|Tools & Resources||35066||3/25/2009 3:33:37 PM|| ||Tools & Resources||Tools & Resources||3/28/2019 2:34:57 PM||8914||https://www.patientsafetyinstitute.ca/en||html||True||aspx|
|Hand Hygiene Toolkit||38911||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 .||7/19/2017 8:04:47 PM||1117||https://www.patientsafetyinstitute.ca/en/toolsResources/Pages/Forms/NewDefaultView.aspx||html||False||aspx|
|Events||35071||Events||6/4/2015 6:09:31 AM|| ||Events||3/25/2019 5:51:33 PM||2153||https://www.patientsafetyinstitute.ca/en||html||True||aspx|
|Medication Safety at Care Transitions Safety Improvement Project Learning Collaborative||36608||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 will launch a new Safety Improvement Project in January 2019, focusing on medication safety. This learning collaborative approach will be delivered by expert faculty and coaches, and mentoring with be provided over 18 months. Participating teams will learn and apply strategies to decrease readmissions related to medication safety issues at discharge among frail patients. Please email email@example.com
a Word version of the Expression of Interest. The deadline to submit
applications is March 15, 2019. Successful applicants will be notified.
Expression of Interest
Teams enrolled in the Medication Safety at Care Transitions Safety Improvement Project will test and implement evidence-informed change ideas to improve patient safety using a quality improvement and knowledge translation/implementation science approach for implementation of medication reconciliation processes at discharge. According to the We Can't Address What We Don't Measure Consistently Building Consensus on Frailty in Canada report produced for the National Institute on Aging, while an individual's health conditions contribute to his or her level of frailty, the number of medications an individual is taking in order to manage those conditions can also contribute to frailty. Polypharmacy - defined as being prescribed five or more medications - is also considered a risk factor for frailty."
Participating teams willLearn to identify Frail clients who are at risk for medication safety issues,Learn and apply new processes for medication management at discharge,Learn and utilize Knowledge Translation and Implementation Science techniques to successfully implement and sustain new evidence-based practices for medication safety at transitions,Share key learnings and challenges, and network with colleagues across Canada,Access, share and adopt advanced patient safety knowledge, tools, and resources within a learning network,Improve your 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.How to learn more? You can learn more about the three new Safety Improvement Projects launching in early 2019 at two information webinars held on February 5 and again on February 12, 2019. These two webinars will have the same content and are a great opportunity for you and your team members to learn more about the learning collaborative and get answers to any questions.
Tuesday, February 5, 2019 at 1200 ET
Tuesday, February 12, 2019 at 1200 ET
How to apply to the Medication Safety at Care Transitions Safety Improvement Project? Please email firstname.lastname@example.org for
a Word version of the Expression of Interest. The deadline to submit
applications is March 15, 2019. Successful applicants will be notified.
Expression of Interest
Need additional information? For additional information about the upcoming learning collaborative, please contact the planning team at
Important Dates & Fees
Faculty and Project Team ||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||2/27/2019 8:56:42 PM||2737||https://www.patientsafetyinstitute.ca/en/toolsResources||html||True||aspx|
|Central Line-Associated Bloodstream Infection (CLABSI): Getting Started Kit||38897||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||3/25/2019 8:12:35 PM||943||https://www.patientsafetyinstitute.ca/en/toolsResources/Pages/Forms/NewDefaultView.aspx||html||False||aspx|
|Advocacy and support for use of a Surgical Safety Checklist||68992||Position Statements||2/5/2019 7:55:32 PM||Position StatementA Surgical Safety Checklist is smart for patients and smart for providers. It's use in Canadian healthcare facilities is endorsed by a
Position Statement supported by many surgical interest groups. Healthcare professionals must make every reasonable effort to provide safe care to their patients. The purpose of this statement is to express the commitment of the undersigned organizations to prioritize perioperative patient safety by creating an environment conducive to the effective adoption and use of a Surgical Safety Checklist.
||Advocacy and support for use of a Surgical Safety Checklist||Position Statement A Surgical Safety Checklist is smart for patients and smart for providers. It's use in Canadian healthcare facilities||2/5/2019 8:17:32 PM||406||https://www.patientsafetyinstitute.ca/en/toolsResources||html||True||aspx|
|STOP! Clean Your Hands Day||36689||Events||6/3/2015 4:46:05 PM||
May 6, 2019 Clean Care Conversations. #STOPCleanYourHandsDay #CleanCareConversations STOP! Clean Your Hands Day takes place on Monday, May 6, 2019. This year's theme is Clean Care Conversations. Learn how to start a compassionate clean care conversation with your healthcare provider, patient, or colleague with our activities this year. Register today to access tools, information and resources to support Clean Care Conversations.
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. Every year, 220,000 Canadian patients (approximately one in nine) develop a hospital-acquired infection during their stay in hospital, and an estimated 8,000 of those patients will lose their lives.
Here's a run down of what we've got planned for STOP! Clean Your Hands Day 2019Clean Care Conversations Webinar Register for our webinar on May 6 to learn how to promote clean care with your patients and colleagues. Moderated by The Germ Guy, Jason Tetro, this webinar includes Prince Edward Island's medical microbiologist and infectious disease consultant, Dr. Greg German, and Saskatchewan Patients for Patient Safety Canada patient partner, Carmen Stephens. Healthcare providers and administrators will learn how to introduce clean care conversations with patients and their families, engaging the public in ways to prevent healthcare-acquired infections.
Special feature of PATIENT Podcast Download a special new episode of our award-winning PATIENT Podcast and learn how to start a clean care conversation. Stay tuned for the new episode!In the meantime, you can catch up on season 1 and season 2 of the PATIENT podcast.
Tip sheets for public and healthcare providers
Public Download tips on how to start a clean care conversation with your provider.
Provider Download tips on how to start a clean care conversation with your patients.
(Coming soon) #CleanCareConversations Quizzes Do you know how to have a conversation about clean care? Take the quiz and see for yourself! We have two quizzes this year. One for the public and one for the healthcare providers.
(Coming soon)Social media campaign Show us on social media how you're starting #CleanCareConversations. Share photos of your #STOPCleanYourHandsDay events and activities and of you cleaning your hands. There will be a giveaway of GOJO products based on social media activity.
Sponsored by Partners
||STOP! Clean Your Hands Day||May 6, 2019 Clean Care Conversations. #STOPCleanYourHandsDay #CleanCareConversations STOP! Clean Your Hands Day takes place on Monday, May 6,||4/17/2019 2:19:14 PM||6673||https://www.patientsafetyinstitute.ca/en/Events||html||True||aspx|
|Canada creates list of events that should never happen in hospitals||63246||News||9/18/2015 2:53:20 PM||9/18/2015 6:00:00 AM|| Report identifies 15 preventable safety incidents (known as never events) that result in serious patient harm or death Toronto, ON – Sept. 18, 2015 - Patients rightfully expect safe health care in Canada and providers strive to deliver the best care possible. Unfortunately, events that harm patients do happen, and can be serious or even cause death. Many of these incidents are avoidable, says a new report from Health Quality Ontario and the Canadian Patient Safety Institute Never Events for Hospital Care in Canada. In the report, never events are classified as patient safety incidents that result in serious patient harm or death and are preventable using organizational checks and balances. Written by a group of health care quality experts from across Canada, the report focuses on 15 events that can occur while a patient is under the care of a hospital. It also highlights strategies to help identify and reduce these events. “We created this report with the Canadian Patient Safety Institute to help increase awareness for incidents that can be prevented,” says Dr. Joshua Tepper president and CEO of Health Quality Ontario. “We hope that by calling attention to these 15 never events, Canadian hospitals will rally around them and harness their collective knowledge, expertise and experiences to prevent them from happening.” A few never events in the report include Surgery on the wrong body part or wrong patient, or conducting the wrong procedure Wrong tissue, biological implant or blood product given to a patient Unintended foreign object left in a patient after a procedure “Until now, we did not have agreement in Canada on a list of never events,” says Chris Power, CEO of the Canadian Patient Safety Institute. “National consensus on never events is an important step in identifying focus. It’s not about blaming and shaming. It’s about identifying problems and sharing solutions to prevent these incidents from happening.” The group who wrote the report, known as the Never Events Action Team, was led by Health Quality Ontario and supported by the Canadian Patient Safety Institute. Together the team researched, surveyed and consulted with health system leaders, providers, patients and the public before recommending a list of never events in Canada’s health care system. The Never Events Action Team includes the following experts, and patient representatives Atlantic Health Quality and Patient Safety Collaborative British Columbia Patient Safety and Quality Council Canadian Patient Safety Institute Health Quality Council of Alberta Health Quality Ontario Manitoba Institute for Patient Safety New Brunswick Health Council Newfoundland and Labrador Provincial Safety and Quality Committee Patients for Patient Safety Canada (a patient led program of the Canadian Patient Safety Institute) To access the full report and read the complete list of never events, visit patientsafetyinstitute.ca and hqontario.ca. Or please contact us to coordinate an interview with Chris Power, CEO, Canadian Patient Safety Institute Dr. Joshua Tepper, president and CEO, Health Quality OntarioABOUT CANADIAN PATIENT SAFETY INSTITUTE The Canadian Patient Safety Institute was established in 2003 as an independent not-for-profit corporation, operating collaboratively with health professionals and organizations, regulatory bodies and governments to build and advance a safer healthcare system for Canada. The Canadian Patient Safety Institute would like to acknowledge funding support from Health Canada. The views expressed here do not necessarily represent the views of Health Canada. Visit www.patientsafetyinstitute.ca for more information.ABOUT HEALTH QUALITY ONTARIO Health Quality Ontario (HQO) is the provincial advisor on quality in health care. HQO reports public on the quality of the health care system, evaluates the effectiveness of new health care technologies and services, and supports quality improvement throughout the system. Visit www.hqontario.ca for more information.- 30 –Media contact Jessica Verhey, Senior Communications Advisor, Health Quality Ontario, 416-323-6868 ext. 614, email@example.com Cecilia Bloxom, Director of Strategic Communications, Canadian Patient Safety Institute, 780-700-8642; firstname.lastname@example.org|| Report identifies 15 preventable safety incidents (known as never events) that result in serious patient harm or death Toronto,||4/18/2016 9:55:38 AM||452||https://www.patientsafetyinstitute.ca/en/NewsAlerts/News/newsReleases/Pages/Forms/AllItems.aspx||html||False||aspx|
|Webinar 1: Introduction to Knowledge Translation and Implementation Science||43271||Events;Presentation||1/29/2018 5:38:53 PM||
Archive February 26th, 2018
Speakers Dr. Jeremy Grimshaw and Dr. Justin Presseau This is the first in a series of interactive webinars designed to build capacity in the basic principles of knowledge translation and implementation science. The webinar series is designed as a suite, with each session building on the last and thus would be ideally suited to those who are able to participate in all six. Familiarize yourself with the historical roots and rationale for knowledge translation and implementation science and to provide an overview of models, theories and frameworks used in the field and how these may be leveraged for implementing and evaluating patient safety initiatives. This webinar will also serve as a primer for what's to come later in the series and will be especially relevant to those new to knowledge translation and implementation science and/or those wanting to gain an overview of how it can be leveraged for improving patient safety.
||Archive: February 26th, 2018
Speakers: Dr. Jeremy Grimshaw and Dr. Justin Presseau This is the first in a series of interactive||3/11/2019 4:44:14 PM||635||https://www.patientsafetyinstitute.ca/en/toolsResources/KTIS-Webcast-Series-2018/Pages/Forms/AllItems.aspx||html||False||aspx|
|#SHIFTtalks Supercharge your hand-hygiene education: Are you a Tough Scrubber?||49430||News||10/2/2017 4:38:32 PM||10/2/2017 6:00:00 AM||
Photo caption Occupational therapist Laura Shapiro (left) and physiotherapist Rebecca Bunston (right) helped develop Tough Scrubber at St. Michael’s Hospital.
By the St. Michael’s Hospital Heart and Vascular Program’s Quality and Safety Leader Group
Fun, fast, challenging, hilarious. Is this how your staff would describe their hand-hygiene education? Try Tough Scrubber and they just might. In the Heart and Vascular Program at St. Michael's Hospital, our traditional hand hygiene interventions were feeling a bit stale. Engagement was low – and honestly, it showed in our compliance rates. We needed more than a poster. We needed a sensation! Enter
Tough Scrubber, the brainchild of our program's Quality and Safety Leader Group. A play on the
Tough Mudder concept, front-line staff go through a fast-paced, over-the-top simulation that's tailored for their clinical area. There's a quick quiz before they start and a quick debrief after they finish… and that's it. The whole process takes 10 minutes or less. We're happy to report, it was a huge hit! This five-minute video will tell you more about how Tough Scrubber works. We've also put together a
toolkit to help hand-hygiene champions implement Tough Scrubber in their own hospitals and health-care organizations.
For us at St. Michael's, Tough Scrubber opened the door to a new way of thinking about hand hygiene. It's OK to ask questions and to give your colleagues feedback – we're all learning. Doing hand hygiene correctly can be tough, but it's much easier when we help each other out. To date, 43 Heart and Vascular staff have completed Tough Scrubber, and our hope is that you will too. All it takes is our toolkit, 4-5 hand-hygiene leaders (to run the activity and pose as patients), an empty patient room with two beds, and the everyday equipment described in the scenarios (e.g. a wheelchair, a basin). In our Heart and Vascular Units, we've improved our compliance rate for Moment 1 by 27% in three years. This is certainly the result of a combination of years of education, hard work and many different kinds of interventions. However our Tough Scrubber sessions truly felt like the tipping point. For more information on Tough Scrubber and to download the toolkit, visit
www.stmichaelshospital.com/toughscrubber. Try it, and let us know how it worked for you! If you have any questions or feedback, please contact us at
Photo caption: Occupational therapist Laura Shapiro (left) and physiotherapist Rebecca Bunston (right)||10/25/2017 2:06:55 AM||164||https://www.patientsafetyinstitute.ca/en/NewsAlerts/News/Pages/Forms/AllItems.aspx||html||False||aspx|
|Education to support mandatory ADR and MDI reporting (Vanessa’s Law)||614||Report;Patient and Family Resource;Guide||3/4/2019 9:27:01 PM||Welcome to the Education Pilot! Here are the five modules for your review
In English only Module 1
Overview of Vanessa’s Law and Reporting Requirements Module 2
Culture of Safety Module 3
ADR and MDI Reporting Processes Module 4
System Supports for Reporting and Learning Module 5
Health Canada’s Review and Communication of Safety Findings This pilot is now complete. If you are interested in finding out more about this pilot, please email email@example.com. Background Adverse drug reactions and medical device incidents occur in hospitals, emergency departments, and people's homes – but the events are significantly underreported. The Protecting Canadians from Unsafe Drugs Act, also known as Vanessa's Law, honours the memory of Vanessa Young, who died at the age of 15 due to a heart problem after being prescribed cisapride. The law increases safety in Canada by strengthening Health Canada's ability to collect information on drugs and medical devices and take quick and appropriate action when a serious health risk is identified. The law includes a requirement for mandatory reporting by hospitals of serious adverse drug reactions (ADR) and medical device incidents (MDI). This provision of the law will come into effect later this year. The Institute for Safe Medication Practices (ISMP Canada) is working in a joint venture with the Health Standards Organization (HSO) and the Canadian Patient Safety Institute (CPSI) to assist Health Canada with outreach and education to encourage ADR and MDI reporting.
After this initial pilot and revisions based on your feedback, the educational materials will be available in July 2019 for use in any setting to support Vanessa's Law.
How the education approach will work The educational materials will be provided in PowerPoint slides (as pdfs for the Pilot) that contain content about ADR and MDI reporting that can be used by healthcare leadership, healthcare providers, patients/ families and educators.
The PowerPoint slides are designed to be "building blocks" for you to integrate into your own learning or to incorporate into orientation, continuing education and other education activities.
Hospitals can include some, or all, of the PowerPoint slides in their orientation programs.
Educators can use the content in presentations or as part of a curriculum. Professional associations, colleges, and societies can use the content to create accredited courses or certification programs for continuing education. Patient and consumer organizations can use the materials to increase awareness and knowledge among their members.
One of the principles guiding this project is that the best people to communicate information about mandatory ADR and MDI reporting are those closest to their audience.How to participate in the Pilot
Anyone, including healthcare leadership, healthcare providers, patients and families, and educators can participate in this Pilot. We have invited healthcare leadership, healthcare providers, patients and families, and educators to participate in this Pilot and we would like to know if the content is helpful. You can review as many of the modules as your time permits.
In English onlyModule 1
Overview of Vanessa’s Law and Reporting RequirementsModule 2
Culture of SafetyModule 3
ADR and MDI Reporting ProcessesModule 4
System Supports for Reporting and LearningModule 5
Health Canada’s Review and Communication of Safety Findings
After looking at the modules, we would like to know if the information is helpful you now have a good understanding of what needs to be reported according to Vanessa's Law this approach will be helpful to you and others there is additional information that you think should be included. Please access the questionnaire here.
We're interested in hearing from you! The final modules, with your feedback incorporated, will be provided in July 2019 as PowerPoint slides.
If you have questions about the Pilot, please contact
||Education to support mandatory ADR and MDI reporting (Vanessa’s Law)||Welcome to the Education Pilot! Here are the five modules for your review:
In English only Module 1:
Overview of||4/16/2019 2:16:26 PM||2198||https://www.patientsafetyinstitute.ca/en/toolsResources||html||True||aspx|
|ISMP Canada, HSO and CPSI Come Together to Support Vanessa’s Law, the Protecting Canadians from Unsafe Drugs Act||68975||News||1/10/2019 8:02:26 PM||1/10/2019 7:00:00 AM||
Institute for Safe Medication Practices Canada (ISMP Canada),
Health Standards Organization (HSO), and the
Canadian Patient Safety Institute (CPSI) are working together to support Vanessa's Law; a Health Canada initiative that requires certain healthcare institutions across Canada to identify and report on serious adverse drug reactions (ADRs) and medical device incidents (MDIs). Each year, millions of Canadians access healthcare services and/or medications. Vanessa's Law will help keep these services and medications safe by ensuring organizations report on ADR and MDI occurrences, thereby allowing Health Canada to take timely, appropriate action when a serious health risk is identified. The Protecting Canadians from Unsafe Drugs Act – named Vanessa's Law in honour of the late daughter of Terence Young (previously a Conservative MP) – amends the Food and Drug Act and strengthens the regulation of therapeutic products including prescription and over-the-counter drugs, vaccines, gene therapies, cells, tissues and organs, and medical devices. In 2016, one in 143 Canadian seniors were hospitalized due to harmful effects from medications1. The three organizations –ISMP Canada, HSO, and CPSI – have come together to support Vanessa's Law by developing educational resources and outreach to help healthcare organizations across Canada in identifying and reporting ADR and MDI occurrences. The project is funded by Health Canada. Carolyn Hoffman, President and CEO of ISMP Canada considers this work to be a key priority. In her own words "The Joint Venture partnership leverages the strengths of our organizations, in collaboration with Health Canada, to support provinces and territories, hospitals and health care providers in preparing for implementation of the Vanessa's Law mandatory reporting requirements. Patient and family members are integral partners in this project to increase reporting and learning related to ADRs and MDIs." "We are extremely proud to be working with Health Canada in partnership with ISMP and CPSI to address serious gaps in safety reporting in hospitals," says Leslee Thompson, CEO of HSO. "The education and outreach activities that arise out of this work will be invaluable to improving the safety of Canadians. HSO is looking forward to collaborating with patients, providers and policy makers to further advance our common goals of achieving meaningful and measurable improvements that honor the legacy of Vanessa and her family." "Vanessa's Law is essential to Canada's healthcare systems," says Chris Power, CEO of the Canadian Patient Safety Institute. "We can't improve what we don't measure. These new reporting requirements will help contribute to improving the safety of drugs and medical devices. Everyone in Canada deserves safe healthcare." Learn more about Vanessa's Law on the
Health Canada website.ABOUT THE ORGANIZATIONS ISMP Canada is an independent, national not-for-profit organization committed to the advancement of medication safety in all health care settings. ISMP Canada's mandate includes a national role in receiving and analyzing medication incident reports, making recommendations for the prevention of harmful medication incidents, and facilitating quality improvement initiatives. HSO develops standards, assessment programs and methodologies to enable health and social service providers around the world to improve quality while doing what they do best; saving and improving lives. CPSI is the only national organization solely dedicated to reducing preventable harm and improving the safety of the Canadian healthcare system. CPSI's bold new strategy, "Patient Safety Right Now", aims to reduce medication errors in Canada by 50% over the next five years. 1 Canadian Institute for Health Information. Drug Use Among Seniors in Canada, 2016. Ottawa, ON CIHI; 2018.
Institute for Safe Medication Practices Canada (ISMP Canada) ,
Health Standards Organization (HSO) , and the
Canadian Patient||1/24/2019 9:10:39 PM||367||https://www.patientsafetyinstitute.ca/en/NewsAlerts/News/Pages/Forms/AllItems.aspx||html||False||aspx|
|A Framework for Establishing a Patient Safety Culture||36622||Framework||2/14/2018 4:54:19 PM||Patient Safety Culture "Bundle" for CEOs/Senior Leaders What is the Patient Safety Culture "Bundle"? Strengthening a safety culture necessitates interventions that simultaneously
enable, enact and elaborate in a way that is attuned to the existing culture. Through a literature review of more than 60 resources, a Patient Safety Culture Bundle has been created and validated through interviews with Canadian thought leaders. The Bundle is based on a set of evidence-based practices that must all be applied in order to deliver good care. All components are required to improve the patient safety culture. The
Patient Safety Culture "Bundle" for CEOs and Senior Leaders encompasses key concepts of safety science, implementation science, just culture, psychological safety, staff safety/health, patient and family engagement, disruptive behavior, high reliability/resilience, patient safety measurement, frontline leadership, physician leadership, staff engagement, teamwork/communication, and industry-wide standardization/alignment.
Download a one-pager of the Patient Safety Culture Bundle for CEOs/Senior Leaders
Why was this Bundle created? A patient safety culture is difficult to operationalize. Improving safety requires an organizational culture that enables and prioritizes patient safety. The importance of culture change needs to be brought to the forefront, rather than taking a backseat to other safety activities. The National Patient Safety Consortium Education Working Group verified the critical role senior leadership plays in ensuring patient safety is an organizational priority. A Working group of partners, led by the Canadian Patient Safety Institute, Canadian College of Health Leaders (CCHL), HealthCareCAN and the Healthcare Insurance Reciprocal of Canada (HIROC) were brought together to establish a framework and advance this work. How can I use the Patient Safety Culture Bundle? The key components required for a Patient Safety Culture are identified under three pillars
Within each pillar you will find links to valuable tools and resources to help your efforts in establishing and sustaining a patient safety culture.
(coming soon)Are you looking to establish and sustain a culture of safety? We are committed to providing a robust framework to advance a safety culture. The Bundle is a dynamic tool that will be continually updated. We invite you to check back often for more links and resources. We also need your participation and input to ensure the Bundle is current and relevant. Please forward any links or comments to
"Patient safety and healthcare quality are advanced when boards and senior leaders are committed to it and are able to show evidence of that commitment. Missing until now is a concise "how to" guide. The Patient Safety bundle for Leaders fills that gap."
Catherine Gaulton, CEO, HIROC
"Leadership is critical to developing a patient safety culture and building leadership capacity requires a vision of the knowledge, skills and behaviours necessary to achieve this. The Patient Safety Leadership Bundle provides this and will be a practical tool for health leaders across the healthcare continuum to assess their personal capabilities. It will also provide both organizations and the system, as a whole, a checklist for what's missing from our collective leadership education toolkits so that we can strategically respond to these needs. HealthCareCAN is committed to the spread of this tool across the country as part of a cultural shift to safety and a drive towards high-reliability culture."
Dale Schierbeck, Vice-President, Learning & Development, HealthCareCAN and Co-Chair, Patient Safety Education for Leaders Working ||A Framework for Establishing a Patient Safety Culture||Patient Safety Culture "Bundle" for CEOs/Senior Leaders What is the Patient Safety Culture "Bundle"? Strengthening a safety||4/4/2019 2:29:25 PM||1152||https://www.patientsafetyinstitute.ca/en/toolsResources||html||True||aspx|
|Five Questions to Ask about your Medications||36619||Patient and Family Resource;Checklists;Toolkits||2/25/2016 8:39:10 PM||
Ask the Right Questions about Your Medications For patients who require multiple medications or who are transitioning between treatments, safety can become a concern. You or your loved one may be at risk of fragmented care, adverse drug reactions, and medication errors. To be an active partner in your health, you need the right information to use your medications safely.
Download CPSI has teamed up with the Institute for Safe Medication Practices Canada, Patients for Patient Safety Canada, the Canadian Pharmacists Association, and the Canadian Society for Hospital Pharmacists to create a list of top questions to help patients and their caregivers have a conversation about medications with their healthcare provider. Use these five questions when you're Attending a doctor's appointment (e.g., family physician or specialist, dentist, optometrist) Interacting with a community pharmacist Leaving the hospital to go home Visited by home care services
Are you a provider? Please share this valuable resource with your patients! Visit ISMP Canada for additional resources and endorsements Click here for Additional resources Click here to endorse and add your organizations logo For more information, contact
firstname.lastname@example.org.||Five Questions to Ask about your Medications ||Ask the Right Questions about Your Medications For patients who require multiple medications or who are transitioning between treatments, safety can||4/5/2017 7:26:26 PM||2171||https://www.patientsafetyinstitute.ca/en/toolsResources||html||True||aspx|
|Sepsis: Prevention, Early Identification and Response: Getting Started Kit Components||36610||Getting Started Kit;Guide||2/24/2016 8:43:33 PM|| Effective March 14 2019, the Canadian Patient Safety
Institute has archived the Sepsis intervention. Though you may continue to access the Getting Started Kit
online, it will no longer be updated. Sepsis is a potentially fatal condition involving the body's response to a severe infection. It manifests in various ways and may involve fever, low blood pressure, and dysfunction in vital organs such as the brain, heart, kidneys, and lungs.Sepsis affects 30,000 Canadians each year, and over one-third of these will die if not treated appropriately. As with polytrauma, heart attack, and stroke, the speed and appropriateness of therapy improves patient outcomes.The Sepsis Getting Started Kit provides you with evidence-based resources to assist you in decreasing sepsis rates in your organization as well as in improving clinical outcomes from septic patients. This free resource contains clinical information, information on the science of improvement, and everything you need to know to start using the intervention.Drawn from the best available evidence and expert advice, and regularly updated, the Sepsis Getting Started Kit will help to decrease the morbidity and mortality from sepsis in hospitalized patients through a structured approach to prevention, early identification and response to sepsis.Getting Started Kit The Sepsis Getting Started Kit is divided into five sections Section 1 Prevention, Identification and Response to Sepsis Section 2 Pediatric Sepsis Section 3 Maternal Sepsis Section 4 Measurement – Technical Descriptions and Data Screens Section 5 Sample Checklists and Other Tools
Want to learn more? Download the complete Sepsis Getting Started Kit
This document was updated in September 2015 The Model for Improvement is designed to accelerate the pace of improvement using the PDSA cycle; a "trial and learn" approach to improvement based on the scientific method. Please refer to the Improvement Frameworks GSK (2015) for additional information. For more information, email
email@example.com or call 1-866-421-6933||Sepsis: Prevention, Early Identification and Response: Getting Started Kit Components ||Effective March 14 2019, the Canadian Patient Safety
Institute has archived the Sepsis intervention. Though you may continue to access the Getting||3/25/2019 8:54:38 PM||1010||https://www.patientsafetyinstitute.ca/en/toolsResources||html||True||aspx|
|Enhanced Recovery After Surgery||36646||Video||7/13/2016 2:57:58 AM||
What is Enhanced Recovery After Surgery? Enhanced Recovery After Surgery - ERAS is a program highlighting surgical best practices and consists of a number of evidence-based principles that support better outcomes for surgical patients including an improved patient experience, reduced length of stay, decreased complication rates and fewer hospital readmissions. As part of CPSI's Integrated Patient Safety Action Plan for Surgical Care Safety and with support from 24 partner organizations from across the country, Enhanced Recovery Canada is leading the drive to improve surgical safety across the country and help disseminate these ERAS principles.
A number of Canadian surgical care teams have already embraced the ERAS principles Alberta Health Services, Eastern Health, McGill University Health Centre, University of Toronto's Best Practices in Surgery, the Winnipeg Regional Health Authority as well as BC's Patient Safety & Quality Council and the Doctors of British Columbia.
Position Statement Application Deadline (March 1, 2019) Enhanced Recovery Canada Safety Improvement Project The Canadian Patient Safety Institute is set to launch a new Safety Improvement Project focused on surgical best practices for colorectal surgeries in January 2019.
Safety Improvement Project Video Series We trust this 6 part interview with international ERAS expert Dr. Henrik Kehlet will whet your appetite. Stay tuned for additional information regarding Enhanced Recovery Canada.
Use the YouTube playlist below to play all, or any of the six videos in the series.
Where can you learn more about ERAS in the interim?
BC's ERAS Collaborative has developed a website providing a variety of resources to support the implementation of Enhanced Surgical Recovery programs. See
Enhanced Recovery BC
The McGill University Health Center has developed a number of ERAS related
Surgery Patient Guides you may find helpful as well.
Connect with an experienced ERAS coordinatorIndustry Partners
For more information, contact us at
firstname.lastname@example.org.||Enhanced Recovery Canada||What is Enhanced Recovery After Surgery ? Enhanced Recovery After Surgery - ERAS is a program highlighting surgical best practices and consists of a||1/17/2019 8:59:46 PM||2141||https://www.patientsafetyinstitute.ca/en/toolsResources||html||True||aspx|
|Safety Improvement Projects||36609||Framework||9/14/2018 2:50:29 PM||
Canadian Patient Safety Institute (CPSI) is offering new Safety Improvement Projects designed with a Quality Improvement/Knowledge Translation integrated learning design for accelerating Patient Safety in Canada.
CPSI is working with committed partners to implement and evaluate measurable and sustainable Safety Improvement Projects that align with pan-Canadian priorities. The new Safety Improvement Projects are as follows
Teamwork and Communication leads to improved patient safety culture and positive patient outcomes.
Medication Safety at Care Transitions improves medication safety at discharge for frail, elderly patients with poly-morbidity in your organization.
Enhanced Recovery Canada leads to improved outcomes and system efficiencies for colorectal surgery patients.
Measurement and Monitoring of Safety creates a culture of safety and reduces harm in your organization. (already in progress) Each Safety Improvement Project lasts 18 months and uses principles from the Institute for Healthcare Improvement Breakthrough Series and the Knowledge to Action Framework. The learning design is unique in that it is guided by a Quality Improvement/Knowledge Translation integrated learning design. By adopting these projects, you and your organization will step in to a leading role in healthcare delivery. Please
sign up to subscribe to our Safety Improvement Project mailing list for updates and to learn more about each of these projects. Consider introducing them in your organization with a goal of supporting higher patient safety standards within your organization and across the country.
Sign up Benefits to participating organizations Support of expert faculty and coaches who are knowledgeable about the best-known evidence as well as practical ideas, tips and tools for application.
Use of a collaborative virtual space for networking with other participating teams and faculty, and continual and ongoing support provided through in-person and virtual contact opportunities with coaches. Opportunity to demonstrate, showcase and share the practices that support meeting strategic and operational objectives at a congress event. If you have any questions, please email
SafetyImprovementProjects@cpsi-icsp.ca ||Safety Improvement Projects ||Canadian Patient Safety Institute (CPSI) is offering new Safety Improvement Projects designed with a Quality Improvement/Knowledge Translation||3/26/2019 7:09:08 PM||1959||https://www.patientsafetyinstitute.ca/en/toolsResources||html||True||aspx|
|Engaging Patients in Patient Safety – a Canadian Guide||36605||Guide||4/25/2017 3:01:50 PM|| During the past decade, we have seen evidence that when healthcare providers work closely with patients and their families, we can achieve great things. The healthcare system will be safer, and patients will have better experiences and health outcomes when patients, families, and the public are fully engaged in program and service design and delivery. Patient involvement is also important in monitoring, evaluating, setting policy and priorities, and governance. This work is not easy and may even be uncomfortable at first. Providers may need to let go of control, change behaviours to listen and understand patients more effectively, brainstorm ideas together, build trust, and incorporate many different perspectives. Patients may need to participate more actively in decisions about their care. Leaders must support all this work by revising practices to embed patient engagement in their procedures, policies, and structures. But finding different and innovative ways to work together, even when it's challenging, benefits everyone. When patients and healthcare providers partner effectively, the results are powerful. We invite you to join us in advancing this work. We welcome diverse perspectives and beliefs to challenge the status quo. Let's explore ways to shape new behaviours, using everyone's unique perspectives and courage to make healthcare a safe and positive experience. A deep belief in the power of partnership inspired the Engaging Patients in Patient Safety - a Canadian Guide. Written by patients and providers
for patients and providers, the information demonstrates our joint commitment to achieving safe and quality healthcare in Canada.
Download Better yet, bookmark this page. This resource is updated regularly. To ensure you are accessing the most up-to-date version, we recommend that you bookmark this page for future reference. Who is this guide for? The guide is for anyone involved with patient engagement, including Patients and families interested in how to partner in their own care to ensure safety Patient partners interested in how to help improve patient safety Providers interested in creating collaborative care relationships with patients and families Managers and leaders responsible for patient engagement, patient safety, and/or quality improvement Anyone else interested in partnering with patients to develop care programs and systems While the guide focuses primarily on patient safety, many engagement practices apply to other areas, including quality, research, and education. The guide is designed to support patient engagement in any healthcare sector. What is the purpose of the guide? This extensive resource, based on evidence and leading practices, helps patients and families, patient partners, providers, and leaders work together more effectively to improve patient safety. Working collaboratively, we can more proactively identify risks, better support those involved in an incident, and help prevent similar incidents from occurring in the future. Together we can shape safe, high-quality care delivery, co-design safer care systems, and continuously improve to keep patients safe.What is included in the guide? Evidence-based guidance Practical patient engagement practices Consolidated information, resources, and tools Supporting evidence and examples from across Canada Experiences from patients and families, providers, and leaders Outstanding questions about how to strengthen current approaches Strategies and policies to meet standards and organizational practice requirementsChapter summariesEngaging patients as partners Why partner on patient safety and quality Current state of patient engagement across Canada Evidence of patient engagement benefits and impact Challenges and enablers to patient engagement Embedding and sustaining patient engagement
Read More Partners at the point of care Partnering in patient safety Partnering in incident management
Read More Partners at organizational and system levels Preparing to partner Partnering in patient safety Partnering in incident management
Read More Evaluating patient engagement Introduction to evaluating patient engagement Evaluating patient engagement at the point of care Evaluating patient engagement at the organizational level Evaluating patient engagement integration
Click here to learn how and why was the guide developed.
Citation Patient Engagement Action Team. 2017. Engaging Patients in Patient Safety – a Canadian Guide. Canadian Patient Safety Institute. Last modified February 2018. Available at www.patientsafetyinstitute.ca/engagingpatients ||Engaging Patients in Patient Safety – a Canadian Guide||During the past decade, we have seen evidence that when healthcare providers work closely with patients and their families, we can achieve great||7/24/2018 7:34:54 PM||2682||https://www.patientsafetyinstitute.ca/en/toolsResources||html||True||aspx|
|Excellence in Patient Engagement for Patient Safety||36690||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 again in the recognition program that aims to identify, celebrate and disseminate leading practices in patient engagement for patient safety.
Two teams from the Centre for Addiction and Mental Health (CAMH) and BC Children's Hospital (an agency of the Provincial Health Services Authority) will present their leading practices in patient engagement for patient safety at the National Health Leadership Conference (NHLC) on June 5th in St. John's NL.In addition, teams from the following organizations have been formally identified and celebrated as leading practices and added to HSO's Leading Practices LibraryAlberta Health ServicesProvincial Health Services Authority (BC Patient Safety & Learning System (BCPSLS))Health Quality Council, SaskatchewanKidney Health, Saskatchewan Health AuthorityBC Children's Hospital (an agency of PHSA)Eastern Health NewfoundlandHolland BloorviewMontfort HospitalMcMaster Children's Hospital Hamilton Health SciencesBC Autism Assessment Network, Sunny Hill Health Centre for Children, BC Children's HospitalSunnybrook Health Sciences CentreHealth Quality OntarioFraser Health
Read More We welcome your questions and suggestions at
email@example.com. ||Excellence in Patient Engagement for Patient Safety||2016 Champion Awards||3/27/2019 3:09:33 PM||1013||https://www.patientsafetyinstitute.ca/en/Events||html||True||aspx|
|Patient Safety and Incident Management Toolkit||36596||Toolkits||12/18/2014 8:28:40 PM||Prevent Patient Safety Incidents and Minimize Harm When They Do Occur When a patient's safety is compromised, or even if someone just comes close to having an incident, you need to know you are taking the right measures to address it, now and in the future. CPSI provides you with practical strategies and resources to manage incidents effectively and keep your patients safe. This integrated toolkit considers the needs and concerns of patients and their families, and how to properly engage them throughout the process. Drawn from the best available evidence and expert advice, this newly designed toolkit is for those responsible for managing patient safety, quality improvement, risk management, and staff training in any healthcare setting.
Patient Safety Management
System Factors For more information, contact us at
firstname.lastname@example.org.Toolkit Focus and Components The toolkit focuses on patient safety and incident management; it touches on ideas and resources for exploring the broader aspects of quality improvement and risk management. There are three sections to the toolkit Incident management—the actions that follow patient safety incidents (including near misses) Patient safety management—the actions that help to proactively anticipate patient safety incidents and prevent them from occurring System factors—the factors that shape and are shaped by patient safety and incident management (legislation, policies, culture, people, processes and resources).
Visual representation of the toolkit.
Incident management Resources to guide the immediate and ongoing actions following a patient safety incident (including near misses). We emphasize immediate response, disclosure, how to prepare for analysis, the analysis process, follow-through, how to close the loop and share learning.
Patient safety management Resources to guide action before the incident (e.g., plan, anticipate, and monitor to respond to expected and unexpected safety issues) so care is safer today and in the future. We promote a patient safety culture and reporting and learning system.
System factors Understanding the factors that shape both patient safety and incident management and identify actions to respond, align, and leverage them is crucial to patient safety. The factors come from different system levels (inside and outside the organization) and include legislation, policies, culture, people, processes and resources.Implementing Patient Safety and Incident Management Processes Consider the following guiding principles when applying the practical strategies and resources.
Patient- and family-centred care. The patient and family are at the centre of all patient safety and incident management activities. Engage with patients and families throughout their care processes, as they are an equal partner and essential to the design, implementation, and evaluation of care and services.
Safety culture. Culture refers to shared values (what is important) and beliefs (what is held to be true) that interact with a system's structures and control mechanisms to produce behavioural norms. An organization with a safety culture avoids, prevents, and mitigates patient safety risks at all levels. This includes a reporting and learning culture.
System perspective. Keep patients safe by understanding and addressing the factors that contribute to an incident at all system levels, redesigning systems, and applying human factor principles. Develop the capability and capacity for effectively assessing the complex system to accurately identify weaknesses and strengths for preventing future incidents.
Shared responsibilities. Teamwork is necessary for safe patient care, particularly at transitions in care. It is the best defence against system failures and should be actively fostered by all team members, including patients and families. In a functional teamwork environment, everyone is valued, empowered, and responsible for taking action to prevent patient safety incidents, including speaking up when they see practices that endanger safety.Resources to Support Patient Safety and Incident Management CPSI's
toolkit resources are practical tools for patient safety and incident management, compiled with input from experts and contributing organizations. You may not require all of them when managing an incident, so please use your discretion in selecting the tools most appropriate for your needs.Toolkit Development and Maintenance CPSI accessed a variety of qualified experts and organizations to compile this practical and evidence-based toolkit. The process included Assigning a CPSI team with support from a writer with experience in the field Seeking advice from an expert faculty that included patient and family representatives Basing the content on the Canadian Incident Analysis Framework Engaging key stakeholders via focus groups and collecting evidence from peer-reviewed journals and publicly available literature The toolkit will be updated every year to keep it relevant. We welcome feedback on what is helpful, what can be improved, and content enhancements at email@example.com.||Patient Safety and Incident Management Toolkit||Prevent Patient Safety Incidents and Minimize Harm When They Do Occur When a patient's safety is compromised, or even if someone just comes close to||6/19/2017 4:19:43 PM||2252||https://www.patientsafetyinstitute.ca/en/toolsResources||html||True||aspx|
|Atlantic Learning Exchange||36691||Events||9/20/2016 6:01:00 PM||
Get Updates ||Atlantic Quality and Patient Safety Learning Exchange||Get Updates||4/1/2019 5:58:42 PM||907||https://www.patientsafetyinstitute.ca/en/Events||html||True||aspx|
|Improvement Frameworks Getting Started Kit||36595||Toolkits;Getting Started Kit;Framework||11/24/2011 4:21:24 PM||12/2/2015 7:00:00 AM||The Improvement Frameworks Getting Started Kit is intended to serve as a common document appended to the Safer Healthcare Now! Getting Started Kits. The goal is to help provide a consistent way for teams and individuals to approach the challenge of making changes that result in improvements.
Download ||Improvement Frameworks Getting Started Kit||The Improvement Frameworks Getting Started Kit is intended to serve as a common document appended to the Safer Healthcare Now! Getting Started||1/5/2016 6:18:07 PM||918||https://www.patientsafetyinstitute.ca/en/toolsResources||html||True||aspx|
|Teamwork and Communication||36597||Publication;Framework||7/22/2009 8:44:35 PM||
Effective teamwork and communication are critical for ensuring high reliability and the safe delivery of care. Teamwork and communication techniques can improve quality and safety, decrease patient harm, promote cross-professional collaboration and the development of common goals, decrease workload issues, and improve staff and patient satisfaction.
Building effective teams and improving communication through standardized tools will move effective teamwork forward in Canada and contribute to a culture of patient safety. CPSI is developing a Canadian Framework for Teamwork and Communication to help healthcare providers and organizations integrate tools and resources into practice.
Canadian Framework for Teamwork and Communication Appendix A
Teamwork and Communication in Healthcare A Literature Review Appendix B
Consultation with Health Professionals and Administrators Regarding Teamwork and Communication Appendix C Report on Summary of Team Training Programs
||Canadian Framework for Teamwork and Communication||Effective Teamwork and Communication to Enhance Patient Safety||11/9/2016 8:44:39 PM||1251||https://www.patientsafetyinstitute.ca/en/toolsResources||html||True||aspx|
|The Safety Competencies Framework||36599||Publication;Framework||4/14/2009 11:53:32 PM|| Achieve safe patient care by incorporating our framework The Safety Competencies into your healthcare organization’s educational programs and professional development activities. Patient safety, defined as the reduction and mitigation of unsafe acts within the healthcare system, and the use of best practices shown to lead to optimal patient outcomes, is a critical aspect of quality healthcare.
Educating healthcare providers about patient safety and enabling them to use the tools and knowledge to build and maintain a safe system is critical to creating one of the safest health systems in the world. The Safety Competencies is a highly relevant, clear, and practical framework designed for all healthcare professionals. Created by the Canadian Patient Safety Institute (CPSI), The Safety Competencies has six core competency domains
Domain 1 Contribute to a Culture of Patient Safety – A commitment to applying core patient safety knowledge, skills, and attitudes to everyday work.
Domain 2 Work in Teams for Patient Safety – Working within interprofessional teams to optimize patient safety and quality of care..
Domain 3 Communicate Effectively for Patient Safety – Promoting patient safety through effective healthcare communication..
Domain 4 Manage Safety Risks – Anticipating, recognizing, and managing situations that place patients at risk..
Domain 5 Optimize Human and Environmental Factors – Managing the relationship between individual and environmental characteristics in order to optimize patient safety..
Domain 6 Recognize, Respond to, and Disclose Adverse Events – Recognizing the occurrence of an adverse event or close call and responding effectively to mitigate harm to the patient, ensure disclosure, and prevent recurrence.. This valuable framework includes 20 key competencies, 140 enabling competencies, 37 knowledge elements, 34 practical skills, and 23 essential attitudes that can lead to safer patient care and quality improvement. CPSI encourages its stakeholders, national, provincial, and territorial health organizations, associations, and governments; and universities and colleges to play a role in engaging stakeholders and spreading the word about this program so that healthcare professionals recognize the knowledge, skills, and attitudes needed to enhance patient safety across the spectrum of care. For further information, please email
firstname.lastname@example.org.||The Safety Competencies||The Safety Competencies: Message from the CEO||9/12/2017 8:43:40 PM||3712||https://www.patientsafetyinstitute.ca/en/toolsResources||html||True||aspx|
|Questions Are the Answer||36606||Checklists;Patient and Family Resource||7/14/2016 9:07:34 PM||Tips and Tools for Talking to Your Healthcare Team Empower yourself with information and tools to help you ask good questions, connect with the right people, and learn as much as you can to keep you or a family member safe while receiving healthcare. Questions Are the Answer helps you effectively prepare for making decisions about medical treatment options by asking the right questions of your healthcare team. It considers topics for before, during, and after appointments, using past, present, and future medicines, medical tests, and surgeries. Always use these resources before you attend any healthcare appointment Questions to ask before an appointment Questions to ask during an appointment Questions to ask after an appointment Overall question checklist SHIFT to Safety helps you advocate for your healthcare safety. Shift your focus to what really matters—the patient. Are you a provider? Please share this valuable resource with your patients! For more information, contact us at email@example.com. Internet Citation Be More Involved in Your Health Care. September 2012. Agency for Healthcare Research and Quality, Rockville, MD.||Questions Are the Answer||Tips and Tools for Talking to Your Healthcare Team Empower yourself with information and tools to help you ask good questions, connect with the||4/5/2017 7:20:44 PM||1205||https://www.patientsafetyinstitute.ca/en/toolsResources||html||True||aspx|
|Effective Governance for Quality and Patient Safety||36615||Toolkits||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.||Effective Governance for Quality and Patient Safety||Effective Governance for Quality and Patient Safety: A Toolkit for Healthcare Board Members and Senior Leaders||4/24/2018 5:35:19 PM||1650||https://www.patientsafetyinstitute.ca/en/toolsResources||html||True||aspx|
|Incident Analysis||36617||Framework;Publication||4/19/2011 9:12:41 PM||
Analyze, manage, and learn from patient safety incidents in any healthcare setting with the Canadian Incident Analysis Framework.
Incident analysis is a structured process for identifying what happened, how and why it happened, what can be done to reduce the risk of recurrence and make care safer, and what was learned. It is an integral activity in the incident management continuum, which represents the activities and processes that surround a patient safety incident.
The framework was developed collaboratively by CPSI, the
Institute for Safe Medication Practices Canada,
Patients for Patient Safety Canada (a patient-led program of CPSI), Paula Beard, Carolyn Hoffman, and Micheline Ste-Marie and is based on the 2006 Canadian Root Cause Analysis Framework.
To learn more about the framework and the resources available, you can
click here to watch the information webinars recorded.
following resources have been carefully selected to support you in implementing the Canadian Incident Analysis Framework.
To contribute a resource or to provide feedback, please email
To learn more about the framework and the learning opportunities available
||Incident Analysis||Root Cause Analysis (RCA)||6/20/2016 3:47:55 PM||2569||https://www.patientsafetyinstitute.ca/en/toolsResources||html||True||aspx|
|Never Events for Hospital Care in Canada||36621||Report||7/25/2015 2:52:36 AM||
Patients rightfully expect safe care, and health care providers work to provide care that results in better health and safe outcomes for patients. Unfortunately, events that harm patients do occur while care is being provided or as a result of that care. Many of these events that cause harm are preventable using current knowledge and practices. "Never events" are patient safety incidents that result in serious patient harm or death, and are preventable using organizational checks and balances.
Download An Action Team from the
National Patient Safety Consortium has sought consensus on the top priorities for Canadian never events in health care. The current focus is on events that can occur while a patient is admitted in a health care facility, where care providers have a high amount of control over care. The Never Events Action Team includes the following experts, and patient representatives Atlantic Health Quality and Patient Safety Collaborative British Columbia Patient Safety and Quality Council Canadian Patient Safety Institute Health Quality Council of Alberta Health Quality Ontario Manitoba Institute for Patient Safety New Brunswick Health Council Newfoundland and Labrador Provincial Safety and Quality Committee
Patients for Patient Safety Canada (a patient led program of the Canadian Patient Safety Institute) Our work aims to provide some areas and targets for continually improving patient safety. We believe various strategies can be effective in identifying and reducing never events, including cultural changes, reporting and learning systems, identification of opportunities for improvement and continuous improvement supported by measurement and evaluation. The
Incident Management Toolkit is an available tool from the Canadian Patient Safety Institute and designed to help healthcare organizations prevent patient safety incidents and minimize harm when incidents do occur.
Click here to access the final report on Never Events for Hospital Care in Canada.||Never Events for Hospital Care in Canada||
Patients rightfully expect safe care, and health care providers work to provide care that results in better health and safe outcomes||5/24/2016 4:37:34 AM||1421||https://www.patientsafetyinstitute.ca/en/toolsResources||html||True||aspx|
|Surgical Safety in Canada: A 10-year review of CMPA and HIROC medico-legal data||36626||Report||4/8/2016 8:36:50 PM||
More than one million surgical procedures were performed annually in Canada between 2004 and 2013. The Canadian healthcare system strives to provide safe care, but patient safety incidents still occur, with over half attributed to surgical care. Safe surgical care requires that physicians and healthcare teams use appropriate tools and contribute to system improvements within a complex professional environment. The Canadian Medical Protective Association (CMPA), which provides medical liability protection for most Canadian physicians, and the Healthcare Insurance Reciprocal of Canada (HIROC), which provides liability insurance for healthcare organizations and their employees, have collaborated to conduct a retrospective analysis of Canadian surgical safety incident data. This analysis of medico-legal data advances knowledge in patient safety concepts, and is intended to lead to system and practice improvements. This analysis was undertaken as part of the
Surgical Care Safety Action Plan. A summary of the results and recommendations can be found in the summary report
Surgical Safety in Canada
A 10-year review of CMPA and HIROC medico-legal data. A deep dive into the methods, limitations and the results can be found in the
Detailed Analysis report.
Detailed Analysis ||Surgical Safety in Canada: A 10-year review of CMPA and HIROC medico-legal data ||More than one million surgical procedures were performed annually in Canada between 2004 and 2013. The Canadian healthcare system strives to provide||4/11/2016 5:18:04 PM||638||https://www.patientsafetyinstitute.ca/en/toolsResources||html||True||aspx|
|Canadian Disclosure Guidelines||36630||Guide;Publication||4/18/2011 4:05:57 PM|| The Canadian Disclosure Guidelines build on various patient safety initiatives currently under way across Canada and assist and support healthcare providers, inter-professional teams, organizations, and regulators. These guidelines symbolize a commitment to patients’ right to be informed if they are involved in a patient safety incident by promoting a clear and consistent approach to disclosure, emphasizing the importance of inter-professional teamwork, and supporting learning from patient safety incidents. The development of the Canadian Disclosure Guidelines is a significant achievement in healthcare in Canada.
Canadian Disclosure Guidelines (November 2011)
Backgrounder Development of the Canadian Disclosure Guidelines (2006)
The Impact of Disclosure on Litigation (2007)||Canadian Disclosure Guidelines: Being open with patients and families||The Canadian Disclosure Guidelines build on various patient safety initiatives currently under way across Canada and assist and support healthcare||6/20/2016 8:35:25 PM||2338||https://www.patientsafetyinstitute.ca/en/toolsResources||html||True||aspx|