Program Overview :

A timeline of patient safety

Important work has taken place to evolve our understanding of patient safety, what it means to different stakeholders, and how to foster it. While there has been tremendous progress, more work is needed to refine this understanding and address harm. As early adopters and leaders on the MMSF in Canada, Healthcare Excellence Canada and partners have a role to play in this effort—one that we hope you will join—so that we can trulytransform to the presence of safety. Together.  

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1999: A report titled To Err is Human: Building a Safer Health System was published by the Institute of Medicine. The report explores patient deaths due to medical error and concludes that the problem is not necessarily people, but the system in which people work.     

2001: The Institute of Medicine in the US releases Closing the Quality Chasm: A New Health System for the 21st Century. This report outlined the Six Aims for Improvement (Safety, Timeliness, Effectiveness, Efficiency, Equity, Patient-Centredness).  

2004: The Canadian Adverse Events Study: the incidence of adverse events among hospital patients in Canada by Baker, Norton et al., is the first Canadian study to provide a national estimate of the incidence of adverse events. The study found that 7.5% of 100 admissions resulted in an adverse event, of which 36.9% were preventable.  

2013: The release of the Measurement and Monitoring of Safety Framework (MMSF) catalyzed a major change in the way safety is defined and practiced. Created by Charles Vincent and colleagues at The Health Foundation, the MMSF presented an approach for shifting away from focusing on the absence of harm towards adopting a broader view of safety.  

2015: Beyond the Quick Fix: Strategies for Improving Patient Safety published by the Institute of Health Policy, Management and Evaluation at the University of Toronto concluded that despite the growing understanding of the safety threats and efforts made to identify safety practices, there is still effort needed to broaden and link efforts to improve care and care environments.  

2016: The Canadian Institute for Health Information (CIHI) releases the Hospital Harm Indicator. This indicator measures the rate of acute care hospitalizations with at least one occurrence of unintended harm during a hospital stay that could potentially have been prevented.    

2017: The Canadian Patient Safety Institute (CPSI), now Healthcare Excellence Canada, began working with healthcare teams from across the country to advance our knowledge and experience of the MMSF in Canada.    

2023: Healthcare Excellence Canada and Patients for Patient Safety Canada released Rethinking Patient Safety: A Discussion Guide for Patients, Healthcare Providers and Leaders which summarizes learnings and ideas suggesting a new way of approaching patient safety.