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Resources for Conducting Incident and/or Prospective Analyses

Canadian Association of Paediatric Health Centres (CAPHC)

Trigger Tool

The CAPHC Paediatric Trigger Tool (CPTT) is a patient safety improvement tool developed in collaboration with patient safety and quality improvement experts from across Canada. Trigger tools have long been considered to be sensitive and efficient strategies for detecting adverse events and have been widely used in adult studies. The CPTT is available for download at no charge to be used by acute care paediatric hospitals and community hospitals as a tool to promote quality improvement and safer care for the paediatric population.

Canadian Patient Safety Institute

Canadian Incident Analysis Framework

The Canadian Incident Analysis Framework is a resource to support those responsible for, or involved in, managing, analyzing and/or learning from patient safety incidents in any healthcare setting. It provides analysis methods (comprehensive, concise and multi-incident) and tools to assist in answering the following questions:

  • What happened?
  • How and why did it happen?
  • What can be done to reduce the likelihood of recurrence and make care safer?
  • What was learned?

Canadian Patient Safety Institute

Global Patient Safety Alerts

Hosted by the Canadian Patient Safety Institute, Global Patient Safety Alerts is a publicly available web-based platform containing an evidence-informed collection of alerts, advisories, recommendations and solutions for improving care and preventing incidents. Recognized by the World Health Organization, Global Patient Safety Alerts provides access and the opportunity to learn from other organizations around the world about specific patient safety incidents. Learning from the experience of other organizations can accelerate improvement.

Canadian Patient Safety Institute

Patient Safety and Incident Management Toolkit

In spring 2015, the Canadian Patient Safety Institute released a new web-based resource that is based on the Canadian Incident Analysis Framework but extends the focus beyond incident analysis to look at the broader spectrum of patient safety and incident management. Canadian and international resources, tools and references are available at the fingertips of users through links and downloadable documents.

Institute for Healthcare Improvement (IHI)

Failure Modes Effects Analysis Tool

Failure modes and effects analysis (FMEA) is a systematic, proactive method for evaluating a process to identify where and how it might fail and to assess the relative impact of different failures, in order to identify the parts of the process that are most in need of change.

Teams use FMEA to evaluate processes for possible failures and to prevent them by correcting the processes proactively rather than reacting to adverse events after failures have occurred. This emphasis on prevention may reduce risk of harm to both patients and staff. FMEA is particularly useful in evaluating a new process prior to implementation and in assessing the impact of a proposed change to an existing process.

Institute for Healthcare Improvement (IHI)

Global Trigger Tool

The IHI Global Trigger Tool for Measuring Adverse Events (AEs) provides instructions for training reviewers in this methodology and conducting a retrospective review of patient records using triggers to identify possible AEs. This tool includes a list of known AE triggers as well as instructions for selecting records, training information, and appendices with references and common questions.

Institute for Safe Medication Practices Canada (ISMP Canada)

Canadian Failure Mode and Effects Analysis Framework©

Failure modes and effects analysis (FMEA) is a proactive safety technique that helps to identify process and product problems before they occur. It is one of several types of prospective risk assessment that can be used in healthcare settings. It is also widely used as an integral aspect of improving quality and safety in other industries (e.g., automotive, aviation, and nuclear power).

ISMP Canada has developed the Canadian Failure Mode and Effects Analysis Framework — Proactively Assessing Risk in Healthcare©, with assistance from healthcare and human factors engineering consultants. It can be applied to all healthcare processes, such as medication use, patient identification, specimen labelling, emergency room triage, identification of risk of patient falls, to list a few examples.