In this resource :

  • Patient Safety Culture Bundle

Learning 

Learning practices that reinforce safe behaviors 

The Patient Safety Culture “Bundle” is arranged in three main parts with subsections under each; as with other safety bundles, all components (vs. a piecemeal approach) are required to improve patient safety culture. Improving patient safety culture requires sequential, iterative and simultaneous interventions that ENABLE, ENACT and LEARN. 

This section specifically examines the LEARNING components of the Bundle. 

The table below addresses learning practices that reinforce safe behaviours. The LEARNING section provides tools and resources to help leadership ensure that there are systems in place to support education and capability building, incident reporting/management/analysis, safety/quality measurement/reporting and operational improvements.  

Click the hyperlinked text within the categories to access freely available tools and resources to support your work within this leadership area. 

Education/capability building


Component Link Resource Author Resource Type Resource Title
Leaders/staff/physicians trained in safety and improvement science, teamwork, communication https://www.royalcollege.ca/rcsite/events/advancing-safety-patients-in-residency-education-aspire-e CPSI Education Program Advancing Safety for Patients In Residency Education
Leaders/staff/physicians trained in safety and improvement science, teamwork, communication https://www.healthcareexcellence.ca/en/what-we-do/all-programs/teamstepps-canada-essentials-course/ CPSI Education Program TeamSTEPPS Canada™
Team-based training, drills https://qualitysafety.bmj.com/content/23/5/359.info BMJ Quality and Safety Article Team-training in healthcare: a narrative synthesis of the literature
Team-based training, drills http://apps.who.int/iris/bitstream/handle/10665/260424/WHO-NMH-NVI-18.4-eng.pdf?sequence=1 World Health Organization (2018) Resource Hearts, Technical package for cardiovascular disease management in primary health care
Team-based training, drills https://www.rcm.org.uk/news-views-and-analysis/analysis/skills-drills-training-the-way-forward Midwives magazine (May 2007) Article Skills drills training: the way forward
Team-based training, drills https://onlinelibrary.wiley.com/doi/full/10.1111/j.1553-2712.2008.00254.x Official Journal of the Society for Academic Emergency Medicine (2008) Article Does Team Training Work? Principles for Health Care
Team-based training, drills https://www.collegianjournal.com/article/S1322-7696(14)00041-9/fulltext The Australian Journal of Nursing Practice, Scholarship & Research (2015) Article Effects of team-based learning on perceived teamwork and academic performance in a health assessment subject

Incident reporting/management/analysis


Component Link Resource Author Resource Type Resource Title
Effective risk/incident reporting system for events related to patients/families and staff/physicians https://www.healthcareexcellence.ca/en/resources/patient-safety-incident-analysis/ CPSI Tools & Resources Incident Analysis
Structured processes for responding to and learning from safety events/critical incidents http://www.patientsafetyinstitute.ca/en/toolsResources/IncidentAnalysis/Pages/incidentanalysis.aspx CPSI Tools & Resources Incident Analysis   Analyse des incidents
Structured processes for responding to and learning from safety events/critical incidents http://www.patientsafetyinstitute.ca/en/toolsResources/InformingMediaAdverseEvent/Pages/default.aspx CPSI Tools & Resources Communicating After Harm in Healthcare
Structured processes for responding to and learning from safety events/critical incidents http://www.ihi.org/resources/Pages/IHIWhitePapers/RespectfulManagementSeriousClinicalAEsWhitePaper.aspx IHI (2011) Article Respectful Management of Serious Clinical Adverse Events
Structured processes for responding to and learning from safety events/critical incidents https://improvement.nhs.uk/resources/learning-from-patient-safety-incidents/ NHS Tools & Resources Learning from patient safety incidents
Structured processes for responding to and learning from safety events/critical incidents https://www.hiroc.com/system/files/resource/files/2018-10/HIROC-Incident-Management-System-for-Critical-Incidents-December-2015.pdf HIROC Tools & Resources Applying the Incident Management System (IMS) Framework to Critical Incidents & Multi – Patient Events
Structured processes for responding to and learning from safety events/critical incidents https://www.healthcareexcellence.ca/en/resources/canadian-disclosure-guidelines/ CPSI Tools & Resources Canadian Disclosure Guidelines: Being open with patients and families

Safety/quality measurement/reporting


Component Link Resource Author Resource Type Resource Title
Regular measurement of safety culture; patient/family complaints; and staff/physician engagement https://qualitysafety.bmj.com/content/qhc/12/suppl_2/ii17.full.pdf Qual Saf Health Care (2003) Article Safety culture assessment: a tool for improving patient safety in healthcare organizations
Regular measurement of safety culture; patient/family complaints; and staff/physician engagement https://digital.library.adelaide.edu.au/dspace/bitstream/2440/48195/8/02whole.pdf University of Adelaide (2007) Article Lessons to be learnt: Evaluating aspects of patient safety culture and quality improvement within an intensive care unit
Regular measurement of safety culture; patient/family complaints; and staff/physician engagement https://pxjournal.org/cgi/viewcontent.cgi?referer=&httpsredir=1&article=1003&context=journal Patient Experience Journal (2014) Article Evaluation and measurement of patient experience
Regular measurement of safety culture; patient/family complaints; and staff/physician engagement https://www.oecd.org/health/health-systems/Measuring-Patient-Safety-April-2018.pdf OECD (2018) Report MEASURING PATIENT SAFETY. Opening the Black Box
Retrospective/prospective safety and quality process and outcome measures https://psnet.ahrq.gov/primers/primer/35/measurement-of-patient-safety AHRQ (2019) Article Measurement of Patient Safety
Retrospective/prospective safety and quality process and outcome measures https://www.sciencedirect.com/science/article/pii/S1532046403000674 Journal of Biomedical Informatics (2003) Article Retrospective data collection and analytical techniques for patient safety studies
Retrospective/prospective safety and quality process and outcome measures http://sphweb.bumc.bu.edu/otlt/MPH-Modules/EP/EP713_AnalyticOverview/EP713_AnalyticOverview3.html Boston University School of Public Health Webpage Prospective and Retrospective Cohort Studies
Regular, transparent reporting of safety/quality plan results https://nam.edu/wp-content/uploads/2016/09/Fostering-Transparency-in-Outcomes-Quality-Safety-and-Costs.pdf National Academy of Medicine (2016) Article Fostering Transparency in Outcomes, Quality, Safety, and Costs A Vital Direction for Health and Health Care
Regular, transparent reporting of safety/quality plan results https://www.mckinsey.com/~/media/mckinsey/dotcom/client_service/Healthcare%20Systems%20and%20Services/Health%20International/Issue%2011%20new%20PDFs/HI11_64%20Transparency_noprint.ashx Health Informational (2011) Report Transparency- the most powerful driver of health care improvement

Operational improvements


Component Link Resource Author Resource Type Resource Title
Structured methods, infrastructure to improve reliability, streamline operations https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2822834/ BMC Health Serv Res (2010) Article Does the process map influence the outcome of quality improvement work? A comparison of a sequential flow diagram and a hierarchical task analysis diagram
Structured methods, infrastructure to improve reliability, streamline operations https://chfg.org/how-to-guide-to-human-factors-top-tips/ Clinical Human Factors Group (2013) Guide Human Factors in Healthcare 'Taking Further Steps'. Case-studies-and-implementation-tips.
Structured methods, infrastructure to improve reliability, streamline operations https://www.ahrq.gov/sites/default/files/publications/files/leancasestudies.pdf Agency for Healthcare Research and Quality (2014) Report Improving Care Delivery Through Lean:<br>Implementation Case Studies
Structured methods, infrastructure to improve reliability, streamline operations http://www.eng.cam.ac.uk/uploads/news/files/engineering-better-care-report-web-3mb-20170922.pdf The Academy of Medical Sciences (2017) Report Engineering better care a systems approach to health and care design and continuous improvement
Structured methods, infrastructure to improve reliability, streamline operations https://innovations.ahrq.gov/qualitytools/plan-do-study-act-pdsa-cycle AHRQ Webpage Plan-Do-Study-Act (PDSA) Cycle
Structured methods, infrastructure to improve reliability, streamline operations https://www.medicalhumanfactors.net/what-is-human-factors/ MedStar Health National Centre for Human Factors in Healthcare Video What is Human Factors in Healthcare?
Structured methods, infrastructure to improve reliability, streamline operations https://www.cmpa-acpm.ca/serve/docs/ela/goodpracticesguide/pages/human_factors/human_factors-e.html CMPA Education Program Human factors influences on performance.