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In this resource :

Resources and Recommended ReadingsÌý

Accreditation Canada. . Ottawa, ON: Accreditation Canada; 2014. (Report, 25 pages)Ìý

.Ìý

• (2011)Ìý
• (Guide, 2 pages)Ìý
• Ìý
• (Guide, 2 pages)Ìý
• Ìý
• Ìý

Alberta Health Services (AHS). . 2012. (Policy, 5 pages)Ìý

Alberta Health Services Engagement and Patient Experience Department. Resource Toolkit for Engaging Patient and Families at the Planning Table. 2014. (Toolkit, 27 pages)Ìý

Baker GR, MacIntosh-Murray A, Porcellato C, Dionne L, Stelmacovich K, Born K. . 2008. (Book)Ìý

BC Patient Safety & Quality Council. . 2018. (Toolkit, 74 pages)Ìý

BC Patient Safety and Learning System (BCPSLS). . 2015. (Case study)Ìý

BC Patient Safety and Learning System (BCPSLS). . 2013Ìý

British Columbia Patient Safety Task Force. . (Guide, 4 pages)Ìý

Canadian Agency for Drugs and Technologies in Health. . 2015. (Collection of knowledge, tool)Ìý

Canadian Association of Paediatric Health Centres. (Webinar)Ìý

Canadian Foundation for Healthcare Improvement (CFHI). Innovative Patient Resource Kit Eases the Process of Engaging Patients. 2015. (Case study)Ìý

Canadian Foundation for Healthcare Improvement (CFHI). . 2015. (Collection of resources)Ìý

Canadian Medication Incident Reporting and Prevention System. (Tool, guide)Ìý

Canadian Patient Safety Institute (CPSI). Canadian Disclosure Guidelines: Being open with patients and families. 2011. (Guide, 52 pages)Ìý

• Diagram B : Circumstances when Disclosure should take placeÌý
• Diagram C : Stages of DisclosureÌý
• Appendix D : Checklist for Disclosure ProcessÌý

HealthcareCAN. (Learning program, $)Ìý

Canadian Patient Safety Institute (CPSI). Disclosure Training Program offered by The Canadian Medical Protective Association. (Learning program, $)

Canadian Patient Safety Institute (CPSI). . Edmonton, AB: CPSI; 2011. Information-Sharing Planning Checklist (Page 4-6). (Guide, 11 pages)Ìý

Canadian Patient Safety Institute (CPSI). . (Learning program)

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

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

Capital Health. .Ìý (Guide for patients/families)Ìý

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)Ìý

Duchscherer C, Davies JM. . Calgary, AB: Health Quality Council of Alberta; 2013.Ìý (Guide, 76 pages)Ìý

Etchells E, Koo M, Daneman N, McDonald A, Baker M, Matlow A, Krahn M. . BMJ Qual Saf. 2012; 21: 448-456. doi:10.1136/bmjqs-2011-000585. (Journal article, open access)Ìý

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)Ìý

Health Canada. 2014. (Legislation)Ìý

Health Canada. . 2014. (Guide)Ìý

Health Canada, , 2011 (Guide)Ìý

Health PEI. . (Toolkit)Ìý

Health Quality Council of Alberta (HQCA). . Calgary, AB: HQCA; 2013. (Report)Ìý

Health Quality Council of Alberta (HQCA). . Calgary, AB: HQCA; 2010. (Guide, 24 pages)Ìý

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

Health Quality Council of Alberta. . (Checklist, 1 page)Ìý

Healthcare Insurance Reciprocal of Canada (HIROC), (Guide)Ìý

Incident Analysis Collaborating Parties. Canadian Incident Analysis Framework. Edmonton, AB: Canadian Patient Safety Institute; 2012. (Guide, tools, 133 pages)Ìý

• Appendix A: Team management checklist.Ìý

• Appendix C: Analysis team membership, roles and responsibilities.Ìý
• Appendix D: Sample analysis team charter.Ìý
• Appendix E: Sample confidentiality agreement.Ìý
• Appendix F: Checklist for effective meetings with patient(s)/ families.Ìý
• Appendix G: Incident analysis guiding questions.Ìý

• Appendix H: Creating a constellation diagram.Ìý
• Appendix I: Incident Analysis Report TemplateÌý
• Appendix J: Case study - comprehensive analysis: elopement from a long-term care home.Ìý
• Appendix K: Case study - concise analysis: medication incident.Ìý
• Appendix M: Legislative Protection for Quality of Care.Ìý

• Appendix N: Three human factors methods that can be used in incident analysis.Ìý
• Figure 2.3 : System Levels.Ìý
• Figure 3.12: Example of tool to track the implementation status of recommended action.Ìý
• Figure 3.14: Useful questions in designing data collection.Ìý
• Section 3.6.6 Developing and Managing Recommended Actions.Ìý

• Section 3.6: Criteria and considerations for selecting an incident analysis.Ìý
• Section 1.4 Incident Analysis and Management from a Patient Perspective.Ìý
• Section 2 Essentials of Analysis.Ìý

Institute for Safe Medication Practices Canada (ISMP Canada). ISMP Canada. (Program, reporting tools)Ìý

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

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

Legislative Assembly of Ontario. 2003. (Legislation)Ìý

Manitoba Institute for Patient Safety, Manitoba Alliance of Health Regulatory Colleges. October; 2014. (Leaflet)Ìý

Ontario Ministry of Health and Long-term Care. . Ontario: 2010. (Legislation)Ìý

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

Province of Alberta. . Alberta Regulation 124/2006. (Legislation)Ìý

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

Royal College of Physicians and Surgeons of Canada. . (Learning program, $)Ìý

Royal College of Physicians and Surgeons of Canada. . 2014. (Report, 141 pages)Ìý

Safer Healthcare Now! . 2011. (Guide, 54 pages)Ìý

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

Saskatchewan Ministry of Health. . 2011. (Toolkit, 33 pages)Ìý

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

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

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

The Canadian Medical Protective Association, Royal College of Physicians and Surgeons of Canada, The College of Family Physicians of Canada, Canadian Medical Association. . 2012. (Report, 14 pages)Ìý

The Canadian Nurses Protective Society. . (Guide)Ìý

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

The Health Foundation. The Measurement and Monitoring of Safety. 2013. (Report, 92 pages)Ìý

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

University of Calgary, Health Quality Council of Alberta. . (Learning program)Ìý

Vincent C,Ìý Taylor-Adams S, Chapman EJ, Hewett D, Prior S, Strange P, Tizzard A. BMJ. 2000; 320(7237): 777-81. (Journal article, open access)Ìý

Agency for Healthcare Research and Quality (AHRQ). . Rockville, MD: AHRQ; 2015. (Toolkit)Ìý

Agency for Healthcare Research and Quality (AHRQ). (Collection of cases)Ìý

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

Agency for Healthcare Research and Quality (AHRQ). . Rockville, MD: AHRQ; 2013. (Toolkit, guide)Ìý

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

Agency for Healthcare Research and Quality (AHRQ). (Incident Reporting). (Guide)Ìý

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

• . 2013.
• . 2013.
• Bader and Associates Governance Consultants. . 2006. (Article, 5 pages)

Berenholtz SM, Hartsell TL, Pronovost PJ. . Am J Med Qual. 2009; 24(3): 192-5. (Journal article, abstract only)Ìý

Boston Consulting Group (BCG). “. (Tool)Ìý

Briner M, Kessler O, Pfeiffer Y, Wehner T, Manser T. (2010). BMC Health Services Research. 10, 337. doi 10.1186/1472-6963-10-337. (Journal article, open access)Ìý

Cochrane D, Taylor A, Miller G, Hait V, Matsui I, Bharadwaj M, Devine P. . Longwoods: 2009. (Journal article, open access)Ìý

Calhoun AW, Boone MC, Porter MB, Miller KH. . The Permanente Journal. 2014; 18(2): 14-20. doi:10.7812/TPP/13-124. (Journal article, open access)Ìý

Carayon P, Xie A, Kianfar S. . 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)Ìý

Card A. . 2013. (Toolkit)Ìý

Chassin MR, Loeb JM. . The Milbank Quarterly. 2013; 91(3): 459-490. doi:10.1111/1468-0009.12023. (Journal article, open access)Ìý

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

• Appendix A: (Guide, log-in required)Ìý

Dekker S. . Safety Science. 2014; 70: 348-357. (Journal article, open access)Ìý

Department of Health, Government of Western Australia. . Perth, WA: Western Australian Department of Health; 2011.Ìý 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)Ìý

Evans, Mike Doc , Youtube, 2014 (Video)Ìý

Frankel A, (editor). . Oakbrook Terrace, Il: JCAHO; 2006. (Book, $)Ìý

Goldman, Brian. Youtube, 2012 (Video)Ìý

Health Service Executive (HSE). . 2013. (Leaflet)2013. (Leaflet)Ìý

Health Service Executive (HSE). .2013. (Policy, 25 pages)Ìý

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

Hughes RG (editor). . Rockville, MD: Agency for Healthcare Research and Quality; 2008. (Book, open access)Ìý

Gamble M. . Becker’s Hospital Review: 2013. (Periodical article)Ìý

Iedema R, Allen S, Piper D, Baker A., Grbich C, et al. . BMJ. 2011; 343: d4423. (Journal article, open access)Ìý

Institute for Healthcare Improvement (IHI). . 2008. (Program, campaign)Ìý

Institute for Healthcare Improvement (IHI). . 2004. (Tool, guide, log-in required)Ìý

Institute for Healthcare Improvement (IHI). 2014. (Guide, tools, open access)Ìý

Institute for Healthcare Improvement (IHI). 2014. (Web article, case study)Ìý

Institute for Healthcare Improvement (IHI). (AHRQ). 2005. (Case study)Ìý

Institute for Healthcare Improvement (IHI). . 2004. (Tool)Ìý

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

Institute for Healthcare Improvement (IHI). . 2006. (Guide, log-in required)Ìý

Institute for Healthcare Improvement (IHI). . Cambridge, MA: 2011. (Guide, log-in required)Ìý

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

John Hopkins Bloomberg School of Public Health. (Videos)Ìý

Joint Commission Center for Transforming Healthcare. (video). 2012. (Video, 4 min)Ìý

Kotter J. . (Guide, books $)Ìý

Markwell S. Ìý

. Health Knowledge. 2009. (Guide)Ìý

McDonald TB, Helmchen LA, Smith KM, Centomani N, Gunderson A, Mayer D, Chamberlin WH. . Quality and Safety in Health Care.Ìý 2010; 19: e11. (Journal article, open access)Ìý

Med Star Health. . 2014. (Video, 5 min)Ìý

Medically Induced Trauma Support Service, US. . (Leaflet)Ìý

National Patient Safety Agency. . 2003. (Tool, guide, 55 pages)Ìý

NHS Scotland. .Ìý Glasgow: NHS Scotland; 2019. (Guide, 37 pages)Guide, 37 pages)Ìý

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

Patient Safety & Quality Healthcare (PSQH). . 2012. (Journal article, open access)Ìý

Prosci Learning Centre. . 2006. (Tool). 2006. (Tool)Ìý

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

Runciman WB, Williamson JAH, Deakin A, Benveniste KA, Bannon K, Hibbert PD. . Quality and Safety in Health Care. 2006;ÌýÌý 15(Suppl I): 82-90. doi: 10.1136/qshc.2005.017467. (Journal article, open access)Ìý

Seys D, Wu AW, Van Gerven E, Vleugels A., Euwema M, et al. Evaluation & the Health Professions. 2013 Jun; 36(2): 135-62. 10.1177/0163278712458918. (Journal article, abstract only)Ìý

TEDx. Amy Edmondson at TEDxHGSE (video). 2014. (Video, 11 min).Ìý

Tezak B, Anderson C, Down A, Gibson H, Lynn B, McKinney S, et al. . Healthcare Quarterly. 2009; 12, 580-84. doi:10.12927/hcq.2009.20972. (Journal article, open access)Ìý

University of Missouri Health System, (Leaflet)Ìý

University of Missouri Health System, , 2009 (Guide, 1 page), 2009 (Guide, 1 page)Ìý

University of Missouri Health System, (Guide, 1 page)Ìý

Vakery P, Antonio K. . American Journal of Medical Quality. 2010; 25(4): 268–273. DOI: 10.1177/1062860610361625. (Journal article, open access)Ìý

Wallace L. Journal of Health Services Research & Policy. 2010; January; 15(sup1):Ìý 75-78. (Journal article, abstract only)Ìý

Washington State Hospital Association (WSHA). . 2013. (Toolkit, 28 pages)Ìý

Waters HR, Korn R, Colantuoni E, Berenholtz SM, GoeschelÌý A, Needham DM, et al. . American Journal of Medical Quality. 2011; 26(5): 333-339. (Journal article, abstract only)Ìý

Wilson K, Burke CS, Priest HA, Salas E. . Qual Saf Health Care. 2005; 14: 303-309. doi: 10.1136/qshc.2004.010090. (Journal article, open access)Ìý

World Health Organization (WHO). . Geneva: WHO; 2014. (Guide, 47 pages)Ìý

World Health Organization (WHO). . 2010. (Videos, booklet)Ìý

World Health Organization (WHO. Geneva: WHO; 2005. (Guide, 80 pages)Ìý

Wu AW, McCay L, Levinson W, Iedema R, Wallace G, Boyle DJ, et al. . 2014. (Journal article, abstract only)Ìý

5 Million Lives Campaign. . Cambridge, MA: Institute for Healthcare Improvement; 2008. (Guide, log-in required)