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This section of the Patient Safety and Incident Management Toolkit provides an integrated set of resources focused on the immediate and ongoing actions following patient safety incidents (including near misses.)  It aims to help those responsible for incident management respond to and reduce the harm to patients/families and providers when incidents do occur.

Below is a description of the components that are part of the incident management section which includes links to practical resources.

  • Immediate response includes the care, support, and communication actions that take place immediately following an incident to mitigate further patient harm and ensure the safety of patients/families and providers.  As appropriate, the immediate response continues throughout the incident management process to promote healing, recovery and learning.
  • Disclosure is a formal process involving open discussion between a patient/family and members of the healthcare organization about a patient safety incident.  Disclosure provides the means for dialogue throughout the incident management process, supports patient safety improvement as well as promotes healing for the patients/families and providers involved.
  • Peer-to-Peer Support (Second Victim Phenomenon) - An ever-growing body of evidence demonstrates that health professionals feel emotionally distressed after a patient safety incident (PSI), and there is an emerging recognition of the potential negative impact on both the health professionals’ health and on patient safety.  As a result of this recognition, healthcare organizations are seeking ways to support health professionals who are emotionally traumatized after a PSI.
  • Prepare for analysis consists of a preliminary review to determine the appropriate follow-up and whether a system-based incident analysis is needed.  If indicated, an incident analysis method, team, and approach are selected and initial interviews are conducted. The findings, actions and decisions made at this point in the incident management process influence the direction and effectiveness of the analysis process.
  • Analysis process is a structured process, focused on system improvement, that aims to identify 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. Analysis is a core component of incident management therefore it is important to ensure it is thorough, fair, unbiased and the recommended actions provide effective safety solutions.
  • Follow-through consists of implementing the final recommended actions, monitoring their impact on safety, and when the goals and sustainability are achieved, transitioning to ongoing operations.  This step involves change and improvement, it spans over a longer period of time, and it is vital in demonstrating that the incident management process improved safety and quality of care.
  • Close the loop/ share learning involves sharing what was learned from a systems analysis, both within an organization and beyond in order to make care safer, prevent the recurrence of similar events, and promote trust and healing. This concluding step, which applies to both patient safety and incident management, offers a valuable opportunity for reflection and the identification of opportunities to further improve quality and safety outcomes as well as the systems and processes supporting it.