This section of the Patient Safety and Incident Management Toolkit provides an integrated set of resources that focus on what actions to take – both immediate and ongoing – following patient safety incidents (including near misses). The resources support people responsible for incident management to respond to incidents and reduce the harm to patients/families and providers when they occur.
Below is a description of the incident management components. Click the hyperlinked text to access guidance and resources.
Immediate response includes the care, support, and communication actions to take immediately following an incident, to mitigate further patient harm and ensure that patients/families and providers are safe. Continue the immediate response throughout the incident management process, where appropriate, to promote healing, recovery and learning.
Disclosure is a formal process in which a patient/family and members of the healthcare team openly discuss a patient safety incident. Disclosure provides the means for dialogue throughout the incident management process, supports patient safety improvement and promotes healing for the patients/families involved.
Support care providers. An ever-growing body of evidence demonstrates that healthcare workers feel distressed after a patient safety incident. There is emerging recognition of the potential negative impact of this on both their health and patient safety. Healthcare organizations are seeking ways to support all people impacted by a patient safety incident.
Prepare for analysis consists of a preliminary review to determine the appropriate follow-up and whether a system-based incident analysis is needed. If it is, the organization selects an incident analysis method, team and approach and conducts initial interviews. The findings, actions and decisions made at this point in the incident management process influence the direction and effectiveness of the analysis process.
Analysis process is a structured process, focused on system improvement, through which people can 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. Analysis is a core component of incident management, therefore it is important to ensure it is thorough, fair, unbiased and the recommended actions provide effective safety solutions.
Follow-through involves the organization implementing the final recommended actions, monitoring their impact on patient safety and, when the goals and sustainability are achieved, integrate them in ongoing operations. This step creates change and improvement, it takes a longer period of time, and it is vital in demonstrating that the incident management process improved safety and quality of care for patients.
Close the loop/share learning involves people sharing what was learned from a systems analysis, both within an organization and beyond, in order to make care safer, prevent the same type of event recurring and promote trust and healing. This concluding step, which applies to both patient safety and incident management, offers a valuable opportunity for people to reflect and identify opportunities to further improve quality and safety outcomes for patients, as well as the systems and processes supporting these outcomes.