Measuring and Improving Patient Safety in Canada
Patients, families, and care providers affected by patient safety incidents expect there will be learning and improvement so that others will not suffer. For that, countries need mature data systems and a culture of safety that includes improving by learning from reporting hazards, harm, and near misses, as well as learning from situations and organizations where safe care is delivered consistently over time, which is in most cases.
While systems are in place to support incident reporting, sharing, and learning from a variety of sources, in Canada truly national incident reporting is limited to medications, adverse drug reactions, and device failures. However, there are other pan-Canadian and grassroots efforts to advance reporting and learning from patient safety incidents that are complementary. System and contextual factors influence the ability to improve safety, learn, and report. An important one is the COVID-19 pandemic, which resulted in limited or delayed patient safety reporting and some scaling back of improvement projects.
The best systems incorporate reporting from multiple sources (patient feedback, coroner reports, etc.) and engage all people involved in care, especially patients and families, in their design, implementation, and continuous improvement. Patient groups, like Patients for Patient Safety Canada (PFPSC), provide the perspective of patients and families with lived experiences that can effectively improve safety. PFPSC contributes to the development of Canadian patient safety strategies, policies, and programs, and innovates and co-leads initiatives that matter to patients and the public.
The World Health Organization’s Global Patient Safety Action Plan includes patient safety incident reporting and learning systems to “ensure a constant flow of information and knowledge to drive the mitigation of risk, a reduction in levels of avoidable harm, and improvements in the safety of care” objective.
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RiskAnalytica. The Case for Investing in Patient Safety in Canada. Canadian Patient Safety Institute website. https://www.patientsafetyinstitute.ca/en/About/Documents/The%20Case%20for%20Investing%20in%20Patient%20Safety.pdf. Published August 2017. Accessed April 26, 2022.
Healthcare Excellence Canada. Status of Patient Safety Incident Legislation and Best Practices Across Canada: Summary Report. HEC website. https://healthcareexcellence.ca/media/pjehatzi/fpt_patientsafetylegislation_summaryreport_en.pdf. Published April 2021. Accessed April 26, 2022.
Davidson, MJ. Unintended Harms: How CIHI is Helping Canadians Receive Safer Care. Canadian Institute for Health Information website. https://www.cihi.ca/en/unintended-harms-how-cihi-is-helping-canadians-receive-safer-care. Published 2021. Accessed April 26, 2022.
Canadian Institute for Health Information. OECD Interactive Tool: International Comparisons — Patient Safety. https://www.cihi.ca/en/oecd-interactive-tool-international-comparisons-patient-safety. Published 2022. Accessed April 26, 2022.
Canadian Patient Safety Institute. The Measurement and Monitoring of Safety.CPSI website. https://www.patientsafetyinstitute.ca/en/toolsResources/Measure-Patient-Safety/Pages/default.aspx. Published 2017. Accessed April 26, 2022.
Patient Engagement Action Team. 2017. Engaging Patients in Patient Safety – a Canadian Guide. Canadian Patient Safety Institute. Last modified December 2019. Available at: https://www.healthcareexcellence.ca/en/resources/engaging-patients-in-patient-safety-a-canadian-guide
Canadian Institute for Healthcare Improvement (CIHI). 2016. Measuring Patient Harm in Canadian Hospitals. https://secure.cihi.ca/free_products/cihi_cpsi_hospital_harm_en.pdf
Canadian Institute for Health Information. Hospital Harm Project. CIHI website. https://www.cihi.ca/en/hospital-harm-project?_ga=2.55099755.1785108960.1640909324-1898624829.1636062717. Published October 21, 2021. Accessed April 22, 2022.
Canadian Patient Safety Institute. Hospital Harm Improvement Resource. CPSI website. https://www.patientsafetyinstitute.ca/en/toolsResources/Hospital-Harm-Measure/Improvement-Resources/Pages/default.aspx. Published August 2021. Accessed April 22, 2022.
CIHI, Healthcare Excellence Canada. 2021.Patient Harm in Canadian Hospitals? It Does Happen. Retrieved from: https://www.cihi.ca/en/patient-harm-in-canadian-hospitals-it-does-happen For more information, contact:Ioana Popescu, Director, Safety Strategies & Programs Healthcare Excellence CanadaIoana.Popescu@hec-esc.ca
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Canadian Institute for Health Information. Discharge Abstract Database, 2020–2021. CIHI website. https://www.cihi.ca/en/discharge-abstract-database-metadata-dad. Published 2021. Accessed April 26, 2022.
Public Health Agency of Canada. Canadian Nosocomial Infection Surveillance Program. Government of Canada website. https://www.canada.ca/en/public-health/services/publications/science-research-data/infographic-canadian-nosocomial-infection-surveillance-program.html. Updated July 5, 2021. Accessed April 26, 2022.
Health Canada. Overview of Vanessa’s Law. Government of Canada website. https://www.canada.ca/en/health-canada/services/drugs-health-products/legislation-guidelines/overview-vannessa-law-protecting-canadians-unsafe-drugs-act-vanessa-law-amendments-food-drugs-act.html. Updated November 6, 2014. Accessed April 22, 2022.
Health Canada. Mid-Year Update: Health Products Approved in 2021 – Adverse Reactions and Incidents. Government of Canada website. https://www.canada.ca/en/health-canada/services/drugs-health-products/highlights-reports/mid-year-update-2021.html#adverse. Updated October 4, 2021. Accessed April 22, 2022.
Canadian Institute for Healthcare Improvement. 2018.Canadian Medication Incident Reporting and Prevention System (CMIRPS). https://www.cmirps-scdpim.ca
Institute for Safe Medication Practices Canada. Canadian Medication Incident Reporting and Prevention System (CMIRPS). ISMP Canada website. https://www.ismp-canada.org/cmirps/index.htm. Published 2021. Accessed April 26, 2022.
Institute for Safe Medication Practices Canada. The National Incident Data Repository for Community Pharmacies (NIDR) Information and Frequently Asked Questions. ISMP Canada website. https://www.ismp-canada.org/CommunityPharmacy/NIDR/NIDR-faq.pdf. Published 2021. Accessed April 26, 2022.
Institute for Safe Medication Practices Canada.Updated Analysis and Shared Learning From COVID-19 Vaccine Errors. ISMP Canada Safety Bulletin. https://www.ismp-canada.org/download/safetyBulletins/2021/ISMPCSB2021-i8-Vaccine-Errors.pdf. Published August 26, 2021. Accessed April 26, 2022.
Institute for Safe Medication Practices Canada. Preventing Errors With COVID-19 Vaccines: Learning From Vaccine Incidents. ISMP Canada Safety Bulletin. https://www.ismp-canada.org/download/safetyBulletins/2021/ISMPCSB2021-i2-COVID19-Vaccine-Error-Prevention.pdf. Published February 25, 2021. Accessed April 26, 2022.
Institute for Safe Medication Practices Canada. Sentinel Medication Incident Results in Safer Product Labelling. ISMP Canada Safety Bulletin. https://www.ismp-canada.org/download/safetyBulletins/2021/ISMPCSB2021-i11-HYDROmorphone-label.pdf. Published December 14, 2021. Accessed April 26, 2022.
Canadian Association of Thoracic Surgeons CATS Database – Canadian Association of Thoracic Surgeons (canadianthoracicsurgeons.ca). Accessed May 11, 2022.
Canadian Association of Thoracic Surgeons. Best Practice Recommendations. https://www.canadianthoracicsurgeons.ca/best-practice/best-practice-recommendations/. Accessed April 26, 2022.
Children’s Hospitals Solutions for Patient Safety. Our Results Impact Report. SPS website. https://www.solutionsforpatientsafety.org/our-results. Updated 2021. Accessed April 22, 2022.
Solutions for Patient Safety (SPS) Learning Network. Central Line Associated Blood Stream Infections Rate: Canada Region Network Aggregate. 2021.
Indigenous Services Canada. https://www.canada.ca/en/indigenous-services-canada.html Accessed February 18, 2022.
Healthcare Excellence Canada, Healthcare Insurance Reciprocal of Canada, the Canadian Medical Protective Association. Surgical Safety in Canada: A 10-Year Review of CMPA and HIROC Medico-Legal Data. 2016. https://www.cmpa-acpm.ca/static-assets/pdf/research-and-policy/system-and-practice-improvement/SSC_Detailed_Analysis_Report-e.pdf
Accreditation Canada, the Healthcare Insurance Reciprocal of Canada, the Canadian Medical Protective Association, and Salus Global Corporation. Obstetrics Services in Canada: Advancing Quality and Strengthening Safety. Ottawa, ON: Accreditation Canada. 2016. https://www.cmpa-acpm.ca/static-assets/pdf/research-and-policy/system-and-practice-improvement/Obstetrics_Joint_Report-e.pdf
Organisation for Economic Cooperation and Development. Safe Acute Care – Workplace Culture and Patient Experiences. Health at a Glance 2021: OECD Indicators. OECD Publishing, Paris. DOI: 10.1787/48aa9909-en
Canadian Patient Safety Institute. Creating a Safe Space: Psychological Safety of Healthcare Workers (Peer to Peer Support and Other Support Models). 2020. Available from: https://www.patientsafetyinstitute.ca/en/toolsResources/Creating-a-Safe-Space-Psychological-Safety-of-Healthcare-Workers/Pages/creating-a-safe-space-addressing-the-psychological-safety-of-healthcare-workers-2020-01-06.aspx
Canadian Patient Safety Institute. Watch on Demand:Reimagining Healing After Healthcare Harm: The Potential for Restorative Practices. 2020.Available from: https://www.patientsafetyinstitute.ca/en/toolsResources/Pages/Reimagining-Healing-After-Healthcare-Harm-2020-07-10.aspx
Vincent C, Burnett S, Carthey J. In Brief: The Measurement and Monitoring of Safety. The Health Foundation. 2013. Available from: https://www.health.org.uk/publications/the-measurement-and-monitoring-of-safety