Learning from patient safety incidents is paramount in advancing a safer healthcare system. 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.
Since the Canadian
Incident Analysis Framework was launched in November 2012, the Canadian Patient Safety Institute has provided a number of learning opportunities to increase knowledge and skills in incident analysis.
The Incident Analysis Learning Program is a series of eight learning modules that covers every section of the Canadian Incident Analysis Framework. The complete list of archived session recordings and documents (in both English and French) are available at no cost at
Diagramming is one of the elements that can increase the credibility, reliability and effectiveness of analysis in making care safer. The Constellation Diagram, a new diagramming method introduced in the Canadian Incident Analysis Framework, can assist teams to better understand systemic factors and the inter-relationships between them, better visualize these relationships, and help avoid the trap of hindsight bias. The
webinar on the Constellation Diagram offers a deeper dive into the diagramming step of the incident analysis process to recognize system issues that may have contributed to the incident. Click on the link above to access the session recording and documents, which are also available at no cost.
A webinar on disclosure is now being developed for delivery in January 2014. If you would like to help shape the content and design of the webinar, please email
For more information and to
download tools and resources on incident analysis and management, visit
Has Incident Analysis Learning made a difference?
The Incident Analysis planning team has developed an anonymous survey to obtain feedback on the impact of the incident analysis program on practice. If you attended one ore more sessions of the learning program, please complete the online survey before October 20, 2013.