Patient Safety and Incident Management Toolkit

Recommended strategies 

Incident management: establish plans and processes

• Proactively develop local incident management policies, procedures, plans, and processes.

• Include tools and resources to support immediate and ongoing response, reporting, disclosure, analysis, tracking implementation of changes (e.g. checklists, flowcharts). 

• Clearly articulate roles, responsibilities and expectations. 

• Partner with both patients/families and frontline staff in their development. 

• Update them on a regular basis. 

• Ensure they are easily accessible to all staff as well as patients/families as appropriate. 

• Ensure leadership support for incident management is consistently visible, and not only during times of crisis, (e.g. have leaders participate in communication related to plans and processes, education, celebrating successes). 

• Allocate and ensure timely access to resources to support: 

  • patients/families (e.g. practical, emotional, financial support) 

  • staff involved in patient safety incidents (e.g. counselling, coaching, coverage of duties) 

  • implementation of recommended actions resulting from incident analysis 

  • communication and information systems (e.g. reporting, tracking, measurement) 

  • incident management training for all staff 

• Align incident management processes with organizational processes for employee human resource reviews and/or physician performance reviews (including reporting to regulatory/licencing bodies) and just culture principles. 

Patient safety management: monitor, analyze, and prioritize safety risks

• Continuously identify and monitor risks, safety gaps as well as strengths using multiple organizational sources (e.g. reporting and learning systems, complaints, compliments, coroner reports.) 

• Seek ways to capture what is not reported (e.g. frustrations, workarounds, inefficiencies, innovations, new ideas, strengths, customized defences) via dialogue, observations, leadership site visits, safety huddles, etc.

• Conduct prospective or multi-incident analyses to determine system strengths and vulnerabilities. 

• Adopt a systematic and consistent approach for tracking,  analyzing, quantifying and prioritizing patient safety risks/gaps/hazards and mitigation strategies. 

• Involve leadership, staff and patient/family partners in the prioritization process so that a broad range of perspectives is included. 

• Establish structures to ensure patient safety risks and their corresponding actions are tracked, updated, reviewed, and prioritized on a regular basis. 

• Develop and integrate mechanisms to monitor and respond to unexpected hazards in real time to improve reliability and resilience (e.g. constant vigilance, safety check-ins, early warning systems safety alerts/reports from both staff and patients/families). 

Patient safety management: implement action plans to mitigate risks and improve quality and safety 

• Develop and implement action plans to mitigate safety risks (e.g. evidence based interventions).

  • outline aims, actions, accountabilities and resources (usually in a project charter format) 

• Identify actions that are most likely to have the greatest impact in improving patient. 

  • consult with internal stakeholders

  • review external sources of evidence (e.g. alerts/ advisories/ recommendations/ best practices)

  • seek expert opinion 

• Design processes that focus on system-based error reduction strategies as they are the most effective (e.g. using forcing functions, automation, simplification and standardization). 

• Assess if safety action plans are resulting in improvements. 

• Engage patients/families:

  • develop care plans

  • share concerns and compliments

  • co-design systems and processes

  • implement safety and improvement initiatives 

Patient safety management: promote teamwork and build capacity

• Strengthen team functioning and relationships through team training using simulation whenever possible. 

• Adopt standardized communication and handoff processes (e.g. I-PASS, SBAR, Ask Me 3). 

• Promote team collaboration through interdisciplinary care models, interprofessional learning and team goals that focus on the patient/family needs. 

• Encourage and support continuous patient safety conversation between patients/families, frontline staff and leaders. 

• Develop multiple strategies that empower staff at all levels to share their concerns (e.g. anonymous reporting system and/or “hot line”) and skills to address hierarchy and power gradient (by using simulation). 

• Promote an understanding that systems are complex, dynamic and can fail. 

• Engage all team members, including patients/families, in all phases of quality improvement and patient safety initiatives to leverage their expertise. 

Recommended strategies

Understand patient safety culture and its components

• Recognize that patient safety culture is multi-dimensional consisting of a number of features:

  • informed culture – relevant safety information is collected, analyzed and actively disseminated

  • 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

  • learning culture – preventable patient safety incidents are seen as opportunities for learning and changes are made as a result

  • just culture – the importance of fairly balancing an understanding system failure with professional accountability

  • flexible culture – people are capable of adapting effectively to changing demands

• 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.

• Appreciate the interconnection 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.

Understand key contributors to a patient safety culture

• Appreciate and understand patient safety culture’s multiple influencers, including:

  • leadership and board commitment and ongoing visibility (at the organization and team levels)

  • patient/family engagement

  • effectiveness and openness of teamwork and communication

  • openness of all team members, including patients/families, in reporting problems and incidents measurement/monitoring and learning from safety and incidents

  • organizational learning

  • organizational resources for patient safety

  • priority of safety versus production

• 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.

Assess patient safety culture

• Determine the best methods and tools to assess patient safety culture in the organization, engaging safety and measurement experts whenever possible. 

• Consider assessing both perceptual indicators (front line staff provide majority of data) and organizational indicators of culture (senior leaders provide majority of data).   

• 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. 

• Engage frontline caregivers in the planning and implementation of the culture measurement initiative. 

• Analyze the results and identify opportunities for improvement, mapping to the various patient safety dimensions and influencers. 

• Communicate the results to key stakeholders in a meaningful way including a timeline for next steps and how improvement actions will be identified. 

• Understand that patient safety culture measurement is a snapshot in time and that ongoing measurement will be needed to monitor progress. 

Develop and implement a patient safety culture strategy 

• Based on the assessment results and environmental factors and with leadership support develop a shared vision and plan for improving patient safety culture.   

• Identify potential opportunities to implement the plan as well as barriers along with corresponding mitigating strategies. 

• 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. 

• Partner with patients and families in patient safety: 

  • 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 

  • engage them in the design of care models, care processes and quality improvement/patient safety initiatives 

• Partner with providers in patient safety:

  • 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) 

  • engage staff in all phases of quality improvement and patient safety initiatives to leverage their expertise 

  • a successful patient safety strategy leads to frontline ownership of local issues and challenges and enables clinicians and providers to action their own solutions 

  • design communication systems that allow for a continuous patient safety conversation between frontline staff and leaders 

Recommended strategies 

Establish a reporting system

• Capture information about hazards, patient safety concerns, incidents and near misses, typically by completing a standardized electronic or paper form 

• 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. stop the line) 

• Compared to those that are mandatory, voluntary (non-legislated) reporting systems have been shown to facilitate greater reporting and learning 

• Empower and support reporting by all care participants, including the patient/family, by ensuring they can access the system 

• Engage the users, including patients/families, in developing and maintaining the system 

• Incorporate best practices into the design of the reporting system whenever possible: 

  • make the system user-friendly aligning with human factors design principles 

  • limit the information required to what is essential and include a narrative portion to allow reporters to tell the story 

  • provide an option for anonymous or confidential reporting to address concerns about potential negative consequences 

  • embed automatic notification of the appropriate department head or manager, eliminating the need for the reporter to determine where to direct the information 

  • acknowledge reports upon receipt conveying appreciation to the individual submitting the report 

  • develop process(es) for the reporter to clarify the information submitted, if required 

  • enable managers to receive and view reports in real-time to facilitate timely feedback and response 

  • facilitate the review of the reports completed by the patient/family in conjunction with those completed by care providers 

  • prompt users to consider external reporting or notification requirements when appropriate (e.g. National System for Incident Reporting, Canadian Medication Incident Reporting and Prevention System) 

  • create easy-to-use data extraction capability to support timely improvement at the local, organizational and system-wide levels 

  • ensure appropriate data confidentiality and security (including de-identification), in accordance with applicable legislation and organizational policies 

Establish processes that support reporting systems 

• Develop and/or review existing reporting policies, procedures, education and training (example of policy and guideline from AHS) to ensure users know what, how and when to report: 

  • 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 

  • develop tools and resources specifically for patients/families 

  • ensure roles and accountabilities around incident reporting are clearly delineated and that staff is familiar with reporting procedures and tools 

  • clearly communicate what happens to the information once it is entered into the reporting system 

• Integrate reporting processes and the responsibility for reporting within existing work processes, structures and accountabilities including role descriptions, staff orientation and leadership development programs 

• Allocate adequate resources (including technical and administrative) to maintain the reporting system and its related processes including data analysis, follow-up, and system oversight 

• Address potential organizational barriers to reporting: 

  • cultivate a patient safety culture, specifically addressing the potential fears associated with reporting, authority gradient, and the risk of reprisal 

  • develop and train leaders to promote openness, facilitate learning, empower teams, and welcome differing perspectives 

Optimize and share learning from reporting systems 

• Analyze data from the reporting system to identify patient safety gaps 

• Integrate reporting system information with other data sources to anticipate and mitigate clinical risk and system vulnerabilities as well as to identify system strengths 

• Provide updates on lessons learned 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 

• 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 

• Evaluate the effectiveness of the reporting system and its related feedback mechanisms on a regular basis and make improvements 

• Update the data elements collected to ensure relevance and incorporate identification of emerging issues

Recommended strategies

Depending on the incident and circumstances, the steps taken immediately after an incident can vary in their order or occur simultaneously. Knowledge of local policies, procedures and available resources, developed before the incident, ensure effective management of these crucial early steps in the incident management process.

Immediate care and support for patient(s), family, providers and others.

• First and foremost, address the immediate clinical needs of the patient(s) involved in the incident

• Attend to the immediate emotional needs of patient(s) and/or family involved in the incident including acknowledgement of the event, empathy, and support

• Ensure that other patients, families and visitors impacted by the incident are cared for, including support for their ongoing clinical needs

• 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 support

• Document facts in the patient’s health record as soon as possible in accordance with professional standards and organizational policies

Make the environment and surroundings safe.

• Institute measures to reduce the risk of imminent recurrence or other potential threats, such as removing potentially harmful medications, equipment or other hazards

• Alert others, such other areas within the organization or other institutions, to risks that extend beyond the local environment

Secure items related to the event that may need to be assessed as part of the incident analysis.

• Items to be secured can include biomedical equipment, intravenous solutions, medications, packaging, garments, linens, technology, video recordings, etc.

• Label and secure items in a protected environment with restricted access

• As directed by organizational policies, secure the health record and provide a copy to care providers if the patient is receiving ongoing care

• Photograph the items and the area where the incident occurred when appropriate as this may prove to be helpful in the review process

Report the incident and ensure appropriate notifications.

• Report the incident in accordance with organizational processes to trigger appropriate notifications and determine next steps in the incident management process

• Notify the attending physician and unit manager and consider others including the leadership team, risk management and public relations in accordance with organizational policy

• 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 media

Begin disclosure.

• Begin the disclosure process with the patient and family as soon as reasonably possible

• Consider adapting the process to fit patient/family needs

• Document the disclosure discussion in accordance with organizational policies

Ongoing support

• Begin to create a plan to provide support and information to patients/families, providers, and others as appropriate.

Download a transcript of "The Impact of Disclosure: Second Victim of Harm" video.

Recommended Strategies

Before an incident

Confirm that organizational processes support disclosure

• Establish guiding principles for disclosure (e.g. patient-centred healthcare, patient autonomy, honesty and transparency, patient safety, just culture, learning and improvement).

• Develop disclosure policies, procedures and tools aligned with the organization’s guiding principles, disciplinary/accountability systems, legislation, regulatory/licensing requirements, and best practices that:

  • involve patients/ families and frontline staff in their development

  • articulate when and where disclosure should take place and how it should be conducted

  • include supports and resources available to the patient/family and healthcare providers

  • provide guidance on how to deal with the media in the event of a public disclosure

  • incorporate processes that address special circumstances such as multi-patient disclosures, paediatric patients or those with mental health issues, or incidents related to research

  • are easily accessible to all, including frontline staff and patients/families (e.g. public site)

  • are updated regularly to ensure relevance and alignment with other policies and current context

• Provide disclosure training programs and educational resources for staff and patients/families.

• Allocate resources to assist patients/families involved in patient safety incidents, ensuring they are available without delay (e.g. practical, emotional, financial).

• Allocate resources to assist staff at the frontline involved in patient safety incidents as needed, including disclosure support and coaching.

After an incident

Develop a specific disclosure plan

• 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.

• If possible, conduct a pre-disclosure team huddle to determine the best approach, including:

  • when the initial disclosure will occur taking into consideration patient/family readiness and preferences

  • where the disclosure will take place, preferably a private area that is free of interruptions or off-site if indicated

  • what information will be shared with the patient/family, including confirmation of the known undisputed facts

  • who is the best person to initiate disclosure and coordinate the ongoing disclosure

  • how the care providers involved in the incident will be supported

  • how the patient/family will be supported and their questions/concerns addressed

  • how disclosure will be documented

• 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.

Initiate initial disclosure

• Use language and terminology that the patient/family can easily understand. Avoid speculation or blame.

• Introduce the participants to the patient/family, including their functions and reasons for attendance.

• Acknowledge the incident or that something unexpected has happened and express apology using the words ‘I’m sorry’.

• Provide an overview of how the meeting will run and ask how the patient/family would like to participate.

• Ask about concerns and questions the patient/family would like to discuss and offer support or resources if needed.

• Share the following information:

  • the currently known facts of the incident

  • the steps for ensuring the ongoing care and well-being of the patient (e.g. clinical care, treatment)

  • a brief overview of the incident analysis process including expected timelines and what the patient/family can expect during the process

• Offer the patient/family an opportunity to speak about their experience and ask questions.

• Ask about preferences for future involvement and information (how, when, where).

• Ask the patient/family to identify a contact person.

• Designate a key contact person from the organization who will provide regular updates.

• Provide practical and emotional support (e.g. spiritual care services, counselling, social work, family arrangements, reimbursement of expenses associated with the disclosure process).

• Document the disclosure discussion in accordance with organizational policies. Include:

  • the time, place, date, the names and relationships of all attendees

  • the facts presented

  • offers of assistance made and the response, questions raised and the answers given

  • patient/family preferences about future disclosure discussions

  • plans for follow-up and key contact information for the organization and the patient/family

Continue disclosure throughout the incident management process as needed

• Continue to be engaged with the patient/family according to their preferences:

  • continue to offer practical and emotional support

  • transparently correct any incorrect or incomplete information that was provided in previous disclosure meetings

  • provide new factual information as it becomes available

  • 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

  • describe any actions that are taken as result of the internal analysis such as system improvements in accordance with organizational policies and applicable legislation

• Continue to offer updates, and practical and emotional support for providers.

• Ensure providers maintain involvement in the disclosure process as appropriate, particularly if leadership takes on a larger role in the post analysis stage.

• Continue to document disclosure discussions per organizational policies.

Recommended strategies

Refer to your organization’s policies, procedures and jurisdictional requirements when implementing these steps.

Conduct a preliminary investigation.

• 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

• Create a high level timeline 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

• 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

• Offer ongoing support to patients/families and care providers

Select an analysis type and method.

• Based on the preliminary understanding of what happened, and using appropriate guidance tools, determine whether a system-based analysis (focused on system improvement) or an accountability review (focused on individual performance) or both is required

• 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

• 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

• 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

Identify the analysis team.

• 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

• 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,

• 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)

• 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

• 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

• 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)

Coordinate meetings.

• 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

• Secure a comfortable and private setting

• Emphasize and maintain confidentiality at all times to ensure information is only communicated in accordance with applicable policies and legislation

• Manage documents in accordance with organizational policies

Plan and conduct interviews.

• If feasible, meet with the team to confirm the approach and ground rules before conducting interviews

• Invite the patient/family and staff to participate in interviews as appropriate, coordinating communication through the key contact assigned earlier

• Conduct interviews as soon as is reasonably possible to help ensure that important information and details are recalled

• Conduct interviews individually to provide an opportunity for those involved in the incident to share their detailed perspective and unique viewpoint

• Consider the ability/readiness of the individuals being interviewed and provide care and support throughout:

  • clearly convey the purpose of the interview and what will be done with the information

  • favour the use of open-ended questions to allow the individual to tell their story

  • ask the individual whether they identified contributing factors related to the incident as well as factors they feel mitigated the outcome

  • 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

Recommended strategies

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.)

Understand what happened.

• 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

• Create a detailed timeline, collating facts from various sources

• Review additional supporting information such as any related policies and procedures, training materials, or evidence-based guidelines

• 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

Determine how and why it happened.

• 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

• Consider aspects of the incident that extend beyond the patient-provider level by probing all influencing factors and circumstances

• 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

• Use diagramming or other analytical tools to identify and understand the relationships between and among contributing factors

• 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

• Articulate concisely what was found in a summary of findings that provides the backbone for the development of recommended actions

Identify what can be done to reduce the risk of recurrence and make care safer.

• Develop recommended actions addressing the analysis findings and that are specific, measurable, attainable, realistic and timely

• Ground recommended actions in evidence whenever possible, utilize the most effective solutions given the circumstances and target them to the appropriate system level(s) to achieve sustained improvement

• 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

• Review and validate the recommended actions with the patient/family, providers and experts (whenever possible)

• Prepare and hand-off the incident analysis report to those responsible for approving recommended actions, allocating the necessary resources, delegating implementation of the recommended actions and monitoring progress

• Include a tracking tool with assigned responsibilities and timeframes in the report to facilitate ongoing monitoring of the recommended actions and their outcomes

• 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

Identify and share what was learned.

• 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.

Recommended strategies

Implement recommended actions.

• Engage frontline staff and patients/families in the planning and implementation of recommended actions, exploring potential barriers and opportunities as well as mitigation strategies

• Ensure ongoing leadership support and adequate human and financial resources for implementation

• Use change management and improvement tools to base change on strong methodology

• 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)

• Test changes on a small scale to allow for feedback and refinement before broader implementation

• 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

Monitor and assess the effectiveness of the recommended actions.

• Rather than simply tracking the completion of recommended actions, establish relevant outcome, process and balancing measures to monitor whether the desired effect was achieved

• Clearly define measures and design data collection to be as practical as possible

• Monitor performance over time to demonstrate sustained improvement or lack thereof

• Use all of the information available to evaluate the overall effectiveness of the recommended actions, including observations, stakeholder feedback, and unintended consequences

• Revisit recommended actions that did not achieve the anticipated improvement and consider adjustments or alternate solutions

Close off the incident analysis and transition to ongoing operations.

• Designate the incident analysis as complete once all of the recommended actions have been evaluated for a pre-determined period of monitoring

• Determine if ongoing performance monitoring (such as unit or organizational quality indicators) is required to ensure sustainability

• 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

• If communicating results of recommended actions, respect patient/family preferences in terms what they want to know and when

• Celebrate successes and improvements highlighting the positive contributions to safety resulting from the incident management process

Recommended strategies

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.

Share what was learned internally.

• 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

• Communicate results of recommended actions, taking care to respect patient/family preferences in terms of what they want to know and when

• Communicate what has been implemented and the results, ensuring messages and channels are appropriate for each audience:

  • review the purpose of analysis, methodology and the findings as appropriate

  • share the factors that contributed to the incident, the defences that worked well, and what was learned about how to avoid similar incidents

  • review the recommended actions, their current status and their impact

  • maintain transparency and trust by being honest if plans have changed and share the reasons why

• 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

• Maintain a record of communication to ensure all appropriate stakeholders have received the information

• Recognize that sharing is a dialogue (not a one-way flow of information) and is ongoing (more than one time)

• Encourage respectful, open communication around the results of the incident analysis at all levels of the organization

Share what was learned externally.

• 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

• Alerts, advisories and repositories can serve as vehicles for informing others about what happened, how and why, what actions were taken, and their impact

• If appropriate, develop an external communication plan 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

• For public announcements, prepare the staff and the patient/family in advance discussing what information will be shared, when and how

Reflect and Improve.

• Consider conducting a multi-incident analysis to better identify recurring system issues

• Determine if what was learned can be applied to other processes in the organization

• Communicate any noteworthy vulnerabilities and/or best practices through senior leadership or other appropriate body (e.g. quality committee, risk management, etc.)

• 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

• Assess the incident management process to identify strengths and opportunities for improvement, taking into consideration:

  • the timeliness of the analysis

  • the quality and effectiveness of the recommended actions

  • organizational guidance and supporting structures

  • communication and processes for sharing what was learned

  • the experience of those involved in the incident and the analysis

• Support research and innovation focussed on learning from incidents

Recommended strategies

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.

Immediate care and support for patient(s), family, providers and others.

• 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.

• Creating a Safe Space: Addressing Confidentiality for Peer-to-Peer Support Programs for Health Professionals

Assess key system factors and understand how they relate to patient safety and incident management

• Outside the boundaries of the organization:

  • public and community awareness of and engagement in patient safety

  • healthcare legislation, standards, policies, regulations and accreditation requirements

  • healthcare infrastructure and resourcing (fiscal, human, facilities and sites, equipment)

  • education of healthcare providers, labour agreements and workforce trends

  • social determinants of health, societal trends (income, social status, education, employment, housing, culture, etc.)

  • health trends, issues and challenges (e.g. disease outbreaks, population health)

  • political environment (local, provincial/ territorial, national), economic, technological and trends influencing the healthcare industry (e.g. through a PESTLE analysis)

  • infrastructure, trends, and funding for patient safety research, evaluation and improvement

  • trends in other sectors that might intersect with healthcare (e.g. technology, social media)

  • geographic location and regional characteristics (remote vs rural vs urban).

• At the organizational and program/service levels:

  • strategic plans, organizational priorities, values and principles

  • leadership team and board level commitment and governance, including their knowledge of patient safety science and best practices

  • leadership visibility and engagement in patient safety

  • how leadership prioritize patient safety – whether it is at the top of meeting agendas and allocated at least 25% of the meeting time

  • organizational leadership’s accountability for patient safety performance, alignment with incentives (formal and informal)

  • patient/family perspective included at board and leadership meetings, in decision-making and in the design of care processes and patient safety initiatives

  • leadership team stability, experience, and style

  • organizational patient safety culture

  • organizational experience, current performance/progress with patient safety

  • the organization’s funding and financial status, including infrastructure and technology investment needs

  • proactive design or redesign of policies and practices related to safety

  • workforce expertise and skill related to patient safety

  • alignment between patient safety, quality improvement and risk management.

• At the point of care:

  • patient/family partnership in care and safety

  • team communication, feedback, culture, composition, hierarchy

  • staff and patients/families being comfortable and able to report incidents, concerns, successes

  • staff competencies, skill, experience, professional requirements regarding patient safety and incident management

  • access to resources to manage safety and incidents

  • staff turnover, staffing levels, protected time for projects.

Identify actions to strengthen patient safety and incident management

• Respond – 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.

• Align – 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.

• Leverage – 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).

• Partner/collaborate – Work with others to make changes that can positively impact healthcare in your setting; support or endorse the work and successes of others.

• Advocate – 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).

This glossary is not intended to be an exhaustive list of terms, but rather a concise list of key terms used throughout the toolkit.

Actions (taken to reduce risk of harm): Actions taken to reduce, manage, or control any future harm, or probability of harm.

Alerts or advisories: 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.

Apology: 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.

Authority gradient: Balance of decision-making power or the steepness of command and hierarchy in a given situation.

Contributing factors: 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.

Culture, Patient Safety: Culture refers to shared values (what is important) and beliefs (what is held to be true) that interact with a system’s structures and control mechanisms to produce behavioural norms.

Disclosure: The process by which a patient safety incident is communicated to the patient by health care providers.

Early warning system: A systemic process for evaluating and measuring risks early in order to take pre-emptive steps to minimize their impact.

Governance: The body having accountability and legal responsibility for the overall performance of an organization and oversight of decisions.

Harm: Impairment of structure or function of the body and/or any deleterious effect arising therefrom. Harm includes disease, injury, suffering, disability and death.

Hazard: Situations with the potential to cause harm.

Healthcare organization: An organization that provides health services in any healthcare sector.

High Reliability Organizations (HROs): Organisations that have few accidents despite operating in highly dynamic, technologically rich and hazardous industries.

Human Factors: A discipline addressing human behaviour, abilities, limitations, and relationship to the work environment (physical, organizational, cultural), with the goal to promote efficiency, safety and effectiveness by improving the design of technologies, processes and work systems.

Incident Analysis: A structured process that aims to identify what happened, how and why it happened, what can be done to reduce the risk of recurrence and make care safer, and what was learned. It is also referred to as system-based analysis.

Incident Management: The various actions and process required to conduct the immediate and ongoing activities following an incident. Incident analysis is a component of incident management.

Patient safety incident: An event or circumstance which could have resulted, or did result, in unnecessary harm to a patient. There are three types of patient safety incidents:

• Harmful incident: A patient safety incident that resulted in harm to the patient. Replaces "preventable adverse event”

• Near miss: A patient safety incident that did not reach the patient and therefore no harm resulted.

• No-harm incident: A patient safety incident that reached the patient but no discernible harm resulted.

Patient safety: The pursuit of the reduction and mitigation of unsafe acts within the health care system, as well as the use of best practices shown to lead to optimal patient outcomes.

Patient: A person who is receiving, has received, or has requested health care.

Family: A person(s) whom the patient wishes to be involved with them in care, and acting on behalf of and in the interest of the patient.

Prospective analysis: An analytical tool to assess and mitigate harm or loss by analyzing a situation or process that carries with it some inherent risk. Its purpose is to identify the way in which a process might potentially fail, with the goal to eliminate or reduce the likelihood or outcome severity of such a failure.

Providers: Refers to physicians, professional, unregulated staff, and others engaged in the delivery of health services.

Quality Improvement (QI): A formal approach to the analysis of performance and systematic efforts to improve it. There are numerous models used.

Reporting: The communication of information about a patient safety incident through appropriate channels inside or outside of healthcare organizations, for the purpose of reducing the risk of occurrence of patient safety incidents in the future.

Resilience: The degree to which a system continuously prevents, detects, mitigates or ameliorates hazards or incidents so that an organization can “bounce back” to its original ability to provide core functions.

Risk management: An organized effort to identify, assess and reduce, where appropriate, risks to patients, visitors, staff and organizational assets. Activities are undertaken to identify, analyze and educate, and to structure processes to reduce the likelihood of adverse events.

Risk mitigation: The process of identifying and implementing precautions or controls that will most effectively reduce the consequence or likelihood of occurrence of a risk.

Risk: The probability that a specific adverse event will occur in a specific time period or as a result of a specific situation.

System Levels: Systems are generally viewed from various levels because they are differences in goals, structures and ways of working in different parts of the system.

System: A health system, or healthcare system, is the sum of all the organizations, institutions, and resources whose primary purpose is to deliver health care services to meet the health needs of a target population.

Systems Thinking: An approach that centers on the dynamic interaction, synchronization and integration of system components and sub-components (e.g. people, processes, technology, incentives, decisions, culture).

Team: Two or more people who interact dynamically, interdependently, and adaptively toward a common and valued goal/objective/ mission. Patients/families are part of the team.

Teamwork: Team members working together to achieve a shared goal.

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Accreditation Canada. 

Alberta Health Services (AHS). Policy: Reporting of clinical adverse events, close calls and hazards. 2012. (Policy, 5 pages) 

Alberta Health Services Engagement and Patient Experience Department. Resource Toolkit for Engaging Patient and Families at the Planning Table. 2014. (Toolkit, 27 pages) 

Baker GR, MacIntosh-Murray A, Porcellato C, Dionne L, Stelmacovich K, Born K. High Performing Healthcare Systems: Delivering quality by design. 2008. (Book) 

BC Patient Safety & Quality Council. Culture Change Toolbox. 2018. (Toolkit, 74 pages) 

BC Patient Safety and Learning System (BCPSLS). Good Catch! Island Health encourages near-miss reporting. 2015. (Case study) 

BC Patient Safety and Learning System (BCPSLS). Fostering safety culture in pediatric care: Surjeet’s story. 2013 

British Columbia Patient Safety Task Force. BC Provincial Guidelines for Policy Related to Disclosure of Adverse Events. (Guide, 4 pages) 

Canadian Agency for Drugs and Technologies in Health. Rapid Response. 2015. (Collection of knowledge, tool) 

Canadian Association of Paediatric Health Centres. What a Shame: The Impact of Mistakes on Healthcare Professionals. (Webinar) 

Canadian Foundation for Healthcare Improvement (CFHI). Innovative Patient Resource Kit Eases the Process of Engaging Patients. 2015. (Case study) 

Canadian Foundation for Healthcare Improvement (CFHI). Patient Engagement Resource Hub. 2015. (Collection of resources) 

Canadian Medication Incident Reporting and Prevention System. How do I report? (Tool, guide) 

Canadian Patient Safety Institute (CPSI). Canadian Disclosure Guidelines: Being open with patients and families. 2011. (Guide, 52 pages) 

• Diagram B : Circumstances when Disclosure should take place 

• Diagram C : Stages of Disclosure 

• Appendix D : Checklist for Disclosure Process 

HealthcareCAN. Canadian Patient Safety Officer Course. (Learning program, $) 

Canadian Patient Safety Institute (CPSI). Disclosure Training Program offered by The Canadian Medical Protective Association. (Learning program, $)

Canadian Patient Safety Institute (CPSI). Guidelines for Informing the Media after an Adverse Event. Edmonton, AB: CPSI; 2011. Information-Sharing Planning Checklist (Page 4-6). (Guide, 11 pages) 

Canadian Patient Safety Institute (CPSI). Patient Safety Education Program – Canada. (Learning program)

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Patients for Patient Safety Canada, Martha’s Legacy Lives On. 2011 (Video) 

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Health Canada. Regulatory Transparency and Openness Framework. 2014. (Guide) 

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Incident Analysis Collaborating Parties. Canadian Incident Analysis Framework. Edmonton, AB: Canadian Patient Safety Institute; 2012. (Guide, tools, 133 pages) 

• Appendix A: Team management checklist. 

• Appendix C: Analysis team membership, roles and responsibilities. 

• Appendix D: Sample analysis team charter. 

• Appendix E: Sample confidentiality agreement. 

• Appendix F: Checklist for effective meetings with patient(s)/ families. 

• Appendix G: Incident analysis guiding questions. 

• Appendix H: Creating a constellation diagram. 

• Appendix I: Incident Analysis Report Template 

• Appendix J: Case study - comprehensive analysis: elopement from a long-term care home. 

• Appendix K: Case study - concise analysis: medication incident. 

• Appendix M: Legislative Protection for Quality of Care. 

• Appendix N: Three human factors methods that can be used in incident analysis. 

• Figure 2.3 : System Levels. 

• Figure 3.12: Example of tool to track the implementation status of recommended action. 

• Figure 3.14: Useful questions in designing data collection. 

• Section 3.6.6 Developing and Managing Recommended Actions. 

• Section 3.6: Criteria and considerations for selecting an incident analysis. 

• Section 1.4 Incident Analysis and Management from a Patient Perspective. 

• Section 2 Essentials of Analysis. 

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Institute for Safe Medication Practices Canada (ISMP). ISMP Canada Safety Bulletins. (Collection of alerts) 

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Manitoba Institute for Patient Safety, Manitoba Alliance of Health Regulatory Colleges. Manitoba has an Apology Act – Learn More About it! October; 2014. (Leaflet) 

Ontario Ministry of Health and Long-term Care. Excellent Care for All Act. Ontario: 2010. (Legislation) 

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• Open Disclosure Resources for Health Service Organisations. 2013.

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• Appendix A: Internal and external communication checklist (Guide, log-in required) 

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Health Service Executive (HSE). Open Disclosure: Communicating when things go wrong. 2013. (Leaflet)2013. (Leaflet) 

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High Reliability Organizing (HRO), Models of HRO , Weick and Sutcliffe/Social Psychology. 2013. (Web article) 

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