Patient Safety Plan 2011/12-2014/15 · Patient Safety Plan. Performance Excellence Framework. The...
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Patient Safety Plan 2011/12-2014/15 Performance Excellence February 2012 1
Transcript of Patient Safety Plan 2011/12-2014/15 · Patient Safety Plan. Performance Excellence Framework. The...
Patient Safety Plan 2011/12-2014/15
Performance Excellence February 2012 1
Introduction
“Quality and patient safety are essential attributes of good health services.” (WHO 2011).
At Capital Health, it is our mission to become a world-leading haven for people-centered health, healing and learning. As a haven, we are committed to helping create and sustain a safe and enriching environment for well being. Purpose The purpose of Capital District Health Authority (Capital Health /CDHA) Patient Safety Plan supports and links with the CDHA Integrated Quality Framework (IQF) and Integrated Risk Management Plan (IRMP) to form the Performance Excellence Framework for Capital Health.
Integrated Quality Framework
Integrated RiskManagement Plan
Patient Safety Plan
Performance Excellence Framework
The CDHA Patient Safety Plan purpose is to support patient safety and reduce risk to patients through the creating and sustaining a safe environment that ensures:
Recognition and acknowledgment of risks to patient safety; Initiation of actions to reduce these patient safety issues and risk; Internal reporting of patient safety issues and corrective actions taken; A focus on processes and systems; Organizational learning about patient safety; and
Performance Excellence February 2012 2
Supporting and sharing knowledge about patient safety issues to foster organizational learning and a culture of patient safety within CDHA and other healthcare organizations.
The main structure and organization of the Quality & Patient Safety Teams and organizational oversight is outlined in the Integrated Quality Framework (2010).
Guiding Principles: The guiding principles and philosophy of patient safety at Capital Health are organized following the Six Domains of Safety Competencies as outlined by the Canadian Patient Safety Institute in The Safety Competencies: Enhancing Patient Safety Across the Health Professions (2008).
Domain 1 – Contribute to a Culture of Patient Safety
1) To encourage and foster organizational and individual learning about patient safety.
2) To focus and coordinate organizational-wide patient safety initiatives.
3) To establish an environment that supports safety, encourages reporting, addresses patient safety issues throughout Capital Health – positive patient safety culture and a just culture.
Domain 2 – Work in Teams for Patient Safety 4) To promote teamwork and group responsibility in identifying
and implementing patient safety initiatives. 5) To ensure staff have the knowledge, skills, and supports to safely perform care.
Domain 3 - Communicate Effectively for Patient Safety 6) To engage the community through openness and transparency – we are all on the same
team working for safer health care. 7) To establish the mechanisms and supports for the disclosure of adverse patient safety
events to patients and their families. Domain 4 - Manage Safety Risks
8) To enhance effective organizational, best practices, and clinical decision-making including required organizational practices (ROPs) with respect to patient safety.
Domain 5 – Optimize Human and Environmental Factors 9) To design and operate a safe environment of care including facilities, equipment and
support systems that promote and foster safe, effective and efficient healthcare. Domain 6 – Recognize, Respond to Disclose Adverse Events
10) To identify, implement and maintain support systems to provide the right information, to the right people, at the right time.
11) To facilitate communication, reporting and documentation of patient safety issues with staff, leadership, the Quality & Patient Safety Council, and the Quality Committee of the Board.
Key Initiatives: Patient Safety Plan is attached as Appendix A. Reporting of Results: The reporting structure and accountabilities are as described in the CDHA IQF.
Performance Excellence February 2012 3
Performance Excellence February 2012 4
Attachments: Appendix A: Patient Safety Plan 2011/12-2014/15 Appendix B: The Safety Competencies & Required Organizational Practices Map References:
1) CDHA Integrated Quality & Patient Safety Framework (September 2010). 2) Canadian Patient Safety Institute. The Safety Competencies: Enhancing Patient Safety
Across the Health Professions (2008). 3) Accreditation Canada. Required Organizational Practices. (2011).
Capital Health Patient Safety Plan 2011/12-2014/15
APPENDIX A
Performance Excellence July 2014 1
Key Objectives – Safety Competencies
Quality Dimension: Safety
ROP: Required Organizational Practice
Progress Target Date Responsibility Status
Domain 1: Contribute to a Culture of Patient Safety
ROP: Client Safety Plan (Patient Safety Plan)
High Priority Criteria:Client (Patient) Safety as a Strategic
Priority
- Reflecting/Refresh Milestones/Our Promise
Tracking Progress District Quality Patient Safety
Council/ DMAC Quality
Tracking Progress District Quality Patient Safety
Council/ DMAC Quality
January 2012
Nov 2012
District Quality
Patient Safety
Council
DMAC Quality
Leadership
VP Performance
Excellence
Completed
Approved
Ongoing
Completed
Approved
ROP: Adverse (Patient Safety Incidents)/ Events Reporting
Report and learn about unsafe processes with the system
- Patient Safety Reporting System (PSRS) education
ongoing /Update Learning Management System
(LMS)
- Develop criteria for participation in Canadian Patient
Safety Institute Global Patient Safety Alerts
Roll-out STAR Patient Look-up interface
Continue to update and revise Patient Safety Reporting
System as appropriate to facilitate reporting of Patient
Safety incidents (Patient Safety Incidents/ Events & Quality
issues)
Tracking Progress District Quality Patient Safety
Council/ DMAC Quality
Enable link to CDHA ADT System to facilitate
patient identification in PSRs.
Added categories for:
1) CDHA Patient Experience Nov 2011
2) Point of Care Testing Jan 2012
3) Tele-health (TEST) Dec 2011 (On Hold)
4) Radiation Therapy Jan 2013
5) Addictions/MHP Pt Experience Comments
Sept/Oct 2011
Fall 2014
Summer 2013
Ongoing
Risk Management/
Patient Safety
Patient Safety Team
Risk Management/
Patient Safety & ITS
District Quality
Patient Safety
Council
DMAC Quality
Completed
Ongoing
Ongoing
Completed
Completed
Completed
Completed
Completed
Capital Health Patient Safety Plan 2011/12-2014/15
APPENDIX A
Performance Excellence July 2014 2
Key Objectives – Safety Competencies
Quality Dimension: Safety
ROP: Required Organizational Practice
Progress Target Date Responsibility Status
July 2012
6) Pressure Ulcers November 2012
7) Leadership Safety Rounds April 2013
8) Continuing Care Fall 2013
9) Quality Review/FMEA/PSRA
Recommendations Summer 2013
10) ER Boarding issues Summer 2013
11) Clinical Product Concerns Fall 2013
12) Public Health dedicated reporting site
13) Continuing Care dedicated site June 2014
14) Ambulatory Systemic Therapy June 2014
15) Risk Assessment Recommendations
July/August 2014
Completed
Completed
In Progress
Completed
Completed
Completed
Completed
In Progress
In Progress
In Progress
ROP: Client Safety-related Quarterly Reports
- Quarterly monitoring and report to Quality
Teams(Strategic Indicator Report, Patient Safety
Reporting System).
Tracking Quarterly Progress District Quality Patient
Safety Council/ DMAC Quality
April 2012
Accreditation
District Quality
Patient Safety
Council
DMAC Quality
In Place
Ongoing
ROP: Hand hygiene education and training (See also Domain 4)
STOP Wash Your Hands Week annually
- Education hand hygiene (IC 06-016)
ROP: Hand-Hygiene Audit
- Infection Control Audits
Tracking Progress District Quality Patient Safety
Council/ DMAC Quality
Module on LMS Hand Hygiene
Tracking Progress District Quality Patient Safety
Annually
Ongoing
March 2012
Infection Control
District Quality
In Place
Ongoing
In Place
Capital Health Patient Safety Plan 2011/12-2014/15
APPENDIX A
Performance Excellence July 2014 3
Key Objectives – Safety Competencies
Quality Dimension: Safety
ROP: Required Organizational Practice
Progress Target Date Responsibility Status
High Priority Criteria: Infection Control Guidelines
- Adhere to international, federal, provincial infection
control guidelines (IC 01-001)
- Track and analyze infection rates
-
Council/ DMAC Quality
In place (Strategic Indicator Report)
Reports to managers to inform staff
May 5th
, 2014 STOP Clean Your Hands Day
Patient Safety
Council
DMAC Quality
Ongoing
In Place
Ongoing
Completed
ROPs: Adverse(Patient Safety Incidents) Events Reporting &
Disclosure
Just Culture education Module Brief (See also Domain 6)
- Overview education for staff and leadership on Just
Culture
- Grand Rounds on Patient Safety Culture
- Working paper Student
- Learning Management System (LMS) module
- Patient Safety Culture Survey
.
Incorporating Just Culture principles
Tracking Progress District Quality Patient Safety
Council/ DMAC Quality
Summer 2013
October 2012
August 2011
Summer 2014
Winter 2012
Risk Management/
Patient Safety
CMPA
Student
Risk Management/
Patient Safety
District Quality
Patient Safety
Council
DMAC Quality
Completed
Completed
Completed
In Progress
Ongoing
ROP: Client Safety: Education & Training
Patient Safety Education
- Patient Safety Reporting System Communique
Issued as needed with updates.
Ongoing
Risk Management/
Patient Safety
In Place
Ongoing
Capital Health Patient Safety Plan 2011/12-2014/15
APPENDIX A
Performance Excellence July 2014 4
Key Objectives – Safety Competencies
Quality Dimension: Safety
ROP: Required Organizational Practice
Progress Target Date Responsibility Status
- Patient Safety Week Virtual Forum
- Revision Orientation Presentation on Learning
Management System (LMS)
- Refreshed Orientation Presentation.
Virtual Forum participation annual education credits LMS
150 LMS Courses that count for Patient Safety Credit
Annually
Posted.
Launched
Staff Patient Safety Education credit.
Ongoing
Feb 2012
October 2012
Fall 2011
Performance
Excellence
Performance
Excellence
District Quality
Patient Safety
Council
Performance
Excellence
DMAC Quality
Performance
Excellence
Ongoing
Completed
Completed
In Place
Ongoing
In Place
Ongoing
Domain 2: Work in Teams for Patient Safety
High Priority Criteria:
Client Safety: Roles and Responsibilities
- Incorporate Patient Safety into performance
appraisals & job descriptions
Tracking Progress District Quality Patient Safety
Council/ DMAC Quality
Awaiting on an appointment from Human
Resources- Staffing changes resulting in delay
Patient Safety education tracked in LMS by
employee number
Fall 2013 Human Resources &
Patient Safety Team
Rep
Performance
Excellence
District Quality
Patient Safety
Council
In Progress
Capital Health Patient Safety Plan 2011/12-2014/15
APPENDIX A
Performance Excellence July 2014 5
Key Objectives – Safety Competencies
Quality Dimension: Safety
ROP: Required Organizational Practice
Progress Target Date Responsibility Status
DMAC Quality
ROP: Information Transfer
Safety huddles to exchange feedback on safety issues
- Information Transfer Audits (Safety Huddles)
- Transfer shift/unit/episodic care encounters
-
- CHSRF/EXTRA project information transfer at discharge:
Process to Improve Quality + Timeliness of Information Transfer
between Inpatient + Primary Care Physicians at Hospital Discharge
Patient Information Transfer – physician focus
- Improving Quality of Care in Transitions is a Capital Health area
of focus for 2013 – 2016.
Tracking Progress District Quality Patient Safety
Council/ DMAC Quality
Education roll-out completed. Episodic Care June
2011.
This includes three initiatives:
1. Safe patient information transfer
2.Electronic discharge tool implementation (this
began as an EXTRA project) – rollout in the
organization underway
3.Improve transitions of care for individuals with
chronic conditions from the child-based to adult-
based system project underway to improve physician
to physician information transfer at the following
transitions:
1. ED transition: ED transfer form developed and on
Fall 2011
Spring 2013
December
2013
Fall 2013
Summer 2014
Transfer of
Accountability Team
Dr. Stavros
Savvopoulis, Sandra
Janes, Dr. Stephanie
Connidis
Dr. Bruce Josephson/
Gail Blackmore
In Place
Ongoing
Completed
Completed
Complete
Capital Health Patient Safety Plan 2011/12-2014/15
APPENDIX A
Performance Excellence July 2014 6
Key Objectives – Safety Competencies
Quality Dimension: Safety
ROP: Required Organizational Practice
Progress Target Date Responsibility Status
-
District Dept of Family Practice site, Nightingale and
Practimax version developed, Expects notice in
EDIS, ED charge physician contact information
provided for verbal notification
2. Change in level of care transition: Approval for
development of e-Transfer form
3. Handover: Physician and resident workshops
completed with CMPA Oct 2012, resident
orientation, approval for development of electronic
handover process for ICU
4. Discharge transition: 1000 chart audit for
inclusion of 5 quality requirements in 2012, 2014,
2015 and 2016
A Steering Committee will be formed for roll-out.
Communication – DMAC Quality, DMAC, LET,
Directors Network, CH Leaders, audit results to co-
leads, District Quality & Patients Safety Council
Winter 2014
Summer 2014
Fall 2013
Completed
In progress
Completed
2012, 2014
Completed
Completed
Patient Safety Area & Patient Safety Goal: Communication
Explore Teamwork models - Canadian Patient Safety
Institute (CPSI) Report.
Teamwork & Communications Report - Canadian
Patient Safety Institute (CPSI). Report reviewed at
Patient Safety Team Jan 2012.
Winter/Spring
2014/5
Patient Safety Team
In Progress
Capital Health Patient Safety Plan 2011/12-2014/15
APPENDIX A
Performance Excellence July 2014 7
Key Objectives – Safety Competencies
Quality Dimension: Safety
ROP: Required Organizational Practice
Progress Target Date Responsibility Status
ROP: Client & Family Role in Safety
Patient Engagement on Quality /Patient Safety Teams
Tracking Progress District Quality Patient Safety
Council/ DMAC Quality
As of April 2013, 85% of Quality & Patient Safety
Teams / Councils (57/67) had patient and/or family
engagement.
Orientation and education sessions jointly developed
by Performance Excellence and Patient & Public
Engagement and provided to Healthcare Experience
Advisors. Sessions have been held in 2011, 2013 and
2014.
April 2013
Patient Safety &
Public Engagement
Performance
Excellence
District Quality
Patient Safety
Council
DMAC Quality
In Place
Ongoing
ROP: Workplace Violence Prevention
Conflict Management for patient safety Link with Conflict
Management program & Our Leadership
Teamwork & Communications Report - Canadian
Patient Safety Institute (CPSI) Report reviewed at
Patient Safety Team Jan 2012.
Policies& LMS education developed and introduced
.
Spring 2012
Fall 2012
Patient Safety Team
Organizational
Health
Completed
Completed
Capital Health Patient Safety Plan 2011/12-2014/15
APPENDIX A
Performance Excellence July 2014 8
Key Objectives – Safety Competencies
Quality Dimension: Safety
ROP: Required Organizational Practice
Progress Target Date Responsibility Status
Domain 3: Communicate Effectively for Patient Safety
ROP: Client Safety: Education and Training
- update and audit compliance – Admission form
ROP: Client and Family Role in Safety - Media monitor updates.
- Patient Education Channel ( in collaboration with
Patient Education)
- Brochure
- Lobby Poster Boards
Tracking Progress District Quality Patient Safety
Council/ DMAC Quality
Combined audit program in development.
Media Monitor slide in place.
Patient Education Channel in place.
Brochure available on-line & through Printing.
Communications & RMPS developed individual
posters & link to Patient Experience.
Summer 2013
Winter 2012
Spring 2012
Summer 2012
Performance
Excellence
Accreditation
Patient Safety Team
District Quality
Patient Safety
Council
DMAC Quality
In Place
Ongoing
In Place
Ongoing
Completed
Completed
ROP: Dangerous Abbreviations
ROP: Medication Reconciliation
(Admission/Discharge/Transfer)
Policy CH30-01 -Progress Reports – District Quality
Patient Safety Council & DMAC Quality quarterly
Tools Completed.
Audits in Progress.
Admission/Discharge - In place in all inpatient units.
Compliance audits in place.
Transfer- went live March 5/14. Audit Compliance.
Ambulatory- Fully implemented in Renal Program.
Resource Team meeting with remaining teams
June/July to finalize implementation plans
Summer 2012
Spring 2013
Fall 2013
December
2014
Pharmacy
District Quality
Patient Safety
Council
DMAC Quality
In Place
Ongoing
Completed
In Progress
In Progress
Capital Health Patient Safety Plan 2011/12-2014/15
APPENDIX A
Performance Excellence July 2014 9
Key Objectives – Safety Competencies
Quality Dimension: Safety
ROP: Required Organizational Practice
Progress Target Date Responsibility Status
ROP: Surgical Checklist (Operating Room Team Executive)
ROP: Information Transfer
ROP: Two Client Identifiers
- Clinical Documentation Policy (Update CH 70-040)
Patient identification Project Lab, PE and Professional
Practice.
Electronic Audit in place
In use HCH,DGH,QEII
Field created in HSM to document completion
Manual audits with Electronic audit being developed
Provincial Working Group
Patient/family focus group regarding discharge
transition
Tracking Quarterly Progress District Quality Patient
Safety Council/ DMAC Quality ( See Domain 2)
Policy Update in Progress – Patient Identification
Health Information Services & Risk Management
Patient Safety meeting with Department Health &
Wellness & Medavie Blue Cross sorted main issue.
Policy updated and campaign September 2013.
Literature review, best practice review, analysis of
data to identify areas doing well and opportunities
for improvement. Related work in ED’s in District.
Focus group meetings held with select clinical
managers to gain insight into barriers or processes
Nov 2012
Fall 2013
Summer 2013
Fall 2014
Accreditation Team
Transfer of
Accountability Team
Health Information
Services, Lab & Risk
Management Patient
Safety
DMAC Quality
District Quality &
Patient Safety
Council
In Place
Ongoing
In Place
Ongoing
Completed
In progress
Capital Health Patient Safety Plan 2011/12-2014/15
APPENDIX A
Performance Excellence July 2014 10
Key Objectives – Safety Competencies
Quality Dimension: Safety
ROP: Required Organizational Practice
Progress Target Date Responsibility Status
leading to incorrect Patient ID. Steering Committee
meeting scheduled for August 2014
ROP: Client Safety Quarterly Reports & Annual
Quarterly Patient Safety Checks – 20 minutes on
agenda Patient Safety Council to report on: Infection
Control, Patient Safety Elements Strategic Indicators
Report, Patient Safety Reporting System,
Accreditation, Medication Safety.
Patient Safety Scorecard
Tracking Quarterly Progress District Quality Patient
Safety Council/DMAC Quality
Ongoing revision
Fall 2011
Fall 2012
District Quality
Patient Safety
Council
DMAC Quality
In Place
Ongoing
In Place
Completed
ROP: Information Transfer
SBAR (Situation, Background, Assessment,
Recommendation) & read-back communication tools
Explore team communication model/vocabulary (see
Domain 2)
SBAR used in interdisciplinary communcation (e.g.
nurse to physician communication re patient issue)
Teamwork & Communications Report - Canadian
Patient Safety Institute (CPSI) Report reviewed at
Patient Safety Team Jan 2012.
Summer 2014
Patient Safety Team
District Quality
Patient Safety
Council
DMAC Quality
In Progress
Capital Health Patient Safety Plan 2011/12-2014/15
APPENDIX A
Performance Excellence July 2014 11
Key Objectives – Safety Competencies
Quality Dimension: Safety
ROP: Required Organizational Practice
Progress Target Date Responsibility Status
ROP: Client Safety: Education & Training
Health literacy/culture diversity as a Patient Safety issue
- Link with Diversity & Language Interpretation
See Domain 2.
Collaboration with Culture & Diversity.
Winter 2013/14
Public Engagement
In Progress
Domain 4: Manage Safety Risks
ROP: Hand Hygiene Audit
ROP: Infection Rates
- Reprocessing (Sterile Processing Department) –
reprocessing audits including compliance audit re-
use single-use item/flash sterilization. Formed &
TOR completed.
- IPAC /Housekeeping and Environmental Audits &
Leadership Rounds
- Review and respond to Infection Prevention Control
Nova Scotia Report: Preliminary Findings to
Clostridium Difficile Outbreak in Cape Breton
District Health Authority
- Plan for Response to Auditor General’s Report
Infection Control
- Compliance Patient Safety Act
Tracking Progress District Quality Patient Safety
Council /DMAC Quality
Tracking Progress District Quality Patient Safety
Council / DMAC Quality
Tracking Progress District Quality Patient Safety
Council/ DMAC Quality
Tracking Progress District Quality Patient Safety
Council/ DMAC Quality
Tracking Progress District Quality Patient Safety
Council
Spring 2013
Oct. 2011
Fall 2012
Ongoing
Spring 2013
Reprocessing
Committee
District Quality
Patient Safety
Council
DMAC Quality
District Infection
Prevention & Control
Committee
In Place
Ongoing
In Place
Ongoing
Completed
In Place
Ongoing
In Place
Ongoing
Capital Health Patient Safety Plan 2011/12-2014/15
APPENDIX A
Performance Excellence July 2014 12
Key Objectives – Safety Competencies
Quality Dimension: Safety
ROP: Required Organizational Practice
Progress Target Date Responsibility Status
High Priority Criteria: Verification High-risk processes
(changed Jan 2013)
Safely managing clinical processes (ie: double check &
allergy) Audit compliance.
Independent double-check policy MM 15-015
Tracking Progress District Quality Patient Safety
Council
PSRS event type under Medication Administration
for Independent Double-Check Issue.
High alert policy revised.
Summer 2013
May 2013
September
2013
Patient Safety Team/
Pharmacy
District Quality
Patient Safety
Council
DMAC Quality
Nursing/Pharmacy
Committee
In Place
Ongoing
Completed
Completed
ROP: Patient-Safety Related Prospective Analysis
- Leadership Safety Rounds
- Patient Safety Risk Assessments(Hazard Analysis)
Tracking Progress District Quality Patient Safety
Council/DMAC Quality
Tracking through Pt Safety Reporting System
Reports as completed:
- ERCP: March 2011
- CV & Pulmonary Hearts in Motion: July 2011
- Rehab Hydrotherapy Pool : January 2012
- OMF Clinic: March 2012
- Cardiac Cath Clinic: April 2012
- MHP Community Transitions Program: Jan 2013
Spring 2011
April 2013
Ongoing
Performance
Excellence
Risk Management/
Patient Safety
In Place
Ongoing
Completed
In Place
Ongoing
Capital Health Patient Safety Plan 2011/12-2014/15
APPENDIX A
Performance Excellence July 2014 13
Key Objectives – Safety Competencies
Quality Dimension: Safety
ROP: Required Organizational Practice
Progress Target Date Responsibility Status
- FMEA
- IRM: Integrated (Enterprise) Risk Management
Assessment
- Quality Review (see: Canadian Incident Analysis
Framework)
- Integrated Quality Framework
- A&MHP Inpatient & Outpatient Opioid Treatment
Program: February 2013
- Offender Health Unit : April 2013
- ER Triage & Registration: August 2013
- VG Day Patient Surgery: September 2013
-Transfer to a Tertiary Care Center
-Medication Transcription (Top 5 PSRS)
High Level Board Risk Assessment
Tracking Progress District Quality Patient Safety
Council/ DMAC Quality
See also: Sustainability Oversight Committee of the
Board
Quality Review policy (Draft in pilot)
Feedback from District Quality & Patient Safety
Council incorporated
Revised.
November
2012
Fall/Winter
2013
Ongoing
Winter 2014
October 2013
Performance
Excellence
Performance
Excellence
District Quality
Patient Safety
Council
DMAC Quality
Performance
Excellence
Performance
Excellence
Completed
In Progress
Completed
In Progress
Completed
Capital Health Patient Safety Plan 2011/12-2014/15
APPENDIX A
Performance Excellence July 2014 14
Key Objectives – Safety Competencies
Quality Dimension: Safety
ROP: Required Organizational Practice
Progress Target Date Responsibility Status
Audit Compliance for:
ROP: Concentrated electrolytes
ROP: Heparin Safety
ROP: Narcotics Safety
Tracking Progress District Quality Patient Safety
Council/ DMAC Quality
Policy MM20-001 KCL for IV Infusion
Policy MM50-003 Med Rec at Discharge
Policy 50-010 High Alert Medications
Policy MM15-015 Independent Double-
Check
Single-dose product selection
Quotas evaluated/restrictions developed
High-potency removed (5 ml vials removed)
Use of single unit syringes
MM35-001 Narcotic & Controlled Drugs
MM50-010 High Alert medications
MM15-015 Independent Double Check
Standardized narcotic forms/strengths
High-potency Hydromorphone removed
Ongoing
Ongoing
Ongoing
Pharmacy
District Quality
Patient Safety
Council
DMAC Quality
Performance
Excellence-
Accreditation
Pharmacy
District Quality
Patient Safety
Council
DMAC Quality
Performance
Excellence-
Accreditation
Pharmacy
District Quality
Patient Safety
Council
In Place
Ongoing
In Place
Ongoing
In Place
Ongoing
Capital Health Patient Safety Plan 2011/12-2014/15
APPENDIX A
Performance Excellence July 2014 15
Key Objectives – Safety Competencies
Quality Dimension: Safety
ROP: Required Organizational Practice
Progress Target Date Responsibility Status
ROP: Medication Concentrations
(Challenge: Manufacturing back-orders )
ROP: Infusion Pumps
(Exp. Palliative Care &SQ low-volume)
Morphine 15m/ml removed.
Oral narcotic liquids one strength.
Standardized packaging with TALL man
lettering. High alert overwrap.
MM35-001 Narcotic & Controlled Drugs
MM25-030 Ward Stock Inpatient Units &
Clinics
Ward stock review annual audit
Standardized narcotic forms/strengths.
Oral narcotic liquids-one strength.
Standardization of insulin project.
Therapeutic inter-changes developed
Standardization of pump.
Training policy pending
LMS Module
Policy revised March 2014
Ongoing
Ongoing
DMAC Quality
Performance
Excellence-
Accreditation
Pharmacy
District Quality
Patient Safety
Council
DMAC Quality
Performance
Excellence-
Accreditation
Professional Px
District Quality
Patient Safety
Council
DMAC Quality
Performance
Excellence-
Accreditation
In Place
Ongoing
In Place
Ongoing
Capital Health Patient Safety Plan 2011/12-2014/15
APPENDIX A
Performance Excellence July 2014 16
Key Objectives – Safety Competencies
Quality Dimension: Safety
ROP: Required Organizational Practice
Progress Target Date Responsibility Status
High Priority Criteria: Pneunococcal Vaccine
IC 06-075 Pneumococcal Immunizations in
LTC Setting
SEE ALSO: CDHA Implementation Map for
Required Organizational Practices (ROP) Tracking.
Completed
ROP: Client Safety: Education & Training
- Teamwork & Communications Report
Rapid response/rapid escalation protocol
Teamwork & Communications Report - Canadian
Patient Safety Institute (CPSI) Report reviewed at
Patient Safety Team
Evaluation (Safer Health Now)
January 2012
Fall 2012
Resuscitation
Committee
District Quality
Patient Safety
Council
DMAC Quality
Completed
In Place
Ongoing
ROP: Home Safety Risk Assessment
Tracking Quarterly Progress District Quality Patient
Safety Council/ DMAC Quality
Ongoing
District Quality
Patient Safety
In Place
Ongoing
Capital Health Patient Safety Plan 2011/12-2014/15
APPENDIX A
Performance Excellence July 2014 17
Key Objectives – Safety Competencies
Quality Dimension: Safety
ROP: Required Organizational Practice
Progress Target Date Responsibility Status
ROP: Pressure Ulcer Prevention
ROP: Falls Prevention Strategy
ROP: Venous Thromboembolism (VTE) Prophylaxis
ROP: Suicide Prevention
Prevalance study completed
CEHQ Pilot Study – data submitted to CIHI
Working group meeting since Fall 2013
Developing a Falls Prevention & Quality
Patient Safety Team
Organizational falls data provided, draft
TOR, feedback session with directors
Decision Support calculating falls rates
VTE policy completed
Implementation Survey
results demonstrate follow up required
regarding full implementation of policy
(assessment and patient education)
Tracking Quarterly Progress District Quality Patient
Safety Council/ DMAC Quality
SEE ALSO: CDHA Implementation Map for
Required Organizational Practices (ROP) Tracking.
January 2014
April 2014
Complete
Complete
Fall 2014
Council
DMAC Quality
Performance
Excellence-
Accreditation
In place-
Ongoing
Capital Health Patient Safety Plan 2011/12-2014/15
APPENDIX A
Performance Excellence July 2014 18
Key Objectives – Safety Competencies
Quality Dimension: Safety
ROP: Required Organizational Practice
Progress Target Date Responsibility Status
Domain 5: Optimize Human & Environmental Factors
ROP: Client Safety: Education & Training
Understanding of how work conditions affect Pt Safety
- Sound, light, surge conditions, work interuptions
- Situational awareness
- Leadership Safety Rounds
(see Domain 2)
- Implementation /Structure Joint Occupational Health
& Safety Committee/ Safety Committee’s
ROP: Preventative Maintenance Program (Facilities
Engineering Policy CH 90-010)
Bed Model & Work OrderTracking Repairs:
High Priority Criteria: Influenza Vaccine ( Policy Ch -080)-
staff rates
Tracking Progress twice per year District Quality
Patient Safety Council/ Tracking Quarterly Progress
District Quality Patient Safety Council/ DMAC
Quality/ Board Annual Report
Teamwork & Communications Report - Canadian
Patient Safety Institute (CPSI) Report reviewed at
Patient Safety Team Jan 2012.
Existing Joint Occupational Health & Safety Council
in place until December 2011.
Database Tracking
All beds inventoried by make, model & serial # and
added to Work Order System.
Tracking through Organizational Health annually.
Fall 2014
Winter 2012
Ongoing
Summer 2013
Ongoing
Patient Safety Team
District Quality
Patient Safety
Council
DMAC Quality
Organizational
Health
Biomedical
Engineering
Maint & Operations
Infection Control,
Organizational
Health
In Progress
In Progress
In Progress
Completed
In Place
Ongoing
Completed
In Place
Ongoing
Ongoing
Capital Health Patient Safety Plan 2011/12-2014/15
APPENDIX A
Performance Excellence July 2014 19
Key Objectives – Safety Competencies
Quality Dimension: Safety
ROP: Required Organizational Practice
Progress Target Date Responsibility Status
Patient Safety Area Worklife/Workforce
PS Goal: Create a worklife and physical environemnt that
supports safe delivery of care and service.
Incorporate Patient Safety, ergonomics, workflow analysis
and human factors in new design/build and renovations.
- Established regular meetingswith Facilities
- Standing specifications in Request for Proposals
(RFP) & contracts reflect best practices in Patient
Safety.
- Review of Alerts/Recall Medical Device/Clinical
Products Process
- Clinical Product Concern reporting in PSRS
Contract Process has been moved to a provincial
level with Merged Services.
Procurement meeting with Health Pro re: process.
Policy & Process re-design
- For presentation at LET Prof Px &
Procurement
Improve reporting and sharing of CPC. Facilitate
reporting to Sentinel Medical Device Project.
Unknown
(Province)
Winter 2014
November
2013
Procurement
Risk Management/
Patient Safety
Biomedical Eng
Procurement
Risk Management/
Patient Safety
Professional Practice
Biomedical Eng
Procurement
Risk Management/
Patient Safety
Completed
Completed
Domain 6: Recognize, Respond to & Disclose AE’s (Patient Safety Incidents)
ROP: Adverse (Patient Safety Incident) Events Reporting
Define and recognize patient safety events and near miss
events and followup after event:
Tracking Progress District Quality Patient Safety
Council/ DMAC Quality
Ongoing
District Quality
Patient Safety
Council
DMAC Quality
In Place
Ongoing
Capital Health Patient Safety Plan 2011/12-2014/15
APPENDIX A
Performance Excellence July 2014 20
Key Objectives – Safety Competencies
Quality Dimension: Safety
ROP: Required Organizational Practice
Progress Target Date Responsibility Status
- Leadership Training & checklist for following up
events
- Revise Patient Safety Reporting System - Learning
Management System (LMS) module
ROP: Adverse (Patient Safety Incidents)Events Disclosure
- Development of pocket tools and education for staff
- Patient education brochure
- Learning Management System module on disclosure
- Grand Rounds Disclosure
Manager 101 developed and distributed.
Course delivered : Oct 2011 X2; May & June 2012;
Feb 2013;June 2013.
Manager 101 developed and distributed online.
Revision after Patient Lookup Process
Developed. Available online and through Printing.
On public website
Developed and posted to LMS
Canadian Disclosure Guidelines – Canadian Patient
Safety Institute Update – Version 2 (2010).
Delivered with CMPA.
Ongoing
Ongoing
March 2014
October 2011
Summer /Fall
2012
Legal/Quality/Risk
Management/Patient
Safety
Risk Management/
Patient Safety
Risk Management/
Patient Safety
District Quality
Patient Safety
Council
DMAC Quality
Risk Management/
Patient Safety
Completed
Ongoing
Completed
Completed
Completed
Completed
Completed
Completed
Capital Health Patient Safety Plan 2011/12-2014/15
APPENDIX A
Performance Excellence July 2014 21
Key Objectives – Safety Competencies
Quality Dimension: Safety
ROP: Required Organizational Practice
Progress Target Date Responsibility Status
Review Canadian Incident Analysis Framework (formerly
Root Cause Analysis)
Quality Review Process (Coherence with Canadian Incident
Analysis Framework)
Trigger Tool evaluation
Draft document released & reviewed.
Patient Safety Team members participated in
Information Calls.
Final draft in pilot
Evaluation of systems
November
2012
Winter 2013/4
Winter 2014
Performance
Excellence
Performance
Excellence
Patient Safety Team
Completed
Completed
APPENDIX B
The Safety Competencies, Education & Required Organizational Practices Map
Performance Excellence – Patient Safety Team Feb 2012 1
Safety Domains Canadian Patient Safety
Institute
Safety Competencies
Canadian Patient Safety Institute
Patient Safety Area & Patient Safety Goal
Accreditation Canada
ROP
Accreditation Canada
Canadian Medical
Protective Association Education Provided By
Domain
Capital Health Education &
Resources By Domain
TBA (To be Announced – In Progress)
Domain 1:
Contribute to a Culture of Patient Safety
1. Commit to patient Provider safety through safe, competent, high-quality daily practice. 2. Describe the fundamental elements of patient safety. 3. Maintain and enhance patient safety practices through ongoing learning. 4. Demonstrate a questioning attitude as a fundamental aspect of professional practice and patient care.
Safety Culture: Create a culture of safety within the organization. Infection Control: Reduce the risk of health care-associated infections and their impact across the continuum of care and service. Worklife/Workforce: Create a worklife and physical environment that supports the safe delivery of care and service.
Adverse Events Disclosure Adverse Events Reporting Client Safety as a Strategic Priority (Patient Safety Plan & Just Culture)) Client Safety Quarterly Reports Client Safety-related Prospective Analysis (Canadian Framework for Managing Patient safety Incidents) Hand–hygiene Audit Hand-hygiene Education & Training Infection Control Guidelines Client Safety Plan Client Safety: Roles & Responsibilities Client Safety: Education & Training
Just Culture of Patient Safety – Core Elements Quality Improvement Accountability & Liability Practice Changes to Reduce Specialty Specific Risks Negligence Anatomy of a Lawsuit Mitigating Adverse Events
Our Promise Strategy Document Milestones CH Policy 70-006 Disclosure of Adverse Patient Safety Events & Harm CH Policy 100-035 Patient Safety Reporting System Canadian Disclosure Guidelines: Being Open with Patients & Families (CPSI 2011) Patient Safety Risk Assessment Overview Learning Management System: On-line Module Patient Safety Reporting System Learning Management System: On-line Module Disclosure (TBA) Learning Management System: On-line Module Just Culture (TBA)
APPENDIX B
The Safety Competencies, Education & Required Organizational Practices Map
Performance Excellence – Patient Safety Team Feb 2012 2
Safety Domains
Canadian Patient Safety Institute
Safety Competencies
Canadian Patient Safety Institute
Patient Safety Area & Patient Safety Goal
Accreditation Canada
ROP
Accreditation Canada
Canadian Medical
Protective Association Education Provided By
Domain
Capital Health Education &
Resources By Domain
TBA (To be Announced – In Progress)
Preventative Maintenance Program Workplace Violence Prevention
Learning Management System: On-line Module Orientation to Patient safety at Capital Health Learning Management System: On-line Module Video One Delivering Patient Safety Learning Management System: On-line Module Video Two –Delivering Patient Safety – Culture Learning Management System: On-line Module Video Three- Delivering Patient Safety – Understanding Error Learning Management System: On-line Module Workplace Violence Prevention and Non-Violent Crisis Intervention Learning Management System: On-line Video Six Building a Better System (TBA) Learning Management System: On-line Video Seven Leading & Learning
APPENDIX B
The Safety Competencies, Education & Required Organizational Practices Map
Performance Excellence – Patient Safety Team Feb 2012
3
Safety Domains
Canadian Patient Safety Institute
Safety Competencies
Canadian Patient Safety Institute
Patient Safety Area & Patient Safety Goal
Accreditation Canada
ROP
Accreditation Canada
Canadian Medical Capital Health Education &
Protective Association Resources By Domain Education Provided By
Domain TBA (To be Announced – In Progress)
(TBA) Tips & Tools Patient Safety Reporting System ( 3 Issues) Tips & Tools Disclosure Tips & Tools Just Culture
Domain 2:
Work in Teams for Patient Safety
1. Participate effectively and appropriately in an inter-professional health care team to optimize patient safety. 2. Meaningfully engage patients as the central participants in their health care teams. 3. Appropriately share authority, leadership, and decision-making. 4. Work effectively with other health care professionals to manage inter-professional conflict.
Communication: Improve the effectiveness and coordination of communication among care and service providers and with the recipients of care and service across the continuum. Worklife/Workforce: Create a worklife and physical environment that supports the safe delivery of care and service.
Client and Family Role in Safety Dangerous Abbreviations Information Transfer Medication Reconciliation* Safe Surgery Checklist Two Client Identifiers Verification Processes for High-risk Activities Teamwork & Communications Client Safety Plan Client Safety: Roles & Responsibilities Client Safety: Education &
Inter-professional Care Health Care Team: Team Member Roles & Responsibilities Scopes of Practice Delegation & Supervision of Non-Regulated Health Professions Enhancing Communication Skills to Deal with Handovers, Consultations, Continuity of Care etc. Intra-Professional Care Risk Management Strategies for Referrals & Consultations Effective Handover of Care: Communication is Essential
Clinical Policy 04-040 Clinical Documentation in the Health Record CH Policy 30-060 Transfer of Health Information CH Policy 70-040 Patient Identification & Same Name Alert (Under Revision) CH Policy 30-060 Transfer of Health Information Medication Policy 50-003 Medication Reconciliation Admission & Discharge DO NOT USE Abbreviations Pocket Card (Pharmacy TBA) Patient Safety Tips for Patients – Pocket Cards & Media Monitor
APPENDIX B
The Safety Competencies, Education & Required Organizational Practices Map
Performance Excellence – Patient Safety Team Feb 2012
4
Safety Domains
Canadian Patient Safety Institute
Safety Competencies
Canadian Patient Safety Institute
Patient Safety Area & Patient Safety Goal
Accreditation Canada
ROP
Accreditation Canada
Canadian Medical Capital Health Education &
Protective Association Resources By Domain Education Provided By
Domain TBA (To be Announced – In Progress)
Training Preventative Maintenance Program Workplace Violence Prevention
Supervision & Delegation Elements of Good Supervision & Delegation
Learning Management System: On-line Module Transfer of Accountability (Shift to Shift, Unit to Unit within CDHA and Episodic Care) Tips & Tools for Patient Identification Tips & Tools on Dangerous Abbreviations
Domain 3:
Communicate Effectively for Patient Safety
1. Demonstrate effective verbal and non-verbal communication abilities to prevent adverse events. 2. Communicate effectively in special high-risk situations to ensure the safety of patients. 3. Use effective written communications for patient safety. 4. Apply communication technologies appropriately and effectively to provide safe patient care.
Communication: Improve the effectiveness and coordination of communication among care and service providers and with the recipients of care and service across the continuum. Safety Culture: Create a culture of safety within the organization.
Client and Family Role in Safety Dangerous Abbreviations Information Transfer Medication Reconciliation* Safe Surgery Checklist Two Client Identifiers Verification Processes for High-risk Activities Client Safety as a Strategic Priority (Patient Safety Plan & Just Culture)) Client Safety Quarterly Reports
Communication with Patients Principles of Patient-Centered Care Disclosure of Adverse Events Dealing with Difficult Patient Behaviours Ending the Doctor-Patient Tips & Tools on Dangerous Abbreviations DO NOT USE Abbreviations Pocket Card (Pharmacy TBA) Relationship Informed Consent
Patient Safety Tips for Patients – Pocket Cards & Media Monitor Canadian Framework for Teamwork & Communications (CPSI 2011) Literature & Tool Review CH Policy 30-060 Transfer of Health Information Medication Policy 50-003 Medication Reconciliation Admission & Discharge Learning Management System: On-line Module Transfer of Accountability (Shift to Shift, Unit to Unit within CDHA and Episodic
APPENDIX B
The Safety Competencies, Education & Required Organizational Practices Map
Performance Excellence – Patient Safety Team Feb 2012
5
Safety Domains
Canadian Patient Safety Institute
Safety Competencies
Canadian Patient Safety Institute
Patient Safety Area & Patient Safety Goal
Accreditation Canada
ROP
Accreditation Canada
Canadian Medical Capital Health Education &
Protective Association Resources By Domain Education Provided By
Domain TBA (To be Announced – In Progress)
Teamwork & Communications
Elements of Informed Consent Informed Discharge Elements of Informed Discharge Confidentiality & Privacy Understanding the Duty of Confidentiality Mandatory Reporting Requirements Documentation: Good Documentation A Guide Electronic Communications Email Communication the Risks Risk Management Strategies for Telehealth
Care)
Domain 4:
Manage Safety Risks
1. Recognize routine situations and settings in which safety in which safety problems may arise. 2. Systematically identify, implement, and evaluate
Medication Use: Ensure the safe use of high-risk medications.
Concentrated Electrolytes Heparin Safety Infusion Pumps Training Medication Concentrations
Medication Issues Risk Reduction Strategies to Decrease Medication Adverse Events Risks of Narcotics: Risks &
Medication Policy 50-010 High Alert Medication Medication Policy 35-001 Narcotics & Controlled Drugs Medication Policy 20-001
APPENDIX B
The Safety Competencies, Education & Required Organizational Practices Map
Performance Excellence – Patient Safety Team Feb 2012 6
Safety Domains
Canadian Patient Safety Institute
Safety Competencies
Canadian Patient Safety Institute
Patient Safety Area & Patient Safety Goal
Accreditation Canada
ROP
Accreditation Canada
Canadian Medical
Protective Association Education Provided By
Domain
Capital Health Education &
Resources By Domain
TBA (To be Announced – In Progress)
context-specific safety solutions. 3. Anticipate, identify, and manage high risk situations.
Infection Control: Reduce the risk of health care-associated infections and their impact across the continuum of care and service. Risk Assessment: Identify safety risks inherent in the client population.
Narcotics Safety Hand–hygiene Audit Hand-hygiene Education & Training Infection Control Guidelines Infection Rates Influenza Vaccine Pneumococcal Vaccine Sterilization Processes Falls Prevention Strategy Home Safety Risk Assessment Pressure Ulcer Prevention Suicide Prevention Venous Thromboembolism (VTE) Prophylaxis Teamwork & Communications
Approaches Checklists & Guidelines Indications for Checklists Using Checklists Clinical Guidelines: Development & Usage Clinical Guidelines: Risks & Benefits Recognize the Importance of Hospital Policies & Bylaws Waitlists: Dealing with Constraints Duty of Care for Orphaned Patients Tracking Investigative Reports & Assuring Appropriate Patient Follow-Up
Potassium Chloride for Intravenous Infusion Medication Policy 25-030 Ward Stock – Inpatient Units & Clinics Medication Policy 50-003 Medication Reconciliation Admission & Discharge Learning Management System: On-line Module 4 Moments of Hand Hygiene Learning Management System: On-line Module Video Operating Room Fire Prevention Learning Management System: On-line Video Four Why Things go Wrong (TBA) Learning Management System: On-line Video Five Building Resistance to Error (TBA) Infection Control Policy 06-016 Hand Hygiene for Health Care Providers Infection Control Policy 01-001 Infection Control Department
APPENDIX B
The Safety Competencies, Education & Required Organizational Practices Map
Performance Excellence – Patient Safety Team Feb 2012 7
Safety Domains
Canadian Patient Safety Institute
Safety Competencies
Canadian Patient Safety Institute
Patient Safety Area & Patient Safety Goal
Accreditation Canada
ROP
Accreditation Canada
Canadian Medical
Protective Association Education Provided By
Domain
Capital Health Education &
Resources By Domain
TBA (To be Announced – In Progress)
Safety Culture: Create a culture of safety within the organization.
Client Safety-related Prospective Analysis (Canadian Framework for Managing Patient safety Incidents)
Infections Control Policy 06-075 Pneumococcal Immunization in LTC Settings Infection Control Policy 08-001 Cleaning Disinfection Sterilization Principles Clinical Policy 55-045 Skin & Wound Assessment & Documentation Clinical Policy 05-045 Falls Prevention – Inpatients Clinical Policy 05-046 Falls Prevention Ambulatory Care Areas Pre-Printed Order 0259- VTE Prophylaxis Pre-Printed Order 0311 – VTE Prophylaxis Orthopedics VTE Memo Learning Management System: On-line Module Transfer of Accountability (Shift to Shift, Unit to Unit within CDHA and Episodic Care)
APPENDIX B
The Safety Competencies, Education & Required Organizational Practices Map
Performance Excellence – Patient Safety Team Feb 2012 8
Safety Domains
Canadian Patient Safety Institute
Safety Competencies
Canadian Patient Safety Institute
Patient Safety Area & Patient Safety Goal
Accreditation Canada
ROP
Accreditation Canada
Canadian Medical Capital Health Education &
Protective Association Resources By Domain Education Provided By
Domain TBA (To be Announced – In Progress)
Tips & Tools Pain Assessment Tips & Tools Blood Special Needs Canadian Framework for Teamwork & Communications (CPSI 2011) Literature & Tool Review
Domain 5:
Optimize Human and Environmental Factors
1. Describe the individual and environmental factors that can affect human performance. 2. Apply techniques in critical thinking to make decisions safely. 3. Appreciate the impact of the human/technology interface on safe care.
Worklife/Workforce: Create a worklife and physical environment that supports the safe delivery of care and service.
Client Safety Plan Client Safety: Roles & Responsibilities Client Safety: Education & Training Preventative Maintenance Program Workplace Violence Prevention
Human Factors and Their Role in Patient Safety Cognitive Dispositions in Diagnosis or Misdiagnosis (Specialty Specific) Mechanisms for Tracking Investigations & Following Up Patients Conduct & Boundary Violations Principles of Appropriate Conduct Identification of “At Risk” Situations Preventing Boundary Violations
CDHA Patient Safety Plan CH Policy 90-010 Biomedical Engineering Medical Instrumentation Management Program CH Policy Workplace Employee Hazards and Incidents – Reporting, Investigation, and Documentation CH Policy 80-095 Violent Behaviour by Patient & Visitors Tips & Tools Medical Devices
APPENDIX B
The Safety Competencies, Education & Required Organizational Practices Map
Performance Excellence – Patient Safety Team Feb 2012 9
Safety Domains
Canadian Patient Safety Institute
Safety Competencies
Canadian Patient Safety Institute
Patient Safety Area & Patient Safety Goal
Accreditation Canada
ROP
Accreditation Canada
Canadian Medical Capital Health Education &
Protective Association Resources By Domain Education Provided By
Domain TBA (To be Announced – In Progress)
Physician Wellness Supports for Physicians Coping with Adverse Events, Complaints & Litigation Ethical Research Considerations
Domain 6:
Recognize, Respond to, & Disclose Adverse Events
1. Recognize the occurrence of an adverse event or near miss. 2. Mitigate harm and address immediate risks for patients and others affected by adverse events and near miss. 3. Disclose the occurrence of an adverse event to the patient and or their families as appropriate and in keeping with relevant legislation. 4. Report the occurrence of an adverse event or near miss. 5. Participate in timely event analysis, reflective practice and planning for the prevention or recurrence.
Safety Culture: Create a culture of safety within the organization.
Adverse Events Disclosure Adverse Events Reporting Client Safety as a Strategic Priority (Patient Safety Plan & Just Culture)) Client Safety Quarterly Reports Client Safety-related Prospective Analysis (Canadian Framework for Managing Patient safety Incidents) Teamwork & Communications
Just Culture of Patient Safety Assurance Activities: Structure & Function Framework for Approaching Adverse Events Disclosure of Adverse Events Principles of Disclosure
CH Policy 70-006 Disclosure of Adverse Patient Safety Events & Harm CH Policy 100-035 Patient Safety Reporting System Learning Management System: On-line Module Patient Safety Reporting System Learning Management System: On-line Module Disclosure (TBA) Learning Management System: On-line Module Just Culture (TBA) Tips & Tools Near Miss Events Tips & Tools Patient Safety Reporting System ( 3 Issues)
APPENDIX B
The Safety Competencies, Education & Required Organizational Practices Map
Performance Excellence – Patient Safety Team Feb 2012 10
Safety Domains
Canadian Patient Safety Institute
Safety Competencies
Canadian Patient Safety Institute
Patient Safety Area & Patient Safety Goal
Accreditation Canada
ROP
Accreditation Canada
Canadian Medical
Protective Association Education Provided By
Domain
Capital Health Education &
Resources By Domain
TBA (To be Announced – In Progress)
Tips & Tools Disclosure Tips & Tools Just Culture Canadian Framework for Teamwork & Communications (CPSI 2011) Literature & Tool Review Canadian Disclosure Guidelines: Being Open with Patients & Families (CPSI 2011) Canadian Framework for Managing Patient Safety Incidents (CPSI 2011) Draft
