetyinstitute.ca/en/toolsResources/Pages/Forms/NewDefaultView.aspx||html||False||aspx|
|Medication Safety at Care Transitions Safety Improvement Project Learning Collaborative||71656||1/15/2019 9:35:30 PM||Medication Safety at Care Transitions Safety Improvement Project – An 18 month learning collaborative
What is happening? The Canadian Patient Safety Institute launched its Medication Safety- Safety Improvement Project in April 2019. This learning collaborative approach is being, delivered by expert faculty and coaches, with mentoring provided over 18 months. Participating teams will learn and apply strategies to decrease readmissions related to medication safety issues at discharge among frail patients.Participating teams are Learning to identify Frail clients who are at risk for medication safety issues, Learning and applying new processes for medication management at discharge, Learning and utilizing Knowledge Translation and Implementation Science techniques to successfully implement and sustain new evidence-based practices for medication safety at transitions, Sharing 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.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. For more information, contact firstname.lastname@example.org. ||Medication Safety at Care Transitions: Safety Improvement Project||Medication Safety at Care Transitions: Safety Improvement Project – An 18 month learning collaborative
What is happening? The Canadian||7/18/2019 7:37:13 PM||4316||https://www.patientsafetyinstitute.ca/en/toolsResources||html||True||aspx|
|Canadian Patient Safety Week (CPSW)||71599||Events||12/8/2009 9:50:43 PM||
Welcome to your home for Canadian Patient Safety Week! #ConquerSilence
Canadian Patient Safety Week runs October 26 to 30, 2020. The Canadian Patient Safety Institute invites all Canadians – the public, providers and leaders – to become involved in making patient safety a priority. We will be announcing our theme, activities and events later in the summer. Register for updates and to receive information about upcoming resources.
About Canadian Patient Safety Week is a national, annual campaign that started in 2005 to inspire extraordinary improvement in patient safety and quality. As the momentum for promoting best practices in patient safety has grown, so has the participation in Canadian Patient Safety Week. Canadian Patient Safety week is relevant to anyone who engages with our healthcare system providers, patients, and citizens. Working together, thousands help spread the message to Conquer Silence.
Sponsorship The Canadian Patient Safety Institute invites you to join our network of Canadians – the public, healthcare providers and healthcare leaders – in making patient safety a priority. If your organization is interested in sponsoring CPSW 2020, please contact
Do you have any questions or suggestions? Contact CPSI CommunicationsPhone (780) 409-8090 Toll free 1-866-421-6933
CPSW@cpsi-icsp.ca Join the conversation at
||Canadian Patient Safety Week||Canadian Patient Safety Week (CPSW)||7/7/2020 6:52:47 PM||69467||https://www.patientsafetyinstitute.ca/en/Events||html||True||aspx|
|Canadian Quality and Patient Safety Framework for Health Services||71683||Framework||3/27/2019 7:47:40 PM||
The Canadian Quality and Patient Safety Framework for Health Services has been developed through a partnership between the Canadian Patient Safety Institute (CPSI) and Health Standards Organization (HSO) and supported by an advisory committee including providers, patients and family members, researchers and policy makers, indigenous and non-indigenous members, from Coast to Coast to Coast.
The framework reflects and builds on the perspectives developed through significant investments and contributions from several federal, national and provincial and territorial organizations, as well as recent work from the OECD, World Bank and WHO. Over the next five years, the framework aims to support national and jurisdictional stakeholders to Describe overarching principles and goals for safe, high quality health services in Canada; Focus policy, action and resources that improve experience and outcomes from health and social services offered;
Enhance collaboration of stakeholders around common goals; Reduce care variations across different communities.
Supporting resources including action guides for the Framework’s target audience are currently in development. The Framework is expected to be published in 2020.
Subscribe to mailing list
||Canadian Quality and Patient Safety Framework for Health Services||The Canadian Quality and Patient Safety Framework for Health Services has been developed through a partnership between the Canadian Patient Safety||6/8/2020 7:15:47 PM||5412||https://www.patientsafetyinstitute.ca/en/toolsResources||html||True||aspx|
|Atlantic Learning Exchange||71603||Events||9/20/2016 6:01:00 PM||
Discover innovative and emerging trends in patient safety & quality improvement
October 8 – 9, 2019 St. John's, NL, The Atlantic Health Quality and Patient Safety Collaborative (AHQPSC), through partnership support of the Canadian Patient Safety Institute (CPSI), welcomes you to attend this year's Atlantic Health Quality & Patient Safety Learning Exchange (ALE 2019) which will take place at the Sheraton Hotel Newfoundland, St. John's, NL,
October 8 – 9, 2019.
Program Who should attend? We look forward to welcoming innovative and engaged care providers, managers, health leaders, academics and students from university and college setting, as well as government representatives from the four Atlantic Provinces in attendance this year. Tickets are limited! Through this conference, you will be given an opportunity to Mobilize energy and enthusiasm for a new era of patient safety and quality improvement; Understand the role innovation and technology play in healthcare improvement; Stimulate change through the power of the patient voice; and Develop the skills for leading transformational change!
Registration $275 Student Registration $199*
*Spaces are limited for student registration. Student ID is required. Conference fees include full conference with light breakfast and lunch provided.Venue & Hotel Accommodations
The conference will be taking place at the
Sheraton Hotel Newfoundland located at 115 Cavendish Square in St. Johns Newfoundland.
For guests that require accommodations, a room block has been reserved for attendees at the Sheraton Hotel Newfoundland starting at $164 a night for a standard room.
Guests can use the booking link below or can call/email to do reserve a room for the conference. When booking via phone or email use reference code “Atlantic Learning Exchange”.
email@example.com Call Local 709-726-4980 or Toll Free 1-888-870-3033
Book Hotel Room Now Partners
Do you want to support this event? Do you want exclusive access to the front line of healthcare in the Atlantic provinces? We are looking for Sponsors and Exhibitors contact Gina Peck at 902-481-5034 or
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||10/2/2019 3:07:21 PM||10306||https://www.patientsafetyinstitute.ca/en/Events||html||True||aspx|
|Story: Patient Safety Incident Management Toolkit||85620||5/15/2015 8:33:48 PM||Alberta’s roadmap to an integrated provincial patient safety and incident management system
Alberta Health Services (AHS) has developed a robust approach to patient safety and incident management that is built on collaboration and engagement with patients and families, and health providers. The approach includes monitoring, measuring and evaluating performance that is aligned with patient outcomes and experiences.
This summary was prepared with valuable input from Carolyn Hoffman, Senior Program Officer, Quality & Healthcare Improvement, Alberta Health Services and Sharon Nettleton, former Senior Advisor, Health Outcomes (Calgary Health Region) and currently Co-Chair of Patients for Patient Safety Canada (a patient-led program of the Canadian Patient Safety Institute). Carolyn and Sharon reflect on the development of a patient safety and incident management system that is still being advanced and improved in Alberta.
Prior to the formation of AHS in 2008, the province’s nine health regions, and three other separate health entities, were developing their own approach to improving patient safety, including enhancing a process for appropriately managing incidents. For the former Calgary Health Region (CHR), it was a sentinel event in 2004, where two patients died as a result of a production error in the preparation of dialysate solutions, containing potassium chloride instead of sodium chloride that provided a platform for leadership to focus attention on the safety of patient care.
Beginning at the leadership level with a commitment from the Board of Directors and CEO, the CHR began a journey to improve the safety of patient care and develop a culture of patient safety. The commitment focused on a new organizational structure, leadership and accountability, and resources and infrastructure. It included a culture of reporting, disclosure, and informing the public; and a culture that is just and trusting, flexible and emphasized learning and improvements. Communication and education would be paramount, as new policies and procedures that focused on critical areas of patient safety were implemented.
The CHR’s Safety Framework became the roadmap for this work and helped in outlining how the organization would build this foundation and a lasting structure for patient safety. The CHR consulted with world patient safety experts and leading practice organizations.
As new patient safety policies were drafted by multidisciplinary teams, extensive consultation processes were used to gather critical input from care providers, managers, administrators and other major stakeholders including health educational centres, unions, regulatory and professional groups. Most importantly, the consultations included hearing from a variety of patients and families who had experienced harm.
Safety policies and procedures were developed in five key areas – just and trusting culture; reporting harm, close calls and hazards; disclosing harm to patients; informing principal health partners and stakeholders about safety hazards, failures and fixes; and adverse event management.
Once the new policies and procedures were approved, educational site-based forums were held (Leading the Way), to explain and discuss new practices that were aimed at teamwork and create the urgency and shared understanding of why patient safety was so critical. Each forum was opened by the CEO and members of the Patient and Family Advisory Council.
“Leading the Way set the expectation that this was extremely important and sent a strong message that this was way we were going to work together from here on in – that we would collaborate with patients and families in making improvements,” says Sharon. “It modeled a new way of providing care through engagement, collaboration and participation. And, it started to catch on like wildfire across the entire health region.”
The formation of AHS in 2008 brought together 12 formerly separate health entities in the province, including the nine geographically-based regional health authorities and three provincial entities working specifically in the areas of mental health, addictions and cancer. This change provided an unprecedented opportunity to establish an integrated Alberta healthcare system.
In the area of patient safety, it was realized that the work developed by the CHR was leading edge and could provide a strong foundation, in collaboration with the work in the other former health entities, to build an AHS integrated provincial patient safety and incident management system.
The integrated provincial patient safety and incident management system now includes the following
Disclosure Policy – a formalized disclosure policy was implemented, building upon work that was collectively underway previously.
Reporting and Learning System – a single reporting and learning system was developed using Datix web-based patient safety software. The system includes three components healthcare provider reporting of close calls, hazards and adverse events; quality assurance recommendation tracker (Rec Tracker) to monitor the implementation of recommendations; and tracking patient concerns and commendations across AHS.
Patient and Family Advisory Group (PFG) – formed in late 2010 the PFG is a partnership with patients and families to improve quality, safety and the patient experience.
Patient Safety Strategic Plan (2013-2016) – a three year-plan that puts patient safety into context for staff, physicians, patients and families. Five overarching areas of focus have been established to achieve the goal of working together to eliminate preventable harm understand and incorporate the patient’s perspective; build a cultural foundation for patient safety, foster meaningful engagement to improve patient safety; enhance continuous learning as a system; and strengthen leadership focus and attention for patient safety. (See Figure 2 AHS Patient Safety Plan Overview)
Systems Analysis Methodology (SAM) – a standardized approach to system analysis, based on work of the Health Quality Council of Alberta, and the Canadian Patient Safety Institute’s Canadian Incident Analysis Framework, to improve and spread capability and capacity for the analysis of adverse events and development of effective recommendations for improvement.
Safety Alerts and Safer Practice Notices – have been compiled and shared across AHS since 2008. AHS recently joined the Canadian Patient Safety Institute’s web-based Global Patient Safety Alerts and is sharing their Safety Alerts and Safer Practice Notices broadly so that other organizations can learn from their experiences, rather than through the harm of their patients.
Patient First Strategy – the focus is now shifting to incorporate a better understanding of the patient and family experience, working back from that partnership to identify any gaps and ensure everything now in place aligns for the best quality of care, including safe care. AHS is reviewing their patient safety and incident management strategies to ensure that patient and family-centred care is at the forefront of delivering seamless and effective health care to Albertans.
Safety is an AHS value that is endorsed and supported at all organizational levels. To ensure AHS is on the right track and know that care is safer, strategic performance measures are in place to track a number of indicators, set goals and compare progress to the national average, including patient satisfaction and adverse events. Key performance indicators are reported on the AHS website at www.albertahealthservices.ca/performance.asp
AHS is collaborating with the Canadian Institute for Health Information (CIHI) and the Canadian Patient Safety Institute (CPSI) as well as other organizations across Canada to develop a harm indicator based on the health records of hospitalized patients. CIHI’s first public report is planned for the fall of 2015 and CPSI will release a resource library of evidence and tools. This objective source of information will further help healthcare organizations to better understand where patients are experiencing harm and more effectively target improvement strategies.
A patient safety culture survey is currently undertaken every four years. With two cycles now complete, data is available across the system, including in many cases at a unit level, to better understand how the perception of safety varies across the organization and to inform an open dialogue with staff and physicians on this topic. “When it comes to safety, we know that important knowledge comes from the frontline providers” says Carolyn.
The recommendation tracker provides a good mechanism for monitoring the implementation of all Quality Assurance recommendations. Tracking now includes Fatality Inquiry recommendations as well. “A just culture is essential for staff and physicians to effectively participate in the reporting and learning system,” says Carolyn. “The number of reports we are getting on adverse events, close calls and hazards continues to grow overall and that is an important indicator of progress in quality and patient safety.”
Many of the health regions were involved with Safer Healthcare Now! and after AHS was launched many hospitals, long-term care facilities and other areas continue to participate. One example where significant progress has been made is medication reconciliation on admission and work is well underway for transitions and discharge. “Harm from not completing medication reconciliation is often invisible unless you talk to patients and families about their medication issues and the impact to their health,” says Carolyn. “We are bringing forward patient stories as an incentive and encouragement to move this work forward and we can show how this is spreading as we track progress. You would not think of that as a report, yet it is major area where harm is occurring and we are increasing awareness to make it more visible.”
AHS recently asked their Internal Audit team to evaluate the implementation of Disclosure policies and procedures to ensure that the process is working for patients, families and providers. “Engagement and collaboration at all levels is necessary,” says Carolyn. “Truly partner with patients and families and do nothing to jeopardize that partnership.”
Copyright 2013 © Alberta Health Services
||Alberta’s roadmap to an integrated provincial patient safety and incident management system
Alberta Health Services (AHS) has developed a robust||7/13/2015 1:30:52 PM||4468||https://www.patientsafetyinstitute.ca/en/toolsResources/PatientSafetyIncidentManagementToolkit/Pages/Forms/AllItems.aspx||html||False||aspx|
|A Framework for Establishing a Patient Safety Culture||71675||Framework||2/14/2018 4:54:19 PM||Patient Safety Culture "Bundle" for CEOs/Senior Leaders What is the Patient Safety Culture "Bundle"? Strengthening a safety culture necessitates interventions that simultaneously
enable, enact and elaborate in a way that is attuned to the existing culture. Through a literature review of more than 60 resources, a Patient Safety Culture Bundle has been created and validated through interviews with Canadian thought leaders. The Bundle is based on a set of evidence-based practices that must all be applied in order to deliver good care. All components are required to improve the patient safety culture. The
Patient Safety Culture "Bundle" for CEOs and Senior Leaders encompasses key concepts of safety science, implementation science, just culture, psychological safety, staff safety/health, patient and family engagement, disruptive behavior, high reliability/resilience, patient safety measurement, frontline leadership, physician leadership, staff engagement, teamwork/communication, and industry-wide standardization/alignment.
Download a one-pager of the Patient Safety Culture Bundle for CEOs/Senior Leaders
Why was this Bundle created? A patient safety culture is difficult to operationalize. Improving safety requires an organizational culture that enables and prioritizes patient safety. The importance of culture change needs to be brought to the forefront, rather than taking a backseat to other safety activities. The National Patient Safety Consortium Education Working Group verified the critical role senior leadership plays in ensuring patient safety is an organizational priority. A Working group of partners, led by the Canadian Patient Safety Institute, Canadian College of Health Leaders (CCHL), HealthCareCAN and the Healthcare Insurance Reciprocal of Canada (HIROC) were brought together to establish a framework and advance this work. How can I use the Patient Safety Culture Bundle? The key components required for a Patient Safety Culture are identified under three pillars
Within each pillar you will find links to valuable tools and resources to help your efforts in establishing and sustaining a patient safety culture.
(coming soon)Are you looking to establish and sustain a culture of safety? We are committed to providing a robust framework to advance a safety culture. The Bundle is a dynamic tool that will be continually updated. We invite you to check back often for more links and resources. We also need your participation and input to ensure the Bundle is current and relevant. Please forward any links or comments to
"Patient safety and healthcare quality are advanced when boards and senior leaders are committed to it and are able to show evidence of that commitment. Missing until now is a concise "how to" guide. The Patient Safety bundle for Leaders fills that gap."
Catherine Gaulton, CEO, HIROC
"Leadership is critical to developing a patient safety culture and building leadership capacity requires a vision of the knowledge, skills and behaviours necessary to achieve this. The Patient Safety Leadership Bundle provides this and will be a practical tool for health leaders across the healthcare continuum to assess their personal capabilities. It will also provide both organizations and the system, as a whole, a checklist for what's missing from our collective leadership education toolkits so that we can strategically respond to these needs. HealthCareCAN is committed to the spread of this tool across the country as part of a cultural shift to safety and a drive towards high-reliability culture."
Dale Schierbeck, Vice-President, Learning & Development, HealthCareCAN and Co-Chair, Patient Safety Education for Leaders Working ||A Framework for Establishing a Patient Safety Culture||Patient Safety Culture "Bundle" for CEOs/Senior Leaders What is the Patient Safety Culture "Bundle"? Strengthening a safety||4/4/2019 2:29:25 PM||10453||https://www.patientsafetyinstitute.ca/en/toolsResources||html||True||aspx|
|Proper Hand Hygiene Technique in Healthcare||101683||Guide||4/1/2020 5:10:49 PM|| Why? Healthcare-associated infections, or infections acquired in healthcare settings, are the most frequent adverse event in healthcare delivery worldwide.1 Hands are the most common means of microbial spread in healthcare. 2 Optimal hand hygiene is one of the most effective measures to reduce the occurrence of healthcare-associated infections (HAIs). When? There are some key moments for hand hygiene Before patient/patient environment contact Before aseptic procedure After body fluid exposure risk After patient/patient environment contact Where? The World Health Organization (WHO) recommends that hand hygiene should be performed at the point of care. How? Clean your hands by rubbing them with an alcohol-based formulation when available. Alcohol-based hand rubs are faster, more effective, and better tolerated by your hands than washing with soap and water.2 Wash your hands with soap and water only when hands are visibly soiled and whenever an alcohol-based formulation if not available.2 Washing hands with soap and water immediately before or after using an alcohol-based hand rub is not recommended as this may predispose the individual to developing contact dermatitis.2 If isolation precautions are in place, always adhere to the hand hygiene directions appropriate to those precautions. Never default to hand rubs where isolation precautions are in place unless the precautions specify that this is acceptable. The act of thorough and vigorous drying is an important measure that helps to eliminate pathogens from your hands. For more information, go to Updated 2009 WHO guidelines full version Updated 2009 WHO guidelines summary version1 World Health Organization (WHO). n.d. Healthcare-Associated Infections Fact Sheet. Retrieved March 20, 2020. 2 WHO Guidelines on Hand Hygiene in Health Care (Updated 2009) ||Why? Healthcare-associated infections, or infections acquired in healthcare settings, are the most frequent adverse event in||4/15/2020 7:56:11 PM||857||https://www.patientsafetyinstitute.ca/en/toolsResources/Hand-Hygiene-Fact-Sheets/Pages/Forms/AllItems.aspx||html||False||aspx|
|Engaging Patients in Patient Safety – a Canadian Guide||71653||Guide;Publication||4/25/2017 3:01:50 PM||
In recent decades, evidence has emerged that demonstrates when healthcare providers work closely with patients and their families, the healthcare system is safer, and patients have better experiences and health outcomes. Engagement with patients and families includes program and service design and delivery as well as monitoring, evaluating, policy and priority setting, and governance. Engagement work is not easy and often may be uncomfortable at first. Providers may need to let go of control, change behaviours to actively listen to what patients are saying, and take additional time to understand the patient perspective. It may require more effective ways to brainstorm ideas together, build trust, and incorporate many different perspectives. Patients may need to participate more actively in decisions about their care. Leaders must support all this work by revising practices to embed patient engagement in their procedures, policies, and structures. Finding innovative ways to work together will benefit everyone. We invite you to join us in advancing engagement by making healthcare safer. Our deep belief in the power of partnership is inspired by the publication, Engaging Patients in Patient Safety – a Canadian Guide. It is written by patients, providers and leaders for patients, providers and leaders. We trust that you will find the information in this guide useful. It demonstrates our joint commitment to achieving safe and quality healthcare in Canada.
Download Better yet, bookmark this page. This resource is updated regularly. To ensure you are accessing the most up-to-date version, we recommend that you bookmark this page for future reference. Who is this guide for? The guide is for anyone involved with patient safety and interested in engagement, including Patients and families interested in how to partner in their own care to ensure safety Patient partners interested in how to help improve patient safety Providers interested in creating collaborative care relationships with patients and families Managers and leaders responsible for patient engagement, patient safety, and/or quality improvement Anyone else interested in partnering with patients to develop care programs and systems While the guide focuses primarily on patient safety, many engagement practices apply to other areas, including quality, research, and education. The guide is designed to support patient engagement across the healthcare sector. What is the purpose of the guide? The purpose of the guide is to help patients and families, providers and leaders work more effectively together to improve patient safety. The guide is an extensive resource that is based on evidence and leading practices. What is included in the guide? Evidence-based guidance Practical patient engagement practices Consolidated information, resources, and tools Supporting evidence and examples from across Canada Experiences from patients and families, providers, and leaders Probing questions about how to strengthen current approaches Strategies and policies to meet standards and organizational practice requirements Click here to learn how and why was the guide developed.
CitationPatient Engagement Action Team. 2017.
Engaging Patients in Patient Safety – a Canadian Guide. Canadian Patient Safety Institute. Last modified December 2019. Available at
www.patientsafetyinstitute.ca/engagingpatients ||Engaging Patients in Patient Safety – a Canadian Guide||In recent decades, evidence has emerged that demonstrates when healthcare providers work closely with patients and their families, the healthcare||6/22/2020 9:52:46 PM||17476||https://www.patientsafetyinstitute.ca/en/toolsResources||html||True||aspx|
|Central Line-Associated Bloodstream Infection (CLABSI): Getting Started Kit||82393||Getting Started Kit||7/1/2015 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 Kit||5/26/2020 1:37:29 PM||6315||https://www.patientsafetyinstitute.ca/en/toolsResources/Pages/Forms/NewDefaultView.aspx||html||False||aspx|
|Hand Hygiene Toolkit||82405||Guide;Toolkits||6/3/2015 4:47:25 PM||This comprehensive Hand Hygiene Toolkit allows you to start improving hand hygiene in your organization. You can buy this toolkit here. Additional copies of some of the tools available in the Hand Hygiene Toolkit can be found below.
Hand Hygiene Toolkit resource links to scholarly literature and fact sheets can also be found in the Resources section.
Copies of the hand hygiene education PowerPoint presentations can be found in Hand Hygiene Education.
Looking for the Patient and Family Guide? You can find it plus other resources in the Patients & Their Families section.
Hand Hygiene Observation Tool
WRHA Hand Hygiene Observation Tool
WRHA Hand Hygiene Audit Instructions
On-the-Spot Feedback Tool
Hand Hygiene Surveillance Instrument
Guidebook for Use of Hand Hygiene Surveillance Instrument
Instructions for Using the Hand Hygiene Surveillance Instrument
A Simple Framework and tools for Establishing Accountability in Hand Hygiene Programs
How to Handrub
How to Handwash
4 Moments for Hand Hygiene (poster)
WHO Facility-Level Situation Analysis
WHO Template Action Plan
||This comprehensive Hand Hygiene Toolkit allows you to start improving hand hygiene in your organization. You can buy this toolkit here .||5/26/2020 8:37:09 PM||6635||https://www.patientsafetyinstitute.ca/en/toolsResources/Pages/Forms/NewDefaultView.aspx||html||False||aspx|
|Patient Safety and the Hidden Curriculum||71701||Report||11/12/2018 10:50:58 PM||
Have you reflected on, seen or felt the impact of unprofessional behaviour on safe patient care? In the complex health care environment within which we live today, safe health care demands constant active and collaborative efforts among healthcare providers, patients and families alike.
Download Learn more about the
Hidden Curriculum and what it takes to ensure the reliable delivery of safe healthcare What is the culture of patient safety? Shifting focus from reactionary measures to commitment and building a safe environment from get-go.
Why do healthcare professionals need to commit to life-long learning? The critical role of learning through informal interactions and its impact on quality care.
How does the workplace culture impact safe care? Strong leadership, teamwork and commitment to improvement play a pivotal part.
Brought to you by the Canadian Patient Safety Institute and the Royal College of Physicians and Surgeons of Canada. ||Patient Safety and the Hidden Curriculum ||Have you reflected on, seen or felt the impact of unprofessional b ehaviour o n sa fe patient care? In the complex health||5/28/2020 5:08:57 PM||724||https://www.patientsafetyinstitute.ca/en/toolsResources||html||True||aspx|
|Canada's Virtual Forum||71597||Events||7/12/2011 8:55:44 PM||
Thank you to the more than 1,100 viewers from the nearly 600 sites in Canada and 6 countries around the world that made Canada's Virtual Forum on Patient Safety & Quality Improvement a huge success! If you weren't able to watch live, or if you want to watch anything again,
click here to access the archives and watch recordings of each of our sessions. Make use of these recordings during your in-services and as part of your local education sessions.
We would like to hear from you To help us plan for future events, we'd like to have your feedback. Please tell us what went well or what we could do better by
completing our survey. Questions or comments? Contact CPSI Communications at
email@example.com.||Canada’s Virtual Forum on Patient Safety and Quality Improvement||
Thank you to the more than 1,100 viewers from the nearly 600 sites in Canada and 6 countries around the world that made Canada's Virtual||5/25/2016 4:28:18 PM||7537||https://www.patientsafetyinstitute.ca/en/Events||html||True||aspx|
|Excellence in Patient Engagement for Patient Safety||71602||Events||7/24/2015 10:09:51 AM|| A Program Recognizing Patient Engagement Leaders and Practices The Canadian Patient Safety Institute, HealthCareCAN and Health Standards Organization, with support from Patients for Patient Safety Canada, have partnered in the yearly recognition program that aims to identify, celebrate and disseminate leading practices in patient engagement for patient safety. Congratulations to the two teams selected by the Award Panel for their excellence. The Regional Medicine Program team from Eastern Health, Newfoundland The Bedside Handover Project has adjusted the delivery of patient information at the change of nursing shifts away from the nursing desk and brought it to the patient's bedside, resulting in patients feeling that they are more involved in their own care. The change has resulted in significant improvements on patient satisfaction surveys. Notably, in the post-implementation survey, 100% of patients felt nurses shared information about their case from one shift to another, up from 72% pre-implementation, and 91% felt nurses had involved patient families in making decisions about patient care, an increase from 66% pre-implementation. The project developed by the
Regional Medicine Program (part of the CPSI Patient Engagement Collaborative), was implemented as a pilot project at Carbonear General Hospital. Led by Regional Medicine Program Managers Shannon Perry and Susan Newhook in partnership with patient advisors Julie Hollett and Dorothy Mary Senior, the project is a leading practice that empowers patients to become involved in their own care by moving the nurse handover process to the patient's bedside – a time when patients feel the most vulnerable.
Read more here and in the
HSO's Leading Practices Library
Read More The Long-Term Care Yorkton team from Saskatchewan Health Authority, Saskatchewan The leading practice, dubbed "Family Engagement & Co-design in Measuring & Monitoring Safety", has led to a significant drop in the number of injuries – 42% drop in resident injuries and 69% reduction in staff injuries. It has also resulted in an incredible 83% reduction in the use of antipsychotics (without a diagnosis of psychosis). Led by Ms. Bellamy, Director of Continuing Care South East, in partnership with resident family member Adelle Kopp-McKay, the practice involves engaging with resident family members to challenge the care team to think broadly about harm and safety. This, along with collaborating closely with patients and family representatives helps promote the safe delivery of resident-and-family-centred care while building accountability at an individual, team and organizational level.
Read more here and in the HSO's Leading Practices Library
Read More In addition, teams from the following organizations have identified by the Award Panel as leading practices and added to HSO's Leading Practices Library. Congratulations to each of them! Alberta Health Services
Achieving Exceptional Service Experience with Design Thinking BC Mental Health & Substance Use Services
Partnerships in Care Huron Perth Healthcare Alliance
Critical Care Indicator Flagging Program Ontario Shores Centre for Mental Health Sciences
Minimizing Harmful Coercive Practices in Mental Health Using Patient Engagement and Human Rights St. Joseph's Health Care London
Improving Care Together Western Health
Patient Driven Hand Hygiene Auditing CancerControl Alberta, Alberta Health Services
My Care Conversations app Nova Scotia Health Authority
Evolution of the Patient/Family Advisor Experience Markham Stouffville Hospital
Falls Prevention Congratulations to all teams who submitted nominations this year. The Award Panel noted that each nomination was excellent and they were impressed by the progress made across Canada in advancing patient safety in partnership with patients. The call for nominations for the 2021 program will be announced in the Fall. We welcome your questions and suggestions at
firstname.lastname@example.org. To learn about the practices and leaders we celebrated in previous years click
here. ||Recognizing Excellence in Patient Engagement for Patient Safety ||2016 Champion Awards||4/28/2020 4:21:39 PM||8725||https://www.patientsafetyinstitute.ca/en/Events||html||True||aspx|