Before the Incident
Patient safety and incident management plans and processes proactively developed and in place, together with active monitoring, analyzing, prioritizing and implementing actions to mitigate risks and improve quality and safety, contribute to effective response to both expected and unexpected safety issues.
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) by clearly outlining the aim, actions, accountabilities and resources (usually in a project charter format)
- Identify actions that are most likely to have the greatest impact in improving patient safety by consulting with internal stakeholders, reviewing external sources of evidence (e.g. alerts/ advisories/ recommendations/ best practices) and/or seeking expert opinion
- Whenever possible, 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 in developing care plans, sharing concerns and compliments, co-designing systems and processes, and implementing 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