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Johnston Chair in Black Canadian Studies, Professor, Faculty of Medicine, Dalhousie University; co-lead, co-founder of Black Health Education Collaborative (BHEC)",{"type":516,"attrs":849,"content":850},{"level":518,"textAlign":519},[851],{"text":852,"type":356,"marks":853},"Co-hosts",[854],{"type":392},{"type":461,"content":856},[857,864],{"type":464,"content":858},[859],{"type":15,"attrs":860,"content":861},{"textAlign":53},[862],{"text":863,"type":356},"Kent Loftsgard, Co-Chair, Healthcare Excellence Canada’s Equity, Diversity and Inclusion Virtual Learning Exchange",{"type":464,"content":865},[866],{"type":15,"attrs":867,"content":868},{"textAlign":53},[869],{"text":870,"type":356},"Brady Comeau, Senior Program Lead, Healthcare Excellence Canada",{"type":12,"content":872},[873],{"type":15,"attrs":874,"content":875},{"textAlign":53},[876],{"text":877,"type":356},"This session will introduce the importance of focusing on Black health through the exploration of the history of anti-Black racism in healthcare in Canada. Understanding privilege and critical allyship will connect with the profound impacts of anti-Black racism in healthcare systems. Topics that will be covered include the structural impacts of white supremacy and privilege, scientific racism, anti-Black racism in medicine and healthcare, and Black health equity in the workforce.",{"_uid":879,"title":880,"ctaLeft":881,"ctaRight":882,"component":505,"columnLeft":887,"columnRight":948},"2ef288d7-7005-4745-8316-02fc93a4b34b","Approaches and Theories to Understanding Black Health and Systemic Anti-Black Racism (Part 2)",[],[883],{"_uid":884,"link":885,"label":503,"component":504},"91863b27-c6c8-4c11-8a8a-7ab238b7e7f7",{"id":16,"url":886,"target":365,"linktype":366,"fieldtype":502,"cached_url":886},"https://youtu.be/ouX8-tVTowk",{"type":12,"content":888},[889,896,902,928,934],{"type":15,"attrs":890,"content":891},{"textAlign":519},[892],{"text":893,"type":356,"marks":894},"June 19, 2024",[895],{"type":392},{"type":516,"attrs":897,"content":898},{"level":518,"textAlign":519},[899],{"text":522,"type":356,"marks":900},[901],{"type":392},{"type":461,"content":903},[904,917],{"type":464,"content":905},[906],{"type":15,"attrs":907,"content":908},{"textAlign":53},[909,915],{"text":910,"type":356,"marks":911},"Sume Ndumbe-Eyoh",[912],{"type":361,"attrs":913},{"href":914,"uuid":53,"anchor":53,"custom":53,"target":365,"linktype":366},"https://www.bhec.ca/staff",{"text":916,"type":356},", Executive Director of the Black Health Education Collaborative, Assistant Professor in the Clinical Public Health Division, Dalla Lana School of Public Health, University of Toronto",{"type":464,"content":918},[919],{"type":15,"attrs":920,"content":921},{"textAlign":53},[922,926],{"text":841,"type":356,"marks":923},[924],{"type":361,"attrs":925},{"href":845,"uuid":53,"anchor":53,"custom":53,"target":365,"linktype":366},{"text":927,"type":356},", D., James R. Johnston Chair in Black Canadian Studies, Professor, Faculty of Medicine, Dalhousie University; co-lead, co-founder of Black Health Education Collaborative (BHEC)",{"type":516,"attrs":929,"content":930},{"level":518,"textAlign":519},[931],{"text":852,"type":356,"marks":932},[933],{"type":392},{"type":461,"content":935},[936,942],{"type":464,"content":937},[938],{"type":15,"attrs":939,"content":940},{"textAlign":53},[941],{"text":863,"type":356},{"type":464,"content":943},[944],{"type":15,"attrs":945,"content":946},{"textAlign":53},[947],{"text":870,"type":356},{"type":12,"content":949},[950],{"type":15,"attrs":951,"content":952},{"textAlign":53},[953,955,961],{"text":954,"type":356},"In this second session, participants will delve into the application of critical race theory related to the structural and social determinants of Black health, including discussions on race-based data collection and an introduction to the ",{"text":956,"type":356,"marks":957},"Black Health Primer",[958],{"type":361,"attrs":959},{"href":960,"uuid":53,"anchor":53,"custom":53,"target":365,"linktype":366},"https://www.bhec.ca/bhp",{"text":962,"type":356}," developed by the Black Health Education Collaborative.","Series: Understanding systems of inequity that impact access to safe and high-quality healthcare for Black people",{"type":12,"content":965},[966],{"type":15,"attrs":967,"content":968},{"textAlign":53},[969],{"text":970,"type":356},"These sessions explore critical race theory, intersectionality, and anti-oppressive practices focusing on Black peoples’ health and anti-Black racism.",{"id":16,"_uid":972,"items":973,"title":1413,"component":798,"description":1414},"620f26d4-1854-4942-9684-5c3b04f3952e",[974,1086,1218,1327],{"_uid":975,"title":976,"ctaLeft":977,"ctaRight":978,"component":505,"columnLeft":983,"columnRight":1028},"bea6d14b-6147-47f1-b5e5-ad7278f1f370","Deepening Our Understanding of Anti-Oppressive Practice and Peacemaking",[],[979],{"_uid":980,"link":981,"label":503,"component":504},"73958e43-b02c-40de-bbf6-179431ea6b5b",{"id":16,"url":982,"target":365,"linktype":366,"fieldtype":502,"cached_url":982},"https://youtu.be/JG7Tqsbod00",{"type":12,"content":984},[985,991,1007,1013],{"type":516,"attrs":986,"content":987},{"level":518,"textAlign":53},[988],{"text":522,"type":356,"marks":989},[990],{"type":392},{"type":461,"content":992},[993,1000],{"type":464,"content":994},[995],{"type":15,"attrs":996,"content":997},{"textAlign":53},[998],{"text":999,"type":356},"Ed Connors, PhD, C. Psych.",{"type":464,"content":1001},[1002],{"type":15,"attrs":1003,"content":1004},{"textAlign":53},[1005],{"text":1006,"type":356},"Stephanie Nixon, PhD, PT",{"type":516,"attrs":1008,"content":1009},{"level":518,"textAlign":53},[1010],{"text":852,"type":356,"marks":1011},[1012],{"type":392},{"type":461,"content":1014},[1015,1021],{"type":464,"content":1016},[1017],{"type":15,"attrs":1018,"content":1019},{"textAlign":53},[1020],{"text":870,"type":356},{"type":464,"content":1022},[1023],{"type":15,"attrs":1024,"content":1025},{"textAlign":53},[1026],{"text":1027,"type":356},"Carol Fancott, Director, Patient Safety, Equity, & Engagement, Healthcare Excellence Canada",{"type":12,"content":1029},[1030,1041,1061,1066,1071,1076,1081],{"type":15,"attrs":1031,"content":1032},{"textAlign":53},[1033,1035,1039],{"text":1034,"type":356},"Building on our ",{"text":1036,"type":356,"marks":1037},"Exploring Anti-Oppression Practices and Unconscious Bias in Our Work",[1038],{"type":397},{"text":1040,"type":356}," series, we’ll nurture new habits of mind to inform action.",{"type":15,"attrs":1042,"content":1043},{"textAlign":519},[1044,1046,1050,1052,1059],{"text":1045,"type":356},"Participants will reason through strategies to foster equity and inclusion in healthcare through anti-oppression practices and peacemaking. We will draw on the lessons within the ",{"text":1047,"type":356,"marks":1048},"Two-Row Wampum Belt Treaty",[1049],{"type":397},{"text":1051,"type":356}," and ",{"text":1053,"type":356,"marks":1054},"the Coin Model of Privilege and Critical Allyship",[1055,1058],{"type":361,"attrs":1056},{"href":1057,"uuid":53,"anchor":53,"custom":53,"target":365,"linktype":366},"https://bmcpublichealth.biomedcentral.com/articles/10.1186/s12889-019-7884-9",{"type":397},{"text":1060,"type":356}," to make sense of and strategize on common challenges in equity, diversity and inclusion work.",{"type":15,"attrs":1062,"content":1063},{"textAlign":519},[1064],{"text":1065,"type":356},"Healthcare Excellence Canada (HEC) would like to thank Dr. Ed Connors (Mohawk) for providing a Thanksgiving address as part of Deepening Our Understanding of Anti-Oppressive Practice and Peacemaking. HEC recognizes that Traditional and Indigenous Knowledge is different than Western Knowledge. “Traditional Knowledge” refers to the knowledge systems, know-how, creations, innovations, skills, practices, stories and other cultural expressions generally regarded as pertaining to First Nations, the Inuit, the Métis and/or their members (Traditional Knowledge Holder) which have been developed, sustained and passed on from generation to generation of First Nation, Inuit, or Métis members and their ancestors.",{"type":15,"attrs":1067,"content":1068},{"textAlign":53},[1069],{"text":1070,"type":356},"In order to honour and respect Traditional Knowledge we ask that you seek permission before sharing this knowledge with others. Please contact Ed Connors (econnors0507@gmail.com) if you wish to learn about this version of the Thanksgiving Address/Prayer of Gratitude in order to share it with others. Please do not share this knowledge with others without first doing so.",{"type":516,"attrs":1072,"content":1073},{"level":518,"textAlign":53},[1074],{"text":1075,"type":356},"About the speakers",{"type":15,"attrs":1077,"content":1078},{"textAlign":53},[1079],{"text":1080,"type":356},"Ed Connors is of Mohawk (from Kahnawake Mohawk Territory) and Irish ancestry. He is a psychologist who has worked with First Nations communities across Canada since 1982 in both urban and rural centres. Dr. Connors' most recent work has involved development of Indigenous Life Promotion projects, including Feather Carriers Leadership for Life Promotion. While developing the above services, Dr. Connors has worked with Elders and apprenticed in traditional First Nations approaches to healing. Today his practice incorporates traditional knowledge about healing while also employing his training as a psychologist. His work has also included consultation and community training to assist with Peacemaking, Reconciliation and Anti-oppression.",{"type":15,"attrs":1082,"content":1083},{"textAlign":53},[1084],{"text":1085,"type":356},"Stephanie Nixon is Vice-Dean (Faculty of Health Sciences) and Director (School of Rehabilitation Therapy) at Queen’s University. Stephanie is a straight, white, middle class, able-bodied, cisgender, settler woman who tries to understand the pervasive effects of privilege. She explores how systems of oppression shape health care, research and education, and the role of people in positions of unearned advantage in disrupting these harmful patterns.",{"_uid":1087,"title":1088,"ctaLeft":1089,"ctaRight":1090,"component":505,"columnLeft":1095,"columnRight":1160},"8eb44c73-6fd6-4626-a7aa-8bdf9e62c02f","Opening ourselves: Understanding unconscious bias and its role in practice",[],[1091],{"_uid":1092,"link":1093,"label":503,"component":504},"c7604a85-f729-432e-8a95-282b80a3d4c4",{"id":16,"url":1094,"target":365,"linktype":366,"fieldtype":502,"cached_url":1094},"https://youtu.be/_wmqrMoxToI",{"type":12,"content":1096},[1097,1104,1110,1138,1144],{"type":15,"attrs":1098,"content":1099},{"textAlign":53},[1100],{"text":1101,"type":356,"marks":1102},"March 23, 2022",[1103],{"type":392},{"type":516,"attrs":1105,"content":1106},{"level":518,"textAlign":53},[1107],{"text":522,"type":356,"marks":1108},[1109],{"type":392},{"type":461,"content":1111},[1112,1119,1126],{"type":464,"content":1113},[1114],{"type":15,"attrs":1115,"content":1116},{"textAlign":519},[1117],{"text":1118,"type":356},"Colleen Schneider, Provincial Lead, Public, Patient, Family Engagement, Shared Health Manitoba",{"type":464,"content":1120},[1121],{"type":15,"attrs":1122,"content":1123},{"textAlign":519},[1124],{"text":1125,"type":356},"Patricia Bocangel, MSc, MEd (She/her), Program Lead – Underserved Populations Program, Professional Development Lead – Community Oncology Program, CancerCare Manitoba",{"type":464,"content":1127},[1128],{"type":15,"attrs":1129,"content":1130},{"textAlign":519},[1131,1133],{"text":1132,"type":356},"Sem Perez, Aquatic Science Technician, Fisheries and Oceans Canada",{"text":529,"type":356,"marks":1134},[1135],{"type":525,"attrs":1136},{"color":1137},"#575757",{"type":516,"attrs":1139,"content":1140},{"level":518,"textAlign":519},[1141],{"text":852,"type":356,"marks":1142},[1143],{"type":392},{"type":461,"content":1145},[1146,1153],{"type":464,"content":1147},[1148],{"type":15,"attrs":1149,"content":1150},{"textAlign":519},[1151],{"text":1152,"type":356},"Maria Judd, Vice-President, Strategic Initiatives & Engagement, Healthcare Excellence Canada",{"type":464,"content":1154},[1155],{"type":15,"attrs":1156,"content":1157},{"textAlign":519},[1158],{"text":1159,"type":356},"Denise McCuaig, Métis Elder/Indigenous Coach",{"type":12,"content":1161},[1162,1167,1172,1179],{"type":15,"attrs":1163,"content":1164},{"textAlign":53},[1165],{"text":1166,"type":356},"Building on previous sessions that explore anti-oppression frameworks, this session looks more deeply at the impact of unconscious bias within a healthcare environment. 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This will be emailed to participants in advance of the session.",{"type":516,"attrs":1173,"content":1174},{"level":518,"textAlign":519},[1175],{"text":1176,"type":356,"marks":1177},"Key resources (currently in English only):",[1178],{"type":392},{"type":461,"content":1180},[1181,1193,1206],{"type":464,"content":1182},[1183],{"type":15,"attrs":1184,"content":1185},{"textAlign":53},[1186,1192],{"text":1187,"type":356,"marks":1188},"Working in good ways | University of Manitoba (umanitoba.ca)",[1189],{"type":361,"attrs":1190},{"href":1191,"uuid":53,"anchor":53,"custom":53,"target":365,"linktype":366},"https://umanitoba.ca/community-engaged-learning/working-in-good-ways",{"text":529,"type":356},{"type":464,"content":1194},[1195],{"type":15,"attrs":1196,"content":1197},{"textAlign":53},[1198,1204],{"text":1199,"type":356,"marks":1200},"Beyond Inclusion: Equity in Public Engagement",[1201],{"type":361,"attrs":1202},{"href":1203,"uuid":53,"anchor":53,"custom":53,"target":365,"linktype":366},"https://www.sfu.ca/content/dam/sfu/dialogue/ImagesAndFiles/ProgramsPage/EDI/BeyondInclusion/Beyond%20Inclusion%20-%20Equity%20in%20Public%20Engagement.pdf",{"text":1205,"type":356},"  ",{"type":464,"content":1207},[1208],{"type":15,"attrs":1209,"content":1210},{"textAlign":53},[1211,1217],{"text":1212,"type":356,"marks":1213},"Valuing All Voices: refining a trauma-informed, intersectional and critical reflexive framework for patient engagement in health research using a qualitative descriptive approach",[1214],{"type":361,"attrs":1215},{"href":1216,"uuid":53,"anchor":53,"custom":53,"target":365,"linktype":366},"https://researchinvolvement.biomedcentral.com/articles/10.1186/s40900-020-00217-2",{"text":1205,"type":356},{"_uid":1219,"title":1220,"ctaLeft":1221,"ctaRight":1222,"component":505,"columnLeft":1227,"columnRight":1278},"0c72e902-eb49-49b8-a6be-f0cc8f322385","Opening ourselves: An introduction to anti-oppression practices and frameworks (part 1)",[],[1223],{"_uid":1224,"link":1225,"label":503,"component":504},"0046c8d1-01e6-47c7-9d0c-a34096bac81e",{"id":16,"url":1226,"target":365,"linktype":366,"fieldtype":502,"cached_url":1226},"https://www.youtube.com/watch?v=kwQ4xR2Cbyk",{"type":12,"content":1228},[1229,1236,1242,1258,1264],{"type":15,"attrs":1230,"content":1231},{"textAlign":53},[1232],{"text":1233,"type":356,"marks":1234},"January 13, 2022",[1235],{"type":392},{"type":516,"attrs":1237,"content":1238},{"level":518,"textAlign":53},[1239],{"text":522,"type":356,"marks":1240},[1241],{"type":392},{"type":461,"content":1243},[1244,1251],{"type":464,"content":1245},[1246],{"type":15,"attrs":1247,"content":1248},{"textAlign":53},[1249],{"text":1250,"type":356},"Ed Connors, PhD, C.Psych.",{"type":464,"content":1252},[1253],{"type":15,"attrs":1254,"content":1255},{"textAlign":53},[1256],{"text":1257,"type":356},"Stephanie Nixon, BA, BHSc, MSc, PhD",{"type":516,"attrs":1259,"content":1260},{"level":518,"textAlign":53},[1261],{"text":852,"type":356,"marks":1262},[1263],{"type":392},{"type":461,"content":1265},[1266,1272],{"type":464,"content":1267},[1268],{"type":15,"attrs":1269,"content":1270},{"textAlign":53},[1271],{"text":1152,"type":356},{"type":464,"content":1273},[1274],{"type":15,"attrs":1275,"content":1276},{"textAlign":53},[1277],{"text":1159,"type":356},{"type":12,"content":1279},[1280,1292,1297,1310,1317,1322],{"type":15,"attrs":1281,"content":1282},{"textAlign":53},[1283,1285,1290],{"text":1284,"type":356},"This session (part 1 of 2) introduces participants to the ",{"text":1286,"type":356,"marks":1287},"Coin Model of Privilege",[1288],{"type":361,"attrs":1289},{"href":1057,"uuid":53,"anchor":53,"custom":53,"target":365,"linktype":366},{"text":1291,"type":356},", Critical Allyship and other approaches to anti-oppressive practice. These frameworks help deepen our understanding of the impact of unearned advantage and disadvantage in different contexts. Participants will reflect on their relationship with different systems of oppression, and ways to foster equity and inclusion in their patient engagement work and the healthcare system more broadly.",{"type":15,"attrs":1293,"content":1294},{"textAlign":53},[1295],{"text":1296,"type":356},"Healthcare Excellence Canada would like to thank Dr. Ed Connors (Mohawk) for providing a Thanksgiving address as part of Opening Ourselves: An introduction to anti-oppression practices and frameworks (part 1). Healthcare Excellence Canada recognizes that Traditional and Indigenous Knowledge is different than Western Knowledge. “Traditional Knowledge” refers to the knowledge systems, know-how, creations, innovations, skills, practices, stories and other cultural expressions generally regarded as pertaining to First Nations, the Inuit, the Métis and/or their members (Traditional Knowledge Holder) which have been developed, sustained and passed on from generation to generation of First Nation, Inuit, or Métis members and their ancestors.",{"type":15,"attrs":1298,"content":1299},{"textAlign":53},[1300,1302,1308],{"text":1301,"type":356},"In order to honour and respect Traditional Knowledge we ask that you seek permission before sharing this knowledge with others. Please contact Ed Connors (",{"text":1303,"type":356,"marks":1304},"econnors0507@gmail.com",[1305],{"type":361,"attrs":1306},{"href":1307,"uuid":53,"anchor":53,"custom":53,"target":53,"linktype":366},"mailto:econnors0507@gmail.com",{"text":1309,"type":356},") if you wish to learn about this version of the Thanksgiving Address/Prayer of Gratitude in order to share it with others. Please do not share this knowledge with others without first doing so.",{"type":516,"attrs":1311,"content":1312},{"level":518,"textAlign":53},[1313],{"text":1314,"type":356,"marks":1315},"About the Speakers",[1316],{"type":392},{"type":15,"attrs":1318,"content":1319},{"textAlign":53},[1320],{"text":1321,"type":356},"Ed Connors is of Mohawk (from Kahnawake Mohawk Territory) and Irish ancestry. He is a psychologist who has worked with First Nations communities across Canada since 1982 in both urban and rural centres. His work over this time has included Clinical Director for an Infant Mental Health Centre in the city of Regina and Director for the Sacred Circle, a Suicide Prevention Program developed to serve First Nations communities in Northwestern Ontario. Ed’s most recent work has involved development of Indigenous Life Promotion projects, including Feather Carriers Leadership for Life Promotion. While developing this service, Ed worked with Elders and apprenticed in traditional First Nations approaches to healing. Today his practice incorporates traditional knowledge about healing while also employing his training as a psychologist. His current work includes consultation and community training to assist First Nations in the development of Restorative Justice programs.",{"type":15,"attrs":1323,"content":1324},{"textAlign":53},[1325],{"text":1326,"type":356},"Stephanie Nixon is a Full Professor in the Department of Physical Therapy and Dalla Lana School of Public Health at the University of Toronto. She completed her PhD in Public Health in 2006 at the University of Toronto, and a post-doc at the University of KwaZulu-Natal in South Africa in 2008. Stephanie is a straight, white, middle class, able-bodied, cisgender, settler woman who tries to understand the pervasive effects of privilege. Stephanie developed the Coin Model of Privilege and Critical Allyship as a way to translate core ideas about anti-oppression and anti-racism to people in positions of unearned advantage. She has conducted workshops on the Coin Model with more than 100 groups including universities, hospitals, community-based organizations, and professional associations across Canada and internationally.",{"_uid":1328,"title":1329,"ctaLeft":1330,"ctaRight":1331,"component":505,"columnLeft":1336,"columnRight":1385},"1a84c993-1825-464d-9be0-12a68511fe9f","Opening ourselves: An introduction to anti-oppression practices and frameworks (part 2)",[],[1332],{"_uid":1333,"link":1334,"label":503,"component":504},"dd18ec86-dacd-4ba6-b496-d2e1a226089c",{"id":16,"url":1335,"target":365,"linktype":366,"fieldtype":502,"cached_url":1335},"https://www.youtube.com/watch?v=Ki-NcunzviQ",{"type":12,"content":1337},[1338,1345,1351,1365,1371],{"type":15,"attrs":1339,"content":1340},{"textAlign":53},[1341],{"text":1342,"type":356,"marks":1343},"February 3, 2022",[1344],{"type":392},{"type":516,"attrs":1346,"content":1347},{"level":518,"textAlign":53},[1348],{"text":522,"type":356,"marks":1349},[1350],{"type":392},{"type":461,"content":1352},[1353,1359],{"type":464,"content":1354},[1355],{"type":15,"attrs":1356,"content":1357},{"textAlign":53},[1358],{"text":1250,"type":356},{"type":464,"content":1360},[1361],{"type":15,"attrs":1362,"content":1363},{"textAlign":53},[1364],{"text":1257,"type":356},{"type":516,"attrs":1366,"content":1367},{"level":518,"textAlign":53},[1368],{"text":852,"type":356,"marks":1369},[1370],{"type":392},{"type":461,"content":1372},[1373,1379],{"type":464,"content":1374},[1375],{"type":15,"attrs":1376,"content":1377},{"textAlign":53},[1378],{"text":1152,"type":356},{"type":464,"content":1380},[1381],{"type":15,"attrs":1382,"content":1383},{"textAlign":53},[1384],{"text":1159,"type":356},{"type":12,"content":1386},[1387,1399,1405,1409],{"type":15,"attrs":1388,"content":1389},{"textAlign":53},[1390,1392,1397],{"text":1391,"type":356},"This session (part 2 of 2) will build on the concepts introduced in the first session. Through engaging and reflective activities, participants will apply the ",{"text":1286,"type":356,"marks":1393},[1394],{"type":361,"attrs":1395},{"href":1057,"uuid":53,"anchor":53,"custom":1396,"target":365,"linktype":366},{},{"text":1398,"type":356}," to develop a practice of critical allyship based on an understanding of the impact of their actions on those who have historically been marginalized. Participants will be supported to build capacity for change at the individual, institutional and systemic level.",{"type":516,"attrs":1400,"content":1401},{"level":518,"textAlign":53},[1402],{"text":1314,"type":356,"marks":1403},[1404],{"type":392},{"type":15,"attrs":1406,"content":1407},{"textAlign":53},[1408],{"text":1321,"type":356},{"type":15,"attrs":1410,"content":1411},{"textAlign":53},[1412],{"text":1326,"type":356},"Series: Exploring Anti-Oppression Practices and Unconscious Bias in Our Work",{"type":12,"content":1415},[1416],{"type":15,"attrs":1417,"content":1418},{"textAlign":519},[1419],{"text":1420,"type":356},"These sessions lay the foundation for taking an anti-oppression approach to equity, diversity and inclusion.",{"id":16,"_uid":1422,"items":1423,"title":1740,"component":798,"description":1741},"d6f70a1b-7615-4717-94e4-dc41f51d8821",[1424,1562],{"_uid":1425,"title":1426,"ctaLeft":1427,"ctaRight":1428,"component":505,"columnLeft":1433,"columnRight":1475},"d029ebca-7d25-4250-bf51-876dfa9d3b7f","Trauma and Resiliency Informed Practice in Action",[],[1429],{"_uid":1430,"link":1431,"label":503,"component":504},"706e4866-ccdc-4ad7-9160-adf92a718a27",{"id":16,"url":1432,"target":365,"linktype":366,"fieldtype":502,"cached_url":1432},"https://youtu.be/3oZ1SOCa-cg",{"type":12,"content":1434},[1435,1442,1448,1464,1470],{"type":15,"attrs":1436,"content":1437},{"textAlign":519},[1438],{"text":1439,"type":356,"marks":1440},"March 7, 2023",[1441],{"type":392},{"type":516,"attrs":1443,"content":1444},{"level":518,"textAlign":519},[1445],{"text":522,"type":356,"marks":1446},[1447],{"type":392},{"type":461,"content":1449},[1450,1457],{"type":464,"content":1451},[1452],{"type":15,"attrs":1453,"content":1454},{"textAlign":53},[1455],{"text":1456,"type":356},"Beverley Pomeroy (she/they), Patient Public Engagement Specialist, Patient-Oriented Researcher",{"type":464,"content":1458},[1459],{"type":15,"attrs":1460,"content":1461},{"textAlign":53},[1462],{"text":1463,"type":356},"Marika Sandrelli (she/her/hers), Knowledge Exchange Leader, Mental Health & Substance Use (MHSU) Services, Fraser Health",{"type":516,"attrs":1465,"content":1466},{"level":518,"textAlign":519},[1467],{"text":559,"type":356,"marks":1468},[1469],{"type":392},{"type":15,"attrs":1471,"content":1472},{"textAlign":519},[1473],{"text":1474,"type":356},"Denise McCuaig, Métis Elder/Indigenous Coach ",{"type":12,"content":1476},[1477,1484,1497,1523,1530],{"type":516,"attrs":1478,"content":1479},{"level":518,"textAlign":519},[1480],{"text":1481,"type":356,"marks":1482},"Learnings",[1483],{"type":392},{"type":15,"attrs":1485,"content":1486},{"textAlign":519},[1487,1489,1495],{"text":1488,"type":356},"This webinar featured a practice change story of how the ",{"text":1490,"type":356,"marks":1491},"Fraser Health Authority",[1492],{"type":361,"attrs":1493},{"href":1494,"uuid":53,"anchor":53,"custom":53,"target":365,"linktype":366},"https://www.fraserhealth.ca/",{"text":1496,"type":356}," developed and implemented Trauma and Resiliency Informed approaches (TRIP program) at the individual, team, organizational and systems levels. Here are some of the key learnings shared by the speakers:   ",{"type":1498,"attrs":1499,"content":1501},"ordered_list",{"order":1500},1,[1502,1509,1516],{"type":464,"content":1503},[1504],{"type":15,"attrs":1505,"content":1506},{"textAlign":53},[1507],{"text":1508,"type":356},"Healthcare is a trauma-organized system. Healthcare is a living system, and its organization can be affected by chronic and repetitive stress. An effect is health and social care organizations tend to have problems that parallel or mirror the problems of their clients.",{"type":464,"content":1510},[1511],{"type":15,"attrs":1512,"content":1513},{"textAlign":53},[1514],{"text":1515,"type":356},"High levels of occupational stress can lead to poorer quality of care. If we do not acknowledge and address this trauma, we risk creating relationships and environments where people may be retraumatized – creating further barriers to working together to improve health outcomes. ",{"type":464,"content":1517},[1518],{"type":15,"attrs":1519,"content":1520},{"textAlign":53},[1521],{"text":1522,"type":356},"An evaluation of the TRIP program showed promising findings. Stigma and compassion fatigue were reduced after the workshop and continued to be reduced three months later. Resiliency and self-compassion increased.  ",{"type":516,"attrs":1524,"content":1525},{"level":518,"textAlign":519},[1526],{"text":1527,"type":356,"marks":1528},"Resources ",[1529],{"type":392},{"type":461,"content":1531},[1532,1547],{"type":464,"content":1533},[1534],{"type":15,"attrs":1535,"content":1536},{"textAlign":53},[1537,1539,1545],{"text":1538,"type":356},"Webpage: ",{"text":1540,"type":356,"marks":1541},"Engaging staff using a trauma and resilience informed approach for an evaluation of the COVID-19 response.",[1542],{"type":361,"attrs":1543},{"href":1544,"uuid":53,"anchor":53,"custom":53,"target":365,"linktype":366},"https://www.fraserhealth.ca/employees/research-and-evaluation/research-news-and-highlights/engaging-staff-using-a-trauma-and-resilience-informed-approach-for-an-evaluation#.ZAntdRXMKUk",{"text":1546,"type":356}," (Fraser Health) ",{"type":464,"content":1548},[1549],{"type":15,"attrs":1550,"content":1551},{"textAlign":53},[1552,1554,1560],{"text":1553,"type":356},"Journal article: ",{"text":1555,"type":356,"marks":1556},"How a shared humanity model can improve provider well-being and client care: An evaluation of Fraser Health’s Trauma and Resiliency Informed Practice (TRIP) training program.",[1557],{"type":361,"attrs":1558},{"href":1559,"uuid":53,"anchor":53,"custom":53,"target":365,"linktype":366},"https://journals.sagepub.com/doi/full/10.1177/0840470420970594",{"text":1561,"type":356}," (Knaak S, Sandrelli M, Patten S., SAGE Journals) ",{"_uid":1563,"title":1564,"ctaLeft":1565,"ctaRight":1566,"component":505,"columnLeft":1571,"columnRight":1645},"7de5e130-7cab-4176-b750-473c0debfa50","Understanding Trauma-Informed Practice and Engagement",[],[1567],{"_uid":1568,"link":1569,"label":503,"component":504},"8bc1b8ea-48df-4437-897b-90bd19f5fc3c",{"id":16,"url":1570,"target":365,"linktype":366,"fieldtype":502,"cached_url":1570},"https://youtu.be/CIpgbxDwRxE",{"type":12,"content":1572},[1573,1580,1586,1623,1630],{"type":15,"attrs":1574,"content":1575},{"textAlign":519},[1576],{"text":1577,"type":356,"marks":1578},"February 7, 2023",[1579],{"type":392},{"type":516,"attrs":1581,"content":1582},{"level":518,"textAlign":519},[1583],{"text":686,"type":356,"marks":1584},[1585],{"type":392},{"type":461,"content":1587},[1588,1595,1602,1609,1616],{"type":464,"content":1589},[1590],{"type":15,"attrs":1591,"content":1592},{"textAlign":53},[1593],{"text":1594,"type":356},"Claire Snyman, (she/her), CMA Patient Voice ",{"type":464,"content":1596},[1597],{"type":15,"attrs":1598,"content":1599},{"textAlign":53},[1600],{"text":1601,"type":356},"Carolyn Shimmin (she/her), George & Fay Yee Centre for Healthcare Innovation ",{"type":464,"content":1603},[1604],{"type":15,"attrs":1605,"content":1606},{"textAlign":53},[1607],{"text":1608,"type":356},"Jake Starratt-Farr (he/they), CMA Patient Voice             ",{"type":464,"content":1610},[1611],{"type":15,"attrs":1612,"content":1613},{"textAlign":53},[1614],{"text":1615,"type":356},"Sudi Barre (she/her), CMA Patient Voice                        ",{"type":464,"content":1617},[1618],{"type":15,"attrs":1619,"content":1620},{"textAlign":53},[1621],{"text":1622,"type":356},"Tammy White Quills-Knife (she/her), CMA Patient Voice ",{"type":516,"attrs":1624,"content":1625},{"level":518,"textAlign":519},[1626],{"text":1627,"type":356,"marks":1628},"Co-Hosts ",[1629],{"type":392},{"type":461,"content":1631},[1632,1638],{"type":464,"content":1633},[1634],{"type":15,"attrs":1635,"content":1636},{"textAlign":53},[1637],{"text":1474,"type":356},{"type":464,"content":1639},[1640],{"type":15,"attrs":1641,"content":1642},{"textAlign":53},[1643],{"text":1644,"type":356},"Carol Fancott, Director, Patient Engagement & Partnerships, HEC",{"type":12,"content":1646},[1647,1654,1659,1682,1688],{"type":516,"attrs":1648,"content":1649},{"level":518,"textAlign":519},[1650],{"text":1651,"type":356,"marks":1652},"Learnings ",[1653],{"type":392},{"type":15,"attrs":1655,"content":1656},{"textAlign":519},[1657],{"text":1658,"type":356},"This webinar featured speakers with lived experience of receiving, providing and leading care. This virtual learning event focused on: ",{"type":461,"content":1660},[1661,1668,1675],{"type":464,"content":1662},[1663],{"type":15,"attrs":1664,"content":1665},{"textAlign":53},[1666],{"text":1667,"type":356},"How structures of inequity, privilege and oppression amplify and re-create trauma by prioritizing the needs of specific groups (i.e. white, able-bodied, cis-gender, non-Indigenous).   ",{"type":464,"content":1669},[1670],{"type":15,"attrs":1671,"content":1672},{"textAlign":53},[1673],{"text":1674,"type":356},"Intergenerational and historical trauma and its effects in the context of engaging with those with lived experience of the health system. ",{"type":464,"content":1676},[1677],{"type":15,"attrs":1678,"content":1679},{"textAlign":53},[1680],{"text":1681,"type":356},"The role of the healthcare system in inducing or perpetuating trauma among those who have past experiences of trauma. ",{"type":516,"attrs":1683,"content":1684},{"level":518,"textAlign":519},[1685],{"text":1527,"type":356,"marks":1686},[1687],{"type":392},{"type":461,"content":1689},[1690,1704,1719,1733],{"type":464,"content":1691},[1692],{"type":15,"attrs":1693,"content":1694},{"textAlign":53},[1695,1697,1702],{"text":1696,"type":356},"Article: ",{"text":1698,"type":356,"marks":1699},"The coin model of privilege and critical allyship",[1700],{"type":361,"attrs":1701},{"href":1057,"uuid":53,"anchor":53,"custom":53,"target":365,"linktype":366},{"text":1703,"type":356}," (Stephanie A. 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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":3242,"content":3243},{"textAlign":53},[3244],{"text":3245,"type":356},"“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":3247},[3248,3255,3262,3331,3338,3411,3418,3483,3490],{"type":15,"attrs":3249,"content":3250},{"textAlign":53},[3251],{"text":3252,"type":356,"marks":3253},"Recommended strategies ",[3254],{"type":392},{"type":15,"attrs":3256,"content":3257},{"textAlign":53},[3258],{"text":3259,"type":356,"marks":3260},"Understand patient safety culture and its components ",[3261],{"type":392},{"type":461,"content":3263},[3264,3308,3315],{"type":464,"content":3265},[3266,3271],{"type":15,"attrs":3267,"content":3268},{"textAlign":53},[3269],{"text":3270,"type":356},"Recognize that patient safety culture is multi-dimensional consisting of a number of features: ",{"type":461,"content":3272},[3273,3280,3287,3294,3301],{"type":464,"content":3274},[3275],{"type":15,"attrs":3276,"content":3277},{"textAlign":53},[3278],{"text":3279,"type":356},"informed culture – relevant safety information is collected, analyzed and actively disseminated ",{"type":464,"content":3281},[3282],{"type":15,"attrs":3283,"content":3284},{"textAlign":53},[3285],{"text":3286,"type":356},"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":464,"content":3288},[3289],{"type":15,"attrs":3290,"content":3291},{"textAlign":53},[3292],{"text":3293,"type":356},"learning culture – preventable patient safety incidents are seen as opportunities for learning and changes are made as a result ",{"type":464,"content":3295},[3296],{"type":15,"attrs":3297,"content":3298},{"textAlign":53},[3299],{"text":3300,"type":356},"just culture – the importance of fairly balancing an understanding system failure with professional accountability ",{"type":464,"content":3302},[3303],{"type":15,"attrs":3304,"content":3305},{"textAlign":53},[3306],{"text":3307,"type":356},"flexible culture – people are capable of adapting effectively to changing demands ",{"type":464,"content":3309},[3310],{"type":15,"attrs":3311,"content":3312},{"textAlign":53},[3313],{"text":3314,"type":356},"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":464,"content":3316},[3317],{"type":15,"attrs":3318,"content":3319},{"textAlign":53},[3320,3322,3329],{"text":3321,"type":356},"Appreciate the ",{"text":3323,"type":356,"marks":3324},"interconnection",[3325],{"type":361,"attrs":3326},{"href":3327,"uuid":53,"anchor":53,"custom":3328,"target":365,"linktype":366},"https://www.youtube.com/watch?v=zeldVu-3DpM","[object Object]",{"text":3330,"type":356}," 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":3332,"content":3333},{"textAlign":53},[3334],{"text":3335,"type":356,"marks":3336},"Understand key contributors to a patient safety culture ",[3337],{"type":392},{"type":461,"content":3339},[3340,3404],{"type":464,"content":3341},[3342,3347],{"type":15,"attrs":3343,"content":3344},{"textAlign":53},[3345],{"text":3346,"type":356},"Appreciate and understand patient safety culture’s multiple influencers, including: ",{"type":461,"content":3348},[3349,3356,3363,3370,3383,3390,3397],{"type":464,"content":3350},[3351],{"type":15,"attrs":3352,"content":3353},{"textAlign":53},[3354],{"text":3355,"type":356},"leadership and board commitment and ongoing visibility (at the organization and team levels) ",{"type":464,"content":3357},[3358],{"type":15,"attrs":3359,"content":3360},{"textAlign":53},[3361],{"text":3362,"type":356},"patient/family engagement ",{"type":464,"content":3364},[3365],{"type":15,"attrs":3366,"content":3367},{"textAlign":53},[3368],{"text":3369,"type":356},"effectiveness and openness of teamwork and communication ",{"type":464,"content":3371},[3372],{"type":15,"attrs":3373,"content":3374},{"textAlign":53},[3375,3381],{"text":3376,"type":356,"marks":3377},"openness",[3378],{"type":361,"attrs":3379},{"href":3380,"uuid":53,"anchor":53,"custom":3328,"target":2317,"linktype":366},"https://www.youtube.com/watch?v=LhoLuui9gX8",{"text":3382,"type":356}," of all team members, including patients/families, in reporting problems and incidents measurement/monitoring and learning from safety and incidents ",{"type":464,"content":3384},[3385],{"type":15,"attrs":3386,"content":3387},{"textAlign":53},[3388],{"text":3389,"type":356},"organizational learning ",{"type":464,"content":3391},[3392],{"type":15,"attrs":3393,"content":3394},{"textAlign":53},[3395],{"text":3396,"type":356},"organizational resources for patient safety ",{"type":464,"content":3398},[3399],{"type":15,"attrs":3400,"content":3401},{"textAlign":53},[3402],{"text":3403,"type":356},"priority of safety versus production ",{"type":464,"content":3405},[3406],{"type":15,"attrs":3407,"content":3408},{"textAlign":53},[3409],{"text":3410,"type":356},"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":3412,"content":3413},{"textAlign":53},[3414],{"text":3415,"type":356,"marks":3416},"Assess patient safety culture ",[3417],{"type":392},{"type":461,"content":3419},[3420,3435,3442,3449,3462,3469,3476],{"type":464,"content":3421},[3422],{"type":15,"attrs":3423,"content":3424},{"textAlign":53},[3425,3427,3433],{"text":3426,"type":356},"Determine the best methods and tools to ",{"text":3428,"type":356,"marks":3429},"assess",[3430],{"type":361,"attrs":3431},{"href":3432,"uuid":53,"anchor":53,"custom":53,"target":365,"linktype":366},"https://www.ahrq.gov/sops/index.html",{"text":3434,"type":356}," patient safety culture in the organization, engaging safety and measurement experts whenever possible. ",{"type":464,"content":3436},[3437],{"type":15,"attrs":3438,"content":3439},{"textAlign":53},[3440],{"text":3441,"type":356},"Consider assessing both perceptual indicators (front line staff provide majority of data) and organizational indicators of culture (senior leaders provide majority of data).   ",{"type":464,"content":3443},[3444],{"type":15,"attrs":3445,"content":3446},{"textAlign":53},[3447],{"text":3448,"type":356},"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":464,"content":3450},[3451],{"type":15,"attrs":3452,"content":3453},{"textAlign":53},[3454,3460],{"text":3455,"type":356,"marks":3456},"Engage frontline",[3457],{"type":361,"attrs":3458},{"href":3459,"uuid":53,"anchor":53,"custom":53,"target":365,"linktype":366},"http://www.hopkinsmedicine.org/armstrong_institute/_files/cusp_toolkit_new/Culture-Check-Up-Process.pdf",{"text":3461,"type":356}," caregivers in the planning and implementation of the culture measurement initiative. ",{"type":464,"content":3463},[3464],{"type":15,"attrs":3465,"content":3466},{"textAlign":53},[3467],{"text":3468,"type":356},"Analyze the results and identify opportunities for improvement, mapping to the various patient safety dimensions and influencers. ",{"type":464,"content":3470},[3471],{"type":15,"attrs":3472,"content":3473},{"textAlign":53},[3474],{"text":3475,"type":356},"Communicate the results to key stakeholders in a meaningful way including a timeline for next steps and how improvement actions will be identified. ",{"type":464,"content":3477},[3478],{"type":15,"attrs":3479,"content":3480},{"textAlign":53},[3481],{"text":3482,"type":356},"Understand that patient safety culture measurement is a snapshot in time and that ongoing measurement will be needed to monitor progress. ",{"type":15,"attrs":3484,"content":3485},{"textAlign":53},[3486],{"text":3487,"type":356,"marks":3488},"Develop and implement a patient safety culture strategy ",[3489],{"type":392},{"type":461,"content":3491},[3492,3507,3514,3521,3549],{"type":464,"content":3493},[3494],{"type":15,"attrs":3495,"content":3496},{"textAlign":53},[3497,3499,3505],{"text":3498,"type":356},"Based on the assessment results and environmental factors and with leadership support develop a shared vision and ",{"text":3500,"type":356,"marks":3501},"plan",[3502],{"type":361,"attrs":3503},{"href":3504,"uuid":53,"anchor":53,"custom":53,"target":365,"linktype":366},"https://bcpsqc.ca/wp-content/uploads/2018/03/culture-toolkit_web.pdf",{"text":3506,"type":356}," for improving patient safety culture.   ",{"type":464,"content":3508},[3509],{"type":15,"attrs":3510,"content":3511},{"textAlign":53},[3512],{"text":3513,"type":356},"Identify potential opportunities to implement the plan as well as barriers along with corresponding mitigating strategies. ",{"type":464,"content":3515},[3516],{"type":15,"attrs":3517,"content":3518},{"textAlign":53},[3519],{"text":3520,"type":356},"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":464,"content":3522},[3523,3533],{"type":15,"attrs":3524,"content":3525},{"textAlign":53},[3526,3531],{"text":3527,"type":356,"marks":3528},"Partner with patients",[3529],{"type":361,"attrs":3530},{"href":3032,"uuid":53,"anchor":53,"custom":53,"target":365,"linktype":366},{"text":3532,"type":356}," and families in patient safety: ",{"type":461,"content":3534},[3535,3542],{"type":464,"content":3536},[3537],{"type":15,"attrs":3538,"content":3539},{"textAlign":53},[3540],{"text":3541,"type":356},"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":464,"content":3543},[3544],{"type":15,"attrs":3545,"content":3546},{"textAlign":53},[3547],{"text":3548,"type":356},"engage them in the design of care models, care processes and quality improvement/patient safety initiatives ",{"type":464,"content":3550},[3551,3562],{"type":15,"attrs":3552,"content":3553},{"textAlign":53},[3554,3560],{"text":3555,"type":356,"marks":3556},"Partner with providers",[3557],{"type":361,"attrs":3558},{"href":3559,"uuid":53,"anchor":53,"custom":53,"target":365,"linktype":366},"http://www.liberatingstructures.com/fs2/",{"text":3561,"type":356}," in patient safety:",{"type":461,"content":3563},[3564,3571,3578,3585,3592],{"type":464,"content":3565},[3566],{"type":15,"attrs":3567,"content":3568},{"textAlign":53},[3569],{"text":3570,"type":356},"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":464,"content":3572},[3573],{"type":15,"attrs":3574,"content":3575},{"textAlign":53},[3576],{"text":3577,"type":356},"engage staff in all phases of quality improvement and patient safety initiatives to leverage their expertise ",{"type":464,"content":3579},[3580],{"type":15,"attrs":3581,"content":3582},{"textAlign":53},[3583],{"text":3584,"type":356},"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":464,"content":3586},[3587],{"type":15,"attrs":3588,"content":3589},{"textAlign":53},[3590],{"text":3591,"type":356},"design communication systems that allow for a continuous patient safety conversation between frontline staff and leaders ",{"type":464,"content":3593},[3594],{"type":15,"attrs":3595},{"textAlign":53},{"_uid":3597,"title":3598,"ctaLeft":3599,"ctaRight":3600,"component":505,"columnLeft":3601,"columnRight":3613},"36d257db-403a-495b-8d69-77e5d56ad80a","Reporting and Learning Systems",[],[],{"type":12,"content":3602},[3603,3608],{"type":15,"attrs":3604,"content":3605},{"textAlign":53},[3606],{"text":3607,"type":356},"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":3609,"content":3610},{"textAlign":53},[3611],{"text":3612,"type":356},"“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":3614},[3615,3626,3635,3909,3921,4061,4073],{"type":516,"attrs":3616,"content":3617},{"level":2463,"textAlign":519},[3618,3623],{"text":2502,"type":356,"marks":3619},[3620,3622],{"type":525,"attrs":3621},{"color":16},{"type":392},{"text":529,"type":356,"marks":3624},[3625],{"type":392},{"type":516,"attrs":3627,"content":3628},{"level":518,"textAlign":519},[3629],{"text":3630,"type":356,"marks":3631},"Establish a reporting system",[3632,3634],{"type":525,"attrs":3633},{"color":16},{"type":392},{"type":461,"content":3636},[3637,3661,3684,3708,3732,3743],{"type":464,"content":3638},[3639],{"type":15,"attrs":3640,"content":3641},{"textAlign":53},[3642,3647,3655,3660],{"text":3643,"type":356,"marks":3644},"Capture information about hazards, patient safety concerns, incidents and near misses, typically by completing a standardized ",[3645],{"type":525,"attrs":3646},{"color":16},{"text":3648,"type":356,"marks":3649},"electronic",[3650,3653],{"type":361,"attrs":3651},{"href":3652,"uuid":53,"anchor":53,"custom":53,"target":365,"linktype":366},"https://psrs.arc.nasa.gov/web_docs/PSRS_ExampleForm.pdf",{"type":525,"attrs":3654},{"color":16},{"text":3656,"type":356,"marks":3657}," or paper form",[3658],{"type":525,"attrs":3659},{"color":16},{"text":529,"type":356},{"type":464,"content":3662},[3663],{"type":15,"attrs":3664,"content":3665},{"textAlign":53},[3666,3671,3679,3683],{"text":3667,"type":356,"marks":3668},"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. ",[3669],{"type":525,"attrs":3670},{"color":16},{"text":3672,"type":356,"marks":3673},"stop the line",[3674,3677],{"type":361,"attrs":3675},{"href":3676,"uuid":53,"anchor":53,"custom":53,"target":365,"linktype":366},"https://www.youtube.com/watch?v=y3j3CErXXH8",{"type":525,"attrs":3678},{"color":16},{"text":2965,"type":356,"marks":3680},[3681],{"type":525,"attrs":3682},{"color":16},{"text":529,"type":356},{"type":464,"content":3685},[3686],{"type":15,"attrs":3687,"content":3688},{"textAlign":53},[3689,3694,3702,3707],{"text":3690,"type":356,"marks":3691},"Compared to those that are mandatory, ",[3692],{"type":525,"attrs":3693},{"color":16},{"text":3695,"type":356,"marks":3696},"voluntary",[3697,3700],{"type":361,"attrs":3698},{"href":3699,"uuid":53,"anchor":53,"custom":53,"target":365,"linktype":366},"http://psnet.ahrq.gov/primer.aspx?primerID=13",{"type":525,"attrs":3701},{"color":16},{"text":3703,"type":356,"marks":3704}," (non-legislated) reporting systems have been shown to facilitate greater reporting and learning",[3705],{"type":525,"attrs":3706},{"color":16},{"text":529,"type":356},{"type":464,"content":3709},[3710],{"type":15,"attrs":3711,"content":3712},{"textAlign":53},[3713,3718,3726,3731],{"text":3714,"type":356,"marks":3715},"Empower and support reporting by all care participants, including the ",[3716],{"type":525,"attrs":3717},{"color":16},{"text":3719,"type":356,"marks":3720},"patient/family",[3721,3724],{"type":361,"attrs":3722},{"href":3723,"uuid":53,"anchor":53,"custom":53,"target":365,"linktype":366},"http://www.safemedicationuse.ca/report/",{"type":525,"attrs":3725},{"color":16},{"text":3727,"type":356,"marks":3728},", by ensuring they can access the system",[3729],{"type":525,"attrs":3730},{"color":16},{"text":529,"type":356},{"type":464,"content":3733},[3734],{"type":15,"attrs":3735,"content":3736},{"textAlign":53},[3737,3742],{"text":3738,"type":356,"marks":3739},"Engage the users, including patients/families, in developing and maintaining the system",[3740],{"type":525,"attrs":3741},{"color":16},{"text":529,"type":356},{"type":464,"content":3744},[3745,3754],{"type":15,"attrs":3746,"content":3747},{"textAlign":53},[3748,3753],{"text":3749,"type":356,"marks":3750},"Incorporate best practices into the design of the reporting system whenever possible:",[3751],{"type":525,"attrs":3752},{"color":16},{"text":529,"type":356},{"type":461,"content":3755},[3756,3775,3786,3797,3808,3819,3830,3841,3852,3887,3898],{"type":464,"content":3757},[3758],{"type":15,"attrs":3759,"content":3760},{"textAlign":53},[3761,3766,3774],{"text":3762,"type":356,"marks":3763},"make the system user-friendly aligning with human factors design ",[3764],{"type":525,"attrs":3765},{"color":16},{"text":3767,"type":356,"marks":3768},"principles",[3769,3772],{"type":361,"attrs":3770},{"href":3771,"uuid":53,"anchor":53,"custom":53,"target":365,"linktype":366},"http://www.ncbi.nlm.nih.gov/books/NBK133393/table/ch31.t2/?report=objectonly",{"type":525,"attrs":3773},{"color":16},{"text":529,"type":356},{"type":464,"content":3776},[3777],{"type":15,"attrs":3778,"content":3779},{"textAlign":53},[3780,3785],{"text":3781,"type":356,"marks":3782},"limit the information required to what is essential and include a narrative portion to allow reporters to tell the story",[3783],{"type":525,"attrs":3784},{"color":16},{"text":529,"type":356},{"type":464,"content":3787},[3788],{"type":15,"attrs":3789,"content":3790},{"textAlign":53},[3791,3796],{"text":3792,"type":356,"marks":3793},"provide an option for anonymous or confidential reporting to address concerns about potential negative consequences",[3794],{"type":525,"attrs":3795},{"color":16},{"text":529,"type":356},{"type":464,"content":3798},[3799],{"type":15,"attrs":3800,"content":3801},{"textAlign":53},[3802,3807],{"text":3803,"type":356,"marks":3804},"embed automatic notification of the appropriate department head or manager, eliminating the need for the reporter to determine where to direct the information",[3805],{"type":525,"attrs":3806},{"color":16},{"text":529,"type":356},{"type":464,"content":3809},[3810],{"type":15,"attrs":3811,"content":3812},{"textAlign":53},[3813,3818],{"text":3814,"type":356,"marks":3815},"acknowledge reports upon receipt conveying appreciation to the individual submitting the report",[3816],{"type":525,"attrs":3817},{"color":16},{"text":529,"type":356},{"type":464,"content":3820},[3821],{"type":15,"attrs":3822,"content":3823},{"textAlign":53},[3824,3829],{"text":3825,"type":356,"marks":3826},"develop process(es) for the reporter to clarify the information submitted, if required",[3827],{"type":525,"attrs":3828},{"color":16},{"text":529,"type":356},{"type":464,"content":3831},[3832],{"type":15,"attrs":3833,"content":3834},{"textAlign":53},[3835,3840],{"text":3836,"type":356,"marks":3837},"enable managers to receive and view reports in real-time to facilitate timely feedback and response",[3838],{"type":525,"attrs":3839},{"color":16},{"text":529,"type":356},{"type":464,"content":3842},[3843],{"type":15,"attrs":3844,"content":3845},{"textAlign":53},[3846,3851],{"text":3847,"type":356,"marks":3848},"facilitate the review of the reports completed by the patient/family in conjunction with those completed by care providers",[3849],{"type":525,"attrs":3850},{"color":16},{"text":529,"type":356},{"type":464,"content":3853},[3854],{"type":15,"attrs":3855,"content":3856},{"textAlign":53},[3857,3862,3870,3874,3882,3886],{"text":3858,"type":356,"marks":3859},"prompt users to consider external reporting or notification requirements when appropriate (e.g. ",[3860],{"type":525,"attrs":3861},{"color":16},{"text":3863,"type":356,"marks":3864},"National System for Incident Reporting",[3865,3868],{"type":361,"attrs":3866},{"href":3867,"uuid":53,"anchor":53,"custom":53,"target":365,"linktype":366},"https://www.cihi.ca/en/national-system-for-incident-reporting-nsir",{"type":525,"attrs":3869},{"color":16},{"text":1965,"type":356,"marks":3871},[3872],{"type":525,"attrs":3873},{"color":16},{"text":3875,"type":356,"marks":3876},"Canadian Medication Incident Reporting and Prevention System",[3877,3880],{"type":361,"attrs":3878},{"href":3879,"uuid":53,"anchor":53,"custom":53,"target":365,"linktype":366},"http://www.cmirps-scdpim.ca/?p=10",{"type":525,"attrs":3881},{"color":16},{"text":2965,"type":356,"marks":3883},[3884],{"type":525,"attrs":3885},{"color":16},{"text":529,"type":356},{"type":464,"content":3888},[3889],{"type":15,"attrs":3890,"content":3891},{"textAlign":53},[3892,3897],{"text":3893,"type":356,"marks":3894},"create easy-to-use data extraction capability to support timely improvement at the local, organizational and system-wide levels",[3895],{"type":525,"attrs":3896},{"color":16},{"text":529,"type":356},{"type":464,"content":3899},[3900],{"type":15,"attrs":3901,"content":3902},{"textAlign":53},[3903,3908],{"text":3904,"type":356,"marks":3905},"ensure appropriate data confidentiality and security (including de-identification), in accordance with applicable legislation and organizational policies",[3906],{"type":525,"attrs":3907},{"color":16},{"text":529,"type":356},{"type":516,"attrs":3910,"content":3911},{"level":518,"textAlign":519},[3912,3918],{"text":3913,"type":356,"marks":3914},"Establish processes that support reporting systems",[3915,3917],{"type":525,"attrs":3916},{"color":16},{"type":392},{"text":529,"type":356,"marks":3919},[3920],{"type":392},{"type":461,"content":3922},[3923,3992,4003,4014],{"type":464,"content":3924},[3925,3946],{"type":15,"attrs":3926,"content":3927},{"textAlign":53},[3928,3933,3940,3945],{"text":3929,"type":356,"marks":3930},"Develop and/or review existing reporting policies, procedures, education and training (example of policy and ",[3931],{"type":525,"attrs":3932},{"color":16},{"text":3934,"type":356,"marks":3935},"guideline",[3936,3938],{"type":361,"attrs":3937},{"href":2546,"uuid":53,"anchor":53,"custom":53,"target":365,"linktype":366},{"type":525,"attrs":3939},{"color":16},{"text":3941,"type":356,"marks":3942}," from AHS) to ensure users know what, how and when to report:",[3943],{"type":525,"attrs":3944},{"color":16},{"text":529,"type":356},{"type":461,"content":3947},[3948,3959,3970,3981],{"type":464,"content":3949},[3950],{"type":15,"attrs":3951,"content":3952},{"textAlign":53},[3953,3958],{"text":3954,"type":356,"marks":3955},"emphasize that reporting is a positive action that contributes to patient safety, and neither the person who reports nor those involved in or caused the event will be reprimanded",[3956],{"type":525,"attrs":3957},{"color":16},{"text":529,"type":356},{"type":464,"content":3960},[3961],{"type":15,"attrs":3962,"content":3963},{"textAlign":53},[3964,3969],{"text":3965,"type":356,"marks":3966},"develop tools and resources specifically for patients/families",[3967],{"type":525,"attrs":3968},{"color":16},{"text":529,"type":356},{"type":464,"content":3971},[3972],{"type":15,"attrs":3973,"content":3974},{"textAlign":53},[3975,3980],{"text":3976,"type":356,"marks":3977},"ensure roles and accountabilities around incident reporting are clearly delineated and that staff is familiar with reporting procedures and tools",[3978],{"type":525,"attrs":3979},{"color":16},{"text":529,"type":356},{"type":464,"content":3982},[3983],{"type":15,"attrs":3984,"content":3985},{"textAlign":53},[3986,3991],{"text":3987,"type":356,"marks":3988},"clearly communicate what happens to the information once it is entered into the reporting system",[3989],{"type":525,"attrs":3990},{"color":16},{"text":529,"type":356},{"type":464,"content":3993},[3994],{"type":15,"attrs":3995,"content":3996},{"textAlign":53},[3997,4002],{"text":3998,"type":356,"marks":3999},"Integrate reporting processes and the responsibility for reporting within existing work processes, structures and accountabilities including role descriptions, staff orientation and leadership development programs",[4000],{"type":525,"attrs":4001},{"color":16},{"text":529,"type":356},{"type":464,"content":4004},[4005],{"type":15,"attrs":4006,"content":4007},{"textAlign":53},[4008,4013],{"text":4009,"type":356,"marks":4010},"Allocate adequate resources (including technical and administrative) to maintain the reporting system and its related processes including data analysis, follow-up, and system oversight",[4011],{"type":525,"attrs":4012},{"color":16},{"text":529,"type":356},{"type":464,"content":4015},[4016,4025],{"type":15,"attrs":4017,"content":4018},{"textAlign":53},[4019,4024],{"text":4020,"type":356,"marks":4021},"Address potential organizational barriers to reporting:",[4022],{"type":525,"attrs":4023},{"color":16},{"text":529,"type":356},{"type":461,"content":4026},[4027,4050],{"type":464,"content":4028},[4029],{"type":15,"attrs":4030,"content":4031},{"textAlign":53},[4032,4037,4044,4049],{"text":4033,"type":356,"marks":4034},"cultivate a ",[4035],{"type":525,"attrs":4036},{"color":16},{"text":4038,"type":356,"marks":4039},"patient safety culture",[4040,4042],{"type":361,"attrs":4041},{"href":2701,"uuid":53,"anchor":53,"custom":53,"target":53,"linktype":366},{"type":525,"attrs":4043},{"color":16},{"text":4045,"type":356,"marks":4046},", specifically addressing the potential fears associated with reporting, authority gradient, and the risk of reprisal",[4047],{"type":525,"attrs":4048},{"color":16},{"text":529,"type":356},{"type":464,"content":4051},[4052],{"type":15,"attrs":4053,"content":4054},{"textAlign":53},[4055,4060],{"text":4056,"type":356,"marks":4057},"develop and train leaders to promote openness, facilitate learning, empower teams, and welcome differing perspectives",[4058],{"type":525,"attrs":4059},{"color":16},{"text":529,"type":356},{"type":516,"attrs":4062,"content":4063},{"level":518,"textAlign":519},[4064,4070],{"text":4065,"type":356,"marks":4066},"Optimize and share learning from reporting systems",[4067,4069],{"type":525,"attrs":4068},{"color":16},{"type":392},{"text":529,"type":356,"marks":4071},[4072],{"type":392},{"type":461,"content":4074},[4075,4086,4110,4134,4145,4156],{"type":464,"content":4076},[4077],{"type":15,"attrs":4078,"content":4079},{"textAlign":53},[4080,4085],{"text":4081,"type":356,"marks":4082},"Analyze data from the reporting system to identify patient safety gaps",[4083],{"type":525,"attrs":4084},{"color":16},{"text":529,"type":356},{"type":464,"content":4087},[4088],{"type":15,"attrs":4089,"content":4090},{"textAlign":53},[4091,4096,4104,4109],{"text":4092,"type":356,"marks":4093},"Integrate reporting system information with other data sources to ",[4094],{"type":525,"attrs":4095},{"color":16},{"text":4097,"type":356,"marks":4098},"anticipate",[4099,4102],{"type":361,"attrs":4100},{"href":4101,"uuid":53,"anchor":53,"custom":53,"target":53,"linktype":366},"https://www.healthcareexcellence.ca/en/resources/patient-safety-and-incident-management-toolkit/patient-safety-management/before-the-incident/",{"type":525,"attrs":4103},{"color":16},{"text":4105,"type":356,"marks":4106}," and mitigate clinical risk and system vulnerabilities as well as to identify system strengths",[4107],{"type":525,"attrs":4108},{"color":16},{"text":529,"type":356},{"type":464,"content":4111},[4112],{"type":15,"attrs":4113,"content":4114},{"textAlign":53},[4115,4120,4128,4133],{"text":4116,"type":356,"marks":4117},"Provide updates on ",[4118],{"type":525,"attrs":4119},{"color":16},{"text":4121,"type":356,"marks":4122},"lessons learned",[4123,4126],{"type":361,"attrs":4124},{"href":4125,"uuid":53,"anchor":53,"custom":53,"target":53,"linktype":366},"https://www.healthcareexcellence.ca/en/resources/patient-safety-and-incident-management-toolkit/incident-management/close-the-loop/",{"type":525,"attrs":4127},{"color":16},{"text":4129,"type":356,"marks":4130}," and improvements made as a result of reporting as part of routine processes, e.g. regular agenda item at staff and board meetings, “good catch” stories in newsletters, summaries at town hall meetings",[4131],{"type":525,"attrs":4132},{"color":16},{"text":529,"type":356},{"type":464,"content":4135},[4136],{"type":15,"attrs":4137,"content":4138},{"textAlign":53},[4139,4144],{"text":4140,"type":356,"marks":4141},"Consider sharing lessons learned with patients, families, communities, public and tailor communication to the needs of the specific audience, e.g. quantitative analyses, patient stories, trend summaries, poster campaigns, social media, blogs",[4142],{"type":525,"attrs":4143},{"color":16},{"text":529,"type":356},{"type":464,"content":4146},[4147],{"type":15,"attrs":4148,"content":4149},{"textAlign":53},[4150,4155],{"text":4151,"type":356,"marks":4152},"Evaluate the effectiveness of the reporting system and its related feedback mechanisms on a regular basis and make improvements",[4153],{"type":525,"attrs":4154},{"color":16},{"text":529,"type":356},{"type":464,"content":4157},[4158],{"type":15,"attrs":4159,"content":4160},{"textAlign":53},[4161],{"text":4162,"type":356,"marks":4163},"Update the data elements collected to ensure relevance and incorporate identification of emerging issues",[4164],{"type":525,"attrs":4165},{"color":16},"Patient Safety Management",{"type":12,"content":4168},[4169],{"type":15,"attrs":4170,"content":4171},{"textAlign":53},[4172],{"text":4173,"type":356},"The actions that help to proactively anticipate patient safety incidents and prevent them from occurring. 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":4175,"items":4176,"title":5985,"component":798,"description":5986},"dbcbd30a-a82c-4049-938e-c2ffda9de3ed",[4177,4440,4943,5246,5477,5665,5917],{"_uid":4178,"title":4179,"ctaLeft":4180,"ctaRight":4181,"component":505,"columnLeft":4187,"columnRight":4199},"ea6233ec-ed14-4652-a620-6da1204cf369","Immediate Response",[],[4182],{"_uid":4183,"link":4184,"label":4186,"component":504},"5fc66b57-c0c0-45c9-9c59-f5d2148ded13",{"id":16,"url":4185,"target":365,"linktype":366,"fieldtype":502,"cached_url":4185},"https://youtu.be/p44wxk7BL20","The Impact of Disclosure: Second Victim of Harm",{"type":12,"content":4188},[4189,4194],{"type":15,"attrs":4190,"content":4191},{"textAlign":53},[4192],{"text":4193,"type":356},"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. As appropriate, the immediate response continues throughout the incident management process to promote healing, recovery and learning. ",{"type":15,"attrs":4195,"content":4196},{"textAlign":53},[4197],{"text":4198,"type":356},"“We could forgive them that our daughter died but we could not forgive them for how they treated us after she died.”  -- Mother, Focus Group Participant ",{"type":12,"content":4200},[4201,4207,4229,4236,4287,4294,4310,4317,4347,4354,4384,4391,4414,4421,4430],{"type":15,"attrs":4202,"content":4203},{"textAlign":53},[4204],{"text":3252,"type":356,"marks":4205},[4206],{"type":392},{"type":15,"attrs":4208,"content":4209},{"textAlign":53},[4210,4212,4219,4221,4227],{"text":4211,"type":356},"Depending on the incident and circumstances, the steps taken immediately after an incident can vary in their order or occur simultaneously. Knowledge of local ",{"text":4213,"type":356,"marks":4214},"policies",[4215],{"type":361,"attrs":4216},{"href":4217,"uuid":53,"anchor":53,"custom":4218,"target":2317,"linktype":283},"https://a-ca.storyblok.com/f/850807391887861/b9f98028b9/sickkids-appendix-a-management-of-serious-patient-safety-incidents-final-ua.pdf",{},{"text":4220,"type":356},", procedures and available ",{"text":411,"type":356,"marks":4222},[4223],{"type":361,"attrs":4224},{"href":4225,"uuid":53,"anchor":53,"custom":4226,"target":2317,"linktype":283},"https://a-ca.storyblok.com/f/850807391887861/4d4818e5a2/ahs-ongoing-management-checklist-immediate-response-final-uae.pdf",{},{"text":4228,"type":356},", developed before the incident, ensure effective management of these crucial early steps in the incident management process. ",{"type":15,"attrs":4230,"content":4231},{"textAlign":53},[4232],{"text":4233,"type":356,"marks":4234},"Immediate care and support for patient(s), family, providers and others. ",[4235],{"type":392},{"type":461,"content":4237},[4238,4245,4252,4259,4273],{"type":464,"content":4239},[4240],{"type":15,"attrs":4241,"content":4242},{"textAlign":53},[4243],{"text":4244,"type":356},"First and foremost, address the immediate clinical needs of the patient(s) involved in the incident ",{"type":464,"content":4246},[4247],{"type":15,"attrs":4248,"content":4249},{"textAlign":53},[4250],{"text":4251,"type":356},"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":464,"content":4253},[4254],{"type":15,"attrs":4255,"content":4256},{"textAlign":53},[4257],{"text":4258,"type":356},"Ensure that other patients, families and visitors impacted by the incident are cared for, including support for their ongoing clinical needs ",{"type":464,"content":4260},[4261],{"type":15,"attrs":4262,"content":4263},{"textAlign":53},[4264,4266],{"text":4265,"type":356},"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":4267,"type":356,"marks":4268},"support",[4269],{"type":361,"attrs":4270},{"href":4271,"uuid":53,"anchor":53,"custom":4272,"target":365,"linktype":366},"http://www.healthpei.ca/src/CISS",{},{"type":464,"content":4274},[4275],{"type":15,"attrs":4276,"content":4277},{"textAlign":53},[4278,4285],{"text":4279,"type":356,"marks":4280},"Document",[4281],{"type":361,"attrs":4282},{"href":4283,"uuid":53,"anchor":53,"custom":4284,"target":365,"linktype":366},"https://www.cmpa-acpm.ca/serve/docs/ela/goodpracticesguide/pages/communication/communication-e.html",{},{"text":4286,"type":356}," facts in the patient’s health record as soon as possible in accordance with professional standards and organizational policies ",{"type":15,"attrs":4288,"content":4289},{"textAlign":53},[4290],{"text":4291,"type":356,"marks":4292},"Make the environment and surroundings safe. ",[4293],{"type":392},{"type":461,"content":4295},[4296,4303],{"type":464,"content":4297},[4298],{"type":15,"attrs":4299,"content":4300},{"textAlign":53},[4301],{"text":4302,"type":356},"Institute measures to reduce the risk of imminent recurrence or other potential threats, such as removing  potentially harmful medications, equipment or other hazards ",{"type":464,"content":4304},[4305],{"type":15,"attrs":4306,"content":4307},{"textAlign":53},[4308],{"text":4309,"type":356},"Alert others, such other areas within the organization or other institutions, to risks that extend beyond the local environment",{"type":15,"attrs":4311,"content":4312},{"textAlign":53},[4313],{"text":4314,"type":356,"marks":4315},"Secure items related to the event that may need to be assessed as part of the incident analysis. ",[4316],{"type":392},{"type":461,"content":4318},[4319,4326,4333,4340],{"type":464,"content":4320},[4321],{"type":15,"attrs":4322,"content":4323},{"textAlign":53},[4324],{"text":4325,"type":356},"Items to be secured can include biomedical equipment, intravenous solutions, medications, packaging, garments, linens, technology, video recordings, etc. ",{"type":464,"content":4327},[4328],{"type":15,"attrs":4329,"content":4330},{"textAlign":53},[4331],{"text":4332,"type":356},"Label and secure items in a protected environment with restricted access ",{"type":464,"content":4334},[4335],{"type":15,"attrs":4336,"content":4337},{"textAlign":53},[4338],{"text":4339,"type":356},"As directed by organizational policies, secure the health record and provide a copy to care providers if the patient is receiving ongoing care ",{"type":464,"content":4341},[4342],{"type":15,"attrs":4343,"content":4344},{"textAlign":53},[4345],{"text":4346,"type":356},"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":4348,"content":4349},{"textAlign":53},[4350],{"text":4351,"type":356,"marks":4352},"Report the incident and ensure appropriate notifications. ",[4353],{"type":392},{"type":461,"content":4355},[4356,4363,4370],{"type":464,"content":4357},[4358],{"type":15,"attrs":4359,"content":4360},{"textAlign":53},[4361],{"text":4362,"type":356},"Report the incident in accordance with organizational processes to trigger appropriate notifications and determine next steps in the incident management process ",{"type":464,"content":4364},[4365],{"type":15,"attrs":4366,"content":4367},{"textAlign":53},[4368],{"text":4369,"type":356},"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":464,"content":4371},[4372],{"type":15,"attrs":4373,"content":4374},{"textAlign":53},[4375,4377],{"text":4376,"type":356},"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":4378,"type":356,"marks":4379},"media",[4380],{"type":361,"attrs":4381},{"href":4382,"uuid":53,"anchor":53,"custom":4383,"target":2317,"linktype":283},"https://a-ca.storyblok.com/f/850807391887861/8b4421ff49/guidelines-for-informing-the-media-checklist-immediate-response-final-uae.pdf",{},{"type":15,"attrs":4385,"content":4386},{"textAlign":53},[4387],{"text":4388,"type":356,"marks":4389},"Begin disclosure. ",[4390],{"type":392},{"type":461,"content":4392},[4393,4400,4407],{"type":464,"content":4394},[4395],{"type":15,"attrs":4396,"content":4397},{"textAlign":53},[4398],{"text":4399,"type":356},"Begin the disclosure process with the patient and family as soon as reasonably possible ",{"type":464,"content":4401},[4402],{"type":15,"attrs":4403,"content":4404},{"textAlign":53},[4405],{"text":4406,"type":356},"Consider adapting the process to fit patient/family needs ",{"type":464,"content":4408},[4409],{"type":15,"attrs":4410,"content":4411},{"textAlign":53},[4412],{"text":4413,"type":356},"Document the disclosure discussion in accordance with organizational policies",{"type":15,"attrs":4415,"content":4416},{"textAlign":53},[4417],{"text":4418,"type":356,"marks":4419},"Ongoing support ",[4420],{"type":392},{"type":461,"content":4422},[4423],{"type":464,"content":4424},[4425],{"type":15,"attrs":4426,"content":4427},{"textAlign":53},[4428],{"text":4429,"type":356},"Begin to create a plan to provide support and information to patients/families, providers, and others as appropriate. ",{"type":15,"attrs":4431,"content":4432},{"textAlign":53},[4433],{"text":4434,"type":356,"marks":4435},"Download a transcript of \"The Impact of Disclosure: Second Victim of Harm\" video.",[4436],{"type":361,"attrs":4437},{"href":4438,"uuid":53,"anchor":53,"custom":4439,"target":2317,"linktype":283},"https://a-ca.storyblok.com/f/850807391887861/17a7f26aba/transcript-the-impact-of-disclosure-second-victim-of-harm-en.pdf",{},{"_uid":4441,"title":4442,"ctaLeft":4443,"ctaRight":4444,"component":505,"columnLeft":4445,"columnRight":4467},"2a750193-9a19-4512-9486-25cffa35731c","Disclosure",[],[],{"type":12,"content":4446},[4447,4452,4457,4462],{"type":15,"attrs":4448,"content":4449},{"textAlign":53},[4450],{"text":4451,"type":356},"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":4453,"content":4454},{"textAlign":53},[4455],{"text":4456,"type":356},"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":4458,"content":4459},{"textAlign":53},[4460],{"text":4461,"type":356},"“…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":4463,"content":4464},{"textAlign":53},[4465],{"text":4466,"type":356},"“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":4468},[4469,4476,4483,4490,4628,4635,4642,4716,4723,4869,4876],{"type":15,"attrs":4470,"content":4471},{"textAlign":53},[4472],{"text":4473,"type":356,"marks":4474},"Recommended Strategies ",[4475],{"type":392},{"type":15,"attrs":4477,"content":4478},{"textAlign":53},[4479],{"text":4480,"type":356,"marks":4481},"Before an incident ",[4482],{"type":392},{"type":15,"attrs":4484,"content":4485},{"textAlign":53},[4486],{"text":4487,"type":356,"marks":4488},"Confirm that organizational processes support disclosure ",[4489],{"type":392},{"type":461,"content":4491},[4492,4499,4607,4614,4621],{"type":464,"content":4493},[4494],{"type":15,"attrs":4495,"content":4496},{"textAlign":53},[4497],{"text":4498,"type":356},"Establish guiding principles for disclosure (e.g. patient-centred healthcare, patient autonomy, honesty and transparency, patient safety, just culture, learning and improvement). ",{"type":464,"content":4500},[4501,4506],{"type":15,"attrs":4502,"content":4503},{"textAlign":53},[4504],{"text":4505,"type":356},"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":461,"content":4507},[4508,4515,4555,4570,4577,4593,4600],{"type":464,"content":4509},[4510],{"type":15,"attrs":4511,"content":4512},{"textAlign":53},[4513],{"text":4514,"type":356},"involve patients/ families and frontline staff in their development ",{"type":464,"content":4516},[4517],{"type":15,"attrs":4518,"content":4519},{"textAlign":53},[4520,4522,4535,4537,4544,4546,4553],{"text":4521,"type":356},"articulate ",{"text":4523,"type":356,"marks":4524},"when",[4525],{"type":361,"attrs":4526},{"href":4527,"uuid":4528,"anchor":53,"custom":4529,"target":2317,"linktype":2255,"story":4530},"/resources/canadian-disclosure-guidelines","f0212af6-3223-4b78-a9df-6c8367a0e422",{},{"name":4531,"id":4532,"uuid":4528,"slug":4533,"url":4534,"full_slug":4534,"_stopResolving":291},"Canadian Disclosure Guidelines",113881379122976,"canadian-disclosure-guidelines","resources/canadian-disclosure-guidelines",{"text":4536,"type":356}," and where disclosure should take place and ",{"text":4538,"type":356,"marks":4539},"how",[4540],{"type":361,"attrs":4541},{"href":4527,"uuid":4528,"anchor":53,"custom":4542,"target":2317,"linktype":2255,"story":4543},{},{"name":4531,"id":4532,"uuid":4528,"slug":4533,"url":4534,"full_slug":4534,"_stopResolving":291},{"text":4545,"type":356}," it should be ",{"text":4547,"type":356,"marks":4548},"conducted",[4549],{"type":361,"attrs":4550},{"href":4551,"uuid":53,"anchor":53,"custom":4552,"target":365,"linktype":366},"https://d10k7k7mywg42z.cloudfront.net/assets/5317823e4f720a21df0001ce/HQCA_checklist_FINAL.pdf",{},{"text":4554,"type":356}," ",{"type":464,"content":4556},[4557],{"type":15,"attrs":4558,"content":4559},{"textAlign":53},[4560,4562,4568],{"text":4561,"type":356},"include supports and ",{"text":411,"type":356,"marks":4563},[4564],{"type":361,"attrs":4565},{"href":4566,"uuid":53,"anchor":53,"custom":4567,"target":365,"linktype":366},"http://www.safetyandquality.gov.au/our-work/open-disclosure/implementing-the-open-disclosure-framework/open-disclosure-resources-for-clinicians-and-health-care-providers/",{},{"text":4569,"type":356}," available to the patient/family and healthcare providers ",{"type":464,"content":4571},[4572],{"type":15,"attrs":4573,"content":4574},{"textAlign":53},[4575],{"text":4576,"type":356},"provide guidance on how to deal with the media in the event of a public disclosure ",{"type":464,"content":4578},[4579],{"type":15,"attrs":4580,"content":4581},{"textAlign":53},[4582,4584,4591],{"text":4583,"type":356},"incorporate processes that address ",{"text":4585,"type":356,"marks":4586},"special circumstances",[4587],{"type":361,"attrs":4588},{"href":4527,"uuid":4528,"anchor":53,"custom":4589,"target":2317,"linktype":2255,"story":4590},{},{"name":4531,"id":4532,"uuid":4528,"slug":4533,"url":4534,"full_slug":4534,"_stopResolving":291},{"text":4592,"type":356}," such as multi-patient disclosures, paediatric patients or those with mental health issues, or incidents related to research ",{"type":464,"content":4594},[4595],{"type":15,"attrs":4596,"content":4597},{"textAlign":53},[4598],{"text":4599,"type":356},"are easily accessible to all, including frontline staff and patients/families (e.g. public site) ",{"type":464,"content":4601},[4602],{"type":15,"attrs":4603,"content":4604},{"textAlign":53},[4605],{"text":4606,"type":356},"are updated regularly to ensure relevance and alignment with other policies and current context ",{"type":464,"content":4608},[4609],{"type":15,"attrs":4610,"content":4611},{"textAlign":53},[4612],{"text":4613,"type":356},"Provide disclosure training programs and educational resources for staff and patients/families. ",{"type":464,"content":4615},[4616],{"type":15,"attrs":4617,"content":4618},{"textAlign":53},[4619],{"text":4620,"type":356},"Allocate resources to assist patients/families involved in patient safety incidents, ensuring they are available without delay (e.g. practical, emotional, financial). ",{"type":464,"content":4622},[4623],{"type":15,"attrs":4624,"content":4625},{"textAlign":53},[4626],{"text":4627,"type":356},"Allocate resources to assist staff at the frontline involved in patient safety incidents as needed, including disclosure support and coaching. ",{"type":15,"attrs":4629,"content":4630},{"textAlign":53},[4631],{"text":4632,"type":356,"marks":4633},"After an incident ",[4634],{"type":392},{"type":15,"attrs":4636,"content":4637},{"textAlign":53},[4638],{"text":4639,"type":356,"marks":4640},"Develop a specific disclosure plan ",[4641],{"type":392},{"type":461,"content":4643},[4644,4651,4709],{"type":464,"content":4645},[4646],{"type":15,"attrs":4647,"content":4648},{"textAlign":53},[4649],{"text":4650,"type":356},"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":464,"content":4652},[4653,4658],{"type":15,"attrs":4654,"content":4655},{"textAlign":53},[4656],{"text":4657,"type":356},"If possible, conduct a pre-disclosure team huddle to determine the best approach, including: ",{"type":461,"content":4659},[4660,4667,4674,4681,4688,4695,4702],{"type":464,"content":4661},[4662],{"type":15,"attrs":4663,"content":4664},{"textAlign":53},[4665],{"text":4666,"type":356},"when the initial disclosure will occur taking into consideration patient/family readiness and preferences ",{"type":464,"content":4668},[4669],{"type":15,"attrs":4670,"content":4671},{"textAlign":53},[4672],{"text":4673,"type":356},"where the disclosure will take place, preferably a private area that is free of interruptions or off-site if indicated ",{"type":464,"content":4675},[4676],{"type":15,"attrs":4677,"content":4678},{"textAlign":53},[4679],{"text":4680,"type":356},"what information will be shared with the patient/family, including confirmation of the known undisputed facts ",{"type":464,"content":4682},[4683],{"type":15,"attrs":4684,"content":4685},{"textAlign":53},[4686],{"text":4687,"type":356},"who is the best person to initiate disclosure and coordinate the ongoing disclosure ",{"type":464,"content":4689},[4690],{"type":15,"attrs":4691,"content":4692},{"textAlign":53},[4693],{"text":4694,"type":356},"how the care providers involved in the incident will be supported ",{"type":464,"content":4696},[4697],{"type":15,"attrs":4698,"content":4699},{"textAlign":53},[4700],{"text":4701,"type":356},"how the patient/family will be supported and their questions/concerns addressed ",{"type":464,"content":4703},[4704],{"type":15,"attrs":4705,"content":4706},{"textAlign":53},[4707],{"text":4708,"type":356},"how disclosure will be documented ",{"type":464,"content":4710},[4711],{"type":15,"attrs":4712,"content":4713},{"textAlign":53},[4714],{"text":4715,"type":356},"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":4717,"content":4718},{"textAlign":53},[4719],{"text":4720,"type":356,"marks":4721},"Initiate initial disclosure ",[4722],{"type":392},{"type":461,"content":4724},[4725,4732,4739,4746,4753,4760,4790,4797,4804,4811,4818,4825],{"type":464,"content":4726},[4727],{"type":15,"attrs":4728,"content":4729},{"textAlign":53},[4730],{"text":4731,"type":356},"Use language and terminology that the patient/family can easily understand. Avoid speculation or blame. ",{"type":464,"content":4733},[4734],{"type":15,"attrs":4735,"content":4736},{"textAlign":53},[4737],{"text":4738,"type":356},"Introduce the participants to the patient/family, including their functions and reasons for attendance. ",{"type":464,"content":4740},[4741],{"type":15,"attrs":4742,"content":4743},{"textAlign":53},[4744],{"text":4745,"type":356},"Acknowledge the incident or that something unexpected has happened and express apology using the words ‘I’m sorry’. ",{"type":464,"content":4747},[4748],{"type":15,"attrs":4749,"content":4750},{"textAlign":53},[4751],{"text":4752,"type":356},"Provide an overview of how the meeting will run and ask how the patient/family would like to participate. ",{"type":464,"content":4754},[4755],{"type":15,"attrs":4756,"content":4757},{"textAlign":53},[4758],{"text":4759,"type":356},"Ask about concerns and questions the patient/family would like to discuss and offer support or resources if needed. ",{"type":464,"content":4761},[4762,4767],{"type":15,"attrs":4763,"content":4764},{"textAlign":53},[4765],{"text":4766,"type":356},"Share the following information: ",{"type":461,"content":4768},[4769,4776,4783],{"type":464,"content":4770},[4771],{"type":15,"attrs":4772,"content":4773},{"textAlign":53},[4774],{"text":4775,"type":356},"the currently known facts of the incident ",{"type":464,"content":4777},[4778],{"type":15,"attrs":4779,"content":4780},{"textAlign":53},[4781],{"text":4782,"type":356},"the steps for ensuring the ongoing care and well-being of the patient (e.g. clinical care, treatment) ",{"type":464,"content":4784},[4785],{"type":15,"attrs":4786,"content":4787},{"textAlign":53},[4788],{"text":4789,"type":356},"a brief overview of the incident analysis process including expected timelines and what the patient/family can expect during the process ",{"type":464,"content":4791},[4792],{"type":15,"attrs":4793,"content":4794},{"textAlign":53},[4795],{"text":4796,"type":356},"Offer the patient/family an opportunity to speak about their experience and ask questions. ",{"type":464,"content":4798},[4799],{"type":15,"attrs":4800,"content":4801},{"textAlign":53},[4802],{"text":4803,"type":356},"Ask about preferences for future involvement and information (how, when, where). ",{"type":464,"content":4805},[4806],{"type":15,"attrs":4807,"content":4808},{"textAlign":53},[4809],{"text":4810,"type":356},"Ask the patient/family to identify a contact person. ",{"type":464,"content":4812},[4813],{"type":15,"attrs":4814,"content":4815},{"textAlign":53},[4816],{"text":4817,"type":356},"Designate a key contact person from the organization who will provide regular updates. ",{"type":464,"content":4819},[4820],{"type":15,"attrs":4821,"content":4822},{"textAlign":53},[4823],{"text":4824,"type":356},"Provide practical and emotional support (e.g. spiritual care services, counselling, social work, family arrangements, reimbursement of expenses associated with the disclosure process). ",{"type":464,"content":4826},[4827,4832],{"type":15,"attrs":4828,"content":4829},{"textAlign":53},[4830],{"text":4831,"type":356},"Document the disclosure discussion in accordance with organizational policies. Include: ",{"type":461,"content":4833},[4834,4841,4848,4855,4862],{"type":464,"content":4835},[4836],{"type":15,"attrs":4837,"content":4838},{"textAlign":53},[4839],{"text":4840,"type":356},"the time, place, date, the names and relationships of all attendees ",{"type":464,"content":4842},[4843],{"type":15,"attrs":4844,"content":4845},{"textAlign":53},[4846],{"text":4847,"type":356},"the facts presented ",{"type":464,"content":4849},[4850],{"type":15,"attrs":4851,"content":4852},{"textAlign":53},[4853],{"text":4854,"type":356},"offers of assistance made and the response, questions raised and the answers given ",{"type":464,"content":4856},[4857],{"type":15,"attrs":4858,"content":4859},{"textAlign":53},[4860],{"text":4861,"type":356},"patient/family preferences about future disclosure discussions ",{"type":464,"content":4863},[4864],{"type":15,"attrs":4865,"content":4866},{"textAlign":53},[4867],{"text":4868,"type":356},"plans for follow-up and key contact information for the organization and the patient/family ",{"type":15,"attrs":4870,"content":4871},{"textAlign":53},[4872],{"text":4873,"type":356,"marks":4874},"Continue disclosure throughout the incident management process as needed ",[4875],{"type":392},{"type":461,"content":4877},[4878,4922,4929,4936],{"type":464,"content":4879},[4880,4885],{"type":15,"attrs":4881,"content":4882},{"textAlign":53},[4883],{"text":4884,"type":356},"Continue to be engaged with the patient/family according to their preferences: ",{"type":461,"content":4886},[4887,4894,4901,4908,4915],{"type":464,"content":4888},[4889],{"type":15,"attrs":4890,"content":4891},{"textAlign":53},[4892],{"text":4893,"type":356},"continue to offer practical and emotional support ",{"type":464,"content":4895},[4896],{"type":15,"attrs":4897,"content":4898},{"textAlign":53},[4899],{"text":4900,"type":356},"transparently correct any incorrect or incomplete information that was provided in previous disclosure meetings ",{"type":464,"content":4902},[4903],{"type":15,"attrs":4904,"content":4905},{"textAlign":53},[4906],{"text":4907,"type":356},"provide new factual information as it becomes available ",{"type":464,"content":4909},[4910],{"type":15,"attrs":4911,"content":4912},{"textAlign":53},[4913],{"text":4914,"type":356},"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":464,"content":4916},[4917],{"type":15,"attrs":4918,"content":4919},{"textAlign":53},[4920],{"text":4921,"type":356},"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":464,"content":4923},[4924],{"type":15,"attrs":4925,"content":4926},{"textAlign":53},[4927],{"text":4928,"type":356},"Continue to offer updates, and practical and emotional support for providers. ",{"type":464,"content":4930},[4931],{"type":15,"attrs":4932,"content":4933},{"textAlign":53},[4934],{"text":4935,"type":356},"Ensure providers maintain involvement in the disclosure process as appropriate, particularly if leadership takes on a larger role in the post analysis stage. ",{"type":464,"content":4937},[4938],{"type":15,"attrs":4939,"content":4940},{"textAlign":53},[4941],{"text":4942,"type":356},"Continue to document disclosure discussions per organizational policies. ",{"_uid":4944,"title":4945,"ctaLeft":4946,"ctaRight":4947,"component":505,"columnLeft":4948,"columnRight":4955},"3ea60bef-a57a-42cc-bbc1-cc4d690feb8f","Prepare for Analysis",[],[],{"type":12,"content":4949},[4950],{"type":15,"attrs":4951,"content":4952},{"textAlign":53},[4953],{"text":4954,"type":356},"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":4956},[4957,4963,4968,4975,5031,5038,5077,5084,5128,5135,5165,5172],{"type":15,"attrs":4958,"content":4959},{"textAlign":53},[4960],{"text":3252,"type":356,"marks":4961},[4962],{"type":392},{"type":15,"attrs":4964,"content":4965},{"textAlign":53},[4966],{"text":4967,"type":356},"Refer to your organization’s policies, procedures and jurisdictional requirements when implementing these steps. ",{"type":15,"attrs":4969,"content":4970},{"textAlign":53},[4971],{"text":4972,"type":356,"marks":4973},"Conduct a preliminary investigation. ",[4974],{"type":392},{"type":461,"content":4976},[4977,4984,5000,5007],{"type":464,"content":4978},[4979],{"type":15,"attrs":4980,"content":4981},{"textAlign":53},[4982],{"text":4983,"type":356},"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":464,"content":4985},[4986],{"type":15,"attrs":4987,"content":4988},{"textAlign":53},[4989,4991,4998],{"text":4990,"type":356},"Create a high level ",{"text":4992,"type":356,"marks":4993},"timeline",[4994],{"type":361,"attrs":4995},{"href":4996,"uuid":53,"anchor":53,"custom":4997,"target":365,"linktype":366},"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":4999,"type":356}," 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":464,"content":5001},[5002],{"type":15,"attrs":5003,"content":5004},{"textAlign":53},[5005],{"text":5006,"type":356},"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":464,"content":5008},[5009],{"type":15,"attrs":5010,"content":5011},{"textAlign":53},[5012,5014,5021,5023,5029],{"text":5013,"type":356},"Offer ",{"text":5015,"type":356,"marks":5016},"ongoing support",[5017],{"type":361,"attrs":5018},{"href":5019,"uuid":53,"anchor":53,"custom":5020,"target":2317,"linktype":283},"https://a-ca.storyblok.com/f/850807391887861/618a2ce867/ahs-immediate-and-ongoing-management-before-the-incident-final-uae.pdf",{},{"text":5022,"type":356}," to ",{"text":3216,"type":356,"marks":5024},[5025],{"type":361,"attrs":5026},{"href":5027,"uuid":53,"anchor":53,"custom":5028,"target":2317,"linktype":283},"https://a-ca.storyblok.com/f/850807391887861/5ee3bacccd/ciaf-appendix-f-cheklist-for-effective-meetings-with-patients-famili-final-ua.pdf",{},{"text":5030,"type":356}," and care providers ",{"type":15,"attrs":5032,"content":5033},{"textAlign":53},[5034],{"text":5035,"type":356,"marks":5036},"Select an analysis type and method. ",[5037],{"type":392},{"type":461,"content":5039},[5040,5056,5063,5070],{"type":464,"content":5041},[5042],{"type":15,"attrs":5043,"content":5044},{"textAlign":53},[5045,5047,5054],{"text":5046,"type":356},"Based on the preliminary understanding of what happened, and using appropriate ",{"text":5048,"type":356,"marks":5049},"guidance tools",[5050],{"type":361,"attrs":5051},{"href":5052,"uuid":53,"anchor":53,"custom":5053,"target":365,"linktype":366},"http://www.suspension-nhs.org/Resources/Safety%20-%20IDT%20(info%20and%20advice%20on%20use).pdf",{},{"text":5055,"type":356},", determine whether a system-based analysis (focused on system improvement) or an accountability review (focused on individual performance) or both is required",{"type":464,"content":5057},[5058],{"type":15,"attrs":5059,"content":5060},{"textAlign":53},[5061],{"text":5062,"type":356},"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":464,"content":5064},[5065],{"type":15,"attrs":5066,"content":5067},{"textAlign":53},[5068],{"text":5069,"type":356},"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":464,"content":5071},[5072],{"type":15,"attrs":5073,"content":5074},{"textAlign":53},[5075],{"text":5076,"type":356},"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":5078,"content":5079},{"textAlign":53},[5080],{"text":5081,"type":356,"marks":5082},"Identify the analysis team. ",[5083],{"type":392},{"type":461,"content":5085},[5086,5093,5100,5107,5114,5121],{"type":464,"content":5087},[5088],{"type":15,"attrs":5089,"content":5090},{"textAlign":53},[5091],{"text":5092,"type":356},"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":464,"content":5094},[5095],{"type":15,"attrs":5096,"content":5097},{"textAlign":53},[5098],{"text":5099,"type":356},"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":464,"content":5101},[5102],{"type":15,"attrs":5103,"content":5104},{"textAlign":53},[5105],{"text":5106,"type":356},"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":464,"content":5108},[5109],{"type":15,"attrs":5110,"content":5111},{"textAlign":53},[5112],{"text":5113,"type":356},"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":464,"content":5115},[5116],{"type":15,"attrs":5117,"content":5118},{"textAlign":53},[5119],{"text":5120,"type":356},"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":464,"content":5122},[5123],{"type":15,"attrs":5124,"content":5125},{"textAlign":53},[5126],{"text":5127,"type":356},"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":5129,"content":5130},{"textAlign":53},[5131],{"text":5132,"type":356,"marks":5133},"Coordinate meetings. ",[5134],{"type":392},{"type":461,"content":5136},[5137,5144,5151,5158],{"type":464,"content":5138},[5139],{"type":15,"attrs":5140,"content":5141},{"textAlign":53},[5142],{"text":5143,"type":356},"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":464,"content":5145},[5146],{"type":15,"attrs":5147,"content":5148},{"textAlign":53},[5149],{"text":5150,"type":356},"Secure a comfortable and private setting ",{"type":464,"content":5152},[5153],{"type":15,"attrs":5154,"content":5155},{"textAlign":53},[5156],{"text":5157,"type":356},"Emphasize and maintain confidentiality at all times to ensure information is only communicated in accordance with applicable policies and legislation ",{"type":464,"content":5159},[5160],{"type":15,"attrs":5161,"content":5162},{"textAlign":53},[5163],{"text":5164,"type":356},"Manage documents in accordance with organizational policies ",{"type":15,"attrs":5166,"content":5167},{"textAlign":53},[5168],{"text":5169,"type":356,"marks":5170},"Plan and conduct interviews. ",[5171],{"type":392},{"type":461,"content":5173},[5174,5181,5195,5202,5209],{"type":464,"content":5175},[5176],{"type":15,"attrs":5177,"content":5178},{"textAlign":53},[5179],{"text":5180,"type":356},"If feasible, meet with the team to confirm the approach and ground rules before conducting interviews ",{"type":464,"content":5182},[5183],{"type":15,"attrs":5184,"content":5185},{"textAlign":53},[5186,5188,5193],{"text":5187,"type":356},"Invite the ",{"text":3719,"type":356,"marks":5189},[5190],{"type":361,"attrs":5191},{"href":5027,"uuid":53,"anchor":53,"custom":5192,"target":2317,"linktype":283},{},{"text":5194,"type":356}," and staff to participate in interviews as appropriate, coordinating communication through the key contact assigned earlier ",{"type":464,"content":5196},[5197],{"type":15,"attrs":5198,"content":5199},{"textAlign":53},[5200],{"text":5201,"type":356},"Conduct interviews as soon as is reasonably possible to help ensure that important information and details are recalled ",{"type":464,"content":5203},[5204],{"type":15,"attrs":5205,"content":5206},{"textAlign":53},[5207],{"text":5208,"type":356},"Conduct interviews individually to provide an opportunity for those involved in the incident to share their detailed perspective and unique viewpoint ",{"type":464,"content":5210},[5211,5216],{"type":15,"attrs":5212,"content":5213},{"textAlign":53},[5214],{"text":5215,"type":356},"Consider the ability/readiness of the individuals being interviewed and provide care and support throughout: ",{"type":461,"content":5217},[5218,5225,5232,5239],{"type":464,"content":5219},[5220],{"type":15,"attrs":5221,"content":5222},{"textAlign":53},[5223],{"text":5224,"type":356},"clearly convey the purpose of the interview and what will be done with the information ",{"type":464,"content":5226},[5227],{"type":15,"attrs":5228,"content":5229},{"textAlign":53},[5230],{"text":5231,"type":356},"favour the use of open-ended questions to allow the individual to tell their story ",{"type":464,"content":5233},[5234],{"type":15,"attrs":5235,"content":5236},{"textAlign":53},[5237],{"text":5238,"type":356},"ask the individual whether they identified contributing factors related to the incident as well as factors they feel mitigated the outcome ",{"type":464,"content":5240},[5241],{"type":15,"attrs":5242,"content":5243},{"textAlign":53},[5244],{"text":5245,"type":356},"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":5247,"title":5248,"ctaLeft":5249,"ctaRight":5250,"component":505,"columnLeft":5251,"columnRight":5263},"d2e5f26d-506c-4567-9e06-2ed37ea8d911","Analysis Process",[],[],{"type":12,"content":5252},[5253,5258],{"type":15,"attrs":5254,"content":5255},{"textAlign":53},[5256],{"text":5257,"type":356},"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":5259,"content":5260},{"textAlign":53},[5261],{"text":5262,"type":356},"“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":5264},[5265,5271,5276,5283,5320,5327,5380,5387,5461,5468],{"type":15,"attrs":5266,"content":5267},{"textAlign":53},[5268],{"text":3252,"type":356,"marks":5269},[5270],{"type":392},{"type":15,"attrs":5272,"content":5273},{"textAlign":53},[5274],{"text":5275,"type":356},"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":5277,"content":5278},{"textAlign":53},[5279],{"text":5280,"type":356,"marks":5281},"Understand what happened. ",[5282],{"type":392},{"type":461,"content":5284},[5285,5292,5306,5313],{"type":464,"content":5286},[5287],{"type":15,"attrs":5288,"content":5289},{"textAlign":53},[5290],{"text":5291,"type":356},"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":464,"content":5293},[5294],{"type":15,"attrs":5295,"content":5296},{"textAlign":53},[5297,5299,5304],{"text":5298,"type":356},"Create a detailed ",{"text":4992,"type":356,"marks":5300},[5301],{"type":361,"attrs":5302},{"href":4996,"uuid":53,"anchor":53,"custom":5303,"target":365,"linktype":366},{},{"text":5305,"type":356},", collating facts from various sources ",{"type":464,"content":5307},[5308],{"type":15,"attrs":5309,"content":5310},{"textAlign":53},[5311],{"text":5312,"type":356},"Review additional supporting information such as any related policies and procedures, training materials, or evidence-based guidelines ",{"type":464,"content":5314},[5315],{"type":15,"attrs":5316,"content":5317},{"textAlign":53},[5318],{"text":5319,"type":356},"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":5321,"content":5322},{"textAlign":53},[5323],{"text":5324,"type":356,"marks":5325},"Determine how and why it happened. ",[5326],{"type":392},{"type":461,"content":5328},[5329,5336,5343,5350,5366,5373],{"type":464,"content":5330},[5331],{"type":15,"attrs":5332,"content":5333},{"textAlign":53},[5334],{"text":5335,"type":356},"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":464,"content":5337},[5338],{"type":15,"attrs":5339,"content":5340},{"textAlign":53},[5341],{"text":5342,"type":356},"Consider aspects of the incident that extend beyond the patient-provider level by probing all influencing factors and circumstances",{"type":464,"content":5344},[5345],{"type":15,"attrs":5346,"content":5347},{"textAlign":53},[5348],{"text":5349,"type":356},"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":464,"content":5351},[5352],{"type":15,"attrs":5353,"content":5354},{"textAlign":53},[5355,5357,5364],{"text":5356,"type":356},"Use diagramming or other ",{"text":5358,"type":356,"marks":5359},"analytical tools",[5360],{"type":361,"attrs":5361},{"href":5362,"uuid":53,"anchor":53,"custom":5363,"target":365,"linktype":366},"https://d10k7k7mywg42z.cloudfront.net/assets/5328a610f002ff2140000338/HQCA_SSA_Patient_Safety_Reviews_FINAL_June_2012.pdf",{},{"text":5365,"type":356}," to identify and understand the relationships between and among contributing factors ",{"type":464,"content":5367},[5368],{"type":15,"attrs":5369,"content":5370},{"textAlign":53},[5371],{"text":5372,"type":356},"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":464,"content":5374},[5375],{"type":15,"attrs":5376,"content":5377},{"textAlign":53},[5378],{"text":5379,"type":356},"Articulate concisely what was found in a summary of findings that provides the backbone for the development of recommended actions ",{"type":15,"attrs":5381,"content":5382},{"textAlign":53},[5383],{"text":5384,"type":356,"marks":5385},"Identify what can be done to reduce the risk of recurrence and make care safer. ",[5386],{"type":392},{"type":461,"content":5388},[5389,5396,5411,5418,5425,5447,5454],{"type":464,"content":5390},[5391],{"type":15,"attrs":5392,"content":5393},{"textAlign":53},[5394],{"text":5395,"type":356},"Develop recommended actions addressing the analysis findings and that are specific, measurable, attainable, realistic and timely ",{"type":464,"content":5397},[5398],{"type":15,"attrs":5399,"content":5400},{"textAlign":53},[5401,5403,5409],{"text":5402,"type":356},"Ground recommended actions in evidence whenever possible, utilize the ",{"text":5404,"type":356,"marks":5405},"most effective solutions",[5406],{"type":361,"attrs":5407},{"href":2995,"uuid":53,"anchor":53,"custom":5408,"target":365,"linktype":366},{},{"text":5410,"type":356}," given the circumstances and target them to the appropriate system level(s) to achieve sustained improvement ",{"type":464,"content":5412},[5413],{"type":15,"attrs":5414,"content":5415},{"textAlign":53},[5416],{"text":5417,"type":356},"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":464,"content":5419},[5420],{"type":15,"attrs":5421,"content":5422},{"textAlign":53},[5423],{"text":5424,"type":356},"Review and validate the recommended actions with the patient/family, providers and experts (whenever possible) ",{"type":464,"content":5426},[5427],{"type":15,"attrs":5428,"content":5429},{"textAlign":53},[5430,5432,5445],{"text":5431,"type":356},"Prepare and hand-off the ",{"text":5433,"type":356,"marks":5434},"incident analysis report",[5435],{"type":361,"attrs":5436},{"href":5437,"uuid":5438,"anchor":53,"custom":5439,"target":2317,"linktype":2255,"story":5440},"/resources/patient-safety-incident-analysis","8094c23a-c722-4bc4-8de1-f5474d690e2d",{},{"name":5441,"id":5442,"uuid":5438,"slug":5443,"url":5444,"full_slug":5444,"_stopResolving":291},"Patient Safety Incident Analysis",113880425582084,"patient-safety-incident-analysis","resources/patient-safety-incident-analysis",{"text":5446,"type":356}," to those responsible for approving recommended actions, allocating the necessary resources, delegating implementation of the recommended actions and monitoring progress ",{"type":464,"content":5448},[5449],{"type":15,"attrs":5450,"content":5451},{"textAlign":53},[5452],{"text":5453,"type":356},"Include a tracking tool with assigned responsibilities and timeframes in the report to facilitate ongoing monitoring of the recommended actions and their outcomes ",{"type":464,"content":5455},[5456],{"type":15,"attrs":5457,"content":5458},{"textAlign":53},[5459],{"text":5460,"type":356},"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":5462,"content":5463},{"textAlign":53},[5464],{"text":5465,"type":356,"marks":5466},"Identify and share what was learned. ",[5467],{"type":392},{"type":461,"content":5469},[5470],{"type":464,"content":5471},[5472],{"type":15,"attrs":5473,"content":5474},{"textAlign":53},[5475],{"text":5476,"type":356},"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":5478,"title":5479,"ctaLeft":5480,"ctaRight":5481,"component":505,"columnLeft":5482,"columnRight":5494},"afdc54f3-8d8b-40bd-bf75-60a0757481e3","Follow Through",[],[],{"type":12,"content":5483},[5484,5489],{"type":15,"attrs":5485,"content":5486},{"textAlign":53},[5487],{"text":5488,"type":356},"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":5490,"content":5491},{"textAlign":53},[5492],{"text":5493,"type":356}," “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":5495},[5496,5502,5509,5562,5569,5621,5628],{"type":15,"attrs":5497,"content":5498},{"textAlign":53},[5499],{"text":3252,"type":356,"marks":5500},[5501],{"type":392},{"type":15,"attrs":5503,"content":5504},{"textAlign":53},[5505],{"text":5506,"type":356,"marks":5507},"Implement recommended actions. ",[5508],{"type":392},{"type":461,"content":5510},[5511,5518,5525,5541,5548,5555],{"type":464,"content":5512},[5513],{"type":15,"attrs":5514,"content":5515},{"textAlign":53},[5516],{"text":5517,"type":356},"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":464,"content":5519},[5520],{"type":15,"attrs":5521,"content":5522},{"textAlign":53},[5523],{"text":5524,"type":356},"Ensure ongoing leadership support and adequate human and financial resources for implementation ",{"type":464,"content":5526},[5527],{"type":15,"attrs":5528,"content":5529},{"textAlign":53},[5530,5532,5539],{"text":5531,"type":356},"Use ",{"text":5533,"type":356,"marks":5534},"change management",[5535],{"type":361,"attrs":5536},{"href":5537,"uuid":53,"anchor":53,"custom":5538,"target":365,"linktype":366},"https://www.infoway-inforoute.ca/en/component/edocman/change-management/565-national-change-management-framework",{},{"text":5540,"type":356}," and improvement tools to base change on strong methodology ",{"type":464,"content":5542},[5543],{"type":15,"attrs":5544,"content":5545},{"textAlign":53},[5546],{"text":5547,"type":356},"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":464,"content":5549},[5550],{"type":15,"attrs":5551,"content":5552},{"textAlign":53},[5553],{"text":5554,"type":356},"Test changes on a small scale to allow for feedback and refinement before broader implementation ",{"type":464,"content":5556},[5557],{"type":15,"attrs":5558,"content":5559},{"textAlign":53},[5560],{"text":5561,"type":356},"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":5563,"content":5564},{"textAlign":53},[5565],{"text":5566,"type":356,"marks":5567},"Monitor and assess the effectiveness of the recommended actions. ",[5568],{"type":392},{"type":461,"content":5570},[5571,5593,5600,5607,5614],{"type":464,"content":5572},[5573],{"type":15,"attrs":5574,"content":5575},{"textAlign":53},[5576,5578,5591],{"text":5577,"type":356},"Rather than simply tracking the completion of recommended actions, establish relevant outcome, process and balancing ",{"text":5579,"type":356,"marks":5580},"measures",[5581],{"type":361,"attrs":5582},{"href":5583,"uuid":5584,"anchor":53,"custom":5585,"target":2317,"linktype":2255,"story":5586},"/resources/hospital-harm-is-everyone-s-concern","3b0b67e4-3791-4e2d-9008-4c21c4bdf065",{},{"name":5587,"id":5588,"uuid":5584,"slug":5589,"url":5590,"full_slug":5590,"_stopResolving":291},"Hospital harm is everyone’s concern",116783774126329,"hospital-harm-is-everyones-concern","resources/hospital-harm-is-everyones-concern",{"text":5592,"type":356}," to monitor whether the desired effect was achieved ",{"type":464,"content":5594},[5595],{"type":15,"attrs":5596,"content":5597},{"textAlign":53},[5598],{"text":5599,"type":356},"Clearly define measures and design data collection to be as practical as possible ",{"type":464,"content":5601},[5602],{"type":15,"attrs":5603,"content":5604},{"textAlign":53},[5605],{"text":5606,"type":356},"Monitor performance over time to demonstrate sustained improvement or lack thereof ",{"type":464,"content":5608},[5609],{"type":15,"attrs":5610,"content":5611},{"textAlign":53},[5612],{"text":5613,"type":356},"Use all of the information available to evaluate the overall effectiveness of the recommended actions, including observations, stakeholder feedback, and unintended consequences ",{"type":464,"content":5615},[5616],{"type":15,"attrs":5617,"content":5618},{"textAlign":53},[5619],{"text":5620,"type":356},"Revisit recommended actions that did not achieve the anticipated improvement and consider adjustments or alternate solutions ",{"type":15,"attrs":5622,"content":5623},{"textAlign":53},[5624],{"text":5625,"type":356,"marks":5626},"Close off the incident analysis and transition to ongoing operations. ",[5627],{"type":392},{"type":461,"content":5629},[5630,5637,5644,5651,5658],{"type":464,"content":5631},[5632],{"type":15,"attrs":5633,"content":5634},{"textAlign":53},[5635],{"text":5636,"type":356},"Designate the incident analysis as complete once all of the recommended actions have been evaluated for a pre-determined period of monitoring",{"type":464,"content":5638},[5639],{"type":15,"attrs":5640,"content":5641},{"textAlign":53},[5642],{"text":5643,"type":356},"Determine if ongoing performance monitoring (such as unit or organizational quality indicators) is required to ensure sustainability ",{"type":464,"content":5645},[5646],{"type":15,"attrs":5647,"content":5648},{"textAlign":53},[5649],{"text":5650,"type":356},"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":464,"content":5652},[5653],{"type":15,"attrs":5654,"content":5655},{"textAlign":53},[5656],{"text":5657,"type":356},"If communicating results of recommended actions, respect patient/family preferences in terms what they want to know and when  ",{"type":464,"content":5659},[5660],{"type":15,"attrs":5661,"content":5662},{"textAlign":53},[5663],{"text":5664,"type":356},"Celebrate successes and improvements highlighting the positive contributions to safety resulting from the incident management process ",{"_uid":5666,"title":5667,"ctaLeft":5668,"ctaRight":5669,"component":505,"columnLeft":5670,"columnRight":5682},"f09c04b3-ced1-428c-9bf3-08ac2a008ede","Close the Loop",[],[],{"type":12,"content":5671},[5672,5677],{"type":15,"attrs":5673,"content":5674},{"textAlign":53},[5675],{"text":5676,"type":356},"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":5678,"content":5679},{"textAlign":53},[5680],{"text":5681,"type":356},"“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":5683},[5684,5690,5695,5702,5783,5790,5829,5836],{"type":15,"attrs":5685,"content":5686},{"textAlign":53},[5687],{"text":3252,"type":356,"marks":5688},[5689],{"type":392},{"type":15,"attrs":5691,"content":5692},{"textAlign":53},[5693],{"text":5694,"type":356},"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":5696,"content":5697},{"textAlign":53},[5698],{"text":5699,"type":356,"marks":5700},"Share what was learned internally. ",[5701],{"type":392},{"type":461,"content":5703},[5704,5711,5718,5755,5762,5769,5776],{"type":464,"content":5705},[5706],{"type":15,"attrs":5707,"content":5708},{"textAlign":53},[5709],{"text":5710,"type":356},"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":464,"content":5712},[5713],{"type":15,"attrs":5714,"content":5715},{"textAlign":53},[5716],{"text":5717,"type":356},"Communicate results of recommended actions, taking care to respect patient/family preferences in terms of what they want to know and when ",{"type":464,"content":5719},[5720,5725],{"type":15,"attrs":5721,"content":5722},{"textAlign":53},[5723],{"text":5724,"type":356},"Communicate what has been implemented and the results, ensuring messages and channels are appropriate for each audience: ",{"type":461,"content":5726},[5727,5734,5741,5748],{"type":464,"content":5728},[5729],{"type":15,"attrs":5730,"content":5731},{"textAlign":53},[5732],{"text":5733,"type":356},"review the purpose of analysis, methodology and the findings as appropriate ",{"type":464,"content":5735},[5736],{"type":15,"attrs":5737,"content":5738},{"textAlign":53},[5739],{"text":5740,"type":356},"share the factors that contributed to the incident, the defences that worked well, and what was learned about how to avoid similar incidents ",{"type":464,"content":5742},[5743],{"type":15,"attrs":5744,"content":5745},{"textAlign":53},[5746],{"text":5747,"type":356},"review the recommended actions, their current status and their impact ",{"type":464,"content":5749},[5750],{"type":15,"attrs":5751,"content":5752},{"textAlign":53},[5753],{"text":5754,"type":356},"maintain transparency and trust by being honest if plans have changed and share the reasons why ",{"type":464,"content":5756},[5757],{"type":15,"attrs":5758,"content":5759},{"textAlign":53},[5760],{"text":5761,"type":356},"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":464,"content":5763},[5764],{"type":15,"attrs":5765,"content":5766},{"textAlign":53},[5767],{"text":5768,"type":356},"Maintain a record of communication to ensure all appropriate stakeholders have received the information ",{"type":464,"content":5770},[5771],{"type":15,"attrs":5772,"content":5773},{"textAlign":53},[5774],{"text":5775,"type":356},"Recognize that sharing is  a dialogue (not a one-way flow of information) and is ongoing (more than one time) ",{"type":464,"content":5777},[5778],{"type":15,"attrs":5779,"content":5780},{"textAlign":53},[5781],{"text":5782,"type":356},"Encourage respectful, open communication around the results of the incident analysis at all levels of the organization ",{"type":15,"attrs":5784,"content":5785},{"textAlign":53},[5786],{"text":5787,"type":356,"marks":5788},"Share what was learned externally. ",[5789],{"type":392},{"type":461,"content":5791},[5792,5799,5806,5822],{"type":464,"content":5793},[5794],{"type":15,"attrs":5795,"content":5796},{"textAlign":53},[5797],{"text":5798,"type":356},"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":464,"content":5800},[5801],{"type":15,"attrs":5802,"content":5803},{"textAlign":53},[5804],{"text":5805,"type":356},"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":464,"content":5807},[5808],{"type":15,"attrs":5809,"content":5810},{"textAlign":53},[5811,5813,5820],{"text":5812,"type":356},"If appropriate, develop an ",{"text":5814,"type":356,"marks":5815},"external communication plan",[5816],{"type":361,"attrs":5817},{"href":5818,"uuid":53,"anchor":53,"custom":5819,"target":365,"linktype":366},"http://hqca.ca/studies-and-reviews/continuity-of-patient-care-study/",{},{"text":5821,"type":356}," 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":464,"content":5823},[5824],{"type":15,"attrs":5825,"content":5826},{"textAlign":53},[5827],{"text":5828,"type":356},"For public announcements, prepare the staff and the patient/family in advance discussing what information will be shared, when and how  ",{"type":15,"attrs":5830,"content":5831},{"textAlign":53},[5832],{"text":5833,"type":356,"marks":5834},"Reflect and Improve. ",[5835],{"type":392},{"type":461,"content":5837},[5838,5845,5852,5859,5866,5910],{"type":464,"content":5839},[5840],{"type":15,"attrs":5841,"content":5842},{"textAlign":53},[5843],{"text":5844,"type":356},"Consider conducting a multi-incident analysis to better identify recurring system issues ",{"type":464,"content":5846},[5847],{"type":15,"attrs":5848,"content":5849},{"textAlign":53},[5850],{"text":5851,"type":356},"Determine if what was learned can be applied to other processes in the organization ",{"type":464,"content":5853},[5854],{"type":15,"attrs":5855,"content":5856},{"textAlign":53},[5857],{"text":5858,"type":356},"Communicate any noteworthy vulnerabilities and/or best practices through senior leadership or other appropriate body (e.g. quality committee, risk management, etc.) ",{"type":464,"content":5860},[5861],{"type":15,"attrs":5862,"content":5863},{"textAlign":53},[5864],{"text":5865,"type":356},"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":464,"content":5867},[5868,5873],{"type":15,"attrs":5869,"content":5870},{"textAlign":53},[5871],{"text":5872,"type":356},"Assess the incident management process to identify strengths and opportunities for improvement, taking into consideration: ",{"type":461,"content":5874},[5875,5882,5889,5896,5903],{"type":464,"content":5876},[5877],{"type":15,"attrs":5878,"content":5879},{"textAlign":53},[5880],{"text":5881,"type":356},"the timeliness of the analysis ",{"type":464,"content":5883},[5884],{"type":15,"attrs":5885,"content":5886},{"textAlign":53},[5887],{"text":5888,"type":356},"the quality and effectiveness of the recommended actions ",{"type":464,"content":5890},[5891],{"type":15,"attrs":5892,"content":5893},{"textAlign":53},[5894],{"text":5895,"type":356},"organizational guidance and supporting structures ",{"type":464,"content":5897},[5898],{"type":15,"attrs":5899,"content":5900},{"textAlign":53},[5901],{"text":5902,"type":356},"communication and processes for sharing what was learned ",{"type":464,"content":5904},[5905],{"type":15,"attrs":5906,"content":5907},{"textAlign":53},[5908],{"text":5909,"type":356},"the experience of those involved in the incident and the analysis ",{"type":464,"content":5911},[5912],{"type":15,"attrs":5913,"content":5914},{"textAlign":53},[5915],{"text":5916,"type":356},"Support research and innovation focussed on learning from incidents",{"_uid":5918,"title":5919,"ctaLeft":5920,"ctaRight":5921,"component":505,"columnLeft":5922,"columnRight":5939},"81c12f23-77c7-4d5a-9ccf-d3c867db635e","Peer-to-Peer Support",[],[],{"type":12,"content":5923},[5924,5929,5934],{"type":15,"attrs":5925,"content":5926},{"textAlign":53},[5927],{"text":5928,"type":356},"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":5930,"content":5931},{"textAlign":53},[5932],{"text":5933,"type":356},"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":5935,"content":5936},{"textAlign":53},[5937],{"text":5938,"type":356},"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":5940},[5941,5947,5952,5958],{"type":15,"attrs":5942,"content":5943},{"textAlign":53},[5944],{"text":3252,"type":356,"marks":5945},[5946],{"type":392},{"type":15,"attrs":5948,"content":5949},{"textAlign":53},[5950],{"text":5951,"type":356},"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":5953,"content":5954},{"textAlign":53},[5955],{"text":4233,"type":356,"marks":5956},[5957],{"type":392},{"type":461,"content":5959},[5960,5967],{"type":464,"content":5961},[5962],{"type":15,"attrs":5963,"content":5964},{"textAlign":53},[5965],{"text":5966,"type":356},"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":464,"content":5968},[5969],{"type":15,"attrs":5970,"content":5971},{"textAlign":53},[5972],{"text":5973,"type":356,"marks":5974},"Creating a Safe Space: Addressing Confidentiality for Peer-to-Peer Support Programs for Health Professionals ",[5975],{"type":361,"attrs":5976},{"href":5977,"uuid":5978,"anchor":53,"custom":5979,"target":2317,"linktype":2255,"story":5980},"/resources/creating-a-safe-space-psychological-safety-of-healthcare-workers-peer-to-peer-support","6c4d31a0-a38c-43aa-b256-52adeaf6b2dc",{},{"name":5981,"id":5982,"uuid":5978,"slug":5983,"url":5984,"full_slug":5984,"_stopResolving":291},"Creating a Safe Space: Psychological Safety of Healthcare Workers (Peer to Peer Support)",113880502320667,"creating-a-safe-space-psychological-safety-of-healthcare-workers-peer-to-peer-support","resources/creating-a-safe-space-psychological-safety-of-healthcare-workers-peer-to-peer-support","Incident Management",{"type":12,"content":5987},[5988],{"type":15,"attrs":5989,"content":5990},{"textAlign":53},[5991],{"text":5992,"type":356},"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":5994,"items":5995,"title":5998,"component":798,"description":6313},"51307eb8-01b5-4003-8fa1-af31f16a758b",[5996],{"_uid":5997,"title":5998,"ctaLeft":5999,"ctaRight":6000,"component":505,"columnLeft":6001,"columnRight":6008},"5026ec1e-868a-42c6-bda6-cbb1dce58c88","System Factors",[],[],{"type":12,"content":6002},[6003],{"type":15,"attrs":6004,"content":6005},{"textAlign":53},[6006],{"text":6007,"type":356},"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":6009},[6010,6017,6249,6256],{"type":15,"attrs":6011,"content":6012},{"textAlign":53},[6013],{"text":6014,"type":356,"marks":6015},"Assess key system factors and understand how they relate to patient safety and incident management ",[6016],{"type":392},{"type":461,"content":6018},[6019,6098,6198],{"type":464,"content":6020},[6021,6026],{"type":15,"attrs":6022,"content":6023},{"textAlign":53},[6024],{"text":6025,"type":356},"Outside the boundaries of the organization: ",{"type":461,"content":6027},[6028,6035,6042,6049,6056,6063,6070,6077,6084,6091],{"type":464,"content":6029},[6030],{"type":15,"attrs":6031,"content":6032},{"textAlign":53},[6033],{"text":6034,"type":356},"public and community awareness of and engagement in patient safety ",{"type":464,"content":6036},[6037],{"type":15,"attrs":6038,"content":6039},{"textAlign":53},[6040],{"text":6041,"type":356},"healthcare legislation, standards, policies, regulations and accreditation requirements",{"type":464,"content":6043},[6044],{"type":15,"attrs":6045,"content":6046},{"textAlign":53},[6047],{"text":6048,"type":356},"healthcare infrastructure and resourcing (fiscal, human, facilities and sites, equipment) ",{"type":464,"content":6050},[6051],{"type":15,"attrs":6052,"content":6053},{"textAlign":53},[6054],{"text":6055,"type":356},"education of healthcare providers, labour agreements and workforce trends ",{"type":464,"content":6057},[6058],{"type":15,"attrs":6059,"content":6060},{"textAlign":53},[6061],{"text":6062,"type":356},"social determinants of health, societal trends (income, social status, education, employment, housing, culture, etc.) ",{"type":464,"content":6064},[6065],{"type":15,"attrs":6066,"content":6067},{"textAlign":53},[6068],{"text":6069,"type":356},"health trends, issues and challenges (e.g. disease outbreaks, population health) ",{"type":464,"content":6071},[6072],{"type":15,"attrs":6073,"content":6074},{"textAlign":53},[6075],{"text":6076,"type":356},"political environment (local, provincial/ territorial, national), economic, technological and trends influencing the healthcare industry (e.g. through a PESTLE analysis) ",{"type":464,"content":6078},[6079],{"type":15,"attrs":6080,"content":6081},{"textAlign":53},[6082],{"text":6083,"type":356},"infrastructure, trends, and funding for patient safety research, evaluation and improvement ",{"type":464,"content":6085},[6086],{"type":15,"attrs":6087,"content":6088},{"textAlign":53},[6089],{"text":6090,"type":356},"trends in other sectors that might intersect with healthcare (e.g. technology, social media) ",{"type":464,"content":6092},[6093],{"type":15,"attrs":6094,"content":6095},{"textAlign":53},[6096],{"text":6097,"type":356},"geographic location and regional characteristics (remote vs rural vs urban). ",{"type":464,"content":6099},[6100,6105],{"type":15,"attrs":6101,"content":6102},{"textAlign":53},[6103],{"text":6104,"type":356},"At the organizational and program/service levels: ",{"type":461,"content":6106},[6107,6114,6121,6128,6135,6142,6149,6156,6163,6170,6177,6184,6191],{"type":464,"content":6108},[6109],{"type":15,"attrs":6110,"content":6111},{"textAlign":53},[6112],{"text":6113,"type":356},"strategic plans, organizational priorities, values and principles ",{"type":464,"content":6115},[6116],{"type":15,"attrs":6117,"content":6118},{"textAlign":53},[6119],{"text":6120,"type":356},"leadership team and board level commitment and governance, including their knowledge of patient safety science and best practices ",{"type":464,"content":6122},[6123],{"type":15,"attrs":6124,"content":6125},{"textAlign":53},[6126],{"text":6127,"type":356},"leadership visibility and engagement in patient safety ",{"type":464,"content":6129},[6130],{"type":15,"attrs":6131,"content":6132},{"textAlign":53},[6133],{"text":6134,"type":356},"how leadership prioritize patient safety – whether it is at the top of meeting agendas and allocated at least 25% of the meeting time ",{"type":464,"content":6136},[6137],{"type":15,"attrs":6138,"content":6139},{"textAlign":53},[6140],{"text":6141,"type":356},"organizational leadership’s accountability for patient safety performance, alignment with incentives (formal and informal) ",{"type":464,"content":6143},[6144],{"type":15,"attrs":6145,"content":6146},{"textAlign":53},[6147],{"text":6148,"type":356},"patient/family perspective included at board and leadership meetings, in decision-making and in the design of care processes and patient safety initiatives ",{"type":464,"content":6150},[6151],{"type":15,"attrs":6152,"content":6153},{"textAlign":53},[6154],{"text":6155,"type":356},"leadership team stability, experience, and style ",{"type":464,"content":6157},[6158],{"type":15,"attrs":6159,"content":6160},{"textAlign":53},[6161],{"text":6162,"type":356},"organizational patient safety culture ",{"type":464,"content":6164},[6165],{"type":15,"attrs":6166,"content":6167},{"textAlign":53},[6168],{"text":6169,"type":356},"organizational experience, current performance/progress with patient safety  ",{"type":464,"content":6171},[6172],{"type":15,"attrs":6173,"content":6174},{"textAlign":53},[6175],{"text":6176,"type":356},"the organization’s funding and financial status, including infrastructure and technology investment needs ",{"type":464,"content":6178},[6179],{"type":15,"attrs":6180,"content":6181},{"textAlign":53},[6182],{"text":6183,"type":356},"proactive design or redesign of policies and practices related to safety ",{"type":464,"content":6185},[6186],{"type":15,"attrs":6187,"content":6188},{"textAlign":53},[6189],{"text":6190,"type":356},"workforce expertise and skill related to patient safety   ",{"type":464,"content":6192},[6193],{"type":15,"attrs":6194,"content":6195},{"textAlign":53},[6196],{"text":6197,"type":356},"alignment between patient safety, quality improvement and risk management. ",{"type":464,"content":6199},[6200,6205],{"type":15,"attrs":6201,"content":6202},{"textAlign":53},[6203],{"text":6204,"type":356},"At the point of care: ",{"type":461,"content":6206},[6207,6214,6221,6228,6235,6242],{"type":464,"content":6208},[6209],{"type":15,"attrs":6210,"content":6211},{"textAlign":53},[6212],{"text":6213,"type":356},"patient/family partnership in care and safety ",{"type":464,"content":6215},[6216],{"type":15,"attrs":6217,"content":6218},{"textAlign":53},[6219],{"text":6220,"type":356},"team communication, feedback, culture, composition, hierarchy ",{"type":464,"content":6222},[6223],{"type":15,"attrs":6224,"content":6225},{"textAlign":53},[6226],{"text":6227,"type":356},"staff and patients/families being comfortable and able to report incidents, concerns, successes ",{"type":464,"content":6229},[6230],{"type":15,"attrs":6231,"content":6232},{"textAlign":53},[6233],{"text":6234,"type":356},"staff competencies, skill, experience, professional requirements regarding patient safety and incident management ",{"type":464,"content":6236},[6237],{"type":15,"attrs":6238,"content":6239},{"textAlign":53},[6240],{"text":6241,"type":356},"access to resources to manage safety and incidents ",{"type":464,"content":6243},[6244],{"type":15,"attrs":6245,"content":6246},{"textAlign":53},[6247],{"text":6248,"type":356},"staff turnover, staffing levels, protected time for projects. ",{"type":15,"attrs":6250,"content":6251},{"textAlign":53},[6252],{"text":6253,"type":356,"marks":6254},"Identify actions to strengthen patient safety and incident management ",[6255],{"type":392},{"type":461,"content":6257},[6258,6269,6280,6291,6302],{"type":464,"content":6259},[6260],{"type":15,"attrs":6261,"content":6262},{"textAlign":53},[6263,6267],{"text":6264,"type":356,"marks":6265},"Respond ",[6266],{"type":392},{"text":6268,"type":356},"– 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":464,"content":6270},[6271],{"type":15,"attrs":6272,"content":6273},{"textAlign":53},[6274,6278],{"text":6275,"type":356,"marks":6276},"Align ",[6277],{"type":392},{"text":6279,"type":356},"– 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":464,"content":6281},[6282],{"type":15,"attrs":6283,"content":6284},{"textAlign":53},[6285,6289],{"text":6286,"type":356,"marks":6287},"Leverage ",[6288],{"type":392},{"text":6290,"type":356},"– 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":464,"content":6292},[6293],{"type":15,"attrs":6294,"content":6295},{"textAlign":53},[6296,6300],{"text":6297,"type":356,"marks":6298},"Partner/collaborate ",[6299],{"type":392},{"text":6301,"type":356},"– Work with others to make changes that can positively impact healthcare in your setting; support or endorse the work and successes of others. ",{"type":464,"content":6303},[6304],{"type":15,"attrs":6305,"content":6306},{"textAlign":53},[6307,6311],{"text":6308,"type":356,"marks":6309},"Advocate ",[6310],{"type":392},{"text":6312,"type":356},"– 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":6314},[6315],{"type":15,"attrs":6316,"content":6317},{"textAlign":53},[6318],{"text":6319,"type":356},"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":6321,"title":6322,"columns":6323,"component":6455,"description":6456},"824a0811-8046-47ee-8e53-bb84f8212913","Team",[6324,6410],{"_uid":6325,"image":6326,"title":6328,"content":6329,"component":6409},"a18a274e-e661-41ff-9992-d4fc203c1849",{"id":53,"alt":53,"name":16,"focus":53,"title":53,"source":53,"filename":16,"copyright":53,"fieldtype":283,"meta_data":6327},{},"Toolkit Faculty",[6330],{"_uid":6331,"content":6332,"component":400},"93db4059-43d4-4feb-8f66-f8737f9c3138",{"type":12,"content":6333},[6334,6339,6344,6349,6354,6359,6364,6369,6374,6379,6384,6389,6394,6399,6404],{"type":15,"attrs":6335,"content":6336},{"textAlign":53},[6337],{"text":6338,"type":356},"Below are the faculty members and positions they held when the Patient Safety Incident Management Toolkit was first developed.       ",{"type":15,"attrs":6340,"content":6341},{"textAlign":53},[6342],{"text":6343,"type":356},"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":6345,"content":6346},{"textAlign":53},[6347],{"text":6348,"type":356},"Dr. Amy Nakajima, MD, FRCSC, Consultant, Bruyère Continuing Care ",{"type":15,"attrs":6350,"content":6351},{"textAlign":53},[6352],{"text":6353,"type":356},"Dr. John Maxted, Assistant Professor, Department of Family and Community Medicine, University of Toronto ",{"type":15,"attrs":6355,"content":6356},{"textAlign":53},[6357],{"text":6358,"type":356},"Julie Greenall, Director of Projects and Education, Institute for Safe Medication Practices Canada ",{"type":15,"attrs":6360,"content":6361},{"textAlign":53},[6362],{"text":6363,"type":356},"Margot Harvie RN, BN, Med, Quality & Safety Education Lead, Health Quality Council of Alberta ",{"type":15,"attrs":6365,"content":6366},{"textAlign":53},[6367],{"text":6368,"type":356},"Annemarie Taylor, Provincial Director, British Columbia Patient Safety & Learning System ",{"type":15,"attrs":6370,"content":6371},{"textAlign":53},[6372],{"text":6373,"type":356},"Brent Windwick, Partner, Field Law (Health Industry Services & Privacy) ",{"type":15,"attrs":6375,"content":6376},{"textAlign":53},[6377],{"text":6378,"type":356},"Carolyn Hoffman, Senior Vice President Quality & Healthcare Improvement, Alberta Health Services ",{"type":15,"attrs":6380,"content":6381},{"textAlign":53},[6382],{"text":6383,"type":356},"Deborah Prowse, Member, Patients for Patient Safety Canada ",{"type":15,"attrs":6385,"content":6386},{"textAlign":53},[6387],{"text":6388,"type":356},"Heather Howley, Health Services Research Specialist, Accreditation Canada ",{"type":15,"attrs":6390,"content":6391},{"textAlign":53},[6392],{"text":6393,"type":356},"Heon-Jae Jeong, Postdoctoral Fellow, Department of Health Policy and Management, Johns Hopkins ",{"type":15,"attrs":6395,"content":6396},{"textAlign":53},[6397],{"text":6398,"type":356},"Jennifer White, Provincial Quality Care Coordinator, Saskatchewan Ministry of Health ",{"type":15,"attrs":6400,"content":6401},{"textAlign":53},[6402],{"text":6403,"type":356},"Sharon Nettleton, Past Co-Chair, Patients for Patient Safety Canada ",{"type":15,"attrs":6405,"content":6406},{"textAlign":53},[6407],{"text":6408,"type":356},"Sherry Espin, Associate Professor, Ryerson University ","wysiwyg-column",{"_uid":6411,"image":6412,"title":6414,"content":6415,"component":6409},"40239f5d-70bc-4192-9983-5a14bb6c7b83",{"id":53,"alt":53,"name":16,"focus":53,"title":53,"source":53,"filename":16,"copyright":53,"fieldtype":283,"meta_data":6413},{},"Toolkit Project Team",[6416],{"_uid":6417,"content":6418,"component":400},"c381e535-7578-4104-befa-7eaa4a4ec7f9",{"type":12,"content":6419},[6420,6425,6430,6435,6440,6445,6450],{"type":15,"attrs":6421,"content":6422},{"textAlign":53},[6423],{"text":6424,"type":356},"Below are the staff members and the positions they held when the Patient Safety Incident Management Toolkit was first developed. ",{"type":15,"attrs":6426,"content":6427},{"textAlign":53},[6428],{"text":6429,"type":356},"Abigail Hain, Senior Director, Capacity Building and Knowledge Translation, Canadian Patient Safety Institute ",{"type":15,"attrs":6431,"content":6432},{"textAlign":53},[6433],{"text":6434,"type":356},"Ioana Popescu, Patient Safety Improvement Lead, Canadian Patient Safety Institute ",{"type":15,"attrs":6436,"content":6437},{"textAlign":53},[6438],{"text":6439,"type":356},"Jennifer Rodgers, Patient Safety Improvement Lead, Canadian Patient Safety Institute ",{"type":15,"attrs":6441,"content":6442},{"textAlign":53},[6443],{"text":6444,"type":356},"Monique Thibodeau, Project Coordinator, Canadian Patient Safety Institute ",{"type":15,"attrs":6446,"content":6447},{"textAlign":53},[6448],{"text":6449,"type":356},"Marie Pinard, Manager, Quality Management, The Hospital For Sick Children ",{"type":15,"attrs":6451,"content":6452},{"textAlign":53},[6453],{"text":6454,"type":356},"Jocelyne Pepin, Assistant Chief, Pharmacy Department, Jewish General Hospital ","wysiwyg-double-column",{"type":12,"content":6457},[6458],{"type":15},{"id":16,"_uid":6460,"content":6461,"component":401},"01cc2d9b-3c22-4f9c-a3d3-1a6a6e43517f",[6462],{"_uid":6463,"content":6464,"component":400},"a5dc5e27-376c-4e0d-bfef-a94ec719246d",{"type":12,"content":6465},[6466,6471,6476],{"type":516,"attrs":6467,"content":6468},{"level":2463,"textAlign":53},[6469],{"text":6470,"type":356},"Toolkit Development and Maintenance ",{"type":15,"attrs":6472,"content":6473},{"textAlign":53},[6474],{"text":6475,"type":356},"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":461,"content":6477},[6478,6485,6492,6499],{"type":464,"content":6479},[6480],{"type":15,"attrs":6481,"content":6482},{"textAlign":53},[6483],{"text":6484,"type":356},"assigning an inhouse team with support from a writer with experience in the field ",{"type":464,"content":6486},[6487],{"type":15,"attrs":6488,"content":6489},{"textAlign":53},[6490],{"text":6491,"type":356},"seeking advice from an expert faculty that included patient and family representatives ",{"type":464,"content":6493},[6494],{"type":15,"attrs":6495,"content":6496},{"textAlign":53},[6497],{"text":6498,"type":356},"basing the content on the Canadian Incident Analysis Framework ",{"type":464,"content":6500},[6501],{"type":15,"attrs":6502,"content":6503},{"textAlign":53},[6504],{"text":6505,"type":356},"engaging key stakeholders via focus groups and collecting evidence from peer-reviewed journals and publicly available literature ",{"id":16,"_uid":6507,"items":6508,"title":6907,"component":798,"description":6908},"9111b6c7-4bde-44d2-8d63-4bb5c0ce1d9b",[6509],{"_uid":6510,"title":6511,"ctaLeft":6512,"ctaRight":6513,"component":505,"columnLeft":6514,"columnRight":6572},"caf5344f-9c37-43ea-a758-0a79831e152a","Expand to see the full list of terms",[],[],{"type":12,"content":6515},[6516,6525,6532,6537,6542,6547,6552,6557,6562,6567],{"type":15,"attrs":6517,"content":6518},{"textAlign":53},[6519,6523],{"text":6520,"type":356,"marks":6521},"Note to Quebec Readers",[6522],{"type":392},{"text":6524,"type":356},": 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":6526,"content":6527},{"textAlign":53},[6528],{"text":6529,"type":356,"marks":6530},"Terms used in the toolkit: Terms used in Quebec  ",[6531],{"type":392},{"type":15,"attrs":6533,"content":6534},{"textAlign":53},[6535],{"text":6536,"type":356},"Patient: User ",{"type":15,"attrs":6538,"content":6539},{"textAlign":53},[6540],{"text":6541,"type":356},"Incident disclosure: Accident disclosure ",{"type":15,"attrs":6543,"content":6544},{"textAlign":53},[6545],{"text":6546,"type":356},"Harm: Consequence ",{"type":15,"attrs":6548,"content":6549},{"textAlign":53},[6550],{"text":6551,"type":356},"Patient safety incident: Patient safety incident resulting from the provision of healthcare or social services ",{"type":15,"attrs":6553,"content":6554},{"textAlign":53},[6555],{"text":6556,"type":356},"Harmful incident: Accident with consequences for the user ",{"type":15,"attrs":6558,"content":6559},{"textAlign":53},[6560],{"text":6561,"type":356},"No harm incident: Accident without consequences but the user was affected ",{"type":15,"attrs":6563,"content":6564},{"textAlign":53},[6565],{"text":6566,"type":356},"Near miss: Incident or near miss ",{"type":15,"attrs":6568,"content":6569},{"textAlign":53},[6570],{"text":6571,"type":356},"Harmful incident, no harm incident, and near miss: Events  ",{"type":12,"content":6573},[6574,6579,6588,6597,6606,6615,6624,6633,6641,6650,6659,6668,6677,6686,6695,6704,6713,6721,6730,6765,6773,6782,6791,6800,6809,6818,6827,6836,6845,6854,6863,6872,6881,6890,6898],{"type":15,"attrs":6575,"content":6576},{"textAlign":53},[6577],{"text":6578,"type":356},"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":6580,"content":6581},{"textAlign":53},[6582,6586],{"text":6583,"type":356,"marks":6584},"Actions ",[6585],{"type":392},{"text":6587,"type":356},"(taken to reduce risk of harm): Actions taken to reduce, manage, or control any future harm, or probability of harm. ",{"type":15,"attrs":6589,"content":6590},{"textAlign":53},[6591,6595],{"text":6592,"type":356,"marks":6593},"Alerts or advisories",[6594],{"type":392},{"text":6596,"type":356},": 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":6598,"content":6599},{"textAlign":53},[6600,6604],{"text":6601,"type":356,"marks":6602},"Apology",[6603],{"type":392},{"text":6605,"type":356},": 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":6607,"content":6608},{"textAlign":53},[6609,6613],{"text":6610,"type":356,"marks":6611},"Authority gradient",[6612],{"type":392},{"text":6614,"type":356},":  Balance of decision-making power or the steepness of command and hierarchy in a given situation. ",{"type":15,"attrs":6616,"content":6617},{"textAlign":53},[6618,6622],{"text":6619,"type":356,"marks":6620},"Contributing factors",[6621],{"type":392},{"text":6623,"type":356},": 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. 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",[8815],{"type":525,"attrs":8816},{"color":16},{"text":8818,"type":356,"marks":8819},"Assessing hospital's clinical risk management: Development of a monitoring instrument.",[8820,8823],{"type":361,"attrs":8821},{"href":8822,"uuid":53,"anchor":53,"custom":53,"target":365,"linktype":366},"http://www.biomedcentral.com/1472-6963/10/337",{"type":525,"attrs":8824},{"color":16},{"text":8826,"type":356,"marks":8827}," BMC Health Services Research. 10, 337. doi 10.1186/1472-6963-10-337. (Journal article, open access)",[8828],{"type":525,"attrs":8829},{"color":16},{"text":529,"type":356},{"type":15,"attrs":8832,"content":8833},{"textAlign":519},[8834,8839,8847,8852],{"text":8835,"type":356,"marks":8836},"Cochrane D, Taylor A, Miller G, Hait V, Matsui I, Bharadwaj M, Devine P. ",[8837],{"type":525,"attrs":8838},{"color":16},{"text":8840,"type":356,"marks":8841},"Establishing a Provincial Patient Safety and Learning System: Pilot project results and lessons learned",[8842,8845],{"type":361,"attrs":8843},{"href":8844,"uuid":53,"anchor":53,"custom":53,"target":365,"linktype":366},"http://www.longwoods.com/content/20717",{"type":525,"attrs":8846},{"color":16},{"text":8848,"type":356,"marks":8849},". Longwoods: 2009. (Journal article, open access)",[8850],{"type":525,"attrs":8851},{"color":16},{"text":529,"type":356},{"type":15,"attrs":8854,"content":8855},{"textAlign":519},[8856,8861,8869,8874],{"text":8857,"type":356,"marks":8858},"Calhoun AW, Boone MC, Porter MB, Miller KH. 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",[8881],{"type":525,"attrs":8882},{"color":16},{"text":8884,"type":356,"marks":8885},"Human Factors and Ergonomics",[8886,8888],{"type":361,"attrs":8887},{"href":8866,"uuid":53,"anchor":53,"custom":53,"target":365,"linktype":366},{"type":525,"attrs":8889},{"color":16},{"text":8891,"type":356,"marks":8892},". In: Making Health Care Safer II: An Updated Critical Analysis of the Evidence for Patient Safety Practices. Rockville (MD): Agency for Healthcare Research and Quality; 2013 Mar. (Evidence Reports/Technology Assessments, No. 211.) Chapter 31. (Book chapter, open access)",[8893],{"type":525,"attrs":8894},{"color":16},{"text":529,"type":356},{"type":15,"attrs":8897,"content":8898},{"textAlign":519},[8899,8904,8911,8916],{"text":8900,"type":356,"marks":8901},"Card A. ",[8902],{"type":525,"attrs":8903},{"color":16},{"text":8905,"type":356,"marks":8906},"The Active Risk Control (ARC) Toolkit",[8907,8909],{"type":361,"attrs":8908},{"href":2806,"uuid":53,"anchor":53,"custom":53,"target":365,"linktype":366},{"type":525,"attrs":8910},{"color":16},{"text":8912,"type":356,"marks":8913},". 2013. (Toolkit)",[8914],{"type":525,"attrs":8915},{"color":16},{"text":529,"type":356},{"type":15,"attrs":8918,"content":8919},{"textAlign":519},[8920,8925,8933,8938],{"text":8921,"type":356,"marks":8922},"Chassin MR, Loeb JM. ",[8923],{"type":525,"attrs":8924},{"color":16},{"text":8926,"type":356,"marks":8927},"High-reliability health care: getting there from here",[8928,8931],{"type":361,"attrs":8929},{"href":8930,"uuid":53,"anchor":53,"custom":53,"target":365,"linktype":366},"http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3790522/",{"type":525,"attrs":8932},{"color":16},{"text":8934,"type":356,"marks":8935},". The Milbank Quarterly. 2013; 91(3): 459-490. doi:10.1111/1468-0009.12023. (Journal article, open access)",[8936],{"type":525,"attrs":8937},{"color":16},{"text":529,"type":356},{"type":15,"attrs":8940,"content":8941},{"textAlign":519},[8942,8947,8955,8960],{"text":8943,"type":356,"marks":8944},"Conway J, Federico F, Steward K, Campbell MJ. ",[8945],{"type":525,"attrs":8946},{"color":16},{"text":8948,"type":356,"marks":8949},"Respectful Management of Serious Clinical Adverse Events",[8950,8953],{"type":361,"attrs":8951},{"href":8952,"uuid":53,"anchor":53,"custom":53,"target":365,"linktype":366},"http://www.ihi.org/resources/Pages/IHIWhitePapers/RespectfulManagementSeriousClinicalAEsWhitePaper.aspx",{"type":525,"attrs":8954},{"color":16},{"text":8956,"type":356,"marks":8957}," (Second Edition). IHI Innovation Series white paper. Cambridge, MA: Institute for Healthcare Improvement; 2011. 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(Toolkit, 94 pages)",[8992],{"type":525,"attrs":8993},{"color":16},{"text":529,"type":356},{"type":15,"attrs":8996,"content":8997},{"textAlign":519},[8998,9003,9011,9016],{"text":8999,"type":356,"marks":9000},"Evans, Mike Doc ",[9001],{"type":525,"attrs":9002},{"color":16},{"text":9004,"type":356,"marks":9005},"Quality Improvement in Healthcare",[9006,9009],{"type":361,"attrs":9007},{"href":9008,"uuid":53,"anchor":53,"custom":53,"target":365,"linktype":366},"https://www.youtube.com/watch?v=jq52ZjMzqyI",{"type":525,"attrs":9010},{"color":16},{"text":9012,"type":356,"marks":9013},", Youtube, 2014 (Video)",[9014],{"type":525,"attrs":9015},{"color":16},{"text":529,"type":356},{"type":15,"attrs":9018,"content":9019},{"textAlign":519},[9020,9025,9033,9038],{"text":9021,"type":356,"marks":9022},"Frankel A, (editor). ",[9023],{"type":525,"attrs":9024},{"color":16},{"text":9026,"type":356,"marks":9027},"Strategies for Building a Hospitalwide Culture of Safety",[9028,9031],{"type":361,"attrs":9029},{"href":9030,"uuid":53,"anchor":53,"custom":53,"target":365,"linktype":366},"http://www.ncbi.nlm.nih.gov/nlmcatalog/101314292",{"type":525,"attrs":9032},{"color":16},{"text":9034,"type":356,"marks":9035},". Oakbrook Terrace, Il: JCAHO; 2006. (Book, $)",[9036],{"type":525,"attrs":9037},{"color":16},{"text":529,"type":356},{"type":15,"attrs":9040,"content":9041},{"textAlign":519},[9042,9047,9055,9056,9061],{"text":9043,"type":356,"marks":9044},"Goldman, Brian. ",[9045],{"type":525,"attrs":9046},{"color":16},{"text":9048,"type":356,"marks":9049},"Doctors Make Mistakes. 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",[9068],{"type":525,"attrs":9069},{"color":16},{"text":9071,"type":356,"marks":9072},"Open Disclosure: Communicating when things go wrong",[9073,9076],{"type":361,"attrs":9074},{"href":9075,"uuid":53,"anchor":53,"custom":53,"target":365,"linktype":366},"https://www.hse.ie/eng/about/who/nqpsd/qps-incident-management/open-disclosure/hse-open-disclosure-full-policy-2019.pdf%22%20/h%20%20HYPERLINK%20%22http://www.hse.ie/eng/about/Who/qualityandpatientsafety/nau/Open_Disclosure/opendiscFiles/opdiscpatinfoleaflet.pdf",{"type":525,"attrs":9077},{"color":16},{"text":9079,"type":356,"marks":9080},". 2013. (Leaflet)2013. (Leaflet)",[9081],{"type":525,"attrs":9082},{"color":16},{"text":529,"type":356},{"type":15,"attrs":9085,"content":9086},{"textAlign":519},[9087,9092],{"text":9088,"type":356,"marks":9089},"Health Service Executive (HSE). Open Disclosure: National policy.2013. (Policy, 25 pages)",[9090],{"type":525,"attrs":9091},{"color":16},{"text":529,"type":356},{"type":15,"attrs":9094,"content":9095},{"textAlign":519},[9096,9101,9109,9114],{"text":9097,"type":356,"marks":9098},"High Reliability Organizing (HRO), ",[9099],{"type":525,"attrs":9100},{"color":16},{"text":9102,"type":356,"marks":9103},"Models of HRO",[9104,9107],{"type":361,"attrs":9105},{"href":9106,"uuid":53,"anchor":53,"custom":53,"target":365,"linktype":366},"http://high-reliability.org/Weick-Sutcliffe",{"type":525,"attrs":9108},{"color":16},{"text":9110,"type":356,"marks":9111}," , Weick and Sutcliffe/Social Psychology. 2013. (Web article)",[9112],{"type":525,"attrs":9113},{"color":16},{"text":529,"type":356},{"type":15,"attrs":9116,"content":9117},{"textAlign":519},[9118,9123,9131,9136],{"text":9119,"type":356,"marks":9120},"Hughes RG (editor). ",[9121],{"type":525,"attrs":9122},{"color":16},{"text":9124,"type":356,"marks":9125},"Patient Safety and Quality: An evidence-based handbook for nurses",[9126,9129],{"type":361,"attrs":9127},{"href":9128,"uuid":53,"anchor":53,"custom":53,"target":365,"linktype":366},"http://www.ncbi.nlm.nih.gov/books/NBK2651/",{"type":525,"attrs":9130},{"color":16},{"text":9132,"type":356,"marks":9133},". Rockville, MD: Agency for Healthcare Research and Quality; 2008. (Book, open access)",[9134],{"type":525,"attrs":9135},{"color":16},{"text":529,"type":356},{"type":15,"attrs":9138,"content":9139},{"textAlign":519},[9140,9145,9153,9158],{"text":9141,"type":356,"marks":9142},"Gamble M. ",[9143],{"type":525,"attrs":9144},{"color":16},{"text":9146,"type":356,"marks":9147},"5 Traits of High Reliability Organizations: How to hardwire each in your organization",[9148,9151],{"type":361,"attrs":9149},{"href":9150,"uuid":53,"anchor":53,"custom":53,"target":365,"linktype":366},"http://www.beckershospitalreview.com/hospital-management-administration/5-traits-of-high-reliability-organizations-how-to-hardwire-each-in-your-organization.html",{"type":525,"attrs":9152},{"color":16},{"text":9154,"type":356,"marks":9155},". Becker’s Hospital Review: 2013. (Periodical article)",[9156],{"type":525,"attrs":9157},{"color":16},{"text":529,"type":356},{"type":15,"attrs":9160,"content":9161},{"textAlign":519},[9162,9167,9175,9180],{"text":9163,"type":356,"marks":9164},"Iedema R, Allen S, Piper D, Baker A., Grbich C, et al. ",[9165],{"type":525,"attrs":9166},{"color":16},{"text":9168,"type":356,"marks":9169},"Patients’ and family members’ views on how clinicians enact and how they should enact incident disclosure: the “100 patient stories” qualitative study",[9170,9173],{"type":361,"attrs":9171},{"href":9172,"uuid":53,"anchor":53,"custom":53,"target":365,"linktype":366},"http://www.bmj.com/content/343/bmj.d4423",{"type":525,"attrs":9174},{"color":16},{"text":9176,"type":356,"marks":9177},". BMJ. 2011; 343: d4423. (Journal article, open access)",[9178],{"type":525,"attrs":9179},{"color":16},{"text":529,"type":356},{"type":15,"attrs":9182,"content":9183},{"textAlign":519},[9184,9189],{"text":9185,"type":356,"marks":9186},"Institute for Healthcare Improvement (IHI). 5 Million Lives Campaign. 2008. (Program, campaign)",[9187],{"type":525,"attrs":9188},{"color":16},{"text":529,"type":356},{"type":15,"attrs":9191,"content":9192},{"textAlign":519},[9193,9198],{"text":9194,"type":356,"marks":9195},"Institute for Healthcare Improvement (IHI). Failure Modes and Effects Analysis (FMEA) Tool. 2004. (Tool, guide, log-in required)",[9196],{"type":525,"attrs":9197},{"color":16},{"text":529,"type":356},{"type":15,"attrs":9200,"content":9201},{"textAlign":519},[9202,9207,9215,9220],{"text":9203,"type":356,"marks":9204},"Institute for Healthcare Improvement (IHI). ",[9205],{"type":525,"attrs":9206},{"color":16},{"text":9208,"type":356,"marks":9209},"How to Improve.",[9210,9213],{"type":361,"attrs":9211},{"href":9212,"uuid":53,"anchor":53,"custom":53,"target":365,"linktype":366},"http://www.ihi.org/resources/Pages/HowtoImprove/default.aspx",{"type":525,"attrs":9214},{"color":16},{"text":9216,"type":356,"marks":9217}," 2014. (Guide, tools, open access)",[9218],{"type":525,"attrs":9219},{"color":16},{"text":529,"type":356},{"type":15,"attrs":9222,"content":9223},{"textAlign":519},[9224,9229],{"text":9225,"type":356,"marks":9226},"Institute for Healthcare Improvement (IHI). Improvement Stories. Delivering Great Care: engaging patients and families as partners. 2014. (Web article, case study)",[9227],{"type":525,"attrs":9228},{"color":16},{"text":529,"type":356},{"type":15,"attrs":9231,"content":9232},{"textAlign":519},[9233,9238],{"text":9234,"type":356,"marks":9235},"Institute for Healthcare Improvement (IHI). Open School Case Study: Low on the totem pole (AHRQ). 2005. (Case study)",[9236],{"type":525,"attrs":9237},{"color":16},{"text":529,"type":356},{"type":15,"attrs":9240,"content":9241},{"textAlign":519},[9242,9246,9254,9259],{"text":9203,"type":356,"marks":9243},[9244],{"type":525,"attrs":9245},{"color":16},{"text":9247,"type":356,"marks":9248},"Patient Safety Leadership WalkRounds",[9249,9252],{"type":361,"attrs":9250},{"href":9251,"uuid":53,"anchor":53,"custom":53,"target":365,"linktype":366},"http://www.ihi.org/resources/Pages/Tools/PatientSafetyLeadershipWalkRounds.aspx",{"type":525,"attrs":9253},{"color":16},{"text":9255,"type":356,"marks":9256},". 2004. 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(Guide, log-in required)",[9308],{"type":525,"attrs":9309},{"color":16},{"text":529,"type":356},{"type":15,"attrs":9312,"content":9313},{"textAlign":519},[9314,9319],{"text":9315,"type":356,"marks":9316},"I-PASS Study Group. I-PASS. Better Handoffs. Safer Care. Boston Children’s Hospital: 2014. (Program, tools on request)",[9317],{"type":525,"attrs":9318},{"color":16},{"text":529,"type":356},{"type":15,"attrs":9321,"content":9322},{"textAlign":519},[9323,9328,9336,9341],{"text":9324,"type":356,"marks":9325},"John Hopkins Bloomberg School of Public Health. ",[9326],{"type":525,"attrs":9327},{"color":16},{"text":9329,"type":356,"marks":9330},"Removing Insult from Injury: Disclosing adverse events: Selected vignettes.",[9331,9334],{"type":361,"attrs":9332},{"href":9333,"uuid":53,"anchor":53,"custom":53,"target":365,"linktype":366},"http://www.jhsph.edu/departments/health-policy-and-management/research-and-centers/featured-research/wu-video/#order",{"type":525,"attrs":9335},{"color":16},{"text":9337,"type":356,"marks":9338}," (Videos)",[9339],{"type":525,"attrs":9340},{"color":16},{"text":529,"type":356},{"type":15,"attrs":9343,"content":9344},{"textAlign":519},[9345,9350,9358,9363],{"text":9346,"type":356,"marks":9347},"Joint Commission Center for Transforming Healthcare. ",[9348],{"type":525,"attrs":9349},{"color":16},{"text":9351,"type":356,"marks":9352},"Creating a Safety Culture",[9353,9356],{"type":361,"attrs":9354},{"href":9355,"uuid":53,"anchor":53,"custom":53,"target":365,"linktype":366},"https://www.youtube.com/watch?v=DBVuu4Qj-Fs",{"type":525,"attrs":9357},{"color":16},{"text":9359,"type":356,"marks":9360}," (video). 2012. (Video, 4 min)",[9361],{"type":525,"attrs":9362},{"color":16},{"text":529,"type":356},{"type":15,"attrs":9365,"content":9366},{"textAlign":519},[9367,9372,9380,9385],{"text":9368,"type":356,"marks":9369},"Kotter J. ",[9370],{"type":525,"attrs":9371},{"color":16},{"text":9373,"type":356,"marks":9374},"The 8-Step Process for Leading Change",[9375,9378],{"type":361,"attrs":9376},{"href":9377,"uuid":53,"anchor":53,"custom":53,"target":365,"linktype":366},"http://www.kotterinternational.com/the-8-step-process-for-leading-change/",{"type":525,"attrs":9379},{"color":16},{"text":9381,"type":356,"marks":9382},". (Guide, books $)",[9383],{"type":525,"attrs":9384},{"color":16},{"text":529,"type":356},{"type":15,"attrs":9387,"content":9388},{"textAlign":519},[9389,9394,9402],{"text":9390,"type":356,"marks":9391},"Markwell S. ",[9392],{"type":525,"attrs":9393},{"color":16},{"text":9395,"type":356,"marks":9396},"Understanding Organisations: Assessing the impact of political, economic,",[9397,9400],{"type":361,"attrs":9398},{"href":9399,"uuid":53,"anchor":53,"custom":53,"target":365,"linktype":366},"http://www.healthknowledge.org.uk/public-health-textbook/organisation-management/5b-understanding-ofs/assessing-impact-external-influences",{"type":525,"attrs":9401},{"color":16},{"text":529,"type":356},{"type":15,"attrs":9404,"content":9405},{"textAlign":519},[9406,9413,9418],{"text":9407,"type":356,"marks":9408},"socio-cultural, environmental and other external influences",[9409,9411],{"type":361,"attrs":9410},{"href":9399,"uuid":53,"anchor":53,"custom":53,"target":365,"linktype":366},{"type":525,"attrs":9412},{"color":16},{"text":9414,"type":356,"marks":9415},". Health Knowledge. 2009. (Guide)",[9416],{"type":525,"attrs":9417},{"color":16},{"text":529,"type":356},{"type":15,"attrs":9420,"content":9421},{"textAlign":519},[9422,9427,9435,9440],{"text":9423,"type":356,"marks":9424},"McDonald TB, Helmchen LA, Smith KM, Centomani N, Gunderson A, Mayer D, Chamberlin WH. ",[9425],{"type":525,"attrs":9426},{"color":16},{"text":9428,"type":356,"marks":9429},"Responding to patient safety incidents: the “seven pillars”",[9430,9433],{"type":361,"attrs":9431},{"href":9432,"uuid":53,"anchor":53,"custom":53,"target":53,"linktype":366},"http://qualitysafety.bmj.com/content/early/2010/02/26/qshc.2008.031633.full",{"type":525,"attrs":9434},{"color":16},{"text":9436,"type":356,"marks":9437},". Quality and Safety in Health Care.  2010; 19: e11. (Journal article, open access)",[9438],{"type":525,"attrs":9439},{"color":16},{"text":529,"type":356},{"type":15,"attrs":9442,"content":9443},{"textAlign":519},[9444,9449],{"text":9445,"type":356,"marks":9446},"Med Star Health. Annie's Story: How A System's Approach Can Change Safety Culture. 2014. (Video, 5 min)",[9447],{"type":525,"attrs":9448},{"color":16},{"text":529,"type":356},{"type":15,"attrs":9451,"content":9452},{"textAlign":519},[9453,9458,9465,9470],{"text":9454,"type":356,"marks":9455},"National Patient Safety Agency. ",[9456],{"type":525,"attrs":9457},{"color":16},{"text":9459,"type":356,"marks":9460},"Incident Decision Tree: Information and advice on use",[9461,9463],{"type":361,"attrs":9462},{"href":5052,"uuid":53,"anchor":53,"custom":53,"target":53,"linktype":366},{"type":525,"attrs":9464},{"color":16},{"text":9466,"type":356,"marks":9467},". 2003. (Tool, guide, 55 pages)",[9468],{"type":525,"attrs":9469},{"color":16},{"text":529,"type":356},{"type":15,"attrs":9472,"content":9473},{"textAlign":519},[9474,9479],{"text":9475,"type":356,"marks":9476},"NHS Scotland. Learning From Adverse Events Through Reporting and Review: A national framework for NHS Scotland.  Glasgow: NHS Scotland; 2019. (Guide, 37 pages)Guide, 37 pages)",[9477],{"type":525,"attrs":9478},{"color":16},{"text":529,"type":356},{"type":15,"attrs":9481,"content":9482},{"textAlign":519},[9483,9488,9496,9501],{"text":9484,"type":356,"marks":9485},"Nolan T, Resar R, Haraden C, Griffin FA. ",[9486],{"type":525,"attrs":9487},{"color":16},{"text":9489,"type":356,"marks":9490},"Improving the Reliability of Health Care",[9491,9494],{"type":361,"attrs":9492},{"href":9493,"uuid":53,"anchor":53,"custom":53,"target":53,"linktype":366},"http://www.ihi.org/resources/Pages/IHIWhitePapers/ImprovingtheReliabilityofHealthCare.aspx",{"type":525,"attrs":9495},{"color":16},{"text":9497,"type":356,"marks":9498},". IHI Innovation Series white paper. Boston, MA: Institute for Healthcare Improvement; 2004. (Article, 20 pages, log-in required)",[9499],{"type":525,"attrs":9500},{"color":16},{"text":529,"type":356},{"type":15,"attrs":9503,"content":9504},{"textAlign":519},[9505,9510,9518,9523],{"text":9506,"type":356,"marks":9507},"Patient Safety & Quality Healthcare (PSQH). ",[9508],{"type":525,"attrs":9509},{"color":16},{"text":9511,"type":356,"marks":9512},"Daily Check-In for Safety: From best practice to common practice",[9513,9516],{"type":361,"attrs":9514},{"href":9515,"uuid":53,"anchor":53,"custom":53,"target":53,"linktype":366},"http://psqh.com/daily-check-in-for-safety-from-best-practice-to-common-practice",{"type":525,"attrs":9517},{"color":16},{"text":9519,"type":356,"marks":9520},". 2012. (Journal article, open access)",[9521],{"type":525,"attrs":9522},{"color":16},{"text":529,"type":356},{"type":15,"attrs":9525,"content":9526},{"textAlign":519},[9527,9532,9540,9545],{"text":9528,"type":356,"marks":9529},"Prosci Learning Centre. ",[9530],{"type":525,"attrs":9531},{"color":16},{"text":9533,"type":356,"marks":9534},"ADKAR: Knowledge, Ability and Reinforcement making the change",[9535,9538],{"type":361,"attrs":9536},{"href":9537,"uuid":53,"anchor":53,"custom":53,"target":365,"linktype":366},"https://www.prosci.com/resources/articles/adkar-model-knowledge",{"type":525,"attrs":9539},{"color":16},{"text":9541,"type":356,"marks":9542},". 2006. (Tool). 2006. (Tool)",[9543],{"type":525,"attrs":9544},{"color":16},{"text":529,"type":356},{"type":15,"attrs":9547,"content":9548},{"textAlign":519},[9549,9554,9562,9567],{"text":9550,"type":356,"marks":9551},"Riesenberg LA, Leitzsch J, Little BW. ",[9552],{"type":525,"attrs":9553},{"color":16},{"text":9555,"type":356,"marks":9556},"Systematic review of handoff mnemonics literature",[9557,9560],{"type":361,"attrs":9558},{"href":9559,"uuid":53,"anchor":53,"custom":53,"target":53,"linktype":366},"https://pubmed.ncbi.nlm.nih.gov/19269930/%22%20/h%20%20HYPERLINK%20%22http://mef.med.ufl.edu/files/2009/11/American-Journal-of-Medical-Quality-2009-Riesenberg.pdf",{"type":525,"attrs":9561},{"color":16},{"text":9563,"type":356,"marks":9564},". American Journal of Medical Quality.2009; 24: 196-204. doi:10.1177/1062860609332512. (Journal article, open access)",[9565],{"type":525,"attrs":9566},{"color":16},{"text":529,"type":356},{"type":15,"attrs":9569,"content":9570},{"textAlign":519},[9571,9576,9584,9589],{"text":9572,"type":356,"marks":9573},"Runciman WB, Williamson JAH, Deakin A, Benveniste KA, Bannon K, Hibbert PD. ",[9574],{"type":525,"attrs":9575},{"color":16},{"text":9577,"type":356,"marks":9578},"An integrated framework for safety, quality and risk management: an information and incident management system based on a universal patient safety classification",[9579,9582],{"type":361,"attrs":9580},{"href":9581,"uuid":53,"anchor":53,"custom":53,"target":53,"linktype":366},"http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2464872/pdf/i82.pdf",{"type":525,"attrs":9583},{"color":16},{"text":9585,"type":356,"marks":9586},". Quality and Safety in Health Care. 2006;   15(Suppl I): 82-90. doi: 10.1136/qshc.2005.017467. (Journal article, open access)",[9587],{"type":525,"attrs":9588},{"color":16},{"text":529,"type":356},{"type":15,"attrs":9591,"content":9592},{"textAlign":519},[9593,9598],{"text":9594,"type":356,"marks":9595},"Seys D, Wu AW, Van Gerven E, Vleugels A., Euwema M, et al. Health care professionals as second victims after adverse events: a systematic review. Evaluation & the Health Professions. 2013 Jun; 36(2): 135-62. 10.1177/0163278712458918. (Journal article, abstract only)",[9596],{"type":525,"attrs":9597},{"color":16},{"text":529,"type":356},{"type":15,"attrs":9600,"content":9601},{"textAlign":519},[9602,9607,9614,9619],{"text":9603,"type":356,"marks":9604},"TEDx. ",[9605],{"type":525,"attrs":9606},{"color":16},{"text":9608,"type":356,"marks":9609},"Building a Psychologically Safe Workplace:",[9610,9612],{"type":361,"attrs":9611},{"href":3380,"uuid":53,"anchor":53,"custom":53,"target":53,"linktype":366},{"type":525,"attrs":9613},{"color":16},{"text":9615,"type":356,"marks":9616}," Amy Edmondson at TEDxHGSE (video). 2014. (Video, 11 min).",[9617],{"type":525,"attrs":9618},{"color":16},{"text":529,"type":356},{"type":15,"attrs":9621,"content":9622},{"textAlign":519},[9623,9628,9636,9641],{"text":9624,"type":356,"marks":9625},"Tezak B, Anderson C, Down A, Gibson H, Lynn B, McKinney S, et al. ",[9626],{"type":525,"attrs":9627},{"color":16},{"text":9629,"type":356,"marks":9630},"Looking ahead: the use of prospective analysis to improve the quality and safety of care",[9631,9634],{"type":361,"attrs":9632},{"href":9633,"uuid":53,"anchor":53,"custom":53,"target":53,"linktype":366},"http://www.longwoods.com/content/20972",{"type":525,"attrs":9635},{"color":16},{"text":9637,"type":356,"marks":9638},". Healthcare Quarterly. 2009; 12, 580-84. doi:10.12927/hcq.2009.20972. (Journal article, open access)",[9639],{"type":525,"attrs":9640},{"color":16},{"text":529,"type":356},{"type":15,"attrs":9643,"content":9644},{"textAlign":519},[9645,9650,9658,9663],{"text":9646,"type":356,"marks":9647},"University of Missouri Health System, ",[9648],{"type":525,"attrs":9649},{"color":16},{"text":9651,"type":356,"marks":9652},"Second Victim Trajectory",[9653,9656],{"type":361,"attrs":9654},{"href":9655,"uuid":53,"anchor":53,"custom":53,"target":365,"linktype":366},"https://www.muhealth.org/sites/default/files/6StagesRecovery.pdf",{"type":525,"attrs":9657},{"color":16},{"text":9659,"type":356,"marks":9660},", 2009 (Guide, 1 page), 2009 (Guide, 1 page)",[9661],{"type":525,"attrs":9662},{"color":16},{"text":529,"type":356},{"type":15,"attrs":9665,"content":9666},{"textAlign":519},[9667,9671,9679,9683],{"text":9646,"type":356,"marks":9668},[9669],{"type":525,"attrs":9670},{"color":16},{"text":9672,"type":356,"marks":9673},"The Scott Three-Tiered Interventional Model of Second Victim Support",[9674,9677],{"type":361,"attrs":9675},{"href":9676,"uuid":53,"anchor":53,"custom":53,"target":53,"linktype":366},"https://www.muhealth.org/sites/default/files/Scotts_Three_Tier_Support.pdf",{"type":525,"attrs":9678},{"color":16},{"text":8590,"type":356,"marks":9680},[9681],{"type":525,"attrs":9682},{"color":16},{"text":529,"type":356},{"type":15,"attrs":9685,"content":9686},{"textAlign":519},[9687,9692,9700,9705],{"text":9688,"type":356,"marks":9689},"Vakery P, Antonio K. ",[9690],{"type":525,"attrs":9691},{"color":16},{"text":9693,"type":356,"marks":9694},"Change management for effective quality improvement: a prime",[9695,9698],{"type":361,"attrs":9696},{"href":9697,"uuid":53,"anchor":53,"custom":53,"target":53,"linktype":366},"https://journals.sagepub.com/doi/abs/10.1177/1062860610361625",{"type":525,"attrs":9699},{"color":16},{"text":9701,"type":356,"marks":9702},". American Journal of Medical Quality. 2010; 25(4): 268–273. DOI: 10.1177/1062860610361625. (Journal article, open access)",[9703],{"type":525,"attrs":9704},{"color":16},{"text":529,"type":356},{"type":15,"attrs":9707,"content":9708},{"textAlign":519},[9709,9714,9722,9727],{"text":9710,"type":356,"marks":9711},"Wallace L. ",[9712],{"type":525,"attrs":9713},{"color":16},{"text":9715,"type":356,"marks":9716},"Feedback from reporting patient safety incidents – are NHS trusts learning lessons?",[9717,9720],{"type":361,"attrs":9718},{"href":9719,"uuid":53,"anchor":53,"custom":53,"target":365,"linktype":366},"https://journals.sagepub.com/doi/10.1258/jhsrp.2009.09s113",{"type":525,"attrs":9721},{"color":16},{"text":9723,"type":356,"marks":9724}," Journal of Health Services Research & Policy. 2010; January; 15(sup1):  75-78. (Journal article, abstract only)",[9725],{"type":525,"attrs":9726},{"color":16},{"text":529,"type":356},{"type":15,"attrs":9729,"content":9730},{"textAlign":519},[9731,9736],{"text":9732,"type":356,"marks":9733},"Washington State Hospital Association (WSHA). Patient Safety: Transforming culture toolkit. 2013. (Toolkit, 28 pages)",[9734],{"type":525,"attrs":9735},{"color":16},{"text":529,"type":356},{"type":15,"attrs":9738,"content":9739},{"textAlign":519},[9740,9745],{"text":9741,"type":356,"marks":9742},"Waters HR, Korn R, Colantuoni E, Berenholtz SM, Goeschel  A, Needham DM, et al. The business case for quality economic analysis of the Michigan Keystone Patient Safety Program in ICUs. American Journal of Medical Quality. 2011; 26(5): 333-339. (Journal article, abstract only)",[9743],{"type":525,"attrs":9744},{"color":16},{"text":529,"type":356},{"type":15,"attrs":9747,"content":9748},{"textAlign":519},[9749,9754,9762,9767],{"text":9750,"type":356,"marks":9751},"Wilson K, Burke CS, Priest HA, Salas E. ",[9752],{"type":525,"attrs":9753},{"color":16},{"text":9755,"type":356,"marks":9756},"Promoting health care safety through training high reliability teams",[9757,9760],{"type":361,"attrs":9758},{"href":9759,"uuid":53,"anchor":53,"custom":53,"target":365,"linktype":366},"http://qualitysafety.bmj.com/content/14/4/303.full.pdf+html?sid=fa6797d4-129b-4900-aa97-9bcba322ddca",{"type":525,"attrs":9761},{"color":16},{"text":9763,"type":356,"marks":9764},". Qual Saf Health Care. 2005; 14: 303-309. doi: 10.1136/qshc.2004.010090. (Journal article, open access)",[9765],{"type":525,"attrs":9766},{"color":16},{"text":529,"type":356},{"type":15,"attrs":9769,"content":9770},{"textAlign":519},[9771,9776,9784,9789],{"text":9772,"type":356,"marks":9773},"World Health Organization (WHO). ",[9774],{"type":525,"attrs":9775},{"color":16},{"text":9777,"type":356,"marks":9778},"Guide for Developing Patient Safety Policy and Strategic Plan",[9779,9782],{"type":361,"attrs":9780},{"href":9781,"uuid":53,"anchor":53,"custom":53,"target":365,"linktype":366},"https://apps.who.int/iris/handle/10665/206546",{"type":525,"attrs":9783},{"color":16},{"text":9785,"type":356,"marks":9786},". Geneva: WHO; 2014. (Guide, 47 pages)",[9787],{"type":525,"attrs":9788},{"color":16},{"text":529,"type":356},{"type":15,"attrs":9791,"content":9792},{"textAlign":519},[9793,9797,9805,9810],{"text":9772,"type":356,"marks":9794},[9795],{"type":525,"attrs":9796},{"color":16},{"text":9798,"type":356,"marks":9799},"Learning from Error - Video and Booklet",[9800,9803],{"type":361,"attrs":9801},{"href":9802,"uuid":53,"anchor":53,"custom":53,"target":365,"linktype":366},"https://www.who.int/health-topics/patient-safety",{"type":525,"attrs":9804},{"color":16},{"text":9806,"type":356,"marks":9807},". 2010. 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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":9921,"content":9922},{"textAlign":53},[9923,9925,9936],{"text":9924,"type":356},"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":9898,"type":356,"marks":9926},[9927],{"type":361,"attrs":9928},{"href":9929,"uuid":9930,"anchor":53,"custom":9931,"target":2317,"linktype":2255,"story":9932},"/resources/rethinking-patient-safety","3469e084-177f-495d-a5ec-7a7882bb627e",{},{"name":9898,"id":9933,"uuid":9930,"slug":9934,"url":9935,"full_slug":9935,"_stopResolving":291},113881326087952,"rethinking-patient-safety","resources/rethinking-patient-safety",{"text":9937,"type":356}," – 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":9939,"content":9940,"component":400},"d4d30c1b-8b31-4282-9fd6-3d43881f4f91",{"type":12,"content":9941},[9942,9947,9952,9957,9987,9992,9997,10002,10007,10014,10019,10026,10031,10038,10043],{"type":516,"attrs":9943,"content":9944},{"level":2463,"textAlign":53},[9945],{"text":9946,"type":356},"What’s inside",{"type":15,"attrs":9948,"content":9949},{"textAlign":53},[9950],{"text":9951,"type":356},"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":9953,"content":9954},{"textAlign":53},[9955],{"text":9956,"type":356},"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":461,"content":9958},[9959,9966,9973,9980],{"type":464,"content":9960},[9961],{"type":15,"attrs":9962,"content":9963},{"textAlign":53},[9964],{"text":9965,"type":356},"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":464,"content":9967},[9968],{"type":15,"attrs":9969,"content":9970},{"textAlign":53},[9971],{"text":9972,"type":356},"How have you approached safety in the past? How might you approach it differently now?",{"type":464,"content":9974},[9975],{"type":15,"attrs":9976,"content":9977},{"textAlign":53},[9978],{"text":9979,"type":356},"How can you encourage the sharing of power among patients, caregivers, communities, providers, staff and leaders to enhance patient safety?",{"type":464,"content":9981},[9982],{"type":15,"attrs":9983,"content":9984},{"textAlign":53},[9985],{"text":9986,"type":356},"How can action on patient safety help reduce health inequities? How can action on health inequities help improve patient safety?",{"type":516,"attrs":9988,"content":9989},{"level":2463,"textAlign":53},[9990],{"text":9991,"type":356},"Why it matters",{"type":15,"attrs":9993,"content":9994},{"textAlign":53},[9995],{"text":9996,"type":356},"To improve patient safety, we must start by thinking and talking about it differently.",{"type":15,"attrs":9998,"content":9999},{"textAlign":53},[10000],{"text":10001,"type":356},"When it comes to keeping patients safe, we need to think about all the ways they might be harmed. In the past, we mostly focused on things like falls and infections in hospitals because they are easier to measure. But there are other kinds of harm we often forget about, like getting too much or too little treatment, getting the wrong treatment, or receiving treatment too late. Other harms include racism, discrimination based on abilities, age, sex, gender, religion and social class, as well as discrimination related to body size and mental health.",{"type":15,"attrs":10003,"content":10004},{"textAlign":53},[10005],{"text":10006,"type":356},"Patient safety is a shared responsibility that goes beyond the roles of managers, quality and patient safety leaders, and practitioners; it involves everyone, including patients, families and care partners. Recognizing how safety is interconnected for all stakeholders, individuals should actively engage by voicing concerns, participating in safety discussions and contributing to solutions. Rethinking Patient Safety highlights the importance of moving beyond just looking at past harm and adopting a proactive approach. Safety isn't just about avoiding harm; it requires ongoing efforts to establish safe conditions through every decision and action, emphasizing that everyone has a role in actively shaping and maintaining a safe healthcare environment.",{"type":516,"attrs":10008,"content":10009},{"level":2463,"textAlign":53},[10010],{"text":10011,"type":356,"marks":10012},"Authors",[10013],{"type":392},{"type":15,"attrs":10015,"content":10016},{"textAlign":53},[10017],{"text":10018,"type":356},"Rachel Gilbert, Maaike Asselbergs, Donna Davis, Anne MacLaurin, Ioana Popescu, Carol Fancott",{"type":516,"attrs":10020,"content":10021},{"level":2463,"textAlign":53},[10022],{"text":10023,"type":356,"marks":10024},"Advisors",[10025],{"type":392},{"type":15,"attrs":10027,"content":10028},{"textAlign":53},[10029],{"text":10030,"type":356},"Wendy Nicklin, G. Ross Baker, Dr. Alika Lafontaine",{"type":516,"attrs":10032,"content":10033},{"level":2463,"textAlign":53},[10034],{"text":10035,"type":356,"marks":10036},"Contributors",[10037],{"type":392},{"type":15,"attrs":10039,"content":10040},{"textAlign":53},[10041],{"text":10042,"type":356},"Carla St. Croix, Andrea Piché, Denise McCuaig, Kim Mumford, Hailey Riendeau, James Rebello, Beatrice Onwuka, Jennifer Schipper at Arc Communications and Shoshanna Hahn-Goldberg and team at OpenLab.",{"type":15,"attrs":10044,"content":10045},{"textAlign":53},[10046],{"text":10047,"type":356},"We would like to thank all Healthcare Excellence Canada staff and leadership, HEC community of patient partners including Patients for Patient Safety Canada and all the participants in the engagement activities who provided invaluable insight into this 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These short summaries were co-developed with healthcare providers and organizations to help raise the profile of promising practices and generate discussion about how similar approaches could be adapted and applied elsewhere. The summaries offer details about:",{"type":461,"content":10141},[10142,10149,10156,10163],{"type":464,"content":10143},[10144],{"type":15,"attrs":10145,"content":10146},{"textAlign":53},[10147],{"text":10148,"type":356},"How communities are implementing promising practices to increase retention of their healthcare workforce.",{"type":464,"content":10150},[10151],{"type":15,"attrs":10152,"content":10153},{"textAlign":53},[10154],{"text":10155,"type":356},"Key success factors for embedding community, staff and Indigenous partnerships into retention approaches.",{"type":464,"content":10157},[10158],{"type":15,"attrs":10159,"content":10160},{"textAlign":53},[10161],{"text":10162,"type":356},"Practices that promote improved work-life balance and wellness.",{"type":464,"content":10164},[10165],{"type":15,"attrs":10166,"content":10167},{"textAlign":53},[10168],{"text":10169,"type":356},"Strategies that healthcare leaders are using to engage staff to develop solutions.",{"type":516,"attrs":10171,"content":10172},{"level":2463,"textAlign":53},[10173],{"text":10174,"type":356},"Why this work matters",{"type":15,"attrs":10176,"content":10177},{"textAlign":53},[10178],{"text":10179,"type":356},"There is a pressing need to support the healthcare workforce to strengthen and restore high-quality, safe care for everyone in Canada. 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positions.",{"_uid":10251,"cards":10252,"title":10269,"content":10270,"component":10213},"4b62b301-0406-4d18-b3d8-72ca83f2260d",[10253],{"_uid":10254,"link":10255,"image":10263,"title":10265,"component":10200,"description":10266},"d62a669b-df17-436a-980b-3fb3afe27908",[10256],{"_uid":10257,"file":10258,"component":10196},"a43ca63f-1957-4d44-8902-145ab51eb7de",{"id":10259,"alt":10260,"name":16,"focus":16,"title":10260,"source":16,"filename":10261,"copyright":16,"fieldtype":283,"meta_data":10262,"is_external_url":285},114292489451651,"20230214 Creating A Meaningful Work Life Balance For Staff Of Churchill Health Centre","https://a-ca.storyblok.com/f/850807391887861/881963a136/20230214-creating-a-meaningful-work-life-balance-for-staff-of-churchill-health-centre.pdf",{},{"id":53,"alt":53,"name":16,"focus":53,"title":53,"source":53,"filename":16,"copyright":53,"fieldtype":283,"meta_data":10264},{},"Creating a Meaningful Work-Life Balance for 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