What comes to mind when you think about healthcare harm?
Canadian Patient Safety Week 2024
And that’s a wrap on Canadian Patient Safety Week 2024! A huge thank you to everyone who participated and made efforts to broaden your understanding of healthcare harm. Our materials and resources will remain available to help you keep exploring and acting.
Let’s broaden our understanding of harm, together
Recognizing and reducing healthcare harm matters to those receiving and delivering care in any setting. As part of championing Rethinking Patient Safety, we encourage everyone to broaden their understanding of healthcare harm as an important step in delivering safer care for all.
A complex healthcare system
Healthcare is incredibly complex. It is delivered by many different people engaging with many processes across various settings and through transitions in care. Sometimes, things go wrong — and this may result in harm. The factors involved can be multiple and varied.
Defences
The system as a whole is safe because it involves multiple layers of defence that combine and overlap to support the safe delivery of care.
Contributing factors
The defences that help promote safe care, when missing or weakened, can become contributing factors when things go wrong. Contributing factors are often interrelated, complex and rarely the result of a single issue. Examples include:
Categories of safety incidents
Incidents can result from a variety of actions or inactions while receiving and delivering care. These safety incidents can be broadly classified as:
Harm experienced by a person
Harm can include more than physical injuries. The person who experiences harm is often best positioned to define and describe it.
Person experiencing harm
People receiving and delivering healthcare across the continuum can experience harm.
Impact of harm
Healthcare harm can have cascading and long-lasting impacts on people and communities. Understanding and supporting those harmed by the healthcare system can help restore trust and contribute to healing. Their ongoing involvement is essential to shape our approach to safer care.
Let’s broaden our understanding of harm, together
Recognizing and reducing healthcare harm matters to those receiving and delivering care in any setting. As part of championing Rethinking Patient Safety, we encourage everyone to broaden their understanding of healthcare harm as an important step in delivering safer care for all.
A complex healthcare system
Healthcare is incredibly complex. It is delivered by many different people engaging with many processes across various settings and through transitions in care. Sometimes, things go wrong — and this may result in harm. The factors involved can be multiple and varied.
Defences
The system as a whole is safe because it involves multiple layers of defence that combine and overlap to support the safe delivery of care.
Contributing factors
The defences that help promote safe care, when missing or weakened, can become contributing factors when things go wrong. Contributing factors are often interrelated, complex and rarely the result of a single issue. Examples include:
Categories of safety incidents
Incidents can result from a variety of actions or inactions while receiving and delivering care. These safety incidents can be broadly classified as:
Harm experienced by a person
Harm can include more than physical injuries. The person who experiences harm is often best positioned to define and describe it.
Person experiencing harm
People receiving and delivering healthcare across the continuum can experience harm.
Impact of harm
Healthcare harm can have cascading and long-lasting impacts on people and communities. Understanding and supporting those harmed by the healthcare system can help restore trust and contribute to healing. Their ongoing involvement is essential to shape our approach to safer care.
Patient/Client/Resident
- Their care partner(s) is present.
- The patient, client or resident is invited to co-create their health and safety plan with their healthcare team.
- Their psychological safety is supported so they feel comfortable to speak up and ask questions.
- Their care is delivered in their preferred language.
- Health literacy resources are available and accessible.
- Their healthcare team members invite them to participate in safety conversations in a way that recognizes cultural, religious and individual needs.
Healthcare Provider
- Healthcare providers feel safe to speak up about safety concerns.
- Healthcare providers are supported and given opportunities to develop relationships that foster safe patient care.
- Their work is designed and assigned to ensure regular breaks, reasonable hours of work and ability to focus on tasks at hand.
- They have experience in the care area they are working in.
- They receive user-friendly training and orientation to new areas of work, equipment, policies and procedures.
- They receive ongoing professional development.
- They have access to supports for mental health and well-being.
- When planning and delivering care, providers consider broader social and structural determinants of health and impacts on health and safety.
Technical
- Equipment and IT systems are up to date and well maintained.
- Equipment and supplies are stored in ways that are easy to access.
- When technological solutions are implemented to reduce safety risks, their usability, accessibility, functionality is tested with healthcare staff who will use them.
- Electronic health records are intuitive to use and have built-in safeguards that match the care environment.
- IT systems support communications across health systems to ensure continuity and coordination of care.
Team
- Staff, regardless of their role and position, feel ownership for safety.
- Safety roles and responsibilities, skills and knowledge are shared appropriately across team members.
- Team members support each other and pitch in during times of stress and strain.
- Staff feel free to question the decisions or actions of those with more authority when they see something that may negatively impact safe care.
- The team collaborates with each other and frequently talks about safety.
- The team uses structured communication tools.
- The team has regular interdisciplinary safety huddles.
- The team participates in team-building activities to enhance trust and communication.
Procedural
- Staff and recipients of care contribute to finding solutions to safety concerns.
- Staff are invited to identify burdensome processes or procedures that may not add value to the quality and safety of care.
- Policies and procedures are developed and regularly reviewed and updated with input regarding their usability, accessibility and workability from those providing and receiving care.
- Standardized procedures for high-risk tasks are in place and followed.
- Staff are invited to contribute to the design of tasks and workplace environments.
Organizational
- The organization cultivates courageous leaders who work to create environments where patients, care partners, healthcare providers and staff feel safe to explore, speak up and act when they see an opportunity to improve safety or reduce risk.
- The organization looks upstream, explores safety risks and acts before they lead to harm.
- The organizational culture is one of learning when things are done well as well as when things go wrong.
- Health inequities and their relation to safe care are understood and work on creating more equitable and safer care is a focus of the organization.
- When safety incidents occur, those involved are supported and positive changes occur.
- Safety information is shared across the organization in a timely and easy to use format.
- Patient and staff safety are prioritized and balanced with other organizational goals.
- A culture of curiosity, inquiry and empowerment is promoted.
- The organization seeks to uphold healthcare standards and participates in an accreditation assessment program.
Funding and Resources
- Appropriate staffing ratios are supported.
- There is investment in new equipment and its maintenance.
- There is investment in staff wellbeing, training and professional development.
- There is an allocation of resources for prevention, risk management and safety promotion activities.
Regulatory and Professional Practice
- Regulatory and professional practice is designed so it effectively supports safety cultures and can identify early warning signs that there are safety risks.
- Provincial safety standards are established with targets and data is transparently shared.
- Provincial/territorial patient safety legislation is in place.
- There is compliance with national and international safety guidelines.
- Staff participate in professional organizations and networks.
- Regulatory approaches are well designed and do not create unnecessary bureaucracy and burden to providers.
Social and Structural Determinants of Health
- Social support networks are available.
- Community health education programs are available.
- Initiatives are in place to address health disparities and health inequalities.
- There are policies promoting equitable access to timely health and social care.
Other
- Their care partner(s) is present
Patient/Client/Resident
- The care recipient has a complex health history with multiple care teams.
- There is no care partner/advocate present.
- The care recipient has limited ability to participate in care.
- They have not been invited to collaborate in their care.
- They have language barriers.
- They have low health literacy and limited supports in place.
- They are unable to follow treatment plans.
Healthcare Provider
- Healthcare providers had inadequate training and orientation to new equipment and care areas.
- They are working in unfamiliar care areas with unfamiliar teams, equipment and clinical conditions.
- They are experiencing distractions, fatigue, exhaustion or stress.
- There is not enough staff to manage the workload, and staff feel rushed and overworked.
- Awareness of current best practices is limited.
- The physical design of the workplace does not support efficient workflow and care.
Technical
- Poor equipment design.
- Equipment malfunction.
- Poorly maintained equipment.
- Chaotic surroundings.
- Outdated technology.
- Insufficient user training on technology.
Team
- There is limited collaboration across teams.
- Safety is rarely talked about, except after something goes wrong.
- There is high staff turnover, high rates of sick time, high rates of overtime.
- Staff are mandated to work overtime.
- Staff are reluctant to speak up about safety risks and concerns.
- Roles and responsibilities are not well defined/clear.
- There is poor team communication and dynamics.
Procedural
- Inefficient, ineffective work processes and procedures.
- Unreliable clinical systems.
- Overly complicated or unclear policies.
- No mechanisms exist to elicit feedback from staff when preparing or updating policies and procedures (e.g. usability, accessibility, volume and length).
- Inadequate protocol, training and practice for high-risk situations.
- Policy and procedures are not updated to align with new evidence or feedback from staff.
Organizational
- Most safety resources are invested in reporting, analyzing and responding after a safety incident occurs with minimal investment in approaches to prevent harm and promote safety.
- The organization tolerates unreliable and unsafe practices.
- When things go wrong, there is a tendency to blame individuals.
- There are inadequate staffing levels.
- There is insufficient leadership support for safety initiatives.
- There is poor organizational communication.
- There are fragmented care processes and/or pathways.
- The organization does not participate in an accreditation program.
Funding and Resources
- Competing priorities limit resources for safety.
- Insufficient funding for training and development.
- Investment in testing and implementing innovative technology is limited.
- Resources are not invested in health and safety initiatives.
- Limited access to necessary supplies, equipment and human resources.
Regulatory and Professional Practice
- There is outdated (or no) patient safety legislation.
- A professional standard of practice is not maintained or enforced.
- There is insufficient regulatory oversight.
- There is limited support for continuing professional development.
Social and Structural Determinants of Health
- Tolerance of discrimination.
- Limited awareness of unconscious bias.
- Socioeconomic disparities affecting access to care.
- Geographic barriers to healthcare access.
- There is limited community resources and support for health and social care.
- Cultural and linguistic barriers.
- Social isolation.
- Housing instability.
Other
- Their care partner(s) is present
Delayed, missed or incorrect diagnosis:
Over-, under- or incorrect treatment/services:
Demeaning and dehumanizing incidents:
Treatment/service-specific and general healthcare incidents:
Incidents arising from transitions of care:
Culturally unsafe care:
Moral distress:
Engage teams with our activity card
Use our healthcare harm activity card with your team to stimulate discussion and thoughtful reflection that inspires proactive action to prevent harm and create safer care for all.
Do a team activity
Facilitate a thoughtful discussion with our activity card.
Enroll in Patient Safety Essentials
Understand the core of patient safety with our free, self-directed e-learning module.
Rethinking Patient Safety Guide
Get informed and kick-start conversations with this statement and discussion guide.
Infographic
An infographic to help you broaden your understanding of healthcare harm.
Webinar series
Missed any of the webinars in our series? Don’t worry—we have the full videos to help inspire reflection and action with your teams here.
Highlighting Patient Safety Champions
Safety champions come in many forms. As part of Canadian Patient Safety Week, we’re shining a light on a few in various healthcare settings.
It doesn’t end with CPSW
CPSW 2024 is over but the chance to champion safer care definitely isn’t. Read our blog thanking everyone who participated and to learn how to keep the momentum going.
Thanks for your ongoing commitment to safer care
We hope the Canadian Patient Safety Week 2024 resources above help you foster a curious mindset year-round. We look forward to seeing and partnering with you again for CPSW 2025!
Thanks for your ongoing commitment to safer care
We hope the Canadian Patient Safety Week 2024 resources above help you foster a curious mindset year-round. We look forward to seeing and partnering with you again for CPSW 2025!