Before the Incident听
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.听
Recommended strategies听
Incident management: establish plans and processes.听
- Proactively develop local incident management policies, procedures, plans, and processes听
- include tools and resources to support immediate and ongoing response, reporting, disclosure, analysis, tracking implementation of changes (e.g. checklists, flowcharts)听
- clearly articulate roles, responsibilities and expectations听
- partner with both and frontline staff in their development听
- update them on a regular basis听
- ensure they are easily accessible to all staff as well as patients/families as appropriate听
- 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)听
- Allocate and ensure timely access to resources to support:听
- patients/families (e.g. practical, emotional, financial support)听
- staff involved in patient safety incidents (e.g. counselling, coaching, coverage of duties)听
- implementation of recommended actions resulting from incident analysis听
- communication and information systems (e.g. reporting, tracking, measurement)听
- incident management training for all staff听
- 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.听
Patient safety management: monitor, analyze, and prioritize safety risks.听
- 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)听
- Seek ways to capture what is not reported (e.g. frustrations, workarounds, inefficiencies, innovations, new ideas, strengths, customized defences) via dialogue, observations, leadership , safety huddles, etc.听
- Conduct or multi-incident analyses to determine system strengths and vulnerabilities听
- Adopt a systematic and consistent approach for tracking,听 , quantifying and patient safety risks/gaps/hazards and mitigation strategies听
- Involve leadership, staff and patient/family partners in the prioritization process so that a broad range of perspectives is included听
- Establish to ensure patient safety risks and their corresponding actions are tracked, updated, reviewed, and prioritized on a regular basis听
- Develop and integrate mechanisms to monitor and respond to unexpected hazards in real time to improve (e.g. constant vigilance, safety check-ins, early warning systems safety alerts/reports from both staff and patients/families)听
Patient safety management: implement action plans to mitigate risks and improve quality and safety听
- 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)听
- 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. / / recommendations/ ) and/or seeking expert opinion听
- Whenever possible, design processes that focus on system-based error reduction strategies as they are the (e.g. using forcing functions, automation, simplification and standardization)听
- Assess if safety action plans are resulting in improvements听
- in developing care plans, sharing concerns and compliments, co-designing systems and processes, and implementing safety and improvement initiatives听
Patient safety management: promote teamwork and build capacity.听
- Strengthen team functioning and relationships through using whenever possible听
- Adopt standardized communication and handoff processes (e.g. , , )听
- Promote team collaboration through interdisciplinary care models, interprofessional learning and team goals that focus on the patient/family needs听
- Encourage and support continuous patient safety conversation between patients/families, frontline staff and leaders听
- Develop multiple strategies that empower staff at all levels to share their concerns (e.g. anonymous reporting system and/or 鈥渉ot line鈥�) and skills to address hierarchy and power gradient (by )听
- Promote an understanding that systems are complex, dynamic and can fail听
- Engage all team members, including , in all phases of quality improvement and patient safety initiatives to leverage their expertise听
