In this resource :

Resources and Recommended Readings 

Accreditation Canada. Canadian Health Accreditation Report: Building a stronger health system through leadership. Ottawa, ON: Accreditation Canada; 2014. (Report, 25 pages) 

Accreditation Canada. 

• Disclosure of Harm - procedure (2011) 
• Preparing for disclosure meetings (Guide, 2 pages) 
• Communicating with the patient/family 
• Supporting patients and families involved in adverse events
• Supporting physicians and staff involved in adverse events (Guide, 2 pages) 
• Coaching and mentoring 
• Approaching challenges 

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)

Patients for Patient Safety Canada (CPSI). Father’s Death Fuels Quest for Healthcare Improvement. 2014 (Video) 

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

Capital Health. Patient Safety – Be Involved.  (Guide for patients/families) 

Dickson G, Lindstrom R, Black C, Van der Gucht D. Management in Canadian Healthcare Organizations. Ottawa, ON: Canadian Health Services Research Foundation; 2012. (Report, 32 pages) 

Duchscherer C, Davies JM. Systematic Systems Analysis: A practical approach to patient safety reviews. Calgary, AB: Health Quality Council of Alberta; 2013.  (Guide, 76 pages) 

Etchells E, Koo M, Daneman N, McDonald A, Baker M, Matlow A, Krahn M. Comparative Economic Analyses of Patient Safety Improvement Strategies in Acute Care: A systematic review. BMJ Qual Saf. 2012; 21: 448-456. doi:10.1136/bmjqs-2011-000585. (Journal article, open access) 

Frank JR, Brien S, (editors) on behalf of The Safety Competencies Steering Committee. The Safety Competencies: Enhancing patient safety across the health professions. Ottawa, ON: Canadian Patient Safety Institute, 2008. (Guide, 56 pages) 

Health Canada. Protecting Canadians from Unsafe Drugs Act (Vanessa’s Law). 2014. (Legislation) 

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

Health Canada, Health Canada’s Role  in the Management and Prevention of Harmful Medication Incidents, 2011 (Guide) 

Health PEI. Critical Incident Staff Support (CISS) Managers' Toolkit. (Toolkit) 

Health Quality Council of Alberta (HQCA). Continuity of Patient Care Study. Calgary, AB: HQCA; 2013. (Report) 

Health Quality Council of Alberta (HQCA). Patient Safety Framework for Albertans: Provincial framework 2010. Calgary, AB: HQCA; 2010. (Guide, 24 pages) 

Health Quality Council of Alberta. Disclosure Framework, 2006  (Guide, checklist, poster) 

Health Quality Council of Alberta. Checklist for Disclosure Team Discussion. (Checklist, 1 page) 

Healthcare Insurance Reciprocal of Canada (HIROC), Policy, Procedure and  Guideline Development (Guide) 

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. 

Institute for Safe Medication Practices Canada (ISMP Canada). Canadian Medication Incident Reporting and Prevention System (CMIRPS) Program. ISMP Canada. (Program, reporting tools) 

Institute for Safe Medication Practices Canada (ISMP). Designing effective recommendations. In: Ontario Critical Incident Learning. 2013; April(Issue 4). (Guide, 2 pages) 

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

Legislative Assembly of Ontario. Tommy Douglas Act (Patients’ Bill of Rights), 2003. (Legislation) 

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) 

Patients for Patient Safety Canada (CPSI). Claire Inspires Change After her Passing. 2011 (Video) 

Province of Alberta. Regional Health Authorities Act - Patient Concerns Resolution. Alberta Regulation 124/2006. (Legislation) 

Renfrew Victoria Hospital, Disclosure of Adverse Events and Adverse Outcomes, General Policy (Policy) 

Royal College of Physicians and Surgeons of Canada. ASPIRE: Advancing safety for patients in residency education. (Learning program, $) 

Royal College of Physicians and Surgeons of Canada. Competence by Design: Reshaping Canadian medical education. 2014. (Report, 141 pages) 

Safer Healthcare Now! Improvement Frameworks: Getting started kit. 2011. (Guide, 54 pages) 

Safer Healthcare Now! Interventions. Canadian Safer Healthcare Now: 2012. (Program, guides, tools) 

Saskatchewan Ministry of Health. Patient and Family‐Centred Care Resources and Tools. 2011. (Toolkit, 33 pages) 

Saskatoon Health Quality Council. Quality Insight. (Program, indicators, videos, resources) 

The Canadian Medical Protective Association (CMPA). Good Practice Guide. Ottawa, ON: CMPA (Guide) 

The Canadian Medical Protective Association (CMPA). Good Practices Guide: Patient safety. Ottawa, ON: CMPA. (Guide) 

The Canadian Medical Protective Association, Royal College of Physicians and Surgeons of Canada, The College of Family Physicians of Canada, Canadian Medical Association. Improving Patient Safety Through Disclosure and Quality Improvement Reviews. 2012. (Report, 14 pages) 

The Canadian Nurses Protective Society. Quality Documentation: Your Best Defence. (Guide) 

The Hospital for Sick Children, Management of Serious Patient Safety Incidents, 2013  (Policy) 

The Health Foundation. The Measurement and Monitoring of Safety. 2013. http://www.health.org.uk/publications/the-measurement-and-monitoring-of-safety/ (Report, 92 pages) 

The Perley and Rideau Veteran’s Health Centre, Safety Incident Flow Chart (Guide, 1 page) 

University of Calgary, Health Quality Council of Alberta. Patient Safety and Quality Management. (Learning program) 

Vincent C,  Taylor-Adams S, Chapman EJ, Hewett D, Prior S, Strange P, Tizzard A. How to investigate and analyse clinical incidents: clinical risk unit and association of litigation and risk management protocol. BMJ. 2000; 320(7237): 777-81. (Journal article, open access) 

Agency for Healthcare Research and Quality (AHRQ). AHRQ Patient Safety Tools and Resources. Rockville, MD: AHRQ; 2015. (Toolkit) 

Agency for Healthcare Research and Quality (AHRQ). AHRQ Web M&M: Morbidity and mortality rounds on the web. (Collection of cases) 

Agency for Healthcare Research and Quality (AHRQ). CUSP Toolkit. (Toolkit) 

Agency for Healthcare Research and Quality (AHRQ). Guide to Patient and Family Engagement in Hospital Quality and Safety. Rockville, MD: AHRQ; 2013. (Toolkit, guide) 

Agency for Healthcare Research and Quality (AHRQ). TeamSTEPPS. Rockville, MD: AHRQ. (Guide, tool) 

Agency for Healthcare Research and Quality (AHRQ). Voluntary Patient Safety Event Reporting (Incident Reporting). (Guide) 

Australian Commission on Quality and Safety in Health Care. Open Disclosure. 2013. (Guide, tools) 

• Open Disclosure Resources for Clinicians and Health Care Providers. 2013.
• Open Disclosure Resources for Health Service Organisations. 2013.
• Bader and Associates Governance Consultants. 7 Things Your Board Can do to Improve Quality and Patient Safety. 2006. (Article, 5 pages)

Berenholtz SM, Hartsell TL, Pronovost PJ. Learning from defects to enhance morbidity and mortality conferences. Am J Med Qual. 2009; 24(3): 192-5. (Journal article, abstract only) 

Boston Consulting Group (BCG). “The Hard Side of Change Management” DICE – How to beat the odds in program execution. (Tool) 

Briner M, Kessler O, Pfeiffer Y, Wehner T, Manser T. (2010). Assessing hospital's clinical risk management: Development of a monitoring instrument. BMC Health Services Research. 10, 337. doi 10.1186/1472-6963-10-337. (Journal article, open access) 

Cochrane D, Taylor A, Miller G, Hait V, Matsui I, Bharadwaj M, Devine P. Establishing a Provincial Patient Safety and Learning System: Pilot project results and lessons learned. Longwoods: 2009. (Journal article, open access) 

Calhoun AW, Boone MC, Porter MB, Miller KH. Using simulation to address hierarchy-related errors in medical practice. The Permanente Journal. 2014; 18(2): 14-20. doi:10.7812/TPP/13-124. (Journal article, open access) 

Carayon P, Xie A, Kianfar S. Human Factors and Ergonomics. In: Making Health Care Safer II: An Updated Critical Analysis of the Evidence for Patient Safety Practices. Rockville (MD): Agency for Healthcare Research and Quality; 2013 Mar. (Evidence Reports/Technology Assessments, No. 211.) Chapter 31. (Book chapter, open access) 

Card A. The Active Risk Control (ARC) Toolkit. 2013. (Toolkit) 

Chassin MR, Loeb JM. High-reliability health care: getting there from here. The Milbank Quarterly. 2013; 91(3): 459-490. doi:10.1111/1468-0009.12023. (Journal article, open access) 

Conway J, Federico F, Steward K, Campbell MJ. Respectful Management of Serious Clinical Adverse Events (Second Edition). IHI Innovation Series white paper. Cambridge, MA: Institute for Healthcare Improvement; 2011. (Guide, log-in required) 

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

Dekker S. The bureaucratization of safety. Safety Science. 2014; 70: 348-357. (Journal article, open access) 

Department of Health, Government of Western Australia. Clinical Incident Management Toolkit. Perth, WA: Western Australian Department of Health; 2011.  Page 24-25 : Develop recommendations. Table 4 : Five models of dback for incident reporting systems with examples of how each may be implemented. (Toolkit, 94 pages) 

Evans, Mike Doc Quality Improvement in Healthcare, Youtube, 2014 (Video) 

Frankel A, (editor). Strategies for Building a Hospitalwide Culture of Safety. Oakbrook Terrace, Il: JCAHO; 2006. (Book, $) 

Goldman, Brian. Doctors Make Mistakes. Can we talk about that? Youtube, 2012 (Video) 

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

Health Service Executive (HSE). Open Disclosure: National policy.2013. (Policy, 25 pages) 

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

Hughes RG (editor). Patient Safety and Quality: An evidence-based handbook for nurses. Rockville, MD: Agency for Healthcare Research and Quality; 2008. (Book, open access) 

Gamble M. 5 Traits of High Reliability Organizations: How to hardwire each in your organization. Becker’s Hospital Review: 2013. (Periodical article) 

Iedema R, Allen S, Piper D, Baker A., Grbich C, et al. Patients’ and family members’ views on how clinicians enact and how they should enact incident disclosure: the “100 patient stories” qualitative study. BMJ. 2011; 343: d4423. (Journal article, open access) 

Institute for Healthcare Improvement (IHI). 5 Million Lives Campaign. 2008. (Program, campaign) 

Institute for Healthcare Improvement (IHI). Failure Modes and Effects Analysis (FMEA) Tool. 2004. (Tool, guide, log-in required) 

Institute for Healthcare Improvement (IHI). How to Improve. 2014. (Guide, tools, open access) 

Institute for Healthcare Improvement (IHI). Improvement Stories. Delivering Great Care: engaging patients and families as partners. 2014. (Web article, case study) 

Institute for Healthcare Improvement (IHI). Open School Case Study: Low on the totem pole (AHRQ). 2005. (Case study) 

Institute for Healthcare Improvement (IHI). Patient Safety Leadership WalkRounds. 2004. (Tool) 

Institute for Healthcare Improvement (IHI). SBAR Toolkit. Oakland, CA: Kaiser Permanente; 2004. (Toolkit) 

Institute for Healthcare Improvement (IHI). The Leadership Guide to Patient Safety. 2006. (Guide, log-in required) 

Institute for Healthcare Improvement (IHI). Leadership Response to a Sentinel Event: Respectful, Effective Crisis Management. Cambridge, MA: 2011. (Guide, log-in required) 

I-PASS Study Group. I-PASS. Better Handoffs. Safer Care. Boston Children’s Hospital: 2014. (Program, tools on request) 

John Hopkins Bloomberg School of Public Health. Removing Insult from Injury: Disclosing adverse events: Selected vignettes. (Videos) 

Joint Commission Center for Transforming Healthcare. Creating a Safety Culture (video). 2012. (Video, 4 min) 

Kotter J. The 8-Step Process for Leading Change. (Guide, books $) 

Markwell S. Understanding Organisations: Assessing the impact of political, economic, 

socio-cultural, environmental and other external influences. Health Knowledge. 2009. (Guide) 

McDonald TB, Helmchen LA, Smith KM, Centomani N, Gunderson A, Mayer D, Chamberlin WH. Responding to patient safety incidents: the “seven pillars”. Quality and Safety in Health Care.  2010; 19: e11. (Journal article, open access) 

Med Star Health. Annie's Story: How A System's Approach Can Change Safety Culture. 2014. (Video, 5 min) 

Medically Induced Trauma Support Service, US. Staff support brochure. (Leaflet) 

National Patient Safety Agency. Incident Decision Tree: Information and advice on use. 2003. (Tool, guide, 55 pages) 

NHS Scotland. Learning From Adverse Events Through Reporting and Review: A national framework for NHS Scotland.  Glasgow: NHS Scotland; 2019. (Guide, 37 pages)Guide, 37 pages) 

Nolan T, Resar R, Haraden C, Griffin FA. Improving the Reliability of Health Care. IHI Innovation Series white paper. Boston, MA: Institute for Healthcare Improvement; 2004. (Article, 20 pages, log-in required) 

Patient Safety & Quality Healthcare (PSQH). Daily Check-In for Safety: From best practice to common practice. 2012. (Journal article, open access) 

Prosci Learning Centre. ADKAR: Knowledge, Ability and Reinforcement making the change. 2006. (Tool). 2006. (Tool) 

Riesenberg LA, Leitzsch J, Little BW. Systematic review of handoff mnemonics literature. American Journal of Medical Quality.2009; 24: 196-204. doi:10.1177/1062860609332512. (Journal article, open access) 

Runciman WB, Williamson JAH, Deakin A, Benveniste KA, Bannon K, Hibbert PD. An integrated framework for safety, quality and risk management: an information and incident management system based on a universal patient safety classification. Quality and Safety in Health Care. 2006;   15(Suppl I): 82-90. doi: 10.1136/qshc.2005.017467. (Journal article, open access) 

Seys D, Wu AW, Van Gerven E, Vleugels A., Euwema M, et al. Health care professionals as second victims after adverse events: a systematic review. Evaluation & the Health Professions. 2013 Jun; 36(2): 135-62. 10.1177/0163278712458918. (Journal article, abstract only) 

TEDx. Building a Psychologically Safe Workplace: Amy Edmondson at TEDxHGSE (video). 2014. (Video, 11 min). 

Tezak B, Anderson C, Down A, Gibson H, Lynn B, McKinney S, et al. Looking ahead: the use of prospective analysis to improve the quality and safety of care. Healthcare Quarterly. 2009; 12, 580-84. doi:10.12927/hcq.2009.20972. (Journal article, open access) 

University of Missouri Health System, Providing Care and Support to our Staff (Leaflet) 

University of Missouri Health System, Second Victim Trajectory, 2009 (Guide, 1 page), 2009 (Guide, 1 page) 

University of Missouri Health System, The Scott Three-Tiered Interventional Model of Second Victim Support (Guide, 1 page) 

Vakery P, Antonio K. Change management for effective quality improvement: a prime. American Journal of Medical Quality. 2010; 25(4): 268–273. DOI: 10.1177/1062860610361625. (Journal article, open access) 

Wallace L. Feedback from reporting patient safety incidents – are NHS trusts learning lessons? Journal of Health Services Research & Policy. 2010; January; 15(sup1):  75-78. (Journal article, abstract only) 

Washington State Hospital Association (WSHA). Patient Safety: Transforming culture toolkit. 2013. (Toolkit, 28 pages) 

Waters HR, Korn R, Colantuoni E, Berenholtz SM, Goeschel  A, Needham DM, et al. The business case for quality economic analysis of the Michigan Keystone Patient Safety Program in ICUs. American Journal of Medical Quality. 2011; 26(5): 333-339. (Journal article, abstract only) 

Wilson K, Burke CS, Priest HA, Salas E. Promoting health care safety through training high reliability teams. Qual Saf Health Care. 2005; 14: 303-309. doi: 10.1136/qshc.2004.010090. (Journal article, open access) 

World Health Organization (WHO). Guide for Developing Patient Safety Policy and Strategic Plan. Geneva: WHO; 2014. (Guide, 47 pages) 

World Health Organization (WHO). Learning from Error - Video and Booklet. 2010. (Videos, booklet) 

World Health Organization (WHO). WHO Draft Guidelines for Adverse Event Reporting and Learning Systems: From information to action. Geneva: WHO; 2005. (Guide, 80 pages) 

Wu AW, McCay L, Levinson W, Iedema R, Wallace G, Boyle DJ, et al. Disclosing Adverse Events to Patients: International norms and trends. 2014. (Journal article, abstract only) 

5 Million Lives Campaign. Getting started kit: Governance leadership “boards on board” how-to guide. Cambridge, MA: Institute for Healthcare Improvement; 2008. (Guide, log-in required)