​​Resources

The resources and recommended readings referred to in this component of the toolkit are listed in this section. A similar list is available for each component and a compilation of all the resources and readings referred to in all toolkit components is available here:

Canadian Patient Safety Institute (CPSI). Global Patient Safety Alerts. (Collection of alerts)

Canadian Patient Safety Institute (CPSI). Guidelines for Informing the Media after an Adverse Event. Edmonton, AB: CPSI; 2011. (Guide, 11 pages)

Duchscherer C, Davies JM. Systematic Systems Analysis: A practical approach to patient safety reviews. Calgary, AB: Health Quality Council of Alberta; 2013.  (Guide, 76 pages)

Health Canada, Health Canada’s Role  in the Management and Prevention of Harmful Medication Incidents, 2011 (Guide)

Incident Analysis Collaborating Parties. Canadian Incident Analysis Framework. Edmonton, AB: Canadian Patient Safety Institute; 2012. (Guide, tools, 133 pages)

• Appendix G: Incident analysis guiding questions.
• Appendix N: Three human factors methods that can be used in incident analysis.
• Appendix H: Creating a constellation diagram.
• Appendix J: Case study - comprehensive analysis: elopement from a long-term care home.
• Appendix K: Case study - concise analysis: medication incident.
• Section 3.6.6 Developing and Managing Recommended Actions.
• Appendix I: Incident Analysis Report Template
• Figure 3.12: Example of tool to track the implementation status of recommended action.

Institute for Safe Medication Practices Canada (ISMP). Designing effective recommendations. In: Ontario Critical Incident Learning. 2013; April(Issue 4). (Guide, 2 pages)

Institute for Safe Medication Practices Canada (ISMP). ISMP Canada Safety Bulletins. (Collection of alerts)

Ontario Hospital Association, From Law to Practice: Revisiting the Quality of Care Information Protection Act, 2007 (Toolkit, $)

Ontario Hospital Association, Quality of Care Information Protection Act Toolkit, 2004 (Toolkit)

Agency for Healthcare Research and Quality (AHRQ). AHRQ Web M&M: Morbidity and mortality rounds on the web. (Collection of cases)

Department of Health, Government of Western Australia. Clinical Incident Management Toolkit. Perth, WA: Western Australian Department of Health; 2011. (Toolkit, 94 pages)
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Recommended Readings

Berenholtz SM, Hartsell TL, Pronovost PJ. Learning from defects to enhance morbidity and mortality conferences. Am J Med Qual. 2009; 24(3): 192-5. (Journal article, abstract only)

NHS England. Patient Safety Resources: Root Cause Analysis (RCA) Investigation Guidance. 2010 (Guide, toolkit)

NHS England. Patient Safety Resources: Root Cause Analysis (RCA) Investigation. 2010 (Guide, toolkit)

Vincent C,  Taylor-Adams S, Chapman EJ, Hewett D, Prior S, Strange P, Tizzard A. How to investigate and analyse clinical incidents: clinical risk unit and association of litigation and risk management protocol. BMJ. 2000; 320(7237): 777-81. (Journal article, open access)