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.
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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.
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.
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
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 firstname.lastname@example.org.