Learning from Harm
Resources for conducting incident and prospective analyses
Healthcare Excellence Canada offers numerous resources to support reporting, responding, and learning from patient harm.
Canadian Incident Analysis Framework
The Canadian Incident Analysis Framework is a resource to support those responsible for, or involved in, managing, analyzing, and learning from patient safety incidents in any healthcare setting. It provides analysis methods (comprehensive, concise, and multi-incident) and tools to assist in answering the following questions.
- What happened?
- How and why did it happen?
- What can be done to reduce the likelihood of recurrence and make care safer?
- What was learned?
Patient Safety and Incident Management Toolkit
This web resource is based on the Canadian Incident Analysis Framework but extends the focus beyond incident analysis to look at the broader spectrum of patient safety and incident management. Resources, tools and references from Canada and international sources are available at the fingertips of users through links and downloadable documents.
Institute for Healthcare Improvement (IHI)
The IHI Global Trigger Tool for Measuring Adverse Events (AEs) provides instructions for training reviewers in this methodology and conducting a retrospective review of patient records using triggers to identify possible AEs. This tool includes a list of known AE triggers as well as instructions for selecting records, training information, and appendices with references and common questions.
Institute for Safe Medication Practices Canada (ISMP Canada)
Canadian Failure Mode and Effects Analysis Framework©
Failure modes and effects analysis (FMEA) is a proactive safety technique that helps to identify process and product problems before they occur. It is one of several types of prospective risk assessment that can be used in healthcare settings. It is also widely used as an integral aspect of improving quality and safety in other industries (e.g., automotive, aviation, and nuclear power).
ISMP Canada has developed the Canadian Failure Mode and Effects Analysis Framework — Proactively Assessing Risk in Healthcare©, with assistance from healthcare and human factors engineering consultants. It can be applied to all healthcare processes, such as medication use, patient identification, specimen labelling, emergency room triage, identification of risk of patient falls.
