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However, safety is much more than the absence of harm. It requires us to look at the whole system to understand how to create lasting conditions and culture for safer care.",{"type":15,"attrs":464,"content":465},{"textAlign":53},[466,468,473],{"text":467,"type":305},"In 2022 and 2023, Healthcare Excellence Canada and Patients for Patient Safety Canada held conversations with healthcare workers and safety scientists. Their reflections guided the development of ",{"text":312,"type":305,"marks":469},[470],{"type":315,"attrs":471},{"href":317,"uuid":318,"anchor":53,"custom":472,"target":320,"linktype":321},{},{"text":474,"type":305}," – a new statement and discussion guide that offers a way of approaching patient safety where everyone can contribute to creating safer conditions and where all forms of healthcare harm are acknowledged, including those related to physical, psychological and cultural safety.",{"_uid":476,"content":477,"component":329},"d4d30c1b-8b31-4282-9fd6-3d43881f4f91",{"type":12,"content":478},[479,486,491,496,528,533,538,543,548,556,561,568,573,580,585],{"type":480,"attrs":481,"content":483},"heading",{"level":482,"textAlign":53},2,[484],{"text":485,"type":305},"What’s inside",{"type":15,"attrs":487,"content":488},{"textAlign":53},[489],{"text":490,"type":305},"This short guide is built around HEC’s new statement on patient safety: “Everyone contributes to patient safety. Together we must learn and act to create safer care and reduce all forms of healthcare harm.”",{"type":15,"attrs":492,"content":493},{"textAlign":53},[494],{"text":495,"type":305},"An explanation of the different components of this statement are provided, supported by discussion questions designed to help you and your team reflect on your efforts to improve patient safety, such as:",{"type":497,"content":498},"bullet_list",[499,507,514,521],{"type":500,"content":501},"list_item",[502],{"type":15,"attrs":503,"content":504},{"textAlign":53},[505],{"text":506,"type":305},"Who do you speak to when you have a safety concern or compliment? How can you create safe spaces for people to talk about safety?",{"type":500,"content":508},[509],{"type":15,"attrs":510,"content":511},{"textAlign":53},[512],{"text":513,"type":305},"How have you approached safety in the past? How might you approach it differently now?",{"type":500,"content":515},[516],{"type":15,"attrs":517,"content":518},{"textAlign":53},[519],{"text":520,"type":305},"How can you encourage the sharing of power among patients, caregivers, communities, providers, staff and leaders to enhance patient safety?",{"type":500,"content":522},[523],{"type":15,"attrs":524,"content":525},{"textAlign":53},[526],{"text":527,"type":305},"How can action on patient safety help reduce health inequities? 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In our toolkit we share practical strategies and resources for you to use to manage incidents effectively and keep your patients safe. We consider patients’ and their families’ needs and concerns, and how to effectively engage them throughout the process.",[76,84],[1112,1141,1154,1180,2879,4677,5004,5143,5190,5595],{"_uid":1113,"content":1114,"component":350},"943e8af8-0f21-4218-8029-2cb2faf66860",[1115],{"_uid":1116,"content":1117,"component":329},"ab554f33-eee7-4276-9299-a948bbb9b394",{"type":12,"content":1118},[1119,1123,1128],{"type":15,"attrs":1120,"content":1121},{"textAlign":53},[1122],{"text":1094,"type":305},{"type":15,"attrs":1124,"content":1125},{"textAlign":53},[1126],{"text":1127,"type":305},"A patient safety incident is defined as an event or circumstance which could have resulted, or did result, in unnecessary harm to a patient. ",{"type":15,"attrs":1129,"content":1130},{"textAlign":53},[1131,1133,1139],{"text":1132,"type":305},"For more information, contact us at ",{"text":1134,"type":305,"marks":1135},"info@hec-esc.ca",[1136],{"type":315,"attrs":1137},{"href":1138,"uuid":53,"anchor":53,"custom":53,"target":53,"linktype":679},"mailto:info@hec-esc.ca",{"text":1140,"type":305},".",{"_uid":1142,"link":1143,"image":1144,"title":16,"video_id":16,"component":722,"media_type":1146,"description":1147,"video_title":16},"dd1a2aa7-8a10-4038-a358-1c88be6e70d2",[],{"id":53,"alt":53,"name":16,"focus":53,"title":53,"source":53,"filename":16,"copyright":53,"fieldtype":289,"meta_data":1145},{},"none",{"type":12,"content":1148},[1149],{"type":15,"attrs":1150,"content":1151},{"textAlign":53},[1152],{"text":1153,"type":305},"We developed this toolkit from the best available evidence and designed it to apply to any program, setting or organization. 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",{"id":16,"_uid":1155,"content":1156,"component":350},"815df81b-8480-4f0e-a92d-93af88bbc8ee",[1157,1171],{"_uid":1158,"content":1159,"component":329},"23d0f0bb-3fba-452b-a649-cf742c6cf4c3",{"type":12,"content":1160},[1161,1166],{"type":480,"attrs":1162,"content":1163},{"level":482,"textAlign":53},[1164],{"text":1165,"type":305},"What This Toolkit Covers",{"type":15,"attrs":1167,"content":1168},{"textAlign":53},[1169],{"text":1170,"type":305},"While patient safety and incident management are the main focus, in the toolkit you will also find some ideas and resources for exploring the broader aspects of quality improvement and risk management.",{"_uid":1172,"image":1173,"component":1179},"53363011-d7bb-44f3-b831-d650c7db7295",{"id":1174,"alt":1175,"name":1176,"focus":16,"title":1175,"source":16,"filename":1177,"copyright":16,"fieldtype":289,"meta_data":1178,"is_external_url":277},114299758337980,"2022 Incidentmanagementdiagram EN","Visual reprensentation of the toolkit: Before the incident: Ensure leadership support, Cultivate a safe and just culture, Develor a plan including resources. Immediate Response: Care for and support patient/family/providers/others, Report incident, Secure items, Begin disclosure process, Reduce risk of imminent recurrence. Prepare for Analysis: Preliminary investigation, Select an analysis method, Identify the team, Coordinate meetings, Plan for/conduct interviews. Analysis Process: Investigate what happened, Understand how and why it happened, Develop and manage recommended actions. Follow Through:  Implement recommended actions, Monitor and assess the effectiveness of actions. Close the Loop: Share learning (internally and externally). 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compliments",[1758],{"type":1205,"attrs":1759},{"color":16},{"type":500,"content":1761},[1762],{"type":15,"attrs":1763,"content":1764},{"textAlign":53},[1765],{"text":1766,"type":305,"marks":1767},"co-design systems and processes",[1768],{"type":1205,"attrs":1769},{"color":16},{"type":500,"content":1771},[1772],{"type":15,"attrs":1773,"content":1774},{"textAlign":53},[1775,1780],{"text":1776,"type":305,"marks":1777},"implement safety and improvement initiatives",[1778],{"type":1205,"attrs":1779},{"color":16},{"text":1209,"type":305},{"type":480,"attrs":1782,"content":1783},{"level":1214,"textAlign":693},[1784],{"text":1785,"type":305,"marks":1786},"Patient safety management: promote teamwork and build capacity",[1787,1789],{"type":1205,"attrs":1788},{"color":16},{"type":555},{"type":497,"content":1791},[1792,1816,1865,1876,1887,1898,1909],{"type":500,"content":1793},[1794],{"type":15,"attrs":1795,"content":1796},{"textAlign":53},[1797,1802,1810,1815],{"text":1798,"type":305,"marks":1799},"Strengthen team functioning and relationships through ",[1800],{"type":1205,"attrs":1801},{"color":16},{"text":1803,"type":305,"marks":1804},"team training",[1805,1808],{"type":315,"attrs":1806},{"href":1807,"uuid":53,"anchor":53,"custom":53,"target":678,"linktype":679},"http://psnet.ahrq.gov/primer.aspx?primerID=8",{"type":1205,"attrs":1809},{"color":16},{"text":1811,"type":305,"marks":1812}," using simulation whenever possible.",[1813],{"type":1205,"attrs":1814},{"color":16},{"text":1209,"type":305},{"type":500,"content":1817},[1818],{"type":15,"attrs":1819,"content":1820},{"textAlign":53},[1821,1826,1834,1839,1847,1851,1859,1864],{"text":1822,"type":305,"marks":1823},"Adopt standardized communication and handoff processes (e.g. ",[1824],{"type":1205,"attrs":1825},{"color":16},{"text":1827,"type":305,"marks":1828},"I-PASS",[1829,1832],{"type":315,"attrs":1830},{"href":1831,"uuid":53,"anchor":53,"custom":53,"target":678,"linktype":679},"http://pediatrics.aappublications.org/content/129/2/201",{"type":1205,"attrs":1833},{"color":16},{"text":1835,"type":305,"marks":1836},", ",[1837],{"type":1205,"attrs":1838},{"color":16},{"text":1840,"type":305,"marks":1841},"SBAR",[1842,1845],{"type":315,"attrs":1843},{"href":1844,"uuid":53,"anchor":53,"custom":53,"target":678,"linktype":679},"http://www.ihi.org/resources/Pages/Tools/SBARToolkit.aspx",{"type":1205,"attrs":1846},{"color":16},{"text":1835,"type":305,"marks":1848},[1849],{"type":1205,"attrs":1850},{"color":16},{"text":1852,"type":305,"marks":1853},"Ask Me 3",[1854,1857],{"type":315,"attrs":1855},{"href":1856,"uuid":53,"anchor":53,"custom":53,"target":678,"linktype":679},"https://www.ihi.org/resources/Pages/Tools/Ask-Me-3-Good-Questions-for-Your-Good-Health.aspx",{"type":1205,"attrs":1858},{"color":16},{"text":1860,"type":305,"marks":1861},").",[1862],{"type":1205,"attrs":1863},{"color":16},{"text":1209,"type":305},{"type":500,"content":1866},[1867],{"type":15,"attrs":1868,"content":1869},{"textAlign":53},[1870,1875],{"text":1871,"type":305,"marks":1872},"Promote team collaboration through interdisciplinary care models, interprofessional learning and team goals that focus on the patient/family needs.",[1873],{"type":1205,"attrs":1874},{"color":16},{"text":1209,"type":305},{"type":500,"content":1877},[1878],{"type":15,"attrs":1879,"content":1880},{"textAlign":53},[1881,1886],{"text":1882,"type":305,"marks":1883},"Encourage and support continuous patient safety conversation between patients/families, frontline staff and leaders.",[1884],{"type":1205,"attrs":1885},{"color":16},{"text":1209,"type":305},{"type":500,"content":1888},[1889],{"type":15,"attrs":1890,"content":1891},{"textAlign":53},[1892,1897],{"text":1893,"type":305,"marks":1894},"Develop multiple strategies that empower staff at all levels to share their concerns (e.g. anonymous reporting system and/or “hot line”) and skills to address hierarchy and power gradient (by using simulation).",[1895],{"type":1205,"attrs":1896},{"color":16},{"text":1209,"type":305},{"type":500,"content":1899},[1900],{"type":15,"attrs":1901,"content":1902},{"textAlign":53},[1903,1908],{"text":1904,"type":305,"marks":1905},"Promote an understanding that systems are complex, dynamic and can fail.",[1906],{"type":1205,"attrs":1907},{"color":16},{"text":1209,"type":305},{"type":500,"content":1910},[1911],{"type":15,"attrs":1912,"content":1913},{"textAlign":53},[1914,1919,1927,1932],{"text":1915,"type":305,"marks":1916},"Engage all team members, including ",[1917],{"type":1205,"attrs":1918},{"color":16},{"text":1920,"type":305,"marks":1921},"patients/families",[1922,1925],{"type":315,"attrs":1923},{"href":1924,"uuid":53,"anchor":53,"custom":53,"target":678,"linktype":679},"http://www.cfhi-fcass.ca/WhatWeDo/PatientEngagement/PatientEngagementResourceHub.aspx",{"type":1205,"attrs":1926},{"color":16},{"text":1928,"type":305,"marks":1929},", in all phases of quality improvement and patient safety initiatives to leverage their expertise.",[1930],{"type":1205,"attrs":1931},{"color":16},{"text":1209,"type":305},{"_uid":1934,"title":1935,"ctaLeft":1936,"ctaRight":1937,"component":1188,"columnLeft":1938,"columnRight":1950},"1066458b-91dc-4bb2-943e-0e5816748b41","Patient Safety Culture",[],[],{"type":12,"content":1939},[1940,1945],{"type":15,"attrs":1941,"content":1942},{"textAlign":53},[1943],{"text":1944,"type":305},"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.  It influences patient safety directly by determining accepted practices and indirectly by acting as a barrier or enabler to the adoption of behaviours that promote patient safety.  Understanding the components and influencers of culture and assessing the safety culture is essential to developing strategies that creates a culture committed to providing the safest possible care for patients. ",{"type":15,"attrs":1946,"content":1947},{"textAlign":53},[1948],{"text":1949,"type":305},"“Culture is tribal; it lives and breathes at provider level and in middle management level. The reality is that there are significant cultural differences between shifts and even team members. Furthermore, a unit’s culture can be influenced – both negatively and positively – by a single individual.” -- Hugh MacLeod, past CEO Canadian Patient Safety Institute (now Healthcare Excellence Canada)",{"type":12,"content":1951},[1952,1959,1966,2035,2042,2115,2122,2187,2194],{"type":15,"attrs":1953,"content":1954},{"textAlign":53},[1955],{"text":1956,"type":305,"marks":1957},"Recommended strategies ",[1958],{"type":555},{"type":15,"attrs":1960,"content":1961},{"textAlign":53},[1962],{"text":1963,"type":305,"marks":1964},"Understand patient safety culture and its components ",[1965],{"type":555},{"type":497,"content":1967},[1968,2012,2019],{"type":500,"content":1969},[1970,1975],{"type":15,"attrs":1971,"content":1972},{"textAlign":53},[1973],{"text":1974,"type":305},"Recognize that patient safety culture is multi-dimensional consisting of a number of features: ",{"type":497,"content":1976},[1977,1984,1991,1998,2005],{"type":500,"content":1978},[1979],{"type":15,"attrs":1980,"content":1981},{"textAlign":53},[1982],{"text":1983,"type":305},"informed culture – relevant safety information is collected, analyzed and actively disseminated ",{"type":500,"content":1985},[1986],{"type":15,"attrs":1987,"content":1988},{"textAlign":53},[1989],{"text":1990,"type":305},"reporting culture – an atmosphere where people have the confidence and feel safe to report safety concerns without fear of blame, and they trust that concerns will be acted upon ",{"type":500,"content":1992},[1993],{"type":15,"attrs":1994,"content":1995},{"textAlign":53},[1996],{"text":1997,"type":305},"learning culture – preventable patient safety incidents are seen as opportunities for learning and changes are made as a result ",{"type":500,"content":1999},[2000],{"type":15,"attrs":2001,"content":2002},{"textAlign":53},[2003],{"text":2004,"type":305},"just culture – the importance of fairly balancing an understanding system failure with professional accountability ",{"type":500,"content":2006},[2007],{"type":15,"attrs":2008,"content":2009},{"textAlign":53},[2010],{"text":2011,"type":305},"flexible culture – people are capable of adapting effectively to changing demands ",{"type":500,"content":2013},[2014],{"type":15,"attrs":2015,"content":2016},{"textAlign":53},[2017],{"text":2018,"type":305},"Understand how culture influences patient safety outcomes directly by determining accepted norms and practices and indirectly by acting as a barrier or enabler to the adoption of interventions designed to promote patient safety. ",{"type":500,"content":2020},[2021],{"type":15,"attrs":2022,"content":2023},{"textAlign":53},[2024,2026,2033],{"text":2025,"type":305},"Appreciate the ",{"text":2027,"type":305,"marks":2028},"interconnection",[2029],{"type":315,"attrs":2030},{"href":2031,"uuid":53,"anchor":53,"custom":2032,"target":678,"linktype":679},"https://www.youtube.com/watch?v=zeldVu-3DpM","[object Object]",{"text":2034,"type":305}," between people, system and culture and how focusing on system improvement and learning, rather than individual performance, drives actions that support patient safety and incident management.",{"type":15,"attrs":2036,"content":2037},{"textAlign":53},[2038],{"text":2039,"type":305,"marks":2040},"Understand key contributors to a patient safety culture ",[2041],{"type":555},{"type":497,"content":2043},[2044,2108],{"type":500,"content":2045},[2046,2051],{"type":15,"attrs":2047,"content":2048},{"textAlign":53},[2049],{"text":2050,"type":305},"Appreciate and understand patient safety culture’s multiple influencers, including: ",{"type":497,"content":2052},[2053,2060,2067,2074,2087,2094,2101],{"type":500,"content":2054},[2055],{"type":15,"attrs":2056,"content":2057},{"textAlign":53},[2058],{"text":2059,"type":305},"leadership and board commitment and ongoing visibility (at the organization and team levels) ",{"type":500,"content":2061},[2062],{"type":15,"attrs":2063,"content":2064},{"textAlign":53},[2065],{"text":2066,"type":305},"patient/family engagement ",{"type":500,"content":2068},[2069],{"type":15,"attrs":2070,"content":2071},{"textAlign":53},[2072],{"text":2073,"type":305},"effectiveness and openness of teamwork and communication ",{"type":500,"content":2075},[2076],{"type":15,"attrs":2077,"content":2078},{"textAlign":53},[2079,2085],{"text":2080,"type":305,"marks":2081},"openness",[2082],{"type":315,"attrs":2083},{"href":2084,"uuid":53,"anchor":53,"custom":2032,"target":320,"linktype":679},"https://www.youtube.com/watch?v=LhoLuui9gX8",{"text":2086,"type":305}," of all team members, including patients/families, in reporting problems and incidents measurement/monitoring and learning from safety and incidents ",{"type":500,"content":2088},[2089],{"type":15,"attrs":2090,"content":2091},{"textAlign":53},[2092],{"text":2093,"type":305},"organizational learning ",{"type":500,"content":2095},[2096],{"type":15,"attrs":2097,"content":2098},{"textAlign":53},[2099],{"text":2100,"type":305},"organizational resources for patient safety ",{"type":500,"content":2102},[2103],{"type":15,"attrs":2104,"content":2105},{"textAlign":53},[2106],{"text":2107,"type":305},"priority of safety versus production ",{"type":500,"content":2109},[2110],{"type":15,"attrs":2111,"content":2112},{"textAlign":53},[2113],{"text":2114,"type":305},"Provide education, training and resources so that everyone is aware of the critical role of culture in patient safety and what they can do to support it. ",{"type":15,"attrs":2116,"content":2117},{"textAlign":53},[2118],{"text":2119,"type":305,"marks":2120},"Assess patient safety culture ",[2121],{"type":555},{"type":497,"content":2123},[2124,2139,2146,2153,2166,2173,2180],{"type":500,"content":2125},[2126],{"type":15,"attrs":2127,"content":2128},{"textAlign":53},[2129,2131,2137],{"text":2130,"type":305},"Determine the best methods and tools to ",{"text":2132,"type":305,"marks":2133},"assess",[2134],{"type":315,"attrs":2135},{"href":2136,"uuid":53,"anchor":53,"custom":53,"target":678,"linktype":679},"https://www.ahrq.gov/sops/index.html",{"text":2138,"type":305}," patient safety culture in the organization, engaging safety and measurement experts whenever possible. ",{"type":500,"content":2140},[2141],{"type":15,"attrs":2142,"content":2143},{"textAlign":53},[2144],{"text":2145,"type":305},"Consider assessing both perceptual indicators (front line staff provide majority of data) and organizational indicators of culture (senior leaders provide majority of data).   ",{"type":500,"content":2147},[2148],{"type":15,"attrs":2149,"content":2150},{"textAlign":53},[2151],{"text":2152,"type":305},"Obtain informed leadership support for the use of patient safety culture measurement tools to ensure an understanding of the resources required, the barriers that may be encountered, and the potential outcomes. ",{"type":500,"content":2154},[2155],{"type":15,"attrs":2156,"content":2157},{"textAlign":53},[2158,2164],{"text":2159,"type":305,"marks":2160},"Engage frontline",[2161],{"type":315,"attrs":2162},{"href":2163,"uuid":53,"anchor":53,"custom":53,"target":678,"linktype":679},"http://www.hopkinsmedicine.org/armstrong_institute/_files/cusp_toolkit_new/Culture-Check-Up-Process.pdf",{"text":2165,"type":305}," caregivers in the planning and implementation of the culture measurement initiative. ",{"type":500,"content":2167},[2168],{"type":15,"attrs":2169,"content":2170},{"textAlign":53},[2171],{"text":2172,"type":305},"Analyze the results and identify opportunities for improvement, mapping to the various patient safety dimensions and influencers. ",{"type":500,"content":2174},[2175],{"type":15,"attrs":2176,"content":2177},{"textAlign":53},[2178],{"text":2179,"type":305},"Communicate the results to key stakeholders in a meaningful way including a timeline for next steps and how improvement actions will be identified. ",{"type":500,"content":2181},[2182],{"type":15,"attrs":2183,"content":2184},{"textAlign":53},[2185],{"text":2186,"type":305},"Understand that patient safety culture measurement is a snapshot in time and that ongoing measurement will be needed to monitor progress. ",{"type":15,"attrs":2188,"content":2189},{"textAlign":53},[2190],{"text":2191,"type":305,"marks":2192},"Develop and implement a patient safety culture strategy ",[2193],{"type":555},{"type":497,"content":2195},[2196,2211,2218,2225,2253],{"type":500,"content":2197},[2198],{"type":15,"attrs":2199,"content":2200},{"textAlign":53},[2201,2203,2209],{"text":2202,"type":305},"Based on the assessment results and environmental factors and with leadership support develop a shared vision and ",{"text":2204,"type":305,"marks":2205},"plan",[2206],{"type":315,"attrs":2207},{"href":2208,"uuid":53,"anchor":53,"custom":53,"target":678,"linktype":679},"https://bcpsqc.ca/wp-content/uploads/2018/03/culture-toolkit_web.pdf",{"text":2210,"type":305}," for improving patient safety culture.   ",{"type":500,"content":2212},[2213],{"type":15,"attrs":2214,"content":2215},{"textAlign":53},[2216],{"text":2217,"type":305},"Identify potential opportunities to implement the plan as well as barriers along with corresponding mitigating strategies. ",{"type":500,"content":2219},[2220],{"type":15,"attrs":2221,"content":2222},{"textAlign":53},[2223],{"text":2224,"type":305},"Address patient safety culture gaps and weaknesses at the organizational and unit/program/service (micro-system) level recognizing that in the same organization culture can be different across units and even between shifts. ",{"type":500,"content":2226},[2227,2237],{"type":15,"attrs":2228,"content":2229},{"textAlign":53},[2230,2235],{"text":2231,"type":305,"marks":2232},"Partner with patients",[2233],{"type":315,"attrs":2234},{"href":1735,"uuid":53,"anchor":53,"custom":53,"target":678,"linktype":679},{"text":2236,"type":305}," and families in patient safety: ",{"type":497,"content":2238},[2239,2246],{"type":500,"content":2240},[2241],{"type":15,"attrs":2242,"content":2243},{"textAlign":53},[2244],{"text":2245,"type":305},"empower them to be active participants in their care by encouraging them to speak up, participate in shared decision-making and the development of personalized care plans ",{"type":500,"content":2247},[2248],{"type":15,"attrs":2249,"content":2250},{"textAlign":53},[2251],{"text":2252,"type":305},"engage them in the design of care models, care processes and quality improvement/patient safety initiatives ",{"type":500,"content":2254},[2255,2266],{"type":15,"attrs":2256,"content":2257},{"textAlign":53},[2258,2264],{"text":2259,"type":305,"marks":2260},"Partner with providers",[2261],{"type":315,"attrs":2262},{"href":2263,"uuid":53,"anchor":53,"custom":53,"target":678,"linktype":679},"http://www.liberatingstructures.com/fs2/",{"text":2265,"type":305}," in patient safety:",{"type":497,"content":2267},[2268,2275,2282,2289,2296],{"type":500,"content":2269},[2270],{"type":15,"attrs":2271,"content":2272},{"textAlign":53},[2273],{"text":2274,"type":305},"develop multiple strategies that empower staff at all levels to share their concerns and speak up (e.g. anonymous incident reporting system, team training that addresses the authority gradient, safety huddles, anonymous email or telephone “hot line” where staff can share concerns) ",{"type":500,"content":2276},[2277],{"type":15,"attrs":2278,"content":2279},{"textAlign":53},[2280],{"text":2281,"type":305},"engage staff in all phases of quality improvement and patient safety initiatives to leverage their expertise ",{"type":500,"content":2283},[2284],{"type":15,"attrs":2285,"content":2286},{"textAlign":53},[2287],{"text":2288,"type":305},"a successful patient safety strategy leads to frontline ownership of local issues and challenges and enables clinicians and providers to action their own solutions ",{"type":500,"content":2290},[2291],{"type":15,"attrs":2292,"content":2293},{"textAlign":53},[2294],{"text":2295,"type":305},"design communication systems that allow for a continuous patient safety conversation between frontline staff and leaders ",{"type":500,"content":2297},[2298],{"type":15,"attrs":2299},{"textAlign":53},{"_uid":2301,"title":2302,"ctaLeft":2303,"ctaRight":2304,"component":1188,"columnLeft":2305,"columnRight":2317},"36d257db-403a-495b-8d69-77e5d56ad80a","Reporting and Learning Systems",[],[],{"type":12,"content":2306},[2307,2312],{"type":15,"attrs":2308,"content":2309},{"textAlign":53},[2310],{"text":2311,"type":305},"Reporting systems (frequently referred to as reporting and learning systems) capture patient safety concerns, hazards and/or incidents and are meant to trigger action, facilitate communication, response, learning and improvement. Establishing a reporting system and processes to support it, including identifying and spreading learning, is foundational to patient safety and incident management and essential to advancing a patient safety culture. ",{"type":15,"attrs":2313,"content":2314},{"textAlign":53},[2315],{"text":2316,"type":305},"“To close the safety gaps in my hospital, first I need to know where they are. Reporting systems serve as a map to show us where the gaps are and guide us in how to close them.” -- Toolkit Faculty ",{"type":12,"content":2318},[2319,2330,2339,2613,2625,2765,2777],{"type":480,"attrs":2320,"content":2321},{"level":482,"textAlign":693},[2322,2327],{"text":1202,"type":305,"marks":2323},[2324,2326],{"type":1205,"attrs":2325},{"color":16},{"type":555},{"text":1209,"type":305,"marks":2328},[2329],{"type":555},{"type":480,"attrs":2331,"content":2332},{"level":1214,"textAlign":693},[2333],{"text":2334,"type":305,"marks":2335},"Establish a reporting system",[2336,2338],{"type":1205,"attrs":2337},{"color":16},{"type":555},{"type":497,"content":2340},[2341,2365,2388,2412,2436,2447],{"type":500,"content":2342},[2343],{"type":15,"attrs":2344,"content":2345},{"textAlign":53},[2346,2351,2359,2364],{"text":2347,"type":305,"marks":2348},"Capture information about hazards, patient safety concerns, incidents and near misses, typically by completing a standardized ",[2349],{"type":1205,"attrs":2350},{"color":16},{"text":2352,"type":305,"marks":2353},"electronic",[2354,2357],{"type":315,"attrs":2355},{"href":2356,"uuid":53,"anchor":53,"custom":53,"target":678,"linktype":679},"https://psrs.arc.nasa.gov/web_docs/PSRS_ExampleForm.pdf",{"type":1205,"attrs":2358},{"color":16},{"text":2360,"type":305,"marks":2361}," or paper form",[2362],{"type":1205,"attrs":2363},{"color":16},{"text":1209,"type":305},{"type":500,"content":2366},[2367],{"type":15,"attrs":2368,"content":2369},{"textAlign":53},[2370,2375,2383,2387],{"text":2371,"type":305,"marks":2372},"Consider establishing alternate reporting mechanisms such as telephone or verbal, particularly for incidents with a high potential for harm to ensure timely response (e.g. ",[2373],{"type":1205,"attrs":2374},{"color":16},{"text":2376,"type":305,"marks":2377},"stop the line",[2378,2381],{"type":315,"attrs":2379},{"href":2380,"uuid":53,"anchor":53,"custom":53,"target":678,"linktype":679},"https://www.youtube.com/watch?v=y3j3CErXXH8",{"type":1205,"attrs":2382},{"color":16},{"text":1668,"type":305,"marks":2384},[2385],{"type":1205,"attrs":2386},{"color":16},{"text":1209,"type":305},{"type":500,"content":2389},[2390],{"type":15,"attrs":2391,"content":2392},{"textAlign":53},[2393,2398,2406,2411],{"text":2394,"type":305,"marks":2395},"Compared to those that are mandatory, ",[2396],{"type":1205,"attrs":2397},{"color":16},{"text":2399,"type":305,"marks":2400},"voluntary",[2401,2404],{"type":315,"attrs":2402},{"href":2403,"uuid":53,"anchor":53,"custom":53,"target":678,"linktype":679},"http://psnet.ahrq.gov/primer.aspx?primerID=13",{"type":1205,"attrs":2405},{"color":16},{"text":2407,"type":305,"marks":2408}," (non-legislated) reporting systems have been shown to facilitate greater reporting and learning",[2409],{"type":1205,"attrs":2410},{"color":16},{"text":1209,"type":305},{"type":500,"content":2413},[2414],{"type":15,"attrs":2415,"content":2416},{"textAlign":53},[2417,2422,2430,2435],{"text":2418,"type":305,"marks":2419},"Empower and support reporting by all care participants, including the ",[2420],{"type":1205,"attrs":2421},{"color":16},{"text":2423,"type":305,"marks":2424},"patient/family",[2425,2428],{"type":315,"attrs":2426},{"href":2427,"uuid":53,"anchor":53,"custom":53,"target":678,"linktype":679},"http://www.safemedicationuse.ca/report/",{"type":1205,"attrs":2429},{"color":16},{"text":2431,"type":305,"marks":2432},", by ensuring they can access the system",[2433],{"type":1205,"attrs":2434},{"color":16},{"text":1209,"type":305},{"type":500,"content":2437},[2438],{"type":15,"attrs":2439,"content":2440},{"textAlign":53},[2441,2446],{"text":2442,"type":305,"marks":2443},"Engage the users, including patients/families, in developing and maintaining the 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In this section, the resources guide you in planning, anticipating and monitoring your response to expected and unexpected safety issues, for safer care today and in the future. We promote a patient safety culture and reporting and learning system.",{"_uid":2880,"items":2881,"title":4669,"component":2871,"description":4670},"dbcbd30a-a82c-4049-938e-c2ffda9de3ed",[2882,3146,3642,3945,4171,4354,4606],{"_uid":2883,"title":2884,"ctaLeft":2885,"ctaRight":2886,"component":1188,"columnLeft":2893,"columnRight":2905},"ea6233ec-ed14-4652-a620-6da1204cf369","Immediate Response",[],[2887],{"_uid":2888,"link":2889,"label":2891,"component":2892},"5fc66b57-c0c0-45c9-9c59-f5d2148ded13",{"id":16,"url":2890,"target":678,"linktype":679,"fieldtype":338,"cached_url":2890},"https://youtu.be/p44wxk7BL20","The Impact of Disclosure: Second Victim of Harm","simple-link-only",{"type":12,"content":2894},[2895,2900],{"type":15,"attrs":2896,"content":2897},{"textAlign":53},[2898],{"text":2899,"type":305},"The 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. 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",[2941],{"type":555},{"type":497,"content":2943},[2944,2951,2958,2965,2979],{"type":500,"content":2945},[2946],{"type":15,"attrs":2947,"content":2948},{"textAlign":53},[2949],{"text":2950,"type":305},"First and foremost, address the immediate clinical needs of the patient(s) involved in the incident ",{"type":500,"content":2952},[2953],{"type":15,"attrs":2954,"content":2955},{"textAlign":53},[2956],{"text":2957,"type":305},"Attend to the immediate emotional needs of patient(s) and/or family involved in the incident including acknowledgement of the event, empathy, and support ",{"type":500,"content":2959},[2960],{"type":15,"attrs":2961,"content":2962},{"textAlign":53},[2963],{"text":2964,"type":305},"Ensure that other patients, families and visitors impacted by the incident are cared for, including support for their ongoing clinical needs ",{"type":500,"content":2966},[2967],{"type":15,"attrs":2968,"content":2969},{"textAlign":53},[2970,2972],{"text":2971,"type":305},"Attend to the safety and well-being of care providers(s) involved in the incident as needed, including arranging for coverage of duties, facilitating access to counselling, and providing peer ",{"text":2973,"type":305,"marks":2974},"support",[2975],{"type":315,"attrs":2976},{"href":2977,"uuid":53,"anchor":53,"custom":2978,"target":678,"linktype":679},"http://www.healthpei.ca/src/CISS",{},{"type":500,"content":2980},[2981],{"type":15,"attrs":2982,"content":2983},{"textAlign":53},[2984,2991],{"text":2985,"type":305,"marks":2986},"Document",[2987],{"type":315,"attrs":2988},{"href":2989,"uuid":53,"anchor":53,"custom":2990,"target":678,"linktype":679},"https://www.cmpa-acpm.ca/serve/docs/ela/goodpracticesguide/pages/communication/communication-e.html",{},{"text":2992,"type":305}," facts in the patient’s health record as soon as possible in accordance with professional standards and organizational policies ",{"type":15,"attrs":2994,"content":2995},{"textAlign":53},[2996],{"text":2997,"type":305,"marks":2998},"Make the environment and surroundings safe. ",[2999],{"type":555},{"type":497,"content":3001},[3002,3009],{"type":500,"content":3003},[3004],{"type":15,"attrs":3005,"content":3006},{"textAlign":53},[3007],{"text":3008,"type":305},"Institute measures to reduce the risk of imminent recurrence or other potential threats, such as removing  potentially harmful medications, equipment or other hazards ",{"type":500,"content":3010},[3011],{"type":15,"attrs":3012,"content":3013},{"textAlign":53},[3014],{"text":3015,"type":305},"Alert others, such other areas within the organization or other institutions, to risks that extend beyond the local environment",{"type":15,"attrs":3017,"content":3018},{"textAlign":53},[3019],{"text":3020,"type":305,"marks":3021},"Secure items related to the event that may need to be assessed as part of the incident analysis. ",[3022],{"type":555},{"type":497,"content":3024},[3025,3032,3039,3046],{"type":500,"content":3026},[3027],{"type":15,"attrs":3028,"content":3029},{"textAlign":53},[3030],{"text":3031,"type":305},"Items to be secured can include biomedical equipment, intravenous solutions, medications, packaging, garments, linens, technology, video recordings, etc. ",{"type":500,"content":3033},[3034],{"type":15,"attrs":3035,"content":3036},{"textAlign":53},[3037],{"text":3038,"type":305},"Label and secure items in a protected environment with restricted access ",{"type":500,"content":3040},[3041],{"type":15,"attrs":3042,"content":3043},{"textAlign":53},[3044],{"text":3045,"type":305},"As directed by organizational policies, secure the health record and provide a copy to care providers if the patient is receiving ongoing care ",{"type":500,"content":3047},[3048],{"type":15,"attrs":3049,"content":3050},{"textAlign":53},[3051],{"text":3052,"type":305},"Photograph the items and the area where the incident occurred when appropriate as this may prove to be helpful in the review process ",{"type":15,"attrs":3054,"content":3055},{"textAlign":53},[3056],{"text":3057,"type":305,"marks":3058},"Report the incident and ensure appropriate notifications. ",[3059],{"type":555},{"type":497,"content":3061},[3062,3069,3076],{"type":500,"content":3063},[3064],{"type":15,"attrs":3065,"content":3066},{"textAlign":53},[3067],{"text":3068,"type":305},"Report the incident in accordance with organizational processes to trigger appropriate notifications and determine next steps in the incident management process ",{"type":500,"content":3070},[3071],{"type":15,"attrs":3072,"content":3073},{"textAlign":53},[3074],{"text":3075,"type":305},"Notify the attending physician and unit manager and consider others including the leadership team, risk management and public relations in accordance with organizational policy ",{"type":500,"content":3077},[3078],{"type":15,"attrs":3079,"content":3080},{"textAlign":53},[3081,3083],{"text":3082,"type":305},"Initiate external notifications as required and depending on the nature of the event, organizational policy and governing legislation; this may include the coroner/medical examiner, Ministry of Health, insurers, and the ",{"text":3084,"type":305,"marks":3085},"media",[3086],{"type":315,"attrs":3087},{"href":3088,"uuid":53,"anchor":53,"custom":3089,"target":320,"linktype":289},"https://a-ca.storyblok.com/f/850807391887861/8b4421ff49/guidelines-for-informing-the-media-checklist-immediate-response-final-uae.pdf",{},{"type":15,"attrs":3091,"content":3092},{"textAlign":53},[3093],{"text":3094,"type":305,"marks":3095},"Begin disclosure. ",[3096],{"type":555},{"type":497,"content":3098},[3099,3106,3113],{"type":500,"content":3100},[3101],{"type":15,"attrs":3102,"content":3103},{"textAlign":53},[3104],{"text":3105,"type":305},"Begin the disclosure process with the patient and family as soon as reasonably possible ",{"type":500,"content":3107},[3108],{"type":15,"attrs":3109,"content":3110},{"textAlign":53},[3111],{"text":3112,"type":305},"Consider adapting the process to fit patient/family needs ",{"type":500,"content":3114},[3115],{"type":15,"attrs":3116,"content":3117},{"textAlign":53},[3118],{"text":3119,"type":305},"Document the disclosure discussion in accordance with organizational policies",{"type":15,"attrs":3121,"content":3122},{"textAlign":53},[3123],{"text":3124,"type":305,"marks":3125},"Ongoing support ",[3126],{"type":555},{"type":497,"content":3128},[3129],{"type":500,"content":3130},[3131],{"type":15,"attrs":3132,"content":3133},{"textAlign":53},[3134],{"text":3135,"type":305},"Begin to create a plan to provide support and information to patients/families, providers, and others as appropriate. ",{"type":15,"attrs":3137,"content":3138},{"textAlign":53},[3139],{"text":3140,"type":305,"marks":3141},"Download a transcript of \"The Impact of Disclosure: Second Victim of Harm\" video.",[3142],{"type":315,"attrs":3143},{"href":3144,"uuid":53,"anchor":53,"custom":3145,"target":320,"linktype":289},"https://a-ca.storyblok.com/f/850807391887861/17a7f26aba/transcript-the-impact-of-disclosure-second-victim-of-harm-en.pdf",{},{"_uid":3147,"title":3148,"ctaLeft":3149,"ctaRight":3150,"component":1188,"columnLeft":3151,"columnRight":3173},"2a750193-9a19-4512-9486-25cffa35731c","Disclosure",[],[],{"type":12,"content":3152},[3153,3158,3163,3168],{"type":15,"attrs":3154,"content":3155},{"textAlign":53},[3156],{"text":3157,"type":305},"Disclosure is a formal process involving open discussion between a patient/family and members of a healthcare organization about a patient safety incident (including near misses). Disclosure provides the means for dialogue throughout the incident management process, supports patient safety improvement and promotes healing for the patients/families and providers involved.  ",{"type":15,"attrs":3159,"content":3160},{"textAlign":53},[3161],{"text":3162,"type":305},"It generally occurs in two broad stages (initial and post-analysis) and is an ongoing process in which multiple disclosure conversations occur over time.  ",{"type":15,"attrs":3164,"content":3165},{"textAlign":53},[3166],{"text":3167,"type":305},"“…It made me feel that I could trust my provider because, I mean she took responsibility… had remorse about what happened.  She wasn’t defensive.” -- A family member ",{"type":15,"attrs":3169,"content":3170},{"textAlign":53},[3171],{"text":3172,"type":305},"“I wasn’t allowed to be a part of the disclosure process, I needed to see the family of the boy who died; I needed to say: ‘I’m sorry.’  I’ll always wonder if they know how sorry I am and how it changed my practice.”  -- A healthcare provider ",{"type":12,"content":3174},[3175,3182,3189,3196,3327,3334,3341,3415,3422,3568,3575],{"type":15,"attrs":3176,"content":3177},{"textAlign":53},[3178],{"text":3179,"type":305,"marks":3180},"Recommended Strategies ",[3181],{"type":555},{"type":15,"attrs":3183,"content":3184},{"textAlign":53},[3185],{"text":3186,"type":305,"marks":3187},"Before an incident ",[3188],{"type":555},{"type":15,"attrs":3190,"content":3191},{"textAlign":53},[3192],{"text":3193,"type":305,"marks":3194},"Confirm that organizational processes support disclosure ",[3195],{"type":555},{"type":497,"content":3197},[3198,3205,3306,3313,3320],{"type":500,"content":3199},[3200],{"type":15,"attrs":3201,"content":3202},{"textAlign":53},[3203],{"text":3204,"type":305},"Establish guiding principles for disclosure (e.g. patient-centred healthcare, patient autonomy, honesty and transparency, patient safety, just culture, learning and improvement). ",{"type":500,"content":3206},[3207,3212],{"type":15,"attrs":3208,"content":3209},{"textAlign":53},[3210],{"text":3211,"type":305},"Develop disclosure policies, procedures and tools aligned with the organization’s guiding principles, disciplinary/accountability systems, legislation, regulatory/licensing requirements, and best practices that: ",{"type":497,"content":3213},[3214,3221,3255,3270,3277,3292,3299],{"type":500,"content":3215},[3216],{"type":15,"attrs":3217,"content":3218},{"textAlign":53},[3219],{"text":3220,"type":305},"involve patients/ families and frontline staff in their development ",{"type":500,"content":3222},[3223],{"type":15,"attrs":3224,"content":3225},{"textAlign":53},[3226,3228,3236,3238,3244,3246,3253],{"text":3227,"type":305},"articulate ",{"text":3229,"type":305,"marks":3230},"when",[3231],{"type":315,"attrs":3232},{"href":3233,"uuid":3234,"anchor":53,"custom":3235,"target":320,"linktype":321},"/resources/canadian-disclosure-guidelines","f0212af6-3223-4b78-a9df-6c8367a0e422",{},{"text":3237,"type":305}," and where disclosure should take place and ",{"text":3239,"type":305,"marks":3240},"how",[3241],{"type":315,"attrs":3242},{"href":3233,"uuid":3234,"anchor":53,"custom":3243,"target":320,"linktype":321},{},{"text":3245,"type":305}," it should be ",{"text":3247,"type":305,"marks":3248},"conducted",[3249],{"type":315,"attrs":3250},{"href":3251,"uuid":53,"anchor":53,"custom":3252,"target":678,"linktype":679},"https://d10k7k7mywg42z.cloudfront.net/assets/5317823e4f720a21df0001ce/HQCA_checklist_FINAL.pdf",{},{"text":3254,"type":305}," ",{"type":500,"content":3256},[3257],{"type":15,"attrs":3258,"content":3259},{"textAlign":53},[3260,3262,3268],{"text":3261,"type":305},"include supports and ",{"text":361,"type":305,"marks":3263},[3264],{"type":315,"attrs":3265},{"href":3266,"uuid":53,"anchor":53,"custom":3267,"target":678,"linktype":679},"http://www.safetyandquality.gov.au/our-work/open-disclosure/implementing-the-open-disclosure-framework/open-disclosure-resources-for-clinicians-and-health-care-providers/",{},{"text":3269,"type":305}," available to the patient/family and healthcare providers ",{"type":500,"content":3271},[3272],{"type":15,"attrs":3273,"content":3274},{"textAlign":53},[3275],{"text":3276,"type":305},"provide guidance on how to deal with the media in the event of a public disclosure ",{"type":500,"content":3278},[3279],{"type":15,"attrs":3280,"content":3281},{"textAlign":53},[3282,3284,3290],{"text":3283,"type":305},"incorporate processes that address ",{"text":3285,"type":305,"marks":3286},"special circumstances",[3287],{"type":315,"attrs":3288},{"href":3233,"uuid":3234,"anchor":53,"custom":3289,"target":320,"linktype":321},{},{"text":3291,"type":305}," such as multi-patient disclosures, paediatric patients or those with mental health issues, or incidents related to research ",{"type":500,"content":3293},[3294],{"type":15,"attrs":3295,"content":3296},{"textAlign":53},[3297],{"text":3298,"type":305},"are easily accessible to all, including frontline staff and patients/families (e.g. public site) ",{"type":500,"content":3300},[3301],{"type":15,"attrs":3302,"content":3303},{"textAlign":53},[3304],{"text":3305,"type":305},"are updated regularly to ensure relevance and alignment with other policies and current context ",{"type":500,"content":3307},[3308],{"type":15,"attrs":3309,"content":3310},{"textAlign":53},[3311],{"text":3312,"type":305},"Provide disclosure training programs and educational resources for staff and patients/families. ",{"type":500,"content":3314},[3315],{"type":15,"attrs":3316,"content":3317},{"textAlign":53},[3318],{"text":3319,"type":305},"Allocate resources to assist patients/families involved in patient safety incidents, ensuring they are available without delay (e.g. practical, emotional, financial). ",{"type":500,"content":3321},[3322],{"type":15,"attrs":3323,"content":3324},{"textAlign":53},[3325],{"text":3326,"type":305},"Allocate resources to assist staff at the frontline involved in patient safety incidents as needed, including disclosure support and coaching. ",{"type":15,"attrs":3328,"content":3329},{"textAlign":53},[3330],{"text":3331,"type":305,"marks":3332},"After an incident ",[3333],{"type":555},{"type":15,"attrs":3335,"content":3336},{"textAlign":53},[3337],{"text":3338,"type":305,"marks":3339},"Develop a specific disclosure plan ",[3340],{"type":555},{"type":497,"content":3342},[3343,3350,3408],{"type":500,"content":3344},[3345],{"type":15,"attrs":3346,"content":3347},{"textAlign":53},[3348],{"text":3349,"type":305},"After caring for the immediate needs of the patient/family and providers, develop a customized disclosure plan specific to the incident and the ongoing needs of those involved. ",{"type":500,"content":3351},[3352,3357],{"type":15,"attrs":3353,"content":3354},{"textAlign":53},[3355],{"text":3356,"type":305},"If possible, conduct a pre-disclosure team huddle to determine the best approach, including: ",{"type":497,"content":3358},[3359,3366,3373,3380,3387,3394,3401],{"type":500,"content":3360},[3361],{"type":15,"attrs":3362,"content":3363},{"textAlign":53},[3364],{"text":3365,"type":305},"when the initial disclosure will occur taking into consideration patient/family readiness and preferences ",{"type":500,"content":3367},[3368],{"type":15,"attrs":3369,"content":3370},{"textAlign":53},[3371],{"text":3372,"type":305},"where the disclosure will take place, preferably a private area that is free of interruptions or off-site if indicated ",{"type":500,"content":3374},[3375],{"type":15,"attrs":3376,"content":3377},{"textAlign":53},[3378],{"text":3379,"type":305},"what information will be shared with the patient/family, including confirmation of the known undisputed facts ",{"type":500,"content":3381},[3382],{"type":15,"attrs":3383,"content":3384},{"textAlign":53},[3385],{"text":3386,"type":305},"who is the best person to initiate disclosure and coordinate the ongoing disclosure ",{"type":500,"content":3388},[3389],{"type":15,"attrs":3390,"content":3391},{"textAlign":53},[3392],{"text":3393,"type":305},"how the care providers involved in the incident will be supported ",{"type":500,"content":3395},[3396],{"type":15,"attrs":3397,"content":3398},{"textAlign":53},[3399],{"text":3400,"type":305},"how the patient/family will be supported and their questions/concerns addressed ",{"type":500,"content":3402},[3403],{"type":15,"attrs":3404,"content":3405},{"textAlign":53},[3406],{"text":3407,"type":305},"how disclosure will be documented ",{"type":500,"content":3409},[3410],{"type":15,"attrs":3411,"content":3412},{"textAlign":53},[3413],{"text":3414,"type":305},"Inquire with the patient/family who will attend the meeting, encourage the patient/family not to attend alone (e.g. other family members, friends, translator, spiritual support), and ask if the patient/family have preferences on who should attend or not attend from the care team. ",{"type":15,"attrs":3416,"content":3417},{"textAlign":53},[3418],{"text":3419,"type":305,"marks":3420},"Initiate initial disclosure ",[3421],{"type":555},{"type":497,"content":3423},[3424,3431,3438,3445,3452,3459,3489,3496,3503,3510,3517,3524],{"type":500,"content":3425},[3426],{"type":15,"attrs":3427,"content":3428},{"textAlign":53},[3429],{"text":3430,"type":305},"Use language and terminology that the patient/family can easily understand. Avoid speculation or blame. ",{"type":500,"content":3432},[3433],{"type":15,"attrs":3434,"content":3435},{"textAlign":53},[3436],{"text":3437,"type":305},"Introduce the participants to the patient/family, including their functions and reasons for attendance. ",{"type":500,"content":3439},[3440],{"type":15,"attrs":3441,"content":3442},{"textAlign":53},[3443],{"text":3444,"type":305},"Acknowledge the incident or that something unexpected has happened and express apology using the words ‘I’m sorry’. ",{"type":500,"content":3446},[3447],{"type":15,"attrs":3448,"content":3449},{"textAlign":53},[3450],{"text":3451,"type":305},"Provide an overview of how the meeting will run and ask how the patient/family would like to participate. ",{"type":500,"content":3453},[3454],{"type":15,"attrs":3455,"content":3456},{"textAlign":53},[3457],{"text":3458,"type":305},"Ask about concerns and questions the patient/family would like to discuss and offer support or resources if needed. ",{"type":500,"content":3460},[3461,3466],{"type":15,"attrs":3462,"content":3463},{"textAlign":53},[3464],{"text":3465,"type":305},"Share the following information: ",{"type":497,"content":3467},[3468,3475,3482],{"type":500,"content":3469},[3470],{"type":15,"attrs":3471,"content":3472},{"textAlign":53},[3473],{"text":3474,"type":305},"the currently known facts of the incident ",{"type":500,"content":3476},[3477],{"type":15,"attrs":3478,"content":3479},{"textAlign":53},[3480],{"text":3481,"type":305},"the steps for ensuring the ongoing care and well-being of the patient (e.g. clinical care, treatment) ",{"type":500,"content":3483},[3484],{"type":15,"attrs":3485,"content":3486},{"textAlign":53},[3487],{"text":3488,"type":305},"a brief overview of the incident analysis process including expected timelines and what the patient/family can expect during the process ",{"type":500,"content":3490},[3491],{"type":15,"attrs":3492,"content":3493},{"textAlign":53},[3494],{"text":3495,"type":305},"Offer the patient/family an opportunity to speak about their experience and ask questions. ",{"type":500,"content":3497},[3498],{"type":15,"attrs":3499,"content":3500},{"textAlign":53},[3501],{"text":3502,"type":305},"Ask about preferences for future involvement and information (how, when, where). ",{"type":500,"content":3504},[3505],{"type":15,"attrs":3506,"content":3507},{"textAlign":53},[3508],{"text":3509,"type":305},"Ask the patient/family to identify a contact person. ",{"type":500,"content":3511},[3512],{"type":15,"attrs":3513,"content":3514},{"textAlign":53},[3515],{"text":3516,"type":305},"Designate a key contact person from the organization who will provide regular updates. ",{"type":500,"content":3518},[3519],{"type":15,"attrs":3520,"content":3521},{"textAlign":53},[3522],{"text":3523,"type":305},"Provide practical and emotional support (e.g. spiritual care services, counselling, social work, family arrangements, reimbursement of expenses associated with the disclosure process). ",{"type":500,"content":3525},[3526,3531],{"type":15,"attrs":3527,"content":3528},{"textAlign":53},[3529],{"text":3530,"type":305},"Document the disclosure discussion in accordance with organizational policies. Include: ",{"type":497,"content":3532},[3533,3540,3547,3554,3561],{"type":500,"content":3534},[3535],{"type":15,"attrs":3536,"content":3537},{"textAlign":53},[3538],{"text":3539,"type":305},"the time, place, date, the names and relationships of all attendees ",{"type":500,"content":3541},[3542],{"type":15,"attrs":3543,"content":3544},{"textAlign":53},[3545],{"text":3546,"type":305},"the facts presented ",{"type":500,"content":3548},[3549],{"type":15,"attrs":3550,"content":3551},{"textAlign":53},[3552],{"text":3553,"type":305},"offers of assistance made and the response, questions raised and the answers given ",{"type":500,"content":3555},[3556],{"type":15,"attrs":3557,"content":3558},{"textAlign":53},[3559],{"text":3560,"type":305},"patient/family preferences about future disclosure discussions ",{"type":500,"content":3562},[3563],{"type":15,"attrs":3564,"content":3565},{"textAlign":53},[3566],{"text":3567,"type":305},"plans for follow-up and key contact information for the organization and the patient/family ",{"type":15,"attrs":3569,"content":3570},{"textAlign":53},[3571],{"text":3572,"type":305,"marks":3573},"Continue disclosure throughout the incident management process as needed ",[3574],{"type":555},{"type":497,"content":3576},[3577,3621,3628,3635],{"type":500,"content":3578},[3579,3584],{"type":15,"attrs":3580,"content":3581},{"textAlign":53},[3582],{"text":3583,"type":305},"Continue to be engaged with the patient/family according to their preferences: ",{"type":497,"content":3585},[3586,3593,3600,3607,3614],{"type":500,"content":3587},[3588],{"type":15,"attrs":3589,"content":3590},{"textAlign":53},[3591],{"text":3592,"type":305},"continue to offer practical and emotional support ",{"type":500,"content":3594},[3595],{"type":15,"attrs":3596,"content":3597},{"textAlign":53},[3598],{"text":3599,"type":305},"transparently correct any incorrect or incomplete information that was provided in previous disclosure meetings ",{"type":500,"content":3601},[3602],{"type":15,"attrs":3603,"content":3604},{"textAlign":53},[3605],{"text":3606,"type":305},"provide new factual information as it becomes available ",{"type":500,"content":3608},[3609],{"type":15,"attrs":3610,"content":3611},{"textAlign":53},[3612],{"text":3613,"type":305},"offer a further apology which might include an acknowledgement of responsibility for what happened as appropriate and in accordance with organizational policies and applicable legislation ",{"type":500,"content":3615},[3616],{"type":15,"attrs":3617,"content":3618},{"textAlign":53},[3619],{"text":3620,"type":305},"describe any actions that are taken as result of the internal analysis such as system improvements in accordance with organizational policies and applicable legislation ",{"type":500,"content":3622},[3623],{"type":15,"attrs":3624,"content":3625},{"textAlign":53},[3626],{"text":3627,"type":305},"Continue to offer updates, and practical and emotional support for providers. ",{"type":500,"content":3629},[3630],{"type":15,"attrs":3631,"content":3632},{"textAlign":53},[3633],{"text":3634,"type":305},"Ensure providers maintain involvement in the disclosure process as appropriate, particularly if leadership takes on a larger role in the post analysis stage. ",{"type":500,"content":3636},[3637],{"type":15,"attrs":3638,"content":3639},{"textAlign":53},[3640],{"text":3641,"type":305},"Continue to document disclosure discussions per organizational policies. ",{"_uid":3643,"title":3644,"ctaLeft":3645,"ctaRight":3646,"component":1188,"columnLeft":3647,"columnRight":3654},"3ea60bef-a57a-42cc-bbc1-cc4d690feb8f","Prepare for Analysis",[],[],{"type":12,"content":3648},[3649],{"type":15,"attrs":3650,"content":3651},{"textAlign":53},[3652],{"text":3653,"type":305},"Preparing 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.",{"type":12,"content":3655},[3656,3662,3667,3674,3730,3737,3776,3783,3827,3834,3864,3871],{"type":15,"attrs":3657,"content":3658},{"textAlign":53},[3659],{"text":1956,"type":305,"marks":3660},[3661],{"type":555},{"type":15,"attrs":3663,"content":3664},{"textAlign":53},[3665],{"text":3666,"type":305},"Refer to your organization’s policies, procedures and jurisdictional requirements when implementing these steps. ",{"type":15,"attrs":3668,"content":3669},{"textAlign":53},[3670],{"text":3671,"type":305,"marks":3672},"Conduct a preliminary investigation. ",[3673],{"type":555},{"type":497,"content":3675},[3676,3683,3699,3706],{"type":500,"content":3677},[3678],{"type":15,"attrs":3679,"content":3680},{"textAlign":53},[3681],{"text":3682,"type":305},"Determine the most appropriate person to conduct the initial review and data gathering. Someone with formal incident analysis and patient safety training and/or accountability for patient safety is recommended",{"type":500,"content":3684},[3685],{"type":15,"attrs":3686,"content":3687},{"textAlign":53},[3688,3690,3697],{"text":3689,"type":305},"Create a high level ",{"text":3691,"type":305,"marks":3692},"timeline",[3693],{"type":315,"attrs":3694},{"href":3695,"uuid":53,"anchor":53,"custom":3696,"target":678,"linktype":679},"https://view.officeapps.live.com/op/view.aspx?src=https%3A%2F%2Fwww.england.nhs.uk%2Fwp-content%2Fuploads%2F2020%2F08%2FPSII_incident_investigation_mapping_worksheet.xls&wdOrigin=BROWSELINK",{},{"text":3698,"type":305}," and document the known facts related to the incident from currently available sources such as the incident report, the patient’s health record, and other documentation",{"type":500,"content":3700},[3701],{"type":15,"attrs":3702,"content":3703},{"textAlign":53},[3704],{"text":3705,"type":305},"If appropriate, find out whether similar incidents or analyses have previously taken place within the organization and beyond to learn from their experience and approach",{"type":500,"content":3707},[3708],{"type":15,"attrs":3709,"content":3710},{"textAlign":53},[3711,3713,3720,3722,3728],{"text":3712,"type":305},"Offer ",{"text":3714,"type":305,"marks":3715},"ongoing support",[3716],{"type":315,"attrs":3717},{"href":3718,"uuid":53,"anchor":53,"custom":3719,"target":320,"linktype":289},"https://a-ca.storyblok.com/f/850807391887861/618a2ce867/ahs-immediate-and-ongoing-management-before-the-incident-final-uae.pdf",{},{"text":3721,"type":305}," to ",{"text":1920,"type":305,"marks":3723},[3724],{"type":315,"attrs":3725},{"href":3726,"uuid":53,"anchor":53,"custom":3727,"target":320,"linktype":289},"https://a-ca.storyblok.com/f/850807391887861/5ee3bacccd/ciaf-appendix-f-cheklist-for-effective-meetings-with-patients-famili-final-ua.pdf",{},{"text":3729,"type":305}," and care providers ",{"type":15,"attrs":3731,"content":3732},{"textAlign":53},[3733],{"text":3734,"type":305,"marks":3735},"Select an analysis type and method. ",[3736],{"type":555},{"type":497,"content":3738},[3739,3755,3762,3769],{"type":500,"content":3740},[3741],{"type":15,"attrs":3742,"content":3743},{"textAlign":53},[3744,3746,3753],{"text":3745,"type":305},"Based on the preliminary understanding of what happened, and using appropriate ",{"text":3747,"type":305,"marks":3748},"guidance tools",[3749],{"type":315,"attrs":3750},{"href":3751,"uuid":53,"anchor":53,"custom":3752,"target":678,"linktype":679},"http://www.suspension-nhs.org/Resources/Safety%20-%20IDT%20(info%20and%20advice%20on%20use).pdf",{},{"text":3754,"type":305},", determine whether a system-based analysis (focused on system improvement) or an accountability review (focused on individual performance) or both is required",{"type":500,"content":3756},[3757],{"type":15,"attrs":3758,"content":3759},{"textAlign":53},[3760],{"text":3761,"type":305},"A system-based analysis is not recommended for incidents that are thought to be the result of a criminal act or purposely unsafe act related to substance abuse by the provider, or involving suspected patient abuse",{"type":500,"content":3763},[3764],{"type":15,"attrs":3765,"content":3766},{"textAlign":53},[3767],{"text":3768,"type":305},"In situations where both a system-based analysis and accountability review are conducted, maintain a secure information firewall, i.e. no communication or influence between the two reviews",{"type":500,"content":3770},[3771],{"type":15,"attrs":3772,"content":3773},{"textAlign":53},[3774],{"text":3775,"type":305},"In the case of a system-based analysis, select the most appropriate analysis method (concise, comprehensive,  multi-incident) taking into consideration the complexity of the incident, the extent of its impact, and contextual factors  such as the likelihood of recurrence, regulatory mandates, and internal or external pressures ",{"type":15,"attrs":3777,"content":3778},{"textAlign":53},[3779],{"text":3780,"type":305,"marks":3781},"Identify the analysis team. ",[3782],{"type":555},{"type":497,"content":3784},[3785,3792,3799,3806,3813,3820],{"type":500,"content":3786},[3787],{"type":15,"attrs":3788,"content":3789},{"textAlign":53},[3790],{"text":3791,"type":305},"Guided by organizational policies and applicable legislative protection, establish an analysis team with clear roles and responsibilities captured in a team charter and clarify how confidentiality will be maintained ",{"type":500,"content":3793},[3794],{"type":15,"attrs":3795,"content":3796},{"textAlign":53},[3797],{"text":3798,"type":305},"While team composition will vary depending on the incident, the involvement of frontline providers and leaders is paramount to the success of the analysis as they can advocate for and support change implementation, ",{"type":500,"content":3800},[3801],{"type":15,"attrs":3802,"content":3803},{"textAlign":53},[3804],{"text":3805,"type":305},"The inclusion of a patient/family representative should be considered and is encouraged (e.g. a current or former patient of the service that was not directly involved in the incident being addressed) ",{"type":500,"content":3807},[3808],{"type":15,"attrs":3809,"content":3810},{"textAlign":53},[3811],{"text":3812,"type":305},"The analysis team may include members from outside the organization depending on the context of the incident and  instances when the required content expertise does not reside within the organization, providers involved in the incident hold leadership positions, or when there is intense public scrutiny ",{"type":500,"content":3814},[3815],{"type":15,"attrs":3816,"content":3817},{"textAlign":53},[3818],{"text":3819,"type":305},"Due to a variety of reasons including intense emotional response, some individuals involved in the incident may not be ready to participate; it is essential that the analysis team be understanding and keep the lines of communication open",{"type":500,"content":3821},[3822],{"type":15,"attrs":3823,"content":3824},{"textAlign":53},[3825],{"text":3826,"type":305},"It is recommended that primary responsibility for conducting, coordinating and reporting on the analysis is shared by a facilitator (with expertise in analysis) and a leader (with operational responsibility) ",{"type":15,"attrs":3828,"content":3829},{"textAlign":53},[3830],{"text":3831,"type":305,"marks":3832},"Coordinate meetings. ",[3833],{"type":555},{"type":497,"content":3835},[3836,3843,3850,3857],{"type":500,"content":3837},[3838],{"type":15,"attrs":3839,"content":3840},{"textAlign":53},[3841],{"text":3842,"type":305},"Before convening the team, gather all of the necessary information to conduct the analysis such as the patient’s health record, the timeline, pertinent equipment, relevant policies and procedures, and other documentation ",{"type":500,"content":3844},[3845],{"type":15,"attrs":3846,"content":3847},{"textAlign":53},[3848],{"text":3849,"type":305},"Secure a comfortable and private setting ",{"type":500,"content":3851},[3852],{"type":15,"attrs":3853,"content":3854},{"textAlign":53},[3855],{"text":3856,"type":305},"Emphasize and maintain confidentiality at all times to ensure information is only communicated in accordance with applicable policies and legislation ",{"type":500,"content":3858},[3859],{"type":15,"attrs":3860,"content":3861},{"textAlign":53},[3862],{"text":3863,"type":305},"Manage documents in accordance with organizational policies ",{"type":15,"attrs":3865,"content":3866},{"textAlign":53},[3867],{"text":3868,"type":305,"marks":3869},"Plan and conduct interviews. ",[3870],{"type":555},{"type":497,"content":3872},[3873,3880,3894,3901,3908],{"type":500,"content":3874},[3875],{"type":15,"attrs":3876,"content":3877},{"textAlign":53},[3878],{"text":3879,"type":305},"If feasible, meet with the team to confirm the approach and ground rules before conducting interviews ",{"type":500,"content":3881},[3882],{"type":15,"attrs":3883,"content":3884},{"textAlign":53},[3885,3887,3892],{"text":3886,"type":305},"Invite the ",{"text":2423,"type":305,"marks":3888},[3889],{"type":315,"attrs":3890},{"href":3726,"uuid":53,"anchor":53,"custom":3891,"target":320,"linktype":289},{},{"text":3893,"type":305}," and staff to participate in interviews as appropriate, coordinating communication through the key contact assigned earlier ",{"type":500,"content":3895},[3896],{"type":15,"attrs":3897,"content":3898},{"textAlign":53},[3899],{"text":3900,"type":305},"Conduct interviews as soon as is reasonably possible to help ensure that important information and details are recalled ",{"type":500,"content":3902},[3903],{"type":15,"attrs":3904,"content":3905},{"textAlign":53},[3906],{"text":3907,"type":305},"Conduct interviews individually to provide an opportunity for those involved in the incident to share their detailed perspective and unique viewpoint ",{"type":500,"content":3909},[3910,3915],{"type":15,"attrs":3911,"content":3912},{"textAlign":53},[3913],{"text":3914,"type":305},"Consider the ability/readiness of the individuals being interviewed and provide care and support throughout: ",{"type":497,"content":3916},[3917,3924,3931,3938],{"type":500,"content":3918},[3919],{"type":15,"attrs":3920,"content":3921},{"textAlign":53},[3922],{"text":3923,"type":305},"clearly convey the purpose of the interview and what will be done with the information ",{"type":500,"content":3925},[3926],{"type":15,"attrs":3927,"content":3928},{"textAlign":53},[3929],{"text":3930,"type":305},"favour the use of open-ended questions to allow the individual to tell their story ",{"type":500,"content":3932},[3933],{"type":15,"attrs":3934,"content":3935},{"textAlign":53},[3936],{"text":3937,"type":305},"ask the individual whether they identified contributing factors related to the incident as well as factors they feel mitigated the outcome ",{"type":500,"content":3939},[3940],{"type":15,"attrs":3941,"content":3942},{"textAlign":53},[3943],{"text":3944,"type":305},"pay particular attention to the needs of patients and family members during interviews, such as assisting with arrangements and logistics of the meeting, careful selection of the location to prevent further trauma, offering support, and providing a list of who will be there in advance ",{"_uid":3946,"title":3947,"ctaLeft":3948,"ctaRight":3949,"component":1188,"columnLeft":3950,"columnRight":3962},"d2e5f26d-506c-4567-9e06-2ed37ea8d911","Analysis Process",[],[],{"type":12,"content":3951},[3952,3957],{"type":15,"attrs":3953,"content":3954},{"textAlign":53},[3955],{"text":3956,"type":305},"Incident analysis 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. ",{"type":15,"attrs":3958,"content":3959},{"textAlign":53},[3960],{"text":3961,"type":305},"“Each time we do an incident analysis we are revealing new information, developing a greater understanding about patient safety, and through learning are moving the culture forward.” -- Toolkit Faculty ",{"type":12,"content":3963},[3964,3970,3975,3982,4019,4026,4079,4086,4155,4162],{"type":15,"attrs":3965,"content":3966},{"textAlign":53},[3967],{"text":1956,"type":305,"marks":3968},[3969],{"type":555},{"type":15,"attrs":3971,"content":3972},{"textAlign":53},[3973],{"text":3974,"type":305},"The guidelines below may be adapted in accordance with local policies and procedures, the nature of the incident and the method of analysis selected.  As new information about the incident is acquired, previous steps may need to be revisited (e.g. conducting additional interviews to explore new contributing factors) or a change may be needed to the analysis method (e.g. moving from a concise analysis to a comprehensive or multi-incident analysis.) ",{"type":15,"attrs":3976,"content":3977},{"textAlign":53},[3978],{"text":3979,"type":305,"marks":3980},"Understand what happened. ",[3981],{"type":555},{"type":497,"content":3983},[3984,3991,4005,4012],{"type":500,"content":3985},[3986],{"type":15,"attrs":3987,"content":3988},{"textAlign":53},[3989],{"text":3990,"type":305},"Expand on the preliminary review by synthesizing additional information gathered from incident report(s), the health record, physical evidence, contextual factors, site visit(s), and interviews with those directly or indirectly involved in the incident ",{"type":500,"content":3992},[3993],{"type":15,"attrs":3994,"content":3995},{"textAlign":53},[3996,3998,4003],{"text":3997,"type":305},"Create a detailed ",{"text":3691,"type":305,"marks":3999},[4000],{"type":315,"attrs":4001},{"href":3695,"uuid":53,"anchor":53,"custom":4002,"target":678,"linktype":679},{},{"text":4004,"type":305},", collating facts from various sources ",{"type":500,"content":4006},[4007],{"type":15,"attrs":4008,"content":4009},{"textAlign":53},[4010],{"text":4011,"type":305},"Review additional supporting information such as any related policies and procedures, training materials, or evidence-based guidelines ",{"type":500,"content":4013},[4014],{"type":15,"attrs":4015,"content":4016},{"textAlign":53},[4017],{"text":4018,"type":305},"Consider that a literature review, environmental scan, expert consultation, or analysis of similar incidents may also be indicated depending on the scope and method of analysis ",{"type":15,"attrs":4020,"content":4021},{"textAlign":53},[4022],{"text":4023,"type":305,"marks":4024},"Determine how and why it happened. ",[4025],{"type":555},{"type":497,"content":4027},[4028,4035,4042,4049,4065,4072],{"type":500,"content":4029},[4030],{"type":15,"attrs":4031,"content":4032},{"textAlign":53},[4033],{"text":4034,"type":305},"Identify contributing factors related to the incident, both those that increased the risk of harm and those that reduced the risk of harm or limited its impact ",{"type":500,"content":4036},[4037],{"type":15,"attrs":4038,"content":4039},{"textAlign":53},[4040],{"text":4041,"type":305},"Consider aspects of the incident that extend beyond the patient-provider level by probing all influencing factors and circumstances",{"type":500,"content":4043},[4044],{"type":15,"attrs":4045,"content":4046},{"textAlign":53},[4047],{"text":4048,"type":305},"Use systems thinking, human factors methods and guiding questions that prompt an exploration of all system components to avoid cognitive biases and keep the analysis focussed on system-based factors ",{"type":500,"content":4050},[4051],{"type":15,"attrs":4052,"content":4053},{"textAlign":53},[4054,4056,4063],{"text":4055,"type":305},"Use diagramming or other ",{"text":4057,"type":305,"marks":4058},"analytical tools",[4059],{"type":315,"attrs":4060},{"href":4061,"uuid":53,"anchor":53,"custom":4062,"target":678,"linktype":679},"https://d10k7k7mywg42z.cloudfront.net/assets/5328a610f002ff2140000338/HQCA_SSA_Patient_Safety_Reviews_FINAL_June_2012.pdf",{},{"text":4064,"type":305}," to identify and understand the relationships between and among contributing factors ",{"type":500,"content":4066},[4067],{"type":15,"attrs":4068,"content":4069},{"textAlign":53},[4070],{"text":4071,"type":305},"Document discrepancy(ies) in information from conflicting sources and the consensus reached by the analysis team as to the most appropriate direction based on the available information ",{"type":500,"content":4073},[4074],{"type":15,"attrs":4075,"content":4076},{"textAlign":53},[4077],{"text":4078,"type":305},"Articulate concisely what was found in a summary of findings that provides the backbone for the development of recommended actions ",{"type":15,"attrs":4080,"content":4081},{"textAlign":53},[4082],{"text":4083,"type":305,"marks":4084},"Identify what can be done to reduce the risk of recurrence and make care safer. ",[4085],{"type":555},{"type":497,"content":4087},[4088,4095,4110,4117,4124,4141,4148],{"type":500,"content":4089},[4090],{"type":15,"attrs":4091,"content":4092},{"textAlign":53},[4093],{"text":4094,"type":305},"Develop recommended actions addressing the analysis findings and that are specific, measurable, attainable, realistic and timely ",{"type":500,"content":4096},[4097],{"type":15,"attrs":4098,"content":4099},{"textAlign":53},[4100,4102,4108],{"text":4101,"type":305},"Ground recommended actions in evidence whenever possible, utilize the ",{"text":4103,"type":305,"marks":4104},"most effective solutions",[4105],{"type":315,"attrs":4106},{"href":1698,"uuid":53,"anchor":53,"custom":4107,"target":678,"linktype":679},{},{"text":4109,"type":305}," given the circumstances and target them to the appropriate system level(s) to achieve sustained improvement ",{"type":500,"content":4111},[4112],{"type":15,"attrs":4113,"content":4114},{"textAlign":53},[4115],{"text":4116,"type":305},"Propose an order of priority for recommended actions based on the degree of change required, ease of implementation, organizational factors, and influences from the external environment ",{"type":500,"content":4118},[4119],{"type":15,"attrs":4120,"content":4121},{"textAlign":53},[4122],{"text":4123,"type":305},"Review and validate the recommended actions with the patient/family, providers and experts (whenever possible) ",{"type":500,"content":4125},[4126],{"type":15,"attrs":4127,"content":4128},{"textAlign":53},[4129,4131,4139],{"text":4130,"type":305},"Prepare and hand-off the ",{"text":4132,"type":305,"marks":4133},"incident analysis report",[4134],{"type":315,"attrs":4135},{"href":4136,"uuid":4137,"anchor":53,"custom":4138,"target":320,"linktype":321},"/resources/patient-safety-incident-analysis","8094c23a-c722-4bc4-8de1-f5474d690e2d",{},{"text":4140,"type":305}," to those responsible for approving recommended actions, allocating the necessary resources, delegating implementation of the recommended actions and monitoring progress ",{"type":500,"content":4142},[4143],{"type":15,"attrs":4144,"content":4145},{"textAlign":53},[4146],{"text":4147,"type":305},"Include a tracking tool with assigned responsibilities and timeframes in the report to facilitate ongoing monitoring of the recommended actions and their outcomes ",{"type":500,"content":4149},[4150],{"type":15,"attrs":4151,"content":4152},{"textAlign":53},[4153],{"text":4154,"type":305},"Once the recommended actions and their order of priority is approved by the leadership team, and in accordance with organizational policies and applicable legislation, communicate them in a timely manner to the patient/family (post-analysis disclosure), providers, management, public and others as needed  ",{"type":15,"attrs":4156,"content":4157},{"textAlign":53},[4158],{"text":4159,"type":305,"marks":4160},"Identify and share what was learned. ",[4161],{"type":555},{"type":497,"content":4163},[4164],{"type":500,"content":4165},[4166],{"type":15,"attrs":4167,"content":4168},{"textAlign":53},[4169],{"text":4170,"type":305},"Share the learning gained from the analysis (outcome of recommended actions implemented and other changes made to improve safety) within the organization (staff, patient/family, individual who reported the incident) and beyond to prevent additional harm and to make care safer. ",{"_uid":4172,"title":4173,"ctaLeft":4174,"ctaRight":4175,"component":1188,"columnLeft":4176,"columnRight":4188},"afdc54f3-8d8b-40bd-bf75-60a0757481e3","Follow Through",[],[],{"type":12,"content":4177},[4178,4183],{"type":15,"attrs":4179,"content":4180},{"textAlign":53},[4181],{"text":4182,"type":305},"Following through after completing an incident analysis 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. ",{"type":15,"attrs":4184,"content":4185},{"textAlign":53},[4186],{"text":4187,"type":305}," “Local leaders should ensure that they, or someone they designate, periodically observe care practices to ascertain if recommended actions have been implemented and sustained. By following through important insights and potential hazards and/or opportunities to patient safety can be discovered.” -- Toolkit Faculty ",{"type":12,"content":4189},[4190,4196,4203,4256,4263,4310,4317],{"type":15,"attrs":4191,"content":4192},{"textAlign":53},[4193],{"text":1956,"type":305,"marks":4194},[4195],{"type":555},{"type":15,"attrs":4197,"content":4198},{"textAlign":53},[4199],{"text":4200,"type":305,"marks":4201},"Implement recommended actions. ",[4202],{"type":555},{"type":497,"content":4204},[4205,4212,4219,4235,4242,4249],{"type":500,"content":4206},[4207],{"type":15,"attrs":4208,"content":4209},{"textAlign":53},[4210],{"text":4211,"type":305},"Engage frontline staff and patients/families in the planning and implementation of recommended actions, exploring potential barriers and opportunities as well as mitigation strategies ",{"type":500,"content":4213},[4214],{"type":15,"attrs":4215,"content":4216},{"textAlign":53},[4217],{"text":4218,"type":305},"Ensure ongoing leadership support and adequate human and financial resources for implementation ",{"type":500,"content":4220},[4221],{"type":15,"attrs":4222,"content":4223},{"textAlign":53},[4224,4226,4233],{"text":4225,"type":305},"Use ",{"text":4227,"type":305,"marks":4228},"change management",[4229],{"type":315,"attrs":4230},{"href":4231,"uuid":53,"anchor":53,"custom":4232,"target":678,"linktype":679},"https://www.infoway-inforoute.ca/en/component/edocman/change-management/565-national-change-management-framework",{},{"text":4234,"type":305}," and improvement tools to base change on strong methodology ",{"type":500,"content":4236},[4237],{"type":15,"attrs":4238,"content":4239},{"textAlign":53},[4240],{"text":4241,"type":305},"Incorporate a variety of communication strategies to maintain interest and engagement in the changes (e.g. small group and/or organization wide announcements in verbal and/or written format) ",{"type":500,"content":4243},[4244],{"type":15,"attrs":4245,"content":4246},{"textAlign":53},[4247],{"text":4248,"type":305},"Test changes on a small scale to allow for feedback and refinement before broader implementation ",{"type":500,"content":4250},[4251],{"type":15,"attrs":4252,"content":4253},{"textAlign":53},[4254],{"text":4255,"type":305},"Integrate the implementation of the recommended actions within the quality improvement and risk management actions (e.g. using a common platform) to monitor, report progress and align efforts ",{"type":15,"attrs":4257,"content":4258},{"textAlign":53},[4259],{"text":4260,"type":305,"marks":4261},"Monitor and assess the effectiveness of the recommended actions. ",[4262],{"type":555},{"type":497,"content":4264},[4265,4282,4289,4296,4303],{"type":500,"content":4266},[4267],{"type":15,"attrs":4268,"content":4269},{"textAlign":53},[4270,4272,4280],{"text":4271,"type":305},"Rather than simply tracking the completion of recommended actions, establish relevant outcome, process and balancing ",{"text":4273,"type":305,"marks":4274},"measures",[4275],{"type":315,"attrs":4276},{"href":4277,"uuid":4278,"anchor":53,"custom":4279,"target":320,"linktype":321},"/resources/hospital-harm-is-everyone-s-concern","3b0b67e4-3791-4e2d-9008-4c21c4bdf065",{},{"text":4281,"type":305}," to monitor whether the desired effect was achieved ",{"type":500,"content":4283},[4284],{"type":15,"attrs":4285,"content":4286},{"textAlign":53},[4287],{"text":4288,"type":305},"Clearly define measures and design data collection to be as practical as possible ",{"type":500,"content":4290},[4291],{"type":15,"attrs":4292,"content":4293},{"textAlign":53},[4294],{"text":4295,"type":305},"Monitor performance over time to demonstrate sustained improvement or lack thereof ",{"type":500,"content":4297},[4298],{"type":15,"attrs":4299,"content":4300},{"textAlign":53},[4301],{"text":4302,"type":305},"Use all of the information available to evaluate the overall effectiveness of the recommended actions, including observations, stakeholder feedback, and unintended consequences ",{"type":500,"content":4304},[4305],{"type":15,"attrs":4306,"content":4307},{"textAlign":53},[4308],{"text":4309,"type":305},"Revisit recommended actions that did not achieve the anticipated improvement and consider adjustments or alternate solutions ",{"type":15,"attrs":4311,"content":4312},{"textAlign":53},[4313],{"text":4314,"type":305,"marks":4315},"Close off the incident analysis and transition to ongoing operations. ",[4316],{"type":555},{"type":497,"content":4318},[4319,4326,4333,4340,4347],{"type":500,"content":4320},[4321],{"type":15,"attrs":4322,"content":4323},{"textAlign":53},[4324],{"text":4325,"type":305},"Designate the incident analysis as complete once all of the recommended actions have been evaluated for a pre-determined period of monitoring",{"type":500,"content":4327},[4328],{"type":15,"attrs":4329,"content":4330},{"textAlign":53},[4331],{"text":4332,"type":305},"Determine if ongoing performance monitoring (such as unit or organizational quality indicators) is required to ensure sustainability ",{"type":500,"content":4334},[4335],{"type":15,"attrs":4336,"content":4337},{"textAlign":53},[4338],{"text":4339,"type":305},"Guided by organizational policies and relevant legislation, communicate the status and impact of the recommended actions to the patient/family, staff, the person(s) who reported the incident, and senior leadership in a timely manner ",{"type":500,"content":4341},[4342],{"type":15,"attrs":4343,"content":4344},{"textAlign":53},[4345],{"text":4346,"type":305},"If communicating results of recommended actions, respect patient/family preferences in terms what they want to know and when  ",{"type":500,"content":4348},[4349],{"type":15,"attrs":4350,"content":4351},{"textAlign":53},[4352],{"text":4353,"type":305},"Celebrate successes and improvements highlighting the positive contributions to safety resulting from the incident management process ",{"_uid":4355,"title":4356,"ctaLeft":4357,"ctaRight":4358,"component":1188,"columnLeft":4359,"columnRight":4371},"f09c04b3-ced1-428c-9bf3-08ac2a008ede","Close the Loop",[],[],{"type":12,"content":4360},[4361,4366],{"type":15,"attrs":4362,"content":4363},{"textAlign":53},[4364],{"text":4365,"type":305},"Closing the loop 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 them. ",{"type":15,"attrs":4367,"content":4368},{"textAlign":53},[4369],{"text":4370,"type":305},"“Every time we take a patient safety incident, hazard through this reporting and learning cycle, we reduce risk, improve quality, and – more importantly – strengthen the patient safety culture which means that care becomes safer for patients.” -- Toolkit Faculty",{"type":12,"content":4372},[4373,4379,4384,4391,4472,4479,4518,4525],{"type":15,"attrs":4374,"content":4375},{"textAlign":53},[4376],{"text":1956,"type":305,"marks":4377},[4378],{"type":555},{"type":15,"attrs":4380,"content":4381},{"textAlign":53},[4382],{"text":4383,"type":305},"This step can take as much, if not more, time than the analysis however, it is very important for learning, improvement and moving the patient safety culture forward.  It is most successful when it is a regular process embedded within existing structures, includes established accountabilities and is aligned with local policies and legislation.   ",{"type":15,"attrs":4385,"content":4386},{"textAlign":53},[4387],{"text":4388,"type":305,"marks":4389},"Share what was learned internally. ",[4390],{"type":555},{"type":497,"content":4392},[4393,4400,4407,4444,4451,4458,4465],{"type":500,"content":4394},[4395],{"type":15,"attrs":4396,"content":4397},{"textAlign":53},[4398],{"text":4399,"type":305},"Share what was learned from the analysis with the patient/family, those involved in the incident, the person who reported it, senior management, the board, and others ",{"type":500,"content":4401},[4402],{"type":15,"attrs":4403,"content":4404},{"textAlign":53},[4405],{"text":4406,"type":305},"Communicate results of recommended actions, taking care to respect patient/family preferences in terms of what they want to know and when ",{"type":500,"content":4408},[4409,4414],{"type":15,"attrs":4410,"content":4411},{"textAlign":53},[4412],{"text":4413,"type":305},"Communicate what has been implemented and the results, ensuring messages and channels are appropriate for each audience: ",{"type":497,"content":4415},[4416,4423,4430,4437],{"type":500,"content":4417},[4418],{"type":15,"attrs":4419,"content":4420},{"textAlign":53},[4421],{"text":4422,"type":305},"review the purpose of analysis, methodology and the findings as appropriate ",{"type":500,"content":4424},[4425],{"type":15,"attrs":4426,"content":4427},{"textAlign":53},[4428],{"text":4429,"type":305},"share the factors that contributed to the incident, the defences that worked well, and what was learned about how to avoid similar incidents ",{"type":500,"content":4431},[4432],{"type":15,"attrs":4433,"content":4434},{"textAlign":53},[4435],{"text":4436,"type":305},"review the recommended actions, their current status and their impact ",{"type":500,"content":4438},[4439],{"type":15,"attrs":4440,"content":4441},{"textAlign":53},[4442],{"text":4443,"type":305},"maintain transparency and trust by being honest if plans have changed and share the reasons why ",{"type":500,"content":4445},[4446],{"type":15,"attrs":4447,"content":4448},{"textAlign":53},[4449],{"text":4450,"type":305},"In accordance with organizational policies, use multiple mechanisms that transfer learning from the analysis between care units including memos, storytelling, huddles, team based peer review rounds, journal clubs, patient safety workshops using case based learning methods and newsletters ",{"type":500,"content":4452},[4453],{"type":15,"attrs":4454,"content":4455},{"textAlign":53},[4456],{"text":4457,"type":305},"Maintain a record of communication to ensure all appropriate stakeholders have received the information ",{"type":500,"content":4459},[4460],{"type":15,"attrs":4461,"content":4462},{"textAlign":53},[4463],{"text":4464,"type":305},"Recognize that sharing is  a dialogue (not a one-way flow of information) and is ongoing (more than one time) ",{"type":500,"content":4466},[4467],{"type":15,"attrs":4468,"content":4469},{"textAlign":53},[4470],{"text":4471,"type":305},"Encourage respectful, open communication around the results of the incident analysis at all levels of the organization ",{"type":15,"attrs":4473,"content":4474},{"textAlign":53},[4475],{"text":4476,"type":305,"marks":4477},"Share what was learned externally. ",[4478],{"type":555},{"type":497,"content":4480},[4481,4488,4495,4511],{"type":500,"content":4482},[4483],{"type":15,"attrs":4484,"content":4485},{"textAlign":53},[4486],{"text":4487,"type":305},"To prevent harm on a broader scale, disseminate what was learned externally through provincial, national and international reporting and learning systems in accordance with applicable legislation ",{"type":500,"content":4489},[4490],{"type":15,"attrs":4491,"content":4492},{"textAlign":53},[4493],{"text":4494,"type":305},"Alerts, advisories and repositories can serve as vehicles for informing others about what happened, how and why, what actions were taken, and their impact ",{"type":500,"content":4496},[4497],{"type":15,"attrs":4498,"content":4499},{"textAlign":53},[4500,4502,4509],{"text":4501,"type":305},"If appropriate, develop an ",{"text":4503,"type":305,"marks":4504},"external communication plan",[4505],{"type":315,"attrs":4506},{"href":4507,"uuid":53,"anchor":53,"custom":4508,"target":678,"linktype":679},"http://hqca.ca/studies-and-reviews/continuity-of-patient-care-study/",{},{"text":4510,"type":305}," for informing the public about the actions taken, their impact, related relevant background and context, and include or exclude the patient/family perspective in accordance with their wishes ",{"type":500,"content":4512},[4513],{"type":15,"attrs":4514,"content":4515},{"textAlign":53},[4516],{"text":4517,"type":305},"For public announcements, prepare the staff and the patient/family in advance discussing what information will be shared, when and how  ",{"type":15,"attrs":4519,"content":4520},{"textAlign":53},[4521],{"text":4522,"type":305,"marks":4523},"Reflect and Improve. ",[4524],{"type":555},{"type":497,"content":4526},[4527,4534,4541,4548,4555,4599],{"type":500,"content":4528},[4529],{"type":15,"attrs":4530,"content":4531},{"textAlign":53},[4532],{"text":4533,"type":305},"Consider conducting a multi-incident analysis to better identify recurring system issues ",{"type":500,"content":4535},[4536],{"type":15,"attrs":4537,"content":4538},{"textAlign":53},[4539],{"text":4540,"type":305},"Determine if what was learned can be applied to other processes in the organization ",{"type":500,"content":4542},[4543],{"type":15,"attrs":4544,"content":4545},{"textAlign":53},[4546],{"text":4547,"type":305},"Communicate any noteworthy vulnerabilities and/or best practices through senior leadership or other appropriate body (e.g. quality committee, risk management, etc.) ",{"type":500,"content":4549},[4550],{"type":15,"attrs":4551,"content":4552},{"textAlign":53},[4553],{"text":4554,"type":305},"Combine findings with those from different systems (e.g. accreditation, insurers, performance systems at a health system level)  to help identify themes/patterns and accelerate learning ",{"type":500,"content":4556},[4557,4562],{"type":15,"attrs":4558,"content":4559},{"textAlign":53},[4560],{"text":4561,"type":305},"Assess the incident management process to identify strengths and opportunities for improvement, taking into consideration: ",{"type":497,"content":4563},[4564,4571,4578,4585,4592],{"type":500,"content":4565},[4566],{"type":15,"attrs":4567,"content":4568},{"textAlign":53},[4569],{"text":4570,"type":305},"the timeliness of the analysis ",{"type":500,"content":4572},[4573],{"type":15,"attrs":4574,"content":4575},{"textAlign":53},[4576],{"text":4577,"type":305},"the quality and effectiveness of the recommended actions ",{"type":500,"content":4579},[4580],{"type":15,"attrs":4581,"content":4582},{"textAlign":53},[4583],{"text":4584,"type":305},"organizational guidance and supporting structures ",{"type":500,"content":4586},[4587],{"type":15,"attrs":4588,"content":4589},{"textAlign":53},[4590],{"text":4591,"type":305},"communication and processes for sharing what was learned ",{"type":500,"content":4593},[4594],{"type":15,"attrs":4595,"content":4596},{"textAlign":53},[4597],{"text":4598,"type":305},"the experience of those involved in the incident and the analysis ",{"type":500,"content":4600},[4601],{"type":15,"attrs":4602,"content":4603},{"textAlign":53},[4604],{"text":4605,"type":305},"Support research and innovation focussed on learning from incidents",{"_uid":4607,"title":4608,"ctaLeft":4609,"ctaRight":4610,"component":1188,"columnLeft":4611,"columnRight":4628},"81c12f23-77c7-4d5a-9ccf-d3c867db635e","Peer-to-Peer Support",[],[],{"type":12,"content":4612},[4613,4618,4623],{"type":15,"attrs":4614,"content":4615},{"textAlign":53},[4616],{"text":4617,"type":305},"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. ",{"type":15,"attrs":4619,"content":4620},{"textAlign":53},[4621],{"text":4622,"type":305},"The Second Victim Phenomenon is a real and serious consequence related to health care roles. Different studies estimate that the prevalence of the Second Victim Phenomenon ranges from 10.4% up to 43.3 %. Although there seems to be great interest in the topic, there are very few comprehensive programs specifically designed to address second victim phenomenon with even fewer and less developed Canadian programs. ",{"type":15,"attrs":4624,"content":4625},{"textAlign":53},[4626],{"text":4627,"type":305},"The distress caused by patient safety incidents, particularly harmful incidents can have negative effects on the care providers health and well-being and the safety of patient care. If not addressed, the provider may suffer in silence, change their role, leave the profession and some very unfortunately, will become victims of suicide. As a result, Healthcare Excellence Canada (HEC) has been working to increase awareness of the second victim phenomenon and available resources.  ",{"type":12,"content":4629},[4630,4636,4641,4647],{"type":15,"attrs":4631,"content":4632},{"textAlign":53},[4633],{"text":1956,"type":305,"marks":4634},[4635],{"type":555},{"type":15,"attrs":4637,"content":4638},{"textAlign":53},[4639],{"text":4640,"type":305},"While provider support programs are mainly targeted at emotionally supporting health care providers that have experienced a patient safety incident, HEC’s commitment to patient safety remains the same.  As part of a comprehensive program, there is a critical need to support patients and families on their journey from harm to healing.  Providers, patients, families and leaders are part of the same system and to do better we need to support and collaborate in a manner that allows us to maximize learning and improvement.  A provider support program will enable healthcare professionals to re-establish or improve their previous levels of work performance and improve patient safety.  Provider programs should not be designed simply to help the provider but must be designed to improve the system and help make patient care safe.  The walking wounded, the silent mistake, the loss of providers all contribute to lost opportunities for, and potential liabilities to patient safety. ",{"type":15,"attrs":4642,"content":4643},{"textAlign":53},[4644],{"text":2939,"type":305,"marks":4645},[4646],{"type":555},{"type":497,"content":4648},[4649,4656],{"type":500,"content":4650},[4651],{"type":15,"attrs":4652,"content":4653},{"textAlign":53},[4654],{"text":4655,"type":305},"Peer-to-peer support programs, where health professionals can discuss their experience with a PSI in a non-judgmental environment with colleagues who can relate to what they are going through, are now seen as a potentially useful approach to helping health professionals cope with the PSI. ",{"type":500,"content":4657},[4658],{"type":15,"attrs":4659,"content":4660},{"textAlign":53},[4661],{"text":4662,"type":305,"marks":4663},"Creating a Safe Space: Addressing Confidentiality for Peer-to-Peer Support Programs for Health Professionals ",[4664],{"type":315,"attrs":4665},{"href":4666,"uuid":4667,"anchor":53,"custom":4668,"target":320,"linktype":321},"/resources/creating-a-safe-space-psychological-safety-of-healthcare-workers-peer-to-peer-support","6c4d31a0-a38c-43aa-b256-52adeaf6b2dc",{},"Incident Management",{"type":12,"content":4671},[4672],{"type":15,"attrs":4673,"content":4674},{"textAlign":53},[4675],{"text":4676,"type":305},"This section of the Patient Safety and Incident Management Toolkit provides an integrated set of resources that focus on what actions to take – both immediate and ongoing – following patient safety incidents (including near misses). The resources support people responsible for incident management to respond to incidents and reduce the harm to patients/families and providers when they occur. ",{"_uid":4678,"items":4679,"title":4682,"component":2871,"description":4997},"51307eb8-01b5-4003-8fa1-af31f16a758b",[4680],{"_uid":4681,"title":4682,"ctaLeft":4683,"ctaRight":4684,"component":1188,"columnLeft":4685,"columnRight":4692},"5026ec1e-868a-42c6-bda6-cbb1dce58c88","System Factors",[],[],{"type":12,"content":4686},[4687],{"type":15,"attrs":4688,"content":4689},{"textAlign":53},[4690],{"text":4691,"type":305},"The healthcare system comprises many sub-systems operating at different levels (e.g. outside of the organization, organization and/or program level, point of care), each with specific goals, resources (human, financial, equipment) and processes (formal and informal). Maintaining a system perspective and regularly assessing the sub-systems and their connectivity is critical in identifying how they influence each other, which in turn can inform what actions are needed to strengthen patient safety and incident management. ",{"type":12,"content":4693},[4694,4701,4933,4940],{"type":15,"attrs":4695,"content":4696},{"textAlign":53},[4697],{"text":4698,"type":305,"marks":4699},"Assess key system factors and understand how they relate to patient safety and incident management ",[4700],{"type":555},{"type":497,"content":4702},[4703,4782,4882],{"type":500,"content":4704},[4705,4710],{"type":15,"attrs":4706,"content":4707},{"textAlign":53},[4708],{"text":4709,"type":305},"Outside the boundaries of the organization: ",{"type":497,"content":4711},[4712,4719,4726,4733,4740,4747,4754,4761,4768,4775],{"type":500,"content":4713},[4714],{"type":15,"attrs":4715,"content":4716},{"textAlign":53},[4717],{"text":4718,"type":305},"public and community awareness of and engagement in patient safety ",{"type":500,"content":4720},[4721],{"type":15,"attrs":4722,"content":4723},{"textAlign":53},[4724],{"text":4725,"type":305},"healthcare legislation, standards, policies, regulations and accreditation requirements",{"type":500,"content":4727},[4728],{"type":15,"attrs":4729,"content":4730},{"textAlign":53},[4731],{"text":4732,"type":305},"healthcare infrastructure and resourcing (fiscal, human, facilities and sites, equipment) ",{"type":500,"content":4734},[4735],{"type":15,"attrs":4736,"content":4737},{"textAlign":53},[4738],{"text":4739,"type":305},"education of healthcare providers, labour agreements and workforce trends ",{"type":500,"content":4741},[4742],{"type":15,"attrs":4743,"content":4744},{"textAlign":53},[4745],{"text":4746,"type":305},"social determinants of health, societal trends (income, social status, education, employment, housing, culture, etc.) ",{"type":500,"content":4748},[4749],{"type":15,"attrs":4750,"content":4751},{"textAlign":53},[4752],{"text":4753,"type":305},"health trends, issues and challenges (e.g. disease outbreaks, population health) ",{"type":500,"content":4755},[4756],{"type":15,"attrs":4757,"content":4758},{"textAlign":53},[4759],{"text":4760,"type":305},"political environment (local, provincial/ territorial, national), economic, technological and trends influencing the healthcare industry (e.g. through a PESTLE analysis) ",{"type":500,"content":4762},[4763],{"type":15,"attrs":4764,"content":4765},{"textAlign":53},[4766],{"text":4767,"type":305},"infrastructure, trends, and funding for patient safety research, evaluation and improvement ",{"type":500,"content":4769},[4770],{"type":15,"attrs":4771,"content":4772},{"textAlign":53},[4773],{"text":4774,"type":305},"trends in other sectors that might intersect with healthcare (e.g. technology, social media) ",{"type":500,"content":4776},[4777],{"type":15,"attrs":4778,"content":4779},{"textAlign":53},[4780],{"text":4781,"type":305},"geographic location and regional characteristics (remote vs rural vs urban). ",{"type":500,"content":4783},[4784,4789],{"type":15,"attrs":4785,"content":4786},{"textAlign":53},[4787],{"text":4788,"type":305},"At the organizational and program/service levels: ",{"type":497,"content":4790},[4791,4798,4805,4812,4819,4826,4833,4840,4847,4854,4861,4868,4875],{"type":500,"content":4792},[4793],{"type":15,"attrs":4794,"content":4795},{"textAlign":53},[4796],{"text":4797,"type":305},"strategic plans, organizational priorities, values and principles ",{"type":500,"content":4799},[4800],{"type":15,"attrs":4801,"content":4802},{"textAlign":53},[4803],{"text":4804,"type":305},"leadership team and board level commitment and governance, including their knowledge of patient safety science and best practices ",{"type":500,"content":4806},[4807],{"type":15,"attrs":4808,"content":4809},{"textAlign":53},[4810],{"text":4811,"type":305},"leadership visibility and engagement in patient safety ",{"type":500,"content":4813},[4814],{"type":15,"attrs":4815,"content":4816},{"textAlign":53},[4817],{"text":4818,"type":305},"how leadership prioritize patient safety – whether it is at the top of meeting agendas and allocated at least 25% of the meeting time ",{"type":500,"content":4820},[4821],{"type":15,"attrs":4822,"content":4823},{"textAlign":53},[4824],{"text":4825,"type":305},"organizational leadership’s accountability for patient safety performance, alignment with incentives (formal and informal) ",{"type":500,"content":4827},[4828],{"type":15,"attrs":4829,"content":4830},{"textAlign":53},[4831],{"text":4832,"type":305},"patient/family perspective included at board and leadership meetings, in decision-making and in the design of care processes and patient safety initiatives ",{"type":500,"content":4834},[4835],{"type":15,"attrs":4836,"content":4837},{"textAlign":53},[4838],{"text":4839,"type":305},"leadership team stability, experience, and style ",{"type":500,"content":4841},[4842],{"type":15,"attrs":4843,"content":4844},{"textAlign":53},[4845],{"text":4846,"type":305},"organizational patient safety culture ",{"type":500,"content":4848},[4849],{"type":15,"attrs":4850,"content":4851},{"textAlign":53},[4852],{"text":4853,"type":305},"organizational experience, current performance/progress with patient safety  ",{"type":500,"content":4855},[4856],{"type":15,"attrs":4857,"content":4858},{"textAlign":53},[4859],{"text":4860,"type":305},"the organization’s funding and financial status, including infrastructure and technology investment needs ",{"type":500,"content":4862},[4863],{"type":15,"attrs":4864,"content":4865},{"textAlign":53},[4866],{"text":4867,"type":305},"proactive design or redesign of policies and practices related to safety ",{"type":500,"content":4869},[4870],{"type":15,"attrs":4871,"content":4872},{"textAlign":53},[4873],{"text":4874,"type":305},"workforce expertise and skill related to patient safety   ",{"type":500,"content":4876},[4877],{"type":15,"attrs":4878,"content":4879},{"textAlign":53},[4880],{"text":4881,"type":305},"alignment between patient safety, quality improvement and risk management. ",{"type":500,"content":4883},[4884,4889],{"type":15,"attrs":4885,"content":4886},{"textAlign":53},[4887],{"text":4888,"type":305},"At the point of care: ",{"type":497,"content":4890},[4891,4898,4905,4912,4919,4926],{"type":500,"content":4892},[4893],{"type":15,"attrs":4894,"content":4895},{"textAlign":53},[4896],{"text":4897,"type":305},"patient/family partnership in care and safety ",{"type":500,"content":4899},[4900],{"type":15,"attrs":4901,"content":4902},{"textAlign":53},[4903],{"text":4904,"type":305},"team communication, feedback, culture, composition, hierarchy ",{"type":500,"content":4906},[4907],{"type":15,"attrs":4908,"content":4909},{"textAlign":53},[4910],{"text":4911,"type":305},"staff and patients/families being comfortable and able to report incidents, concerns, successes ",{"type":500,"content":4913},[4914],{"type":15,"attrs":4915,"content":4916},{"textAlign":53},[4917],{"text":4918,"type":305},"staff competencies, skill, experience, professional requirements regarding patient safety and incident management ",{"type":500,"content":4920},[4921],{"type":15,"attrs":4922,"content":4923},{"textAlign":53},[4924],{"text":4925,"type":305},"access to resources to manage safety and incidents ",{"type":500,"content":4927},[4928],{"type":15,"attrs":4929,"content":4930},{"textAlign":53},[4931],{"text":4932,"type":305},"staff turnover, staffing levels, protected time for projects. ",{"type":15,"attrs":4934,"content":4935},{"textAlign":53},[4936],{"text":4937,"type":305,"marks":4938},"Identify actions to strengthen patient safety and incident management ",[4939],{"type":555},{"type":497,"content":4941},[4942,4953,4964,4975,4986],{"type":500,"content":4943},[4944],{"type":15,"attrs":4945,"content":4946},{"textAlign":53},[4947,4951],{"text":4948,"type":305,"marks":4949},"Respond ",[4950],{"type":555},{"text":4952,"type":305},"– Monitor and anticipate system factors that influence and impact patient safety (e.g. changes in regulations, workforce shortages, changes to health funding), ensure patient safety remains at the forefront of decision-making (e.g. regular updates at key meetings, assigning responsibility to stay informed to key leaders) and take action to respond as appropriate. ",{"type":500,"content":4954},[4955],{"type":15,"attrs":4956,"content":4957},{"textAlign":53},[4958,4962],{"text":4959,"type":305,"marks":4960},"Align ",[4961],{"type":555},{"text":4963,"type":305},"– Use internal and external system factors in assessing priority of patient safety and incident management initiatives. Initiatives that align at different system levels create multiple wins, which will accelerate uptake and spread, and promote best practices known to reduce harm. ",{"type":500,"content":4965},[4966],{"type":15,"attrs":4967,"content":4968},{"textAlign":53},[4969,4973],{"text":4970,"type":305,"marks":4971},"Leverage ",[4972],{"type":555},{"text":4974,"type":305},"– Take advantage of system factors to improve patient safety and incident management (e.g. use Accreditation Canada’s Required Organizational Practices as a lever to implement best practices known to improve patient safety). ",{"type":500,"content":4976},[4977],{"type":15,"attrs":4978,"content":4979},{"textAlign":53},[4980,4984],{"text":4981,"type":305,"marks":4982},"Partner/collaborate ",[4983],{"type":555},{"text":4985,"type":305},"– Work with others to make changes that can positively impact healthcare in your setting; support or endorse the work and successes of others. ",{"type":500,"content":4987},[4988],{"type":15,"attrs":4989,"content":4990},{"textAlign":53},[4991,4995],{"text":4992,"type":305,"marks":4993},"Advocate ",[4994],{"type":555},{"text":4996,"type":305},"– Promote learning from patient safety incident management to shape system factors for the benefit of your healthcare organization and providers, as well as others (e.g. work with advocacy groups to change public policy, engage funders in addressing known safety issues).",{"type":12,"content":4998},[4999],{"type":15,"attrs":5000,"content":5001},{"textAlign":53},[5002],{"text":5003,"type":305},"In order to keep patients safe, it is essential that we understand the factors that shape both patient safety and incident management, then identify actions to respond to, align with and leverage these factors. They originate from different system levels (inside and outside the organization) and include legislation, policies, culture, people, processes and resources. ",{"_uid":5005,"title":5006,"columns":5007,"component":5139,"description":5140},"824a0811-8046-47ee-8e53-bb84f8212913","Team",[5008,5094],{"_uid":5009,"image":5010,"title":5012,"content":5013,"component":5093},"a18a274e-e661-41ff-9992-d4fc203c1849",{"id":53,"alt":53,"name":16,"focus":53,"title":53,"source":53,"filename":16,"copyright":53,"fieldtype":289,"meta_data":5011},{},"Toolkit Faculty",[5014],{"_uid":5015,"content":5016,"component":329},"93db4059-43d4-4feb-8f66-f8737f9c3138",{"type":12,"content":5017},[5018,5023,5028,5033,5038,5043,5048,5053,5058,5063,5068,5073,5078,5083,5088],{"type":15,"attrs":5019,"content":5020},{"textAlign":53},[5021],{"text":5022,"type":305},"Below are the faculty members and positions they held when the Patient Safety Incident Management Toolkit was first developed.       ",{"type":15,"attrs":5024,"content":5025},{"textAlign":53},[5026],{"text":5027,"type":305},"Dr. Amir Ginzburg, Medical Director Quality and Performance, Trillium Health Partners; Assistant Professor, Institute of Health Management, Policy and Evaluation, University of Toronto ",{"type":15,"attrs":5029,"content":5030},{"textAlign":53},[5031],{"text":5032,"type":305},"Dr. Amy Nakajima, MD, FRCSC, Consultant, Bruyère Continuing Care ",{"type":15,"attrs":5034,"content":5035},{"textAlign":53},[5036],{"text":5037,"type":305},"Dr. John Maxted, Assistant Professor, Department of Family and Community Medicine, University of Toronto ",{"type":15,"attrs":5039,"content":5040},{"textAlign":53},[5041],{"text":5042,"type":305},"Julie Greenall, Director of Projects and Education, Institute for Safe Medication Practices Canada ",{"type":15,"attrs":5044,"content":5045},{"textAlign":53},[5046],{"text":5047,"type":305},"Margot Harvie RN, BN, Med, Quality & Safety Education Lead, Health Quality Council of Alberta ",{"type":15,"attrs":5049,"content":5050},{"textAlign":53},[5051],{"text":5052,"type":305},"Annemarie Taylor, Provincial Director, British Columbia Patient Safety & Learning System ",{"type":15,"attrs":5054,"content":5055},{"textAlign":53},[5056],{"text":5057,"type":305},"Brent Windwick, Partner, Field Law (Health Industry Services & Privacy) ",{"type":15,"attrs":5059,"content":5060},{"textAlign":53},[5061],{"text":5062,"type":305},"Carolyn Hoffman, Senior Vice President Quality & Healthcare Improvement, Alberta Health Services ",{"type":15,"attrs":5064,"content":5065},{"textAlign":53},[5066],{"text":5067,"type":305},"Deborah Prowse, Member, Patients for Patient Safety Canada ",{"type":15,"attrs":5069,"content":5070},{"textAlign":53},[5071],{"text":5072,"type":305},"Heather Howley, Health Services Research Specialist, Accreditation Canada ",{"type":15,"attrs":5074,"content":5075},{"textAlign":53},[5076],{"text":5077,"type":305},"Heon-Jae Jeong, Postdoctoral Fellow, Department of Health Policy and Management, Johns Hopkins ",{"type":15,"attrs":5079,"content":5080},{"textAlign":53},[5081],{"text":5082,"type":305},"Jennifer White, Provincial Quality Care Coordinator, Saskatchewan Ministry of Health ",{"type":15,"attrs":5084,"content":5085},{"textAlign":53},[5086],{"text":5087,"type":305},"Sharon Nettleton, Past Co-Chair, Patients for Patient Safety Canada ",{"type":15,"attrs":5089,"content":5090},{"textAlign":53},[5091],{"text":5092,"type":305},"Sherry Espin, Associate Professor, Ryerson University ","wysiwyg-column",{"_uid":5095,"image":5096,"title":5098,"content":5099,"component":5093},"40239f5d-70bc-4192-9983-5a14bb6c7b83",{"id":53,"alt":53,"name":16,"focus":53,"title":53,"source":53,"filename":16,"copyright":53,"fieldtype":289,"meta_data":5097},{},"Toolkit Project Team",[5100],{"_uid":5101,"content":5102,"component":329},"c381e535-7578-4104-befa-7eaa4a4ec7f9",{"type":12,"content":5103},[5104,5109,5114,5119,5124,5129,5134],{"type":15,"attrs":5105,"content":5106},{"textAlign":53},[5107],{"text":5108,"type":305},"Below are the staff members and the positions they held when the Patient Safety Incident Management Toolkit was first developed. ",{"type":15,"attrs":5110,"content":5111},{"textAlign":53},[5112],{"text":5113,"type":305},"Abigail Hain, Senior Director, Capacity Building and Knowledge Translation, Canadian Patient Safety Institute ",{"type":15,"attrs":5115,"content":5116},{"textAlign":53},[5117],{"text":5118,"type":305},"Ioana Popescu, Patient Safety Improvement Lead, Canadian Patient Safety Institute ",{"type":15,"attrs":5120,"content":5121},{"textAlign":53},[5122],{"text":5123,"type":305},"Jennifer Rodgers, Patient Safety Improvement Lead, Canadian Patient Safety Institute ",{"type":15,"attrs":5125,"content":5126},{"textAlign":53},[5127],{"text":5128,"type":305},"Monique Thibodeau, Project Coordinator, Canadian Patient Safety Institute ",{"type":15,"attrs":5130,"content":5131},{"textAlign":53},[5132],{"text":5133,"type":305},"Marie Pinard, Manager, Quality Management, The Hospital For Sick Children ",{"type":15,"attrs":5135,"content":5136},{"textAlign":53},[5137],{"text":5138,"type":305},"Jocelyne Pepin, Assistant Chief, Pharmacy Department, Jewish General Hospital ","wysiwyg-double-column",{"type":12,"content":5141},[5142],{"type":15},{"id":16,"_uid":5144,"content":5145,"component":350},"01cc2d9b-3c22-4f9c-a3d3-1a6a6e43517f",[5146],{"_uid":5147,"content":5148,"component":329},"a5dc5e27-376c-4e0d-bfef-a94ec719246d",{"type":12,"content":5149},[5150,5155,5160],{"type":480,"attrs":5151,"content":5152},{"level":482,"textAlign":53},[5153],{"text":5154,"type":305},"Toolkit Development and Maintenance ",{"type":15,"attrs":5156,"content":5157},{"textAlign":53},[5158],{"text":5159,"type":305},"A variety of qualified experts and organizations worked with the Canadian Patient Safety Institute (now Healthcare Excellence Canada) to compile this practical and evidence-based toolkit. The process included: ",{"type":497,"content":5161},[5162,5169,5176,5183],{"type":500,"content":5163},[5164],{"type":15,"attrs":5165,"content":5166},{"textAlign":53},[5167],{"text":5168,"type":305},"assigning an inhouse team with support from a writer with experience in the field ",{"type":500,"content":5170},[5171],{"type":15,"attrs":5172,"content":5173},{"textAlign":53},[5174],{"text":5175,"type":305},"seeking advice from an expert faculty that included patient and family representatives ",{"type":500,"content":5177},[5178],{"type":15,"attrs":5179,"content":5180},{"textAlign":53},[5181],{"text":5182,"type":305},"basing the content on the Canadian Incident Analysis Framework ",{"type":500,"content":5184},[5185],{"type":15,"attrs":5186,"content":5187},{"textAlign":53},[5188],{"text":5189,"type":305},"engaging key stakeholders via focus groups and collecting evidence from peer-reviewed journals and publicly available literature ",{"id":16,"_uid":5191,"items":5192,"title":5591,"component":2871,"description":5592},"9111b6c7-4bde-44d2-8d63-4bb5c0ce1d9b",[5193],{"_uid":5194,"title":5195,"ctaLeft":5196,"ctaRight":5197,"component":1188,"columnLeft":5198,"columnRight":5256},"caf5344f-9c37-43ea-a758-0a79831e152a","Expand to see the full list of terms",[],[],{"type":12,"content":5199},[5200,5209,5216,5221,5226,5231,5236,5241,5246,5251],{"type":15,"attrs":5201,"content":5202},{"textAlign":53},[5203,5207],{"text":5204,"type":305,"marks":5205},"Note to Quebec Readers",[5206],{"type":555},{"text":5208,"type":305},": The toolkit was developed by and for English and French speaking Canadians and the terms used throughout were chosen by consensus. However, given the provisions contained in the Act Respecting Health Services and Social Services (R.S.Q., chapter S-4.2) effective in Quebec, various terms have been  adapted. During the toolkit development we also consulted with Accreditation Canada to maintain consistency with the revised Disclosure and Incident Management Required Organizational Practices (2014) and the patient safety terminology used therein. Please make the necessary conversions when reading this toolkit text. ",{"type":15,"attrs":5210,"content":5211},{"textAlign":53},[5212],{"text":5213,"type":305,"marks":5214},"Terms used in the toolkit: Terms used in Quebec  ",[5215],{"type":555},{"type":15,"attrs":5217,"content":5218},{"textAlign":53},[5219],{"text":5220,"type":305},"Patient: User ",{"type":15,"attrs":5222,"content":5223},{"textAlign":53},[5224],{"text":5225,"type":305},"Incident disclosure: Accident disclosure ",{"type":15,"attrs":5227,"content":5228},{"textAlign":53},[5229],{"text":5230,"type":305},"Harm: Consequence ",{"type":15,"attrs":5232,"content":5233},{"textAlign":53},[5234],{"text":5235,"type":305},"Patient safety incident: Patient safety incident resulting from the provision of healthcare or social services ",{"type":15,"attrs":5237,"content":5238},{"textAlign":53},[5239],{"text":5240,"type":305},"Harmful incident: Accident with consequences for the user ",{"type":15,"attrs":5242,"content":5243},{"textAlign":53},[5244],{"text":5245,"type":305},"No harm incident: Accident without consequences but the user was affected ",{"type":15,"attrs":5247,"content":5248},{"textAlign":53},[5249],{"text":5250,"type":305},"Near miss: Incident or near miss ",{"type":15,"attrs":5252,"content":5253},{"textAlign":53},[5254],{"text":5255,"type":305},"Harmful incident, no harm incident, and near miss: Events  ",{"type":12,"content":5257},[5258,5263,5272,5281,5290,5299,5308,5317,5325,5334,5343,5352,5361,5370,5379,5388,5397,5405,5414,5449,5457,5466,5475,5484,5493,5502,5511,5520,5529,5538,5547,5556,5565,5574,5582],{"type":15,"attrs":5259,"content":5260},{"textAlign":53},[5261],{"text":5262,"type":305},"This glossary is not intended to be an exhaustive list of terms, but rather a concise list of key terms used throughout the toolkit. ",{"type":15,"attrs":5264,"content":5265},{"textAlign":53},[5266,5270],{"text":5267,"type":305,"marks":5268},"Actions ",[5269],{"type":555},{"text":5271,"type":305},"(taken to reduce risk of harm): Actions taken to reduce, manage, or control any future harm, or probability of harm. ",{"type":15,"attrs":5273,"content":5274},{"textAlign":53},[5275,5279],{"text":5276,"type":305,"marks":5277},"Alerts or advisories",[5278],{"type":555},{"text":5280,"type":305},": An alert or advisory is a piece of information that has been produced and publicly posted that outlines a specific type of patient safety incident or series of incidents that did occur or could occur.  ",{"type":15,"attrs":5282,"content":5283},{"textAlign":53},[5284,5288],{"text":5285,"type":305,"marks":5286},"Apology",[5287],{"type":555},{"text":5289,"type":305},": A genuine expression of sympathy or regret, a statement that one is sorry for what has happened. An apology includes an acknowledgement of responsibility if such responsibility has been determined after the analysis of the adverse event. ",{"type":15,"attrs":5291,"content":5292},{"textAlign":53},[5293,5297],{"text":5294,"type":305,"marks":5295},"Authority gradient",[5296],{"type":555},{"text":5298,"type":305},":  Balance of decision-making power or the steepness of command and hierarchy in a given situation. ",{"type":15,"attrs":5300,"content":5301},{"textAlign":53},[5302,5306],{"text":5303,"type":305,"marks":5304},"Contributing factors",[5305],{"type":555},{"text":5307,"type":305},": A circumstance, action or influence which is thought to have played a part in the origin or development of an incident or to increase the risk of an incident. ",{"type":15,"attrs":5309,"content":5310},{"textAlign":53},[5311,5315],{"text":5312,"type":305,"marks":5313},"Culture, Patient Safety",[5314],{"type":555},{"text":5316,"type":305},": 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. ",{"type":15,"attrs":5318,"content":5319},{"textAlign":53},[5320,5323],{"text":3148,"type":305,"marks":5321},[5322],{"type":555},{"text":5324,"type":305},": The process by which a patient safety incident is communicated to the patient by health care providers. ",{"type":15,"attrs":5326,"content":5327},{"textAlign":53},[5328,5332],{"text":5329,"type":305,"marks":5330},"Early warning system",[5331],{"type":555},{"text":5333,"type":305},": A systemic process for evaluating and measuring risks early in order to take pre-emptive steps to minimize their impact. ",{"type":15,"attrs":5335,"content":5336},{"textAlign":53},[5337,5341],{"text":5338,"type":305,"marks":5339},"Governance",[5340],{"type":555},{"text":5342,"type":305},": The body having accountability and legal responsibility for the overall performance of an organization and oversight of decisions. ",{"type":15,"attrs":5344,"content":5345},{"textAlign":53},[5346,5350],{"text":5347,"type":305,"marks":5348},"Harm",[5349],{"type":555},{"text":5351,"type":305},": Impairment of structure or function of the body and/or any deleterious effect arising therefrom. Harm includes disease, injury, suffering, disability and death. ",{"type":15,"attrs":5353,"content":5354},{"textAlign":53},[5355,5359],{"text":5356,"type":305,"marks":5357},"Hazard",[5358],{"type":555},{"text":5360,"type":305},": Situations with the potential to cause harm. ",{"type":15,"attrs":5362,"content":5363},{"textAlign":53},[5364,5368],{"text":5365,"type":305,"marks":5366},"Healthcare organization",[5367],{"type":555},{"text":5369,"type":305},": An organization that provides health services in any healthcare sector. ",{"type":15,"attrs":5371,"content":5372},{"textAlign":53},[5373,5377],{"text":5374,"type":305,"marks":5375},"High Reliability Organizations (HROs)",[5376],{"type":555},{"text":5378,"type":305},": Organisations that have few accidents despite operating in highly dynamic, technologically rich and hazardous industries. ",{"type":15,"attrs":5380,"content":5381},{"textAlign":53},[5382,5386],{"text":5383,"type":305,"marks":5384},"Human Factors",[5385],{"type":555},{"text":5387,"type":305},": A discipline addressing human behaviour, abilities, limitations, and relationship to the work environment (physical, organizational, cultural), with the goal to promote efficiency, safety and effectiveness by improving the design of technologies, processes and work systems.",{"type":15,"attrs":5389,"content":5390},{"textAlign":53},[5391,5395],{"text":5392,"type":305,"marks":5393},"Incident Analysis",[5394],{"type":555},{"text":5396,"type":305},": A structured process 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. It is also referred to as system-based analysis. ",{"type":15,"attrs":5398,"content":5399},{"textAlign":53},[5400,5403],{"text":4669,"type":305,"marks":5401},[5402],{"type":555},{"text":5404,"type":305},": The various actions and process required to conduct the immediate and ongoing activities following an incident. Incident analysis is a component of incident management. ",{"type":15,"attrs":5406,"content":5407},{"textAlign":53},[5408,5412],{"text":5409,"type":305,"marks":5410},"Patient safety incident",[5411],{"type":555},{"text":5413,"type":305},": An event or circumstance which could have resulted, or did result, in unnecessary harm to a patient. There are three types of patient safety incidents: ",{"type":497,"content":5415},[5416,5427,5438],{"type":500,"content":5417},[5418],{"type":15,"attrs":5419,"content":5420},{"textAlign":53},[5421,5425],{"text":5422,"type":305,"marks":5423},"Harmful incident",[5424],{"type":555},{"text":5426,"type":305},": A patient safety incident that resulted in harm to the patient. Replaces \"preventable adverse event” ",{"type":500,"content":5428},[5429],{"type":15,"attrs":5430,"content":5431},{"textAlign":53},[5432,5436],{"text":5433,"type":305,"marks":5434},"Near miss",[5435],{"type":555},{"text":5437,"type":305},": A patient safety incident that did not reach the patient and therefore no harm resulted. ",{"type":500,"content":5439},[5440],{"type":15,"attrs":5441,"content":5442},{"textAlign":53},[5443,5447],{"text":5444,"type":305,"marks":5445},"No-harm incident",[5446],{"type":555},{"text":5448,"type":305},": A patient safety incident that reached the patient but no discernible harm resulted. ",{"type":15,"attrs":5450,"content":5451},{"textAlign":53},[5452,5455],{"text":78,"type":305,"marks":5453},[5454],{"type":555},{"text":5456,"type":305},": The pursuit of the reduction and mitigation of unsafe acts within the health care system, as well as the use of best practices shown to lead to optimal patient outcomes. ",{"type":15,"attrs":5458,"content":5459},{"textAlign":53},[5460,5464],{"text":5461,"type":305,"marks":5462},"Patient",[5463],{"type":555},{"text":5465,"type":305},": A person who is receiving, has received, or has requested health care. ",{"type":15,"attrs":5467,"content":5468},{"textAlign":53},[5469,5473],{"text":5470,"type":305,"marks":5471},"Family",[5472],{"type":555},{"text":5474,"type":305},": A person(s) whom the patient wishes to be involved with them in care, and acting on behalf of and in the interest of the patient. ",{"type":15,"attrs":5476,"content":5477},{"textAlign":53},[5478,5482],{"text":5479,"type":305,"marks":5480},"Prospective analysis",[5481],{"type":555},{"text":5483,"type":305},": An analytical tool to assess and mitigate harm or loss by analyzing a situation or process that carries with it some inherent risk. Its purpose is to identify the way in which a process might potentially fail, with the goal to eliminate or reduce the likelihood or outcome severity of such a failure.  ",{"type":15,"attrs":5485,"content":5486},{"textAlign":53},[5487,5491],{"text":5488,"type":305,"marks":5489},"Providers",[5490],{"type":555},{"text":5492,"type":305},": Refers to physicians, professional, unregulated staff, and others engaged in the delivery of health services. ",{"type":15,"attrs":5494,"content":5495},{"textAlign":53},[5496,5500],{"text":5497,"type":305,"marks":5498},"Quality Improvement (QI)",[5499],{"type":555},{"text":5501,"type":305},": A formal approach to the analysis of performance and systematic efforts to improve it. There are numerous models used. ",{"type":15,"attrs":5503,"content":5504},{"textAlign":53},[5505,5509],{"text":5506,"type":305,"marks":5507},"Reporting",[5508],{"type":555},{"text":5510,"type":305},": The communication of information about a patient safety incident through appropriate channels inside or outside of healthcare organizations, for the purpose of reducing the risk of occurrence of patient safety incidents in the future. ",{"type":15,"attrs":5512,"content":5513},{"textAlign":53},[5514,5518],{"text":5515,"type":305,"marks":5516},"Resilience",[5517],{"type":555},{"text":5519,"type":305},": The degree to which a system continuously prevents, detects, mitigates or ameliorates hazards or incidents so that an organization can “bounce back” to its original ability to provide core functions. ",{"type":15,"attrs":5521,"content":5522},{"textAlign":53},[5523,5527],{"text":5524,"type":305,"marks":5525},"Risk management",[5526],{"type":555},{"text":5528,"type":305},": An organized effort to identify, assess and reduce, where appropriate, risks to patients, visitors, staff and organizational assets. Activities are undertaken to identify, analyze and educate, and to structure processes to reduce the likelihood of adverse events. ",{"type":15,"attrs":5530,"content":5531},{"textAlign":53},[5532,5536],{"text":5533,"type":305,"marks":5534},"Risk mitigation",[5535],{"type":555},{"text":5537,"type":305},": The process of identifying and implementing precautions or controls that will most effectively reduce the consequence or likelihood of occurrence of a risk. ",{"type":15,"attrs":5539,"content":5540},{"textAlign":53},[5541,5545],{"text":5542,"type":305,"marks":5543},"Risk",[5544],{"type":555},{"text":5546,"type":305},": The probability that a specific adverse event will occur in a specific time period or as a result of a specific situation. ",{"type":15,"attrs":5548,"content":5549},{"textAlign":53},[5550,5554],{"text":5551,"type":305,"marks":5552},"System Levels",[5553],{"type":555},{"text":5555,"type":305},":  Systems are generally viewed from various levels because they are differences in goals, structures and ways of working in different parts of the system.  ",{"type":15,"attrs":5557,"content":5558},{"textAlign":53},[5559,5563],{"text":5560,"type":305,"marks":5561},"System",[5562],{"type":555},{"text":5564,"type":305},": A health system, or healthcare system, is the sum of all the organizations, institutions, and resources whose primary purpose is to deliver health care services to meet the health needs of a target population. ",{"type":15,"attrs":5566,"content":5567},{"textAlign":53},[5568,5572],{"text":5569,"type":305,"marks":5570},"Systems Thinking",[5571],{"type":555},{"text":5573,"type":305},": An approach that centers on the dynamic interaction, synchronization and integration of system components and sub-components (e.g. people, processes, technology, incentives, decisions, culture). ",{"type":15,"attrs":5575,"content":5576},{"textAlign":53},[5577,5580],{"text":5006,"type":305,"marks":5578},[5579],{"type":555},{"text":5581,"type":305},": Two or more people who interact dynamically, interdependently, and adaptively toward a common and valued goal/objective/ mission. Patients/families are part of the team.  ",{"type":15,"attrs":5583,"content":5584},{"textAlign":53},[5585,5589],{"text":5586,"type":305,"marks":5587},"Teamwork",[5588],{"type":555},{"text":5590,"type":305},": Team members working together to achieve a shared goal. 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",[8373],{"type":1205,"attrs":8374},{"color":16},{"text":8376,"type":305,"marks":8377},"Change management for effective quality improvement: a prime",[8378,8381],{"type":315,"attrs":8379},{"href":8380,"uuid":53,"anchor":53,"custom":53,"target":53,"linktype":679},"https://journals.sagepub.com/doi/abs/10.1177/1062860610361625",{"type":1205,"attrs":8382},{"color":16},{"text":8384,"type":305,"marks":8385},". American Journal of Medical Quality. 2010; 25(4): 268–273. DOI: 10.1177/1062860610361625. (Journal article, open access)",[8386],{"type":1205,"attrs":8387},{"color":16},{"text":1209,"type":305},{"type":15,"attrs":8390,"content":8391},{"textAlign":693},[8392,8397,8405,8410],{"text":8393,"type":305,"marks":8394},"Wallace L. ",[8395],{"type":1205,"attrs":8396},{"color":16},{"text":8398,"type":305,"marks":8399},"Feedback from reporting patient safety incidents – are NHS trusts learning lessons?",[8400,8403],{"type":315,"attrs":8401},{"href":8402,"uuid":53,"anchor":53,"custom":53,"target":678,"linktype":679},"https://journals.sagepub.com/doi/10.1258/jhsrp.2009.09s113",{"type":1205,"attrs":8404},{"color":16},{"text":8406,"type":305,"marks":8407}," Journal of Health Services Research & Policy. 2010; January; 15(sup1):  75-78. (Journal article, abstract only)",[8408],{"type":1205,"attrs":8409},{"color":16},{"text":1209,"type":305},{"type":15,"attrs":8412,"content":8413},{"textAlign":693},[8414,8419],{"text":8415,"type":305,"marks":8416},"Washington State Hospital Association (WSHA). Patient Safety: Transforming culture toolkit. 2013. 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",[8435],{"type":1205,"attrs":8436},{"color":16},{"text":8438,"type":305,"marks":8439},"Promoting health care safety through training high reliability teams",[8440,8443],{"type":315,"attrs":8441},{"href":8442,"uuid":53,"anchor":53,"custom":53,"target":678,"linktype":679},"http://qualitysafety.bmj.com/content/14/4/303.full.pdf+html?sid=fa6797d4-129b-4900-aa97-9bcba322ddca",{"type":1205,"attrs":8444},{"color":16},{"text":8446,"type":305,"marks":8447},". Qual Saf Health Care. 2005; 14: 303-309. doi: 10.1136/qshc.2004.010090. (Journal article, open access)",[8448],{"type":1205,"attrs":8449},{"color":16},{"text":1209,"type":305},{"type":15,"attrs":8452,"content":8453},{"textAlign":693},[8454,8459,8467,8472],{"text":8455,"type":305,"marks":8456},"World Health Organization (WHO). 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",[8521],{"type":1205,"attrs":8522},{"color":16},{"text":8524,"type":305,"marks":8525},"Disclosing Adverse Events to Patients: International norms and trends",[8526,8529],{"type":315,"attrs":8527},{"href":8528,"uuid":53,"anchor":53,"custom":53,"target":678,"linktype":679},"http://www.ncbi.nlm.nih.gov/pubmed/24717530",{"type":1205,"attrs":8530},{"color":16},{"text":8532,"type":305,"marks":8533},". 2014. (Journal article, abstract only)",[8534],{"type":1205,"attrs":8535},{"color":16},{"text":1209,"type":305},{"type":15,"attrs":8538,"content":8539},{"textAlign":693},[8540],{"text":8541,"type":305},"5 Million Lives Campaign. Getting started kit: Governance leadership “boards on board” how-to guide. Cambridge, MA: Institute for Healthcare Improvement; 2008. 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But finding innovative ways to work together will benefit everyone.",{"type":15,"attrs":8619,"content":8620},{"textAlign":53},[8621],{"text":8622,"type":305},"Engagement with patients and families includes:",{"type":497,"content":8624},[8625,8632,8639],{"type":500,"content":8626},[8627],{"type":15,"attrs":8628,"content":8629},{"textAlign":53},[8630],{"text":8631,"type":305},"Program and service design and delivery",{"type":500,"content":8633},[8634],{"type":15,"attrs":8635,"content":8636},{"textAlign":53},[8637],{"text":8638,"type":305},"Monitoring, evaluating, policy and priority setting",{"type":500,"content":8640},[8641],{"type":15,"attrs":8642,"content":8643},{"textAlign":53},[8644],{"text":5338,"type":305},{"type":15,"attrs":8646,"content":8647},{"textAlign":53},[8648],{"text":8649,"type":305},"Providers, patients and leaders all have a role to play.",{"type":15,"attrs":8651,"content":8652},{"textAlign":53},[8653],{"text":8654,"type":305},"Providers may need to let go of control, change behaviours to actively listen to what patients are saying and take additional time to understand the patient perspective. They’ll also need more effective ways to brainstorm ideas together, build trust and incorporate different perspectives.",{"type":15,"attrs":8656,"content":8657},{"textAlign":53},[8658],{"text":8659,"type":305},"Patients need to be encouraged to participate more actively in decisions about their care.",{"type":15,"attrs":8661,"content":8662},{"textAlign":53},[8663],{"text":8664,"type":305},"Leaders must support all of this work by revising their practices to embed patient engagement in their procedures, policies and structures.",{"type":15,"attrs":8666,"content":8667},{"textAlign":53},[8668],{"text":8669,"type":305},"We invite you to join us in advancing patient safety through patient and family engagement.",{"_uid":8671,"content":8672,"component":329},"a9684446-7c7f-48ab-9cf5-527fac055163",{"type":12,"content":8673},[8674,8679,8684,8689,8694,8699,8736,8741,8746,8751,8802],{"type":15,"attrs":8675,"content":8676},{"textAlign":53},[8677],{"text":8678,"type":305},"We update this resource regularly. To ensure you are accessing the most up-to-date version, we recommend that you bookmark this page for future reference.",{"type":480,"attrs":8680,"content":8681},{"level":482,"textAlign":53},[8682],{"text":8683,"type":305},"What is the purpose of the guide?",{"type":15,"attrs":8685,"content":8686},{"textAlign":53},[8687],{"text":8688,"type":305},"The purpose of this guide is to help patients and families, providers and leaders work more effectively together to improve patient safety. The guide is an extensive resource that is based on evidence and leading practices.",{"type":480,"attrs":8690,"content":8691},{"level":482,"textAlign":53},[8692],{"text":8693,"type":305},"Who is this guide for?",{"type":15,"attrs":8695,"content":8696},{"textAlign":53},[8697],{"text":8698,"type":305},"This guide is for anyone involved with patient safety and interested in engagement, including:",{"type":497,"content":8700},[8701,8708,8715,8722,8729],{"type":500,"content":8702},[8703],{"type":15,"attrs":8704,"content":8705},{"textAlign":53},[8706],{"text":8707,"type":305},"Patients and families interested in how to partner in their own care to ensure safety",{"type":500,"content":8709},[8710],{"type":15,"attrs":8711,"content":8712},{"textAlign":53},[8713],{"text":8714,"type":305},"Patient partners interested in how to help improve patient safety",{"type":500,"content":8716},[8717],{"type":15,"attrs":8718,"content":8719},{"textAlign":53},[8720],{"text":8721,"type":305},"Providers interested in creating collaborative care relationships with patients and families",{"type":500,"content":8723},[8724],{"type":15,"attrs":8725,"content":8726},{"textAlign":53},[8727],{"text":8728,"type":305},"Managers and leaders responsible for patient engagement, patient safety and/or quality improvement",{"type":500,"content":8730},[8731],{"type":15,"attrs":8732,"content":8733},{"textAlign":53},[8734],{"text":8735,"type":305},"Anyone interested in partnering with patients to develop care programs and systems.",{"type":15,"attrs":8737,"content":8738},{"textAlign":53},[8739],{"text":8740,"type":305},"While the guide focuses primarily on patient safety, many engagement practices apply to other areas, including quality, research and education. The guide is designed to support patient engagement across the healthcare sector.",{"type":480,"attrs":8742,"content":8743},{"level":482,"textAlign":53},[8744],{"text":8745,"type":305},"What is included in the guide?",{"type":15,"attrs":8747,"content":8748},{"textAlign":53},[8749],{"text":8750,"type":305},"In this guide you will find:",{"type":497,"content":8752},[8753,8760,8767,8774,8781,8788,8795],{"type":500,"content":8754},[8755],{"type":15,"attrs":8756,"content":8757},{"textAlign":53},[8758],{"text":8759,"type":305},"Evidence-based guidance",{"type":500,"content":8761},[8762],{"type":15,"attrs":8763,"content":8764},{"textAlign":53},[8765],{"text":8766,"type":305},"Practical patient engagement practices",{"type":500,"content":8768},[8769],{"type":15,"attrs":8770,"content":8771},{"textAlign":53},[8772],{"text":8773,"type":305},"Consolidated information, resources and tools",{"type":500,"content":8775},[8776],{"type":15,"attrs":8777,"content":8778},{"textAlign":53},[8779],{"text":8780,"type":305},"Supporting evidence and examples from across Canada",{"type":500,"content":8782},[8783],{"type":15,"attrs":8784,"content":8785},{"textAlign":53},[8786],{"text":8787,"type":305},"Experiences from patients and families, providers and leaders",{"type":500,"content":8789},[8790],{"type":15,"attrs":8791,"content":8792},{"textAlign":53},[8793],{"text":8794,"type":305},"Probing questions about how to strengthen current approaches",{"type":500,"content":8796},[8797],{"type":15,"attrs":8798,"content":8799},{"textAlign":53},[8800],{"text":8801,"type":305},"Strategies and policies to meet standards and organizational practice requirements.",{"type":15,"attrs":8803,"content":8804},{"textAlign":53},[8805,8809,8811,8813,8816],{"text":8806,"type":305,"marks":8807},"Citation:",[8808],{"type":555},{"type":8810},"hard_break",{"text":8812,"type":305},"Patient Engagement Action Team. 2017.",{"text":8563,"type":305,"marks":8814},[8815],{"type":5620},{"text":8817,"type":305},". HEC. Last modified December 2019.",{"_uid":8819,"file":8820,"link":8822,"label":8583,"linkType":339,"component":340,"linkLabel":16},"a3f2c980-14c0-4b6c-ad10-c391293bdd68",{"id":8579,"alt":8580,"name":16,"focus":16,"title":8580,"source":16,"filename":8581,"copyright":16,"fieldtype":289,"meta_data":8821,"is_external_url":277},{},{"id":16,"url":16,"linktype":321,"fieldtype":338,"cached_url":16},{"_uid":8824,"title":8825,"component":8826,"description":8827,"partners_list":8834},"e7bfa257-dd22-4b1a-9ebf-bbd8c17ff8dc","Partners","partners-list",{"type":12,"content":8828},[8829],{"type":15,"attrs":8830,"content":8831},{"textAlign":53},[8832],{"text":8833,"type":305},"Because of the key role accreditation plays in establishing patient engagement as a core feature of healthcare, the guide is closely aligned with the standards established by the Health Standards Organization (HSO)/Accreditation Canada. Throughout the guide, the HSO logo indicates the points of alignment.",[8835,8845,8854],{"_uid":8836,"link":8837,"image":8838,"component":8843,"partner_name":8844},"db49a4ff-6287-45da-a291-e7157a3e2bc6",[],{"id":8839,"alt":8840,"name":16,"focus":16,"title":8840,"source":16,"filename":8841,"copyright":16,"fieldtype":289,"meta_data":8842,"is_external_url":277},114299152314143,"Atlantic Collaborative Logo","https://a-ca.storyblok.com/f/850807391887861/c05f0ccb5b/atlantic-collaborative-logo.jpg",{},"partners-item","Atlantic Collaborative",{"_uid":8846,"link":8847,"image":8848,"component":8843,"partner_name":8853},"076872ad-9254-4a8d-b634-7a5b1b7f5e0c",[],{"id":8849,"alt":8850,"name":16,"focus":16,"title":8850,"source":16,"filename":8851,"copyright":16,"fieldtype":289,"meta_data":8852,"is_external_url":277},114299156221729,"Helth Quality Ontario Logo","https://a-ca.storyblok.com/f/850807391887861/8d747eae6e/helth-quality-ontario-logo.jpg",{},"Health Quality Ontario",{"_uid":8855,"link":8856,"image":8857,"component":8843,"partner_name":8862},"9580a49a-02f8-497e-af59-8ac30786c6d2",[],{"id":8858,"alt":8859,"name":16,"focus":16,"title":8859,"source":16,"filename":8860,"copyright":16,"fieldtype":289,"meta_data":8861,"is_external_url":277},114300519825531,"Pfpsc","https://a-ca.storyblok.com/f/850807391887861/87607b8c76/pfpsc.png",{},"Patients for Patient Safety Canada",{"id":5591,"_uid":8864,"content":8865,"component":350},"1deae1cc-8408-44e6-9484-be902445a00e",[8866],{"_uid":8867,"content":8868,"component":329},"9bb6f300-25f7-4586-8d21-6b452e878d14",{"type":12,"content":8869},[8870,8875,8885,8894,8903,8912,8921,8930,8939,8962,8967,8993,9002,9011,9020,9029,9038,9045,9068,9084,9093,9102,9111,9134,9143,9152,9161,9169,9203,9216,9225,9282,9291,9300,9309,9316,9329,9342,9351,9360,9384,9397,9406,9411],{"type":480,"attrs":8871,"content":8872},{"level":482,"textAlign":53},[8873],{"text":8874,"type":305},"Glossary of Terms",{"type":15,"attrs":8876,"content":8877},{"textAlign":53},[8878,8880,8883],{"text":8879,"type":305},"This Glossary defines and describes the terms used in the ",{"text":8563,"type":305,"marks":8881},[8882],{"type":555},{"text":8884,"type":305},". When appropriate, use your organization's preferred or commonly used terms.",{"type":15,"attrs":8886,"content":8887},{"textAlign":53},[8888,8892],{"text":8889,"type":305,"marks":8890},"Accreditation: ",[8891],{"type":555},{"text":8893,"type":305},"A self-assessment and external peer assessment process used by health and social service organizations to accurately assess performance levels against established standards, and to implement ways to continuously improve.",{"type":15,"attrs":8895,"content":8896},{"textAlign":53},[8897,8901],{"text":8898,"type":305,"marks":8899},"Culture of safety: ",[8900],{"type":555},{"text":8902,"type":305},"Culture is \"the way we do things around here.\" Culture refers to people's shared values (what is important) and beliefs (what is held to be true), which interact with an organization's structure or system to produce behavioural norms (what people do).",{"type":15,"attrs":8904,"content":8905},{"textAlign":53},[8906,8910],{"text":8907,"type":305,"marks":8908},"Positive safety culture: ",[8909],{"type":555},{"text":8911,"type":305},"Communication is open and honest, there is mutual respect and trust among providers and patients, people are comfortable reporting safety concerns, and there are fair and just processes in place to examine, address, and learn from failures.",{"type":15,"attrs":8913,"content":8914},{"textAlign":53},[8915,8919],{"text":8916,"type":305,"marks":8917},"Disclosure: ",[8918],{"type":555},{"text":8920,"type":305},"A formal process to openly discuss a patient safety incident with the patient, their family, and members of the healthcare organization.",{"type":15,"attrs":8922,"content":8923},{"textAlign":53},[8924,8928],{"text":8925,"type":305,"marks":8926},"Engagement: ",[8927],{"type":555},{"text":8929,"type":305},"An approach to encourage the people most impacted to participate actively in defining their issues of concern, and help decide, plan, deliver, implement, evaluate, and improve initiatives, processes, and/or policies. Ongoing engagement involves developing and sustaining constructive relationships, building strong, active partnerships at various levels across the healthcare system, and holding a meaningful dialogue with partners. Types of engagement include surveys, consultations, and shared decision making, as described in the spectrum of engagement. Effective engagement is goal-focused, decision-oriented and values-based.",{"type":15,"attrs":8931,"content":8932},{"textAlign":53},[8933,8937],{"text":8934,"type":305,"marks":8935},"Patient engagement: ",[8936],{"type":555},{"text":8938,"type":305},"An approach to involve patients, families, and/or patient partners in:",{"type":497,"content":8940},[8941,8948,8955],{"type":500,"content":8942},[8943],{"type":15,"attrs":8944,"content":8945},{"textAlign":53},[8946],{"text":8947,"type":305},"Their own healthcare",{"type":500,"content":8949},[8950],{"type":15,"attrs":8951,"content":8952},{"textAlign":53},[8953],{"text":8954,"type":305},"The design, delivery, evaluation of health services",{"type":500,"content":8956},[8957],{"type":15,"attrs":8958,"content":8959},{"textAlign":53},[8960],{"text":8961,"type":305},"A way that fits their circumstances",{"type":15,"attrs":8963,"content":8964},{"textAlign":53},[8965],{"text":8966,"type":305},"Patients' experiential knowledge is recognized; and power is shared in ongoing, meaningful, constructive relationships at all system levels:",{"type":497,"content":8968},[8969,8979,8986],{"type":500,"content":8970},[8971],{"type":15,"attrs":8972,"content":8973},{"textAlign":53},[8974],{"text":8975,"type":305,"marks":8976},"Direct care",[8977],{"type":1205,"attrs":8978},{"color":16},{"type":500,"content":8980},[8981],{"type":15,"attrs":8982,"content":8983},{"textAlign":53},[8984],{"text":8985,"type":305},"Healthcare organization (service design, governance)",{"type":500,"content":8987},[8988],{"type":15,"attrs":8989,"content":8990},{"textAlign":53},[8991],{"text":8992,"type":305},"Health system (setting priorities and policies)",{"type":15,"attrs":8994,"content":8995},{"textAlign":53},[8996,9000],{"text":8997,"type":305,"marks":8998},"Public engagement: ",[8999],{"type":555},{"text":9001,"type":305},"involving the public/ citizens before or after they access the healthcare system (e.g. make healthy and informed decisions regarding care)",{"type":15,"attrs":9003,"content":9004},{"textAlign":53},[9005,9009],{"text":9006,"type":305,"marks":9007},"Spectrum (continuum, levels) of engagement: ",[9008],{"type":555},{"text":9010,"type":305},"The range of ways patient engagement takes place. It can span from input and consultation to shared leadership, accountability, and decision making.",{"type":15,"attrs":9012,"content":9013},{"textAlign":53},[9014,9018],{"text":9015,"type":305,"marks":9016},"Evaluation: ",[9017],{"type":555},{"text":9019,"type":305},"Collecting, analyzing, and using data and information to understand how a project, program, or policy is progressing and/or what is its impact on individuals, organizations, and/or society. Evaluation often measures success or importance in relation to goals, objectives, and needs.",{"type":15,"attrs":9021,"content":9022},{"textAlign":53},[9023,9027],{"text":9024,"type":305,"marks":9025},"Incident analysis (or root cause analysis): ",[9026],{"type":555},{"text":9028,"type":305},"Structured, rigorous, often legally-protected and confidential process to review a patient safety incident. It identifies what happened, how, why it happened, what can be done to reduce the risk of recurrence and make care safer, and what was learned. It examines the whole system of care to identify the factors that contributed to the patient safety incident.",{"type":15,"attrs":9030,"content":9031},{"textAlign":53},[9032,9036],{"text":9033,"type":305,"marks":9034},"Incident management: ",[9035],{"type":555},{"text":9037,"type":305},"Various actions and processes required immediately and on an ongoing basis following a patient safety incident. It includes immediate response, disclosure, incident analysis, sharing and learning.",{"type":15,"attrs":9039,"content":9040},{"textAlign":53},[9041],{"text":9042,"type":305,"marks":9043},"Patient and family:",[9044],{"type":555},{"type":497,"content":9046},[9047,9057],{"type":500,"content":9048},[9049],{"type":15,"attrs":9050,"content":9051},{"textAlign":53},[9052,9055],{"text":5461,"type":305,"marks":9053},[9054],{"type":555},{"text":9056,"type":305},": Person who is receiving, has received, or has requested health services. It refers to all other terms for patient, including client, resident, person, and individual.",{"type":500,"content":9058},[9059],{"type":15,"attrs":9060,"content":9061},{"textAlign":53},[9062,9066],{"text":9063,"type":305,"marks":9064},"Family:",[9065],{"type":555},{"text":9067,"type":305},"Person(s) whom the patient wishes to be involved in their care, and act on their behalf or interests. Family is defined by the patient. This person speaks up on behalf of the patient with the patient's input.",{"type":15,"attrs":9069,"content":9070},{"textAlign":53},[9071,9075,9077,9082],{"text":9072,"type":305,"marks":9073},"Note: ",[9074],{"type":555},{"text":9076,"type":305},"because of the inconsistent terminology some use the term ",{"text":9078,"type":305,"marks":9079},"\"those most impacted",[9080,9081],{"type":555},{"type":5620},{"text":9083,"type":305},"\" instead of patient.",{"type":15,"attrs":9085,"content":9086},{"textAlign":53},[9087,9091],{"text":9088,"type":305,"marks":9089},"Patient partner (or advisor)",[9090],{"type":555},{"text":9092,"type":305},": An individual who experienced care in the healthcare system (as a patient, family member or caregiver) and who, as part of a patient group (e.g., patient/family council), engages in shaping decisions, policies, and/or practices at all system levels.",{"type":15,"attrs":9094,"content":9095},{"textAlign":53},[9096,9100],{"text":9097,"type":305,"marks":9098},"Patient representative: ",[9099],{"type":555},{"text":9101,"type":305},"An employee working in a healthcare setting who helps patients and families with their specific concerns, and answers their questions while in a healthcare facility. This person is the link between patients/ families, and providers/ organization.",{"type":15,"attrs":9103,"content":9104},{"textAlign":53},[9105,9109],{"text":9106,"type":305,"marks":9107},"Person (Patient, family) Centred Care: ",[9108],{"type":555},{"text":9110,"type":305},"An approach to care where patients and healthcare professionals partner to:",{"type":497,"content":9112},[9113,9120,9127],{"type":500,"content":9114},[9115],{"type":15,"attrs":9116,"content":9117},{"textAlign":53},[9118],{"text":9119,"type":305},"Give patients a voice in the design and delivery of the care and services they receive",{"type":500,"content":9121},[9122],{"type":15,"attrs":9123,"content":9124},{"textAlign":53},[9125],{"text":9126,"type":305},"Allow patients to be proactive in their healthcare journey for better health outcome; and",{"type":500,"content":9128},[9129],{"type":15,"attrs":9130,"content":9131},{"textAlign":53},[9132],{"text":9133,"type":305},"Improve the experience of patients",{"type":15,"attrs":9135,"content":9136},{"textAlign":53},[9137,9141],{"text":9138,"type":305,"marks":9139},"People-centred care: ",[9140],{"type":555},{"text":9142,"type":305},"An approach to care that consciously adopts individuals', carers', families' and communities' perspectives as participants in, and beneficiaries of, trusted health systems that are organized around the comprehensive needs of people rather than individual diseases, and respects their preferences. People-centred care is broader than patient and person-centred care, encompassing not only clinical encounters, but also including attention to the health of people in their communities and their crucial role in shaping health policy and health services.",{"type":15,"attrs":9144,"content":9145},{"textAlign":53},[9146,9150],{"text":9147,"type":305,"marks":9148},"Patient empowerment (or activation): ",[9149],{"type":555},{"text":9151,"type":305},"Helping patients gain control over their own lives and increase their capacity to act on issues that they themselves define as important. Aspects of empowerment include self-efficacy, self-awareness, confidence, coping skills, and health literacy.",{"type":15,"attrs":9153,"content":9154},{"textAlign":53},[9155,9159],{"text":9156,"type":305,"marks":9157},"Patient experience: ",[9158],{"type":555},{"text":9160,"type":305},"The sum of all interactions, shaped by an organization's culture, that influence patient perceptions, across the continuum of care.",{"type":15,"attrs":9162,"content":9163},{"textAlign":53},[9164,9167],{"text":78,"type":305,"marks":9165},[9166],{"type":555},{"text":9168,"type":305},": The pursuit of the reduction and mitigation of unsafe acts within the health care system, as well as the use of best practices shown to lead to optimal patient outcomes. Patient safety is one of the dimensions of quality.",{"type":497,"content":9170},[9171,9182,9189,9196],{"type":500,"content":9172},[9173],{"type":15,"attrs":9174,"content":9175},{"textAlign":53},[9176,9180],{"text":9177,"type":305,"marks":9178},"Patient safety incident: ",[9179],{"type":555},{"text":9181,"type":305},"An event or circumstance which could have resulted, or did result, in unnecessary harm to a patient. It includes:",{"type":500,"content":9183},[9184],{"type":15,"attrs":9185,"content":9186},{"textAlign":53},[9187],{"text":9188,"type":305},"Near miss: A patient safety incident that did not reach the patient. Replaces \"close call.\"",{"type":500,"content":9190},[9191],{"type":15,"attrs":9192,"content":9193},{"textAlign":53},[9194],{"text":9195,"type":305},"No harm incident: A patient safety incident that reached a patient, but no discernible harm resulted.",{"type":500,"content":9197},[9198],{"type":15,"attrs":9199,"content":9200},{"textAlign":53},[9201],{"text":9202,"type":305},"Harmful incident: A patient safety incident that resulted in harm to the patient. Other terms sometimes still used to describe a harmful incident are: adverse event or critical incident.",{"type":497,"content":9204},[9205],{"type":500,"content":9206},[9207],{"type":15,"attrs":9208,"content":9209},{"textAlign":53},[9210,9214],{"text":9211,"type":305,"marks":9212},"Patient safety science: ",[9213],{"type":555},{"text":9215,"type":305},"Methods to acquire and apply safety knowledge to create highly reliable systems that approach \"fail-safe\" conditions (i.e., those in which the operator cannot perform the function improperly). Past effort has been directed toward developing defences, which are barriers that prevent an unsafe act from resulting in harm. Over the years, healthcare has developed many of these barriers, and usually several must be breached for patient harm to occur",{"type":15,"attrs":9217,"content":9218},{"textAlign":53},[9219,9223],{"text":9220,"type":305,"marks":9221},"Measurement: ",[9222],{"type":555},{"text":9224,"type":305},"A process essential to monitoring success. It indicates what's working and what's not, and can provide evidence for others to improve the quality of patient safety.",{"type":497,"content":9226},[9227,9238,9249,9260,9271],{"type":500,"content":9228},[9229],{"type":15,"attrs":9230,"content":9231},{"textAlign":53},[9232,9236],{"text":9233,"type":305,"marks":9234},"Measures(metrics): ",[9235],{"type":555},{"text":9237,"type":305},"Standard for determining an organization or initiative's activities and performance.",{"type":500,"content":9239},[9240],{"type":15,"attrs":9241,"content":9242},{"textAlign":53},[9243,9247],{"text":9244,"type":305,"marks":9245},"Performance measures: ",[9246],{"type":555},{"text":9248,"type":305},"Monitors, evaluates, and communicates the extent to which various activities of the organization or the healthcare system meet their key objectives.",{"type":500,"content":9250},[9251],{"type":15,"attrs":9252,"content":9253},{"textAlign":53},[9254,9258],{"text":9255,"type":305,"marks":9256},"Process measures:",[9257],{"type":555},{"text":9259,"type":305}," Assesses what is being done and how (e.g., engagement activities, strategies or methods which directly affect the outcome), what is working well, and what needs to be changed or improved (e.g., the delivery of timely prophylactic antibiotics to reduce surgical site infection).",{"type":500,"content":9261},[9262],{"type":15,"attrs":9263,"content":9264},{"textAlign":53},[9265,9269],{"text":9266,"type":305,"marks":9267},"Outcome measures: ",[9268],{"type":555},{"text":9270,"type":305},"Determines what effects the engagement had, what it did or did not accomplish, and what success looks like (e.g., to reduce falls, teams should measure the number of falls).",{"type":500,"content":9272},[9273],{"type":15,"attrs":9274,"content":9275},{"textAlign":53},[9276,9280],{"text":9277,"type":305,"marks":9278},"Balancing measures: ",[9279],{"type":555},{"text":9281,"type":305},"Determines if improvements in one part of the system were made at the expense of other processes in other parts of the system (e.g., in a project to reduce the average length of stay for a group of patients, the team should also monitor the percent of readmissions within 30 days for the same group).",{"type":15,"attrs":9283,"content":9284},{"textAlign":53},[9285,9289],{"text":9286,"type":305,"marks":9287},"Providers (or clinicians): ",[9288],{"type":555},{"text":9290,"type":305},"Includes physicians, nurses, and allied health care professionals who directly provide healthcare services to patients. The term does not include the family members providing care (family caregivers or care partners).",{"type":15,"attrs":9292,"content":9293},{"textAlign":53},[9294,9298],{"text":9295,"type":305,"marks":9296},"Quality of care: ",[9297],{"type":555},{"text":9299,"type":305},"The degree to which healthcare services produce the desired health outcomes and measure up to current evidence and knowledge. The attributes most often used to describe quality care are safe, patient-centred, accessible, appropriate, effective, efficient, and equitable. Each province or organization may have their own quality frameworks.",{"type":15,"attrs":9301,"content":9302},{"textAlign":53},[9303,9307],{"text":9304,"type":305,"marks":9305},"Quality Improvement: ",[9306],{"type":555},{"text":9308,"type":305},"A systematic approach to making changes that lead to better patient outcomes and stronger health system performance. It involves applying quality improvement science, which provides a robust structure, tools, and processes to assess and accelerate efforts for testing, implementing, and spreading good practices.",{"type":15,"attrs":9310,"content":9311},{"textAlign":53},[9312],{"text":9313,"type":305,"marks":9314},"Information",[9315],{"type":555},{"type":497,"content":9317},[9318],{"type":500,"content":9319},[9320],{"type":15,"attrs":9321,"content":9322},{"textAlign":53},[9323,9327],{"text":9324,"type":305,"marks":9325},"Qualitative information",[9326],{"type":555},{"text":9328,"type":305},": Descriptive information, such as patient stories, notes from interviews or focus group discussions, and observation notes. Qualitative information can be systematically analyzed to identify issues of interest.",{"type":497,"content":9330},[9331],{"type":500,"content":9332},[9333],{"type":15,"attrs":9334,"content":9335},{"textAlign":53},[9336,9340],{"text":9337,"type":305,"marks":9338},"Quantitative information",[9339],{"type":555},{"text":9341,"type":305},": Information that measures characteristics using a numeric value (e.g., gender, income, marital status, etc.). The numeric values can be statistically analyzed to identify issues of interest.",{"type":15,"attrs":9343,"content":9344},{"textAlign":53},[9345,9349],{"text":9346,"type":305,"marks":9347},"Stakeholder: ",[9348],{"type":555},{"text":9350,"type":305},"A person who has a vested interest in engagement outcomes and who could be affected by any decisions taken or changes made. Stakeholders could include: patients, families, caregivers, providers, administrative staff, suppliers, organizational partners, the community, the public and others.",{"type":15,"attrs":9352,"content":9353},{"textAlign":53},[9354,9358],{"text":9355,"type":305,"marks":9356},"System levels: ",[9357],{"type":555},{"text":9359,"type":305},"The healthcare system is comprised of many sub-systems operating at different levels (e.g., outside of the organization, within the organization and/or program level, at point of care) each with specific goals, resources (e.g., human, financial, equipment), and formal or informal processes.",{"type":497,"content":9361},[9362,9373],{"type":500,"content":9363},[9364],{"type":15,"attrs":9365,"content":9366},{"textAlign":53},[9367,9371],{"text":9368,"type":305,"marks":9369},"Point of care: ",[9370],{"type":555},{"text":9372,"type":305},"direct care (patient and family receiving care and providers and others who deliver care and services)",{"type":500,"content":9374},[9375],{"type":15,"attrs":9376,"content":9377},{"textAlign":53},[9378,9382],{"text":9379,"type":305,"marks":9380},"Organization: ",[9381],{"type":555},{"text":9383,"type":305},"program/ unit/service and facility/organization/ health region (service design and delivery, strategy, system planning, organizational design, governance)",{"type":497,"content":9385},[9386],{"type":500,"content":9387},[9388],{"type":15,"attrs":9389,"content":9390},{"textAlign":53},[9391,9395],{"text":9392,"type":305,"marks":9393},"System: ",[9394],{"type":555},{"text":9396,"type":305},"the sum of all the organizations, institutions, and resources that deliver health care services to meet the health needs of a target population (policy, planning, resourcing, research, education, accreditation)",{"type":15,"attrs":9398,"content":9399},{"textAlign":53},[9400,9404],{"text":9401,"type":305,"marks":9402},"Validated tool/survey/questionnaire: ",[9403],{"type":555},{"text":9405,"type":305},"A measurement tool that has been tested for reliability (produces consistent results) and validity (produces true results).",{"type":480,"attrs":9407,"content":9408},{"level":482,"textAlign":53},[9409],{"text":9410,"type":305},"References",{"type":497,"content":9412},[9413,9428,9435,9450,9464,9476,9483,9498,9512,9519],{"type":500,"content":9414},[9415],{"type":15,"attrs":9416,"content":9417},{"textAlign":53},[9418,9420,9426],{"text":9419,"type":305},"Healthcare Excellence Canada. ",{"text":1087,"type":305,"marks":9421},[9422],{"type":315,"attrs":9423},{"href":9424,"uuid":368,"anchor":53,"custom":9425,"target":320,"linktype":321},"/resources/patient-safety-and-incident-management-toolkit",{},{"text":9427,"type":305},". Glossary. 2015.",{"type":500,"content":9429},[9430],{"type":15,"attrs":9431,"content":9432},{"textAlign":53},[9433],{"text":9434,"type":305},"Carman KL, Dardess P, Maurer M, Sofaer S, Adams K, Bechtel C, Sweeney J. Patient and family engagement: a framework for understanding the elements and developing interventions and policies. Health Aff (Millwood). 2013 Feb;32(2):223-31",{"type":500,"content":9436},[9437],{"type":15,"attrs":9438,"content":9439},{"textAlign":53},[9440,9442,9448],{"text":9441,"type":305},"Charles Vincent, René Amalberti. Safer Healthcare. ",{"text":9443,"type":305,"marks":9444},"Strategies for the Real World",[9445],{"type":315,"attrs":9446},{"href":9447,"uuid":53,"anchor":53,"custom":53,"target":678,"linktype":679},"https://link.springer.com/book/10.1007/978-3-319-25559-0",{"text":9449,"type":305},". Springer, Cham. 2016.",{"type":500,"content":9451},[9452],{"type":15,"attrs":9453,"content":9454},{"textAlign":53},[9455,9457,9462],{"text":9456,"type":305},"Emanuel LL, Taylor L, Hain A, Combes JR, Hatlie MJ, Karsh B, Lau DT, Shalowitz J, Shaw T, Walton M, eds. ",{"text":9458,"type":305,"marks":9459},"The Patient Safety Education Program – Canada (PSEP – Canada) Curriculum",[9460],{"type":315,"attrs":9461},{"href":6112,"uuid":53,"anchor":53,"custom":53,"target":678,"linktype":679},{"text":9463,"type":305},". © PSEP – Canada, 2016.",{"type":500,"content":9465},[9466],{"type":15,"attrs":9467,"content":9468},{"textAlign":53},[9469,9471],{"text":9470,"type":305},"European Patients Forum. Patient Empowerment: ",{"text":9472,"type":305,"marks":9473},"https://www.eu-patient.eu/policy/Policy/patient-empowerment/",[9474],{"type":315,"attrs":9475},{"href":9472,"uuid":53,"anchor":53,"custom":53,"target":678,"linktype":679},{"type":500,"content":9477},[9478],{"type":15,"attrs":9479,"content":9480},{"textAlign":53},[9481],{"text":9482,"type":305},"Health Quality Council of Alberta. The Alberta Quality Matrix for Health.",{"type":500,"content":9484},[9485],{"type":15,"attrs":9486,"content":9487},{"textAlign":53},[9488,9490,9496],{"text":9489,"type":305},"Health Quality Ontario. ",{"text":9491,"type":305,"marks":9492},"Quality Matters: Realizing Excellent Care for All",[9493],{"type":315,"attrs":9494},{"href":9495,"uuid":53,"anchor":53,"custom":53,"target":678,"linktype":679},"http://www.hqontario.ca/Portals/0/documents/health-quality/realizing-excellent-care-for-all-en.pdf",{"text":9497,"type":305},". 2015.",{"type":500,"content":9499},[9500],{"type":15,"attrs":9501,"content":9502},{"textAlign":53},[9503,9505,9511],{"text":9504,"type":305},"Institute for Patient- and Family-Centered Care. ",{"text":9506,"type":305,"marks":9507},"What is patient and family centred care",[9508],{"type":315,"attrs":9509},{"href":9510,"uuid":53,"anchor":53,"custom":53,"target":678,"linktype":679},"http://www.ipfcc.org/about/pfcc.html",{"text":1140,"type":305},{"type":500,"content":9513},[9514],{"type":15,"attrs":9515,"content":9516},{"textAlign":53},[9517],{"text":9518,"type":305},"The Beryl Institute. Defining Patient Experience.",{"type":500,"content":9520},[9521],{"type":15,"attrs":9522,"content":9523},{"textAlign":53},[9524,9526,9530,9532,9537],{"text":9525,"type":305},"World Health Organization Secretariat. ",{"text":9527,"type":305,"marks":9528},"Framework on Integrated, People-Centred Health Services",[9529],{"type":5620},{"text":9531,"type":305},". World Health Organization; 2016. ",{"text":9533,"type":305,"marks":9534},"https://apps.who.int/gb/ebwha/pdf_files/WHA69/A69_39-en.pdf?ua=1&ua=1",[9535],{"type":315,"attrs":9536},{"href":9533,"uuid":53,"anchor":53,"custom":53,"target":678,"linktype":679},{"text":1140,"type":305},[129,122,150],[185,192,200],"engaging-patients-in-patient-safety-a-canadian-guide","resources/engaging-patients-in-patient-safety-a-canadian-guide",-16870,[],{"parent_slug":361,"umbraco_path":9545,"umbraco_uuid":9546},"/HealthcareExcellenceCanada/Resources/EngagingPatientsInPatientSafetyACanadianGuide","c7c8cec5-d126-4a71-bf4b-03ad6b358cbf","0e6ed5c9-e317-4daf-b78f-843de98aa9f1","2025-11-18T19:04:41.279Z",[],[9551],{"path":9552,"name":9553,"lang":393,"published":326},"ressources/engager-les-patients-dans-la-securite-des-patients-un-guide-canadien","Engager les patients dans la sécurité des patients – un guide canadien",{"name":9555,"created_at":9556,"published_at":9557,"updated_at":9558,"id":9559,"uuid":370,"content":9560,"slug":11461,"full_slug":11462,"sort_by_date":53,"position":11463,"tag_list":11464,"is_startpage":277,"parent_id":381,"meta_data":11465,"group_id":11468,"first_published_at":11469,"release_id":53,"lang":387,"path":53,"alternates":11470,"default_full_slug":11462,"translated_slugs":11471},"A Framework for Establishing a Patient Safety Culture","2025-11-26T23:54:01.836Z","2026-02-27T17:41:04.817Z","2026-02-27T17:41:04.943Z",116783685107956,{"new":277,"seo":9561,"_uid":9564,"hero":9565,"type":174,"topics":9580,"Noindex":277,"content":9581,"audience":11459,"duration":16,"regional":11460,"component":376},{"title":9562,"plugin":279,"description":9563},"Patient Safety Culture Bundle","The Framework is based on a set of evidence-based practices that must all be applied in order to deliver good, safe care.","49df0bce-fd9d-46d2-8dc6-0ff0774021c5",[9566],{"_uid":9567,"file":9568,"image":9569,"title":9555,"format":16,"component":290,"description":9570,"key_learning":16,"prerequisite":16},"79e09932-73e6-42b2-9a8d-e64a6f111b31",[],{"id":1101,"filename":1102,"fieldtype":289},{"type":12,"content":9571},[9572],{"type":15,"attrs":9573,"content":9574},{"textAlign":53},[9575],{"text":9563,"type":305,"marks":9576},[9577],{"type":1205,"attrs":9578},{"color":9579},"#000000",[84,76,39],[9582,9982,10383],{"_uid":9583,"content":9584,"component":350},"99f5eb80-72f4-4d41-a1e4-3e90cccf2d8e",[9585,9623,9632,9834],{"_uid":9586,"content":9587,"component":329},"5cebfb0b-2763-49f2-8765-c93c4b22ba83",{"type":12,"content":9588},[9589,9596,9601,9612],{"type":480,"attrs":9590,"content":9591},{"level":482,"textAlign":53},[9592],{"text":9593,"type":305,"marks":9594},"Patient Safety Culture \"Bundle\" for CEOs/Senior Leaders",[9595],{"type":555},{"type":480,"attrs":9597,"content":9598},{"level":1214,"textAlign":53},[9599],{"text":9600,"type":305},"What is the Patient Safety Culture \"Bundle\"?",{"type":15,"attrs":9602,"content":9603},{"textAlign":53},[9604,9606,9610],{"text":9605,"type":305},"Strengthening a safety culture necessitates sequential, iterative and simultaneous interventions that",{"text":9607,"type":305,"marks":9608}," enable, enact and learn ",[9609],{"type":555},{"text":9611,"type":305},"in a way that is attuned to the existing culture. Through a literature review of more than 60 resources, we created a Patient Safety Culture “Bundle” that has been validated through interviews with Canadian thought leaders. The Bundle is based on a set of evidence-based practices that must all be applied in order to deliver good care. All components are required to improve the patient safety culture.",{"type":15,"attrs":9613,"content":9614},{"textAlign":53},[9615,9617,9621],{"text":9616,"type":305},"The ",{"text":9618,"type":305,"marks":9619},"Patient Safety Culture \"Bundle\" for CEOs and Senior Leaders ",[9620],{"type":555},{"text":9622,"type":305},"encompasses key concepts of safety science, implementation science, just culture, psychological safety, staff safety/health, patient and family engagement, disruptive behaviour, high reliability/resilience, patient safety measurement, frontline leadership, physician leadership, staff engagement, teamwork/communication and industry-wide standardization/alignment.",{"_uid":9624,"file":9625,"link":9630,"label":9631,"linkType":339,"component":340,"linkLabel":16},"4fa0996b-9c01-4306-9c98-2f469b22b816",{"id":9626,"alt":9627,"name":16,"focus":16,"title":9627,"source":16,"filename":9628,"copyright":16,"fieldtype":289,"meta_data":9629,"is_external_url":277},114293328894289,"Patient Safety Culture Bundle For Leaders EN FINAL Ua","https://a-ca.storyblok.com/f/850807391887861/7677ee3692/patient-safety-culture-bundle-for-leaders-en-final-ua.pdf",{},{"id":16,"url":16,"linktype":321,"fieldtype":338,"cached_url":16},"One-Pager of the Patient Safety Culture “Bundle” for CEOs/Senior Leaders",{"_uid":9633,"content":9634,"component":329},"7bdfc769-9073-4c00-ab3b-8bbad7e07ce0",{"type":12,"content":9635},[9636,9641,9646,9651,9656,9661,9670,9677,9694,9699,9711,9718,9730,9737,9749,9756,9774,9781,9790,9797,9812,9819],{"type":480,"attrs":9637,"content":9638},{"level":482,"textAlign":53},[9639],{"text":9640,"type":305},"Why was this Bundle created?",{"type":15,"attrs":9642,"content":9643},{"textAlign":53},[9644],{"text":9645,"type":305},"A patient safety culture is difficult to operationalize. Improving safety requires an organizational culture that enables and prioritizes patient safety. The importance of culture change needs to be brought to the forefront, rather than taking a back seat to other safety activities.",{"type":15,"attrs":9647,"content":9648},{"textAlign":53},[9649],{"text":9650,"type":305},"The National Patient Safety Consortium Education Working Group verified the critical role senior leadership plays in ensuring patient safety is an organizational priority. A working group of partners, led by the Canadian Patient Safety Institute (now Healthcare Excellence Canada), Canadian College of Health Leaders (CCHL), HealthCareCAN and the Healthcare Insurance Reciprocal of Canada (HIROC), joined together to establish a framework and advance this work.",{"type":480,"attrs":9652,"content":9653},{"level":482,"textAlign":53},[9654],{"text":9655,"type":305},"Testimonials",{"type":15,"attrs":9657,"content":9658},{"textAlign":53},[9659],{"text":9660,"type":305},"\"Patient safety and healthcare quality are advanced when boards and senior leaders are committed to it and are able to show evidence of that commitment. Missing until now is a concise \"how to\" guide. The Patient Safety bundle for Leaders fills that gap.\"",{"type":15,"attrs":9662,"content":9663},{"textAlign":53},[9664,9668],{"text":9665,"type":305,"marks":9666},"Catherine Gaulton",[9667],{"type":555},{"text":9669,"type":305},", CEO, HIROC",{"type":15,"attrs":9671,"content":9672},{"textAlign":53},[9673],{"text":9674,"type":305,"marks":9675},"\"Leadership is critical to developing a patient safety culture and building leadership capacity requires a vision of the knowledge, skills and behaviours necessary to achieve this. The Patient Safety Leadership Bundle provides this and will be a practical tool for health leaders across the healthcare continuum to assess their personal capabilities. It will also provide both organizations and the system, as a whole, a checklist for what's missing from our collective leadership education toolkits so that we can strategically respond to these needs. HealthCareCAN is committed to the spread of this tool across the country as part of a cultural shift to safety and a drive towards high-reliability culture.\"",[9676],{"type":5620},{"type":15,"attrs":9678,"content":9679},{"textAlign":53},[9680,9684,9686,9689,9690],{"text":9681,"type":305,"marks":9682},"Dale Schierbeck",[9683],{"type":555},{"text":9685,"type":305},", Vice-President, Learning & Development, HealthCare",{"text":6021,"type":305,"marks":9687},[9688],{"type":5620},{"type":8810},{"text":9691,"type":305,"marks":9692},"and Co-Chair, Patient Safety Education for Leaders Working",[9693],{"type":5620},{"type":15,"attrs":9695,"content":9696},{"textAlign":53},[9697],{"text":9698,"type":305},"\"The drive to quality and patient safety must start at the top with the board of directors – they are a critical enabler of culture change. It has been well-recognized that taking a passive role in this fundamental responsibility is not an option. Governors need insight into best practice principles and a corresponding framework to help guide them in this important task – this bundle delivers that.\"",{"type":15,"attrs":9700,"content":9701},{"textAlign":53},[9702,9706,9708,9709],{"text":9703,"type":305,"marks":9704},"Elizabeth Martin",[9705],{"type":555},{"text":9707,"type":305},", Board Chair, HIROC;",{"type":8810},{"text":9710,"type":305},"former Board member, Sunnybrook Health Sciences Centre",{"type":15,"attrs":9712,"content":9713},{"textAlign":53},[9714],{"text":9715,"type":305,"marks":9716},"\"Preventable harm must remain a focus for all Boards as they consider their organization's commitment to the people they care for. The depth of information and insight contained within the Patient Safety Culture Bundle will assist all leaders, boards and organizations to fully appreciate the importance culture plays in achieving these goals. Armed with this knowledge, the dedicated people within healthcare organizations can be supported to deliver consistently safe care.\"",[9717],{"type":5620},{"type":15,"attrs":9719,"content":9720},{"textAlign":53},[9721,9725,9727,9728],{"text":9722,"type":305,"marks":9723},"Ruthe Anne Conyngham",[9724],{"type":555},{"text":9726,"type":305},", Faculty, Canadian Patient Safety Institute;",{"type":8810},{"text":9729,"type":305},"Member, Cancer Quality Council of Ontario",{"type":15,"attrs":9731,"content":9732},{"textAlign":53},[9733],{"text":9734,"type":305,"marks":9735},"\"For years, senior leaders have promoted the use of checklists to support evidence-informed clinical practice. Now leaders have their own checklist to support a safety culture. The Patient Safety Leadership Bundle will be an invaluable resource to help leaders walk the talk and lead by example\"",[9736],{"type":5620},{"type":15,"attrs":9738,"content":9739},{"textAlign":53},[9740,9744,9746,9747],{"text":9741,"type":305,"marks":9742},"Maura Davies",[9743],{"type":555},{"text":9745,"type":305},", Former President and CEO, Saskatoon Health Region;",{"type":8810},{"text":9748,"type":305},"President, Maura Davies Healthcare Consulting Inc.",{"type":15,"attrs":9750,"content":9751},{"textAlign":53},[9752],{"text":9753,"type":305,"marks":9754},"\"The patient safety and quality culture bundle is a key resource that provides useful guidance for senior leaders on the critical knowledge and actions needed to support improvements in safety culture and outcomes.\"",[9755],{"type":5620},{"type":15,"attrs":9757,"content":9758},{"textAlign":53},[9759,9763,9765,9766,9768,9769,9771,9772],{"text":9760,"type":305,"marks":9761},"Ross Baker",[9762],{"type":555},{"text":9764,"type":305},", Ph.D., Professor and Program Lead, Quality Improvement and Patient Safety,",{"type":8810},{"text":9767,"type":305},"Institute of Health Policy, Management and Evaluation,",{"type":8810},{"text":9770,"type":305},"Dalla Lana School of Public Health,",{"type":8810},{"text":9773,"type":305},"University of Toronto",{"type":15,"attrs":9775,"content":9776},{"textAlign":53},[9777],{"text":9778,"type":305,"marks":9779},"\"One of many actions resulting from the work of National Patient Safety Consortium is the Safety Bundle for Leaders/CEOs, which demonstrates the critical role senior leadership plays in ensuring patient safety is an organizational priority. The Safety Bundle will help identify the best practices, skills, tools and resources healthcare leaders can deploy to advance patient safety and facilitate the spread of this knowledge within their organizations.\"",[9780],{"type":5620},{"type":15,"attrs":9782,"content":9783},{"textAlign":53},[9784,9788],{"text":9785,"type":305,"marks":9786},"Chris Power",[9787],{"type":555},{"text":9789,"type":305},", Chief Executive Officer, Canadian Patient Safety Institute",{"type":15,"attrs":9791,"content":9792},{"textAlign":53},[9793],{"text":9794,"type":305,"marks":9795},"\"The Board is ultimately accountable for the performance of the organization. The \"Patient Safety Culture Bundle\" is an excellent resource to assist the Board in improving organizational culture and advancing its patient safety agenda.\"",[9796],{"type":5620},{"type":15,"attrs":9798,"content":9799},{"textAlign":53},[9800,9804,9806,9807,9809,9810],{"text":9801,"type":305,"marks":9802},"Joan Dawe",[9803],{"type":555},{"text":9805,"type":305},", Peer facilitator Effective Governance for Quality and Patient Safety",{"type":8810},{"text":9808,"type":305},"Education Program; Past Chair, Eastern Health Regional Authority;",{"type":8810},{"text":9811,"type":305},"Past Chair, Health and Community Services, St. John's Region",{"type":15,"attrs":9813,"content":9814},{"textAlign":53},[9815],{"text":9816,"type":305,"marks":9817},"\"The Board, CEO and Senior Leaders all play critical roles in setting the tone and championing the importance of a safety culture in their organizations. Engaging staff in this effort starts at the top and demands attention and concerted ongoing effort. It requires support for and engagement with front line staff and respect for what they do, and equally important, engaging those being served and the shared knowledge this experience generates for improving care processes. This work is complex and the Bundle will serve as a useful guide for the scope of effort required to improve safety and eliminate harm.\"",[9818],{"type":5620},{"type":15,"attrs":9820,"content":9821},{"textAlign":53},[9822,9826,9828,9832],{"text":9823,"type":305,"marks":9824},"Ray Racette",[9825],{"type":555},{"text":9827,"type":305},", former ",{"text":9829,"type":305,"marks":9830},"CEO",[9831],{"type":555},{"text":9833,"type":305}," Canadian College of Health 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",{"type":12,"content":10372},[10373,10378],{"type":15,"attrs":10374,"content":10375},{"textAlign":53},[10376],{"text":10377,"type":305},"The key components required for a Patient Safety Culture are identified under three pillars.",{"type":15,"attrs":10379,"content":10380},{"textAlign":53},[10381],{"text":10382,"type":305},"Adapted from: Singer & Vogus (2013). Reducing hospital errors: Interventions that build safety culture. ARPH 34:373-96 JANUARY 2018",{"_uid":10384,"items":10385,"title":359,"component":2871,"description":11456},"ebd2f041-18f8-48f8-b84b-5efd37257a29",[10386],{"_uid":10387,"title":5600,"ctaLeft":10388,"ctaRight":10389,"component":1188,"columnLeft":10390,"columnRight":10393},"3ac89885-aee2-4328-addf-62c5a787340f",[],[],{"type":12,"content":10391},[10392],{"type":15},{"type":12,"content":10394},[10395,10407,10416,10454,10466,10475,10487,10496,10505,10517,10526,10538,10547,10559,10568,10580,10589,10601,10610,10622,10631,10643,10652,10664,10734,10821,10908,10920,10941,10963,10972,10995,11016,11038,11047,11069,11091,11112,11121,11143,11166,11188,11211,11220,11229,11238,11261,11282,11304,11326,11335,11358,11380,11403,11425,11447],{"type":480,"attrs":10396,"content":10397},{"level":482,"textAlign":693},[10398,10404],{"text":10399,"type":305,"marks":10400},"Singer and Vogus – Interventions That Build Safety Culture (2013)",[10401,10403],{"type":1205,"attrs":10402},{"color":16},{"type":555},{"text":1209,"type":305,"marks":10405},[10406],{"type":555},{"type":15,"attrs":10408,"content":10409},{"textAlign":693},[10410,10415],{"text":10411,"type":305,"marks":10412},"Piecemeal initiatives to improve a patient safety culture are inadequate; 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education; monitoring (prospective, retrospective, concurrent); operational improvements (industrial techniques, infrastructure).",[10451],{"type":1205,"attrs":10452},{"color":16},{"text":1209,"type":305},{"type":480,"attrs":10455,"content":10456},{"level":482,"textAlign":693},[10457,10463],{"text":10458,"type":305,"marks":10459},"Baker – Beyond the Quick Fix (2015)",[10460,10462],{"type":1205,"attrs":10461},{"color":16},{"type":555},{"text":1209,"type":305,"marks":10464},[10465],{"type":555},{"type":15,"attrs":10467,"content":10468},{"textAlign":693},[10469,10474],{"text":10470,"type":305,"marks":10471},"Recommendations: Patient safety /quality improvement strategy; board monitoring of performance; measurement (organizational and microsystem levels); event reporting and analysis (focus on gaps and feasible recommendations); investments in work climate; patients and care givers included in patient safety and quality improvement; investments in patient safety /quality improvement infrastructure; leadership development; collaboration across organizations; pan-Canadian information systems.",[10472],{"type":1205,"attrs":10473},{"color":16},{"text":1209,"type":305},{"type":480,"attrs":10476,"content":10477},{"level":482,"textAlign":693},[10478,10484],{"text":10479,"type":305,"marks":10480},"Canadian Patient Safety Institute – Patient Safety Culture",[10481,10483],{"type":1205,"attrs":10482},{"color":16},{"type":555},{"text":1209,"type":305,"marks":10485},[10486],{"type":555},{"type":15,"attrs":10488,"content":10489},{"textAlign":693},[10490,10495],{"text":10491,"type":305,"marks":10492},"Dimensions: informed; reporting; learning; just; flexible.",[10493],{"type":1205,"attrs":10494},{"color":16},{"text":1209,"type":305},{"type":15,"attrs":10497,"content":10498},{"textAlign":693},[10499,10504],{"text":10500,"type":305,"marks":10501},"Contributors: leadership; patient/family engagement; teamwork and communication; openness to reporting; learning; resources; priority of safety versus production; education and training.",[10502],{"type":1205,"attrs":10503},{"color":16},{"text":1209,"type":305},{"type":480,"attrs":10506,"content":10507},{"level":482,"textAlign":693},[10508,10514],{"text":10509,"type":305,"marks":10510},"British Columbia – Culture Change Toolbox: Components of Patient Safety Culture (2013)",[10511,10513],{"type":1205,"attrs":10512},{"color":16},{"type":555},{"text":1209,"type":305,"marks":10515},[10516],{"type":555},{"type":15,"attrs":10518,"content":10519},{"textAlign":693},[10520,10525],{"text":10521,"type":305,"marks":10522},"Teamwork and communication; safety climate; psychological safety; organizational fairness; just culture; stress recognition; working conditions; leadership; learning and improvement; patients as partners; transparency.",[10523],{"type":1205,"attrs":10524},{"color":16},{"text":1209,"type":305},{"type":480,"attrs":10527,"content":10528},{"level":482,"textAlign":693},[10529,10535],{"text":10530,"type":305,"marks":10531},"American College of Healthcare Executives (ACHE) / Institute for Healthcare Improvement (IHI) / National Patient Safety Foundation (NPSF) – Leadership Blueprint for Culture of Safety (2017)",[10532,10534],{"type":1205,"attrs":10533},{"color":16},{"type":555},{"text":1209,"type":305,"marks":10536},[10537],{"type":555},{"type":15,"attrs":10539,"content":10540},{"textAlign":693},[10541,10546],{"text":10542,"type":305,"marks":10543},"Six leadership domains: vision; trust, respect and inclusion; board engagement; leadership development; just culture; behaviour expectations.",[10544],{"type":1205,"attrs":10545},{"color":16},{"text":1209,"type":305},{"type":480,"attrs":10548,"content":10549},{"level":482,"textAlign":693},[10550,10556],{"text":10551,"type":305,"marks":10552},"IHI Whitepaper – Patient Safety (2006)",[10553,10555],{"type":1205,"attrs":10554},{"color":16},{"type":555},{"text":1209,"type":305,"marks":10557},[10558],{"type":555},{"type":15,"attrs":10560,"content":10561},{"textAlign":693},[10562,10567],{"text":10563,"type":305,"marks":10564},"Patient safety strategy/aims; senior leader communication and awareness building (e.g., walk-rounds); engage stakeholders (board, leaders, physicians, staff, patients/families) in patient safety; implement \"just\" culture; focus on process redesign/improved reliability (e.g., evidence-based standardization, human factors); leader/ manager/staff accountability  (e.g., for safety reporting, reliable processes/\"daily work\") and aligned incentives for patient safety; patient safety infrastructure (staff and committees); assess patient safety  culture; measure/track patient safety (e.g. mortality, trigger tool); support patients/families impacted by errors.",[10565],{"type":1205,"attrs":10566},{"color":16},{"text":1209,"type":305},{"type":480,"attrs":10569,"content":10570},{"level":482,"textAlign":693},[10571,10577],{"text":10572,"type":305,"marks":10573},"IHI Whitepaper – 7 Leadership Leverage Points (2008)",[10574,10576],{"type":1205,"attrs":10575},{"color":16},{"type":555},{"text":1209,"type":305,"marks":10578},[10579],{"type":555},{"type":15,"attrs":10581,"content":10582},{"textAlign":693},[10583,10588],{"text":10584,"type":305,"marks":10585},"System-level aims; executable strategy; leadership attention; patients /families; Chief Financial Officer (CFO) as quality champion; engage physicians; improvement capability.",[10586],{"type":1205,"attrs":10587},{"color":16},{"text":1209,"type":305},{"type":480,"attrs":10590,"content":10591},{"level":482,"textAlign":693},[10592,10598],{"text":10593,"type":305,"marks":10594},"IHI Whitepaper – High-Impact Leadership (2013)",[10595,10597],{"type":1205,"attrs":10596},{"color":16},{"type":555},{"text":1209,"type":305,"marks":10599},[10600],{"type":555},{"type":15,"attrs":10602,"content":10603},{"textAlign":693},[10604,10609],{"text":10605,"type":305,"marks":10606},"Person-centredness (e.g., patient involvement/stories); front-line engagement (e.g., regular presence at frontlines, visible champion, lead projects); relentless focus (e.g., talk about vision every day, align schedule with high-priority initiatives; designate resources); transparency; build will to improve (e.g., communicate and model desired behaviours, openness, swift action against undesired behaviour); boundary-lessness (e.g., systems thinking, harvest ideas from and partner with other organizations).",[10607],{"type":1205,"attrs":10608},{"color":16},{"text":1209,"type":305},{"type":480,"attrs":10611,"content":10612},{"level":482,"textAlign":693},[10613,10619],{"text":10614,"type":305,"marks":10615},"IHI Whitepaper – Sustaining Improvement (2016)",[10616,10618],{"type":1205,"attrs":10617},{"color":16},{"type":555},{"text":1209,"type":305,"marks":10620},[10621],{"type":555},{"type":15,"attrs":10623,"content":10624},{"textAlign":693},[10625,10630],{"text":10626,"type":305,"marks":10627},"Quality control, improvement, culture; standardization; accountability (standard work); visual management; problem solving; escalation; integration; prioritization; daily work; policy; transparency; trust.",[10628],{"type":1205,"attrs":10629},{"color":16},{"text":1209,"type":305},{"type":480,"attrs":10632,"content":10633},{"level":482,"textAlign":693},[10634,10640],{"text":10635,"type":305,"marks":10636},"IHI Whitepaper – Safe, Reliable and Effective Care (2017)",[10637,10639],{"type":1205,"attrs":10638},{"color":16},{"type":555},{"text":1209,"type":305,"marks":10641},[10642],{"type":555},{"type":15,"attrs":10644,"content":10645},{"textAlign":693},[10646,10651],{"text":10647,"type":305,"marks":10648},"Leadership; psychological safety; accountability (act in safe and respectful manner); teamwork and communication; negotiation; continuous learning; improvement and measurement; reliability; transparency.",[10649],{"type":1205,"attrs":10650},{"color":16},{"text":1209,"type":305},{"type":480,"attrs":10653,"content":10654},{"level":482,"textAlign":693},[10655,10661],{"text":10656,"type":305,"marks":10657},"Key Concepts",[10658,10660],{"type":1205,"attrs":10659},{"color":16},{"type":555},{"text":1209,"type":305,"marks":10662},[10663],{"type":555},{"type":497,"content":10665},[10666,10683,10700,10717],{"type":500,"content":10667},[10668],{"type":15,"attrs":10669,"content":10670},{"textAlign":53},[10671,10677,10682],{"text":10672,"type":305,"marks":10673},"Safety science ",[10674,10676],{"type":1205,"attrs":10675},{"color":16},{"type":555},{"text":10678,"type":305,"marks":10679},"– focusses on contributing factors and underlying causes of risk and harm, including errors and human factors. It includes many disciplines not typically considered part of healthcare. Recognizes the fundamental importance of system design in driving workforce behaviour. In other industries, such as aviation, safety experts accept that human error must be expected, anticipated, and its effects mitigated. Safety science and human factors engineering is used to design systems to prevent errors, and to mitigate harm when errors occur. (Berwick et al., 2015).",[10680],{"type":1205,"attrs":10681},{"color":16},{"text":1209,"type":305},{"type":500,"content":10684},[10685],{"type":15,"attrs":10686,"content":10687},{"textAlign":53},[10688,10694,10699],{"text":10689,"type":305,"marks":10690},"Implementation science ",[10691,10693],{"type":1205,"attrs":10692},{"color":16},{"type":555},{"text":10695,"type":305,"marks":10696},"– supplements patient safety science; focusses on identifying and implementing valuable practices and lessons learned, and scaling up/translation across the organization and system. (Berwick et al., 2015).",[10697],{"type":1205,"attrs":10698},{"color":16},{"text":1209,"type":305},{"type":500,"content":10701},[10702],{"type":15,"attrs":10703,"content":10704},{"textAlign":53},[10705,10711,10716],{"text":10706,"type":305,"marks":10707},"Just culture ",[10708,10710],{"type":1205,"attrs":10709},{"color":16},{"type":555},{"text":10712,"type":305,"marks":10713},"– a culture that recognizes that individual practitioners should not be held accountable for system failings over which they have no control. A just culture recognizes many individual or \"active\" errors represent predictable interactions between humans and the systems in which they work. A just culture also does not tolerate conscious disregard of clear risks to patients or gross misconduct. (Berwick et al., 2015).",[10714],{"type":1205,"attrs":10715},{"color":16},{"text":1209,"type":305},{"type":500,"content":10718},[10719],{"type":15,"attrs":10720,"content":10721},{"textAlign":53},[10722,10728,10733],{"text":10723,"type":305,"marks":10724},"Psychological safety ",[10725,10727],{"type":1205,"attrs":10726},{"color":16},{"type":555},{"text":10729,"type":305,"marks":10730},"– an environment where: anyone can ask questions without looking stupid; anyone can ask for feedback without looking incompetent; anyone can be respectfully critical without appearing negative; anyone can suggest innovative ideas without being perceived as disruptive. (Frankel, 2017).",[10731],{"type":1205,"attrs":10732},{"color":16},{"text":1209,"type":305},{"type":497,"content":10735},[10736,10753,10770,10787,10804],{"type":500,"content":10737},[10738],{"type":15,"attrs":10739,"content":10740},{"textAlign":53},[10741,10747,10752],{"text":10742,"type":305,"marks":10743},"Staff safety/health",[10744,10746],{"type":1205,"attrs":10745},{"color":16},{"type":555},{"text":10748,"type":305,"marks":10749}," – A precursor to providing high quality care are staff that are free from physical harm during daily work. (Perlo, 2017)",[10750],{"type":1205,"attrs":10751},{"color":16},{"text":1209,"type":305},{"type":500,"content":10754},[10755],{"type":15,"attrs":10756,"content":10757},{"textAlign":53},[10758,10764,10769],{"text":10759,"type":305,"marks":10760},"Patient and family engagement ",[10761,10763],{"type":1205,"attrs":10762},{"color":16},{"type":555},{"text":10765,"type":305,"marks":10766},"– recognized as a primary area of focus in patient safety and quality; includes engagement at three levels: direct care (diagnosis, treatment decisions, monitoring), organizational design and governance (planning, patient advisory councils, quality improvement projects), policy making (public health, research priorities, resource allocation). (Carman, 2013).",[10767],{"type":1205,"attrs":10768},{"color":16},{"text":1209,"type":305},{"type":500,"content":10771},[10772],{"type":15,"attrs":10773,"content":10774},{"textAlign":53},[10775,10781,10786],{"text":10776,"type":305,"marks":10777},"Disruptive behaviour ",[10778,10780],{"type":1205,"attrs":10779},{"color":16},{"type":555},{"text":10782,"type":305,"marks":10783},"– any behaviour that shows disrespect for others or any interpersonal interactions that impede the delivery of patient care; this behaviour poses a threat to patient safety. (AHRQ PS Net, 2017).",[10784],{"type":1205,"attrs":10785},{"color":16},{"text":1209,"type":305},{"type":500,"content":10788},[10789],{"type":15,"attrs":10790,"content":10791},{"textAlign":53},[10792,10798,10803],{"text":10793,"type":305,"marks":10794},"High reliability/resilience ",[10795,10797],{"type":1205,"attrs":10796},{"color":16},{"type":555},{"text":10799,"type":305,"marks":10800},"– reliable/mindful organizations are:  preoccupied with failure (look for small signals of failure vs. preoccupation with success); reluctant to simplify interpretations (acknowledge complexity); sensitive to operations (aware of what is happening at frontlines); committed to resilience (acting quickly when things go wrong, e.g., patient deterioration); and defer to experts (vs. authority). (Weick & Sutcliffe, 2015).",[10801],{"type":1205,"attrs":10802},{"color":16},{"text":1209,"type":305},{"type":500,"content":10805},[10806],{"type":15,"attrs":10807,"content":10808},{"textAlign":53},[10809,10815,10820],{"text":10810,"type":305,"marks":10811},"Patient safety measurement ",[10812,10814],{"type":1205,"attrs":10813},{"color":16},{"type":555},{"text":10816,"type":305,"marks":10817},"– five dimensions: past harm (incidents, mortality); reliability (compliance); sensitivity to operations (walk-rounds, staffing levels, escalation); anticipation and preparedness (risk registers, safety culture scores, absenteeism); integration and learning (automated alerts, board dashboards). (Vincent, 2016).",[10818],{"type":1205,"attrs":10819},{"color":16},{"text":1209,"type":305},{"type":497,"content":10822},[10823,10840,10857,10874,10891],{"type":500,"content":10824},[10825],{"type":15,"attrs":10826,"content":10827},{"textAlign":53},[10828,10834,10839],{"text":10829,"type":305,"marks":10830},"Frontline leadership/distributed leadership",[10831,10833],{"type":1205,"attrs":10832},{"color":16},{"type":555},{"text":10835,"type":305,"marks":10836}," – recognized as a key driver for change in healthcare; local leaders translate senior leader priorities/values into action at the microsystem level; they have great impact on unit cultures and learning processes. (IHI, 2016).",[10837],{"type":1205,"attrs":10838},{"color":16},{"text":1209,"type":305},{"type":500,"content":10841},[10842],{"type":15,"attrs":10843,"content":10844},{"textAlign":53},[10845,10851,10856],{"text":10846,"type":305,"marks":10847},"Physician leadership",[10848,10850],{"type":1205,"attrs":10849},{"color":16},{"type":555},{"text":10852,"type":305,"marks":10853}," – recognized as a key driver for change in healthcare; six strategies for engaging physicians: discover common purpose; reframe values and beliefs; segment the engagement plan; use engaging improvement methods; show courage; adopt an engaging style. (Reinertsen, 2007).",[10854],{"type":1205,"attrs":10855},{"color":16},{"text":1209,"type":305},{"type":500,"content":10858},[10859],{"type":15,"attrs":10860,"content":10861},{"textAlign":53},[10862,10868,10873],{"text":10863,"type":305,"marks":10864},"Staff engagement",[10865,10867],{"type":1205,"attrs":10866},{"color":16},{"type":555},{"text":10869,"type":305,"marks":10870}," – A joyful, engaged workforce will have: physical and psychological safety; meaning and purpose; choice and autonomy; recognition and rewards; participative management; camaraderie and teamwork; daily improvement; wellness and resilience; real-time measurement. (Perlo, 2017)",[10871],{"type":1205,"attrs":10872},{"color":16},{"text":1209,"type":305},{"type":500,"content":10875},[10876],{"type":15,"attrs":10877,"content":10878},{"textAlign":53},[10879,10885,10890],{"text":10880,"type":305,"marks":10881},"Teamwork/communication ",[10882,10884],{"type":1205,"attrs":10883},{"color":16},{"type":555},{"text":10886,"type":305,"marks":10887},"– gaps in communication and/or poor teamwork are frequently noted as contributing factors to many patient safety events. Strong teams which train together and have established and reliable communication practices will have superior patient safety performance. (Baker, 2015).",[10888],{"type":1205,"attrs":10889},{"color":16},{"text":1209,"type":305},{"type":500,"content":10892},[10893],{"type":15,"attrs":10894,"content":10895},{"textAlign":53},[10896,10902,10907],{"text":10897,"type":305,"marks":10898},"Industry-wide standardization/alignment ",[10899,10901],{"type":1205,"attrs":10900},{"color":16},{"type":555},{"text":10903,"type":305,"marks":10904},"– A key feature in other high-risk industries is alignment across the sector related to key priorities, national/international standards and regulation of safety-critical practices and technologies. (Dixon-Woods, 2016, Berwick et al., 2015).",[10905],{"type":1205,"attrs":10906},{"color":16},{"text":1209,"type":305},{"type":480,"attrs":10909,"content":10910},{"level":482,"textAlign":693},[10911,10917],{"text":10912,"type":305,"marks":10913},"Environmental Scan",[10914,10916],{"type":1205,"attrs":10915},{"color":16},{"type":555},{"text":1209,"type":305,"marks":10918},[10919],{"type":555},{"type":15,"attrs":10921,"content":10922},{"textAlign":693},[10923,10928,10936,10940],{"text":10924,"type":305,"marks":10925},"ACHE, NPSF Lucian Leape Institute. (2017). ",[10926],{"type":1205,"attrs":10927},{"color":16},{"text":10929,"type":305,"marks":10930},"Leading a culture of safety: a blueprint for success",[10931,10934],{"type":315,"attrs":10932},{"href":10933,"uuid":53,"anchor":53,"custom":53,"target":678,"linktype":679},"https://www.ihi.org/resources/Pages/Publications/Leading-a-Culture-of-Safety-A-Blueprint-for-Success.aspx",{"type":1205,"attrs":10935},{"color":16},{"text":1140,"type":305,"marks":10937},[10938],{"type":1205,"attrs":10939},{"color":16},{"text":1209,"type":305},{"type":15,"attrs":10942,"content":10943},{"textAlign":693},[10944,10949,10958,10962],{"text":10945,"type":305,"marks":10946},"AHRQ PS Net. (2017). ",[10947],{"type":1205,"attrs":10948},{"color":16},{"text":10950,"type":305,"marks":10951},"Disruptive and unprofessional behavior",[10952,10956],{"type":315,"attrs":10953},{"href":10954,"uuid":53,"anchor":53,"custom":10955,"target":678,"linktype":679},"https://psnet.ahrq.gov/primers/primer/15/disruptive-and-unprofessional-behavior",{},{"type":1205,"attrs":10957},{"color":16},{"text":1140,"type":305,"marks":10959},[10960],{"type":1205,"attrs":10961},{"color":16},{"text":1209,"type":305},{"type":15,"attrs":10964,"content":10965},{"textAlign":693},[10966,10971],{"text":10967,"type":305,"marks":10968},"Baker R.  (2015). Beyond the quick fix – strategies for improving patient safety. Institute of Health Policy, Management and Evaluation at the University of Toronto.",[10969],{"type":1205,"attrs":10970},{"color":16},{"text":1209,"type":305},{"type":15,"attrs":10973,"content":10974},{"textAlign":693},[10975,10980,10989,10994],{"text":10976,"type":305,"marks":10977},"Baker R, Norton P, et al. (2004). ",[10978],{"type":1205,"attrs":10979},{"color":16},{"text":10981,"type":305,"marks":10982},"The Canadian Adverse Events Study: the incidence of adverse events among hospital patients in Canada",[10983,10987],{"type":315,"attrs":10984},{"href":10985,"uuid":53,"anchor":53,"custom":10986,"target":678,"linktype":679},"http://www.cmaj.ca/content/170/11/1678.full",{},{"type":1205,"attrs":10988},{"color":16},{"text":10990,"type":305,"marks":10991},". CMAJ. 170(11):1678-86.",[10992],{"type":1205,"attrs":10993},{"color":16},{"text":1209,"type":305},{"type":15,"attrs":10996,"content":10997},{"textAlign":693},[10998,11003,11011,11015],{"text":10999,"type":305,"marks":11000},"BC Patient Safety and Quality Council. (2013). ",[11001],{"type":1205,"attrs":11002},{"color":16},{"text":11004,"type":305,"marks":11005},"Culture change toolbox",[11006,11009],{"type":315,"attrs":11007},{"href":2208,"uuid":53,"anchor":53,"custom":11008,"target":678,"linktype":679},{},{"type":1205,"attrs":11010},{"color":16},{"text":1140,"type":305,"marks":11012},[11013],{"type":1205,"attrs":11014},{"color":16},{"text":1209,"type":305},{"type":15,"attrs":11017,"content":11018},{"textAlign":693},[11019,11024,11032,11037],{"text":11020,"type":305,"marks":11021},"Berwick D, Shojania K, et al. (2015). ",[11022],{"type":1205,"attrs":11023},{"color":16},{"text":11025,"type":305,"marks":11026},"Free from harm: accelerating patient safety improvement fifteen years after To Err Is Human",[11027,11030],{"type":315,"attrs":11028},{"href":11029,"uuid":53,"anchor":53,"custom":53,"target":678,"linktype":679},"https://www.ihi.org/resources/Pages/Publications/Free-from-Harm-Accelerating-Patient-Safety-Improvement.aspx",{"type":1205,"attrs":11031},{"color":16},{"text":11033,"type":305,"marks":11034},". National Patient Safety Foundation.",[11035],{"type":1205,"attrs":11036},{"color":16},{"text":1209,"type":305},{"type":15,"attrs":11039,"content":11040},{"textAlign":693},[11041,11046],{"text":11042,"type":305,"marks":11043},"Berwick D, Feely D. (2017). WIHI: the next wave of patient safety. Institute for Healthcare Improvement (IHI) webinar.",[11044],{"type":1205,"attrs":11045},{"color":16},{"text":1209,"type":305},{"type":15,"attrs":11048,"content":11049},{"textAlign":693},[11050,11055,11063,11068],{"text":11051,"type":305,"marks":11052},"Botwinick L, Bisognano M, Haraden C. (2006). ",[11053],{"type":1205,"attrs":11054},{"color":16},{"text":11056,"type":305,"marks":11057},"Leadership guide to patient safety",[11058,11061],{"type":315,"attrs":11059},{"href":7976,"uuid":53,"anchor":53,"custom":11060,"target":678,"linktype":679},{},{"type":1205,"attrs":11062},{"color":16},{"text":11064,"type":305,"marks":11065},". IHI White Paper.",[11066],{"type":1205,"attrs":11067},{"color":16},{"text":1209,"type":305},{"type":15,"attrs":11070,"content":11071},{"textAlign":693},[11072,11077,11086,11090],{"text":11073,"type":305,"marks":11074},"Canadian Institute for Health Information, Canadian Patient Safety Institute (2016). ",[11075],{"type":1205,"attrs":11076},{"color":16},{"text":11078,"type":305,"marks":11079},"Measuring patient harm in Canadian hospitals",[11080,11084],{"type":315,"attrs":11081},{"href":11082,"uuid":53,"anchor":53,"custom":11083,"target":678,"linktype":679},"https://www.cihi.ca/sites/default/files/document/hospital_harm_technical_notes_en.pdf",{},{"type":1205,"attrs":11085},{"color":16},{"text":1140,"type":305,"marks":11087},[11088],{"type":1205,"attrs":11089},{"color":16},{"text":1209,"type":305},{"type":15,"attrs":11092,"content":11093},{"textAlign":693},[11094,11099,11107,11111],{"text":11095,"type":305,"marks":11096},"Canadian Patient Safety Institute (CPSI). (Date unknown). ",[11097],{"type":1205,"attrs":11098},{"color":16},{"text":11100,"type":305,"marks":11101},"Patient safety culture",[11102,11105],{"type":315,"attrs":11103},{"href":317,"uuid":318,"anchor":53,"custom":11104,"target":320,"linktype":321},{},{"type":1205,"attrs":11106},{"color":16},{"text":1140,"type":305,"marks":11108},[11109],{"type":1205,"attrs":11110},{"color":16},{"text":1209,"type":305},{"type":15,"attrs":11113,"content":11114},{"textAlign":693},[11115,11120],{"text":11116,"type":305,"marks":11117},"Carman L, Dardess P, Maurer M, et al. (2013). Patient and family engagement: a framework for understanding the elements and developing interventions and policies. Health Affairs. 32(2):223-231.",[11118],{"type":1205,"attrs":11119},{"color":16},{"text":1209,"type":305},{"type":15,"attrs":11122,"content":11123},{"textAlign":693},[11124,11129,11138,11142],{"text":11125,"type":305,"marks":11126},"CPSI, AHQPSC, HQO, PFPSC. (2017). ",[11127],{"type":1205,"attrs":11128},{"color":16},{"text":11130,"type":305,"marks":11131},"Engaging patients in patient safety: a Canadian guide",[11132,11136],{"type":315,"attrs":11133},{"href":11134,"uuid":369,"anchor":53,"custom":11135,"target":320,"linktype":321},"/resources/engaging-patients-in-patient-safety-a-canadian-guide",{},{"type":1205,"attrs":11137},{"color":16},{"text":1140,"type":305,"marks":11139},[11140],{"type":1205,"attrs":11141},{"color":16},{"text":1209,"type":305},{"type":15,"attrs":11144,"content":11145},{"textAlign":693},[11146,11151,11160,11165],{"text":11147,"type":305,"marks":11148},"Dixon-Woods M, Pronovost P. (2016). ",[11149],{"type":1205,"attrs":11150},{"color":16},{"text":11152,"type":305,"marks":11153},"Patient safety and the problem of many hands",[11154,11158],{"type":315,"attrs":11155},{"href":11156,"uuid":53,"anchor":53,"custom":11157,"target":678,"linktype":679},"http://qualitysafety.bmj.com/content/early/2016/02/24/bmjqs-2016-005232.extract",{},{"type":1205,"attrs":11159},{"color":16},{"text":11161,"type":305,"marks":11162},". BMJ Qual Saf. 25(7):485-488.",[11163],{"type":1205,"attrs":11164},{"color":16},{"text":1209,"type":305},{"type":15,"attrs":11167,"content":11168},{"textAlign":693},[11169,11174,11183,11187],{"text":11170,"type":305,"marks":11171},"Frankel A, et al. (2017). ",[11172],{"type":1205,"attrs":11173},{"color":16},{"text":11175,"type":305,"marks":11176},"A framework for safe, reliable, and effective care",[11177,11181],{"type":315,"attrs":11178},{"href":11179,"uuid":53,"anchor":53,"custom":11180,"target":678,"linktype":679},"http://www.ihi.org/resources/Pages/IHIWhitePapers/Framework-Safe-Reliable-Effective-Care.aspx",{},{"type":1205,"attrs":11182},{"color":16},{"text":11064,"type":305,"marks":11184},[11185],{"type":1205,"attrs":11186},{"color":16},{"text":1209,"type":305},{"type":15,"attrs":11189,"content":11190},{"textAlign":693},[11191,11196,11205,11210],{"text":11192,"type":305,"marks":11193},"IHI. (Date unknown). 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