Advancing Patient Safety Right Now


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A Bold New Direction

Patient Safety Right Now … is the rallying cry and the foundation for a bold new direction defined in the Canadian Patient Safety Institute’s 2018-2023 Strategic Plan. This new five-year strategy launched on April 1, 2018 focuses on making patient safety a priority. Patient Safety Right Now helps the Canadian Patient Safety Institute to achieve its vision of making Canada’s healthcare system the safest in the world.

At the Canadian Patient Safety Institute, we believe that every patient experience should be safe. Unfortunately, that is not the reality. In terms of mortality, patient safety ranks third behind cancer and heart disease. In Canada today, an adverse event occurs every 1 minute and 18 seconds, and every 13 minutes and 14 seconds, someone will die from preventable harm. That impacts about 28,000 people per year. Hospital-acquired infections will account for roughly 70,000 patient safety incidents annually. And, it’s no better in the community, where up to 13 per cent of people receiving home care will experience a harmful adverse event like a fall or medication error.1

In 2014-2015, an estimated 138,000 hospitalizations

resulted in harm, with a fifth of those with more than one occurrence. Over 40 per cent of complex surgical patients suffer harm and those who do are four times more likely to die in hospital. 2 And, harm can affect the young and old alike. A recent study revealed that 9.2 per cent of children experience harm while in hospital; 3 and an estimated 37 per cent of seniors in nine provinces received a prescription for a drug that should not be taken by this population. 4

These facts are staggering, and this level of harm is simply unacceptable.
Now is the time to act. Consider these facts:

Over the next 30 years in Canada, 12.1 million Canadians will be harmed by the healthcare system;

1.2 million Canadians will lose their lives to a patient safety incident;

within acute and home care settings, patient safety incidents will cost the healthcare system $82 billion (2017 $).1

The Canadian Patient Safety Institute is committed to inspiring and advancing a culture committed to sustained improvement for safer care. You will hear the urgency in our call to action. We will ensure safe healthcare by demonstrating what works and strengthening commitment to patient safety in Canada … right now! The Canadian Patient Safety Institute will “push“ more strategically by focussing on system change, but it will also create “pull“ by raising the profile of patient safety, setting targets, securing greater commitment from everyone, and reporting to Canadians.

1 The Case for Investing in Patient Safety in Canada. RiskAnalytica, August 2017.

2 Measuring Patient Harm in Hospitals. Canadian Institute for Healthcare Improvement, 2016.

3 Adverse events among children in Canadian hospitals: The Canadian Paediatric Adverse Events Study. Canadian Medical Association Journal. September 2012.

4 Drug Use Among Seniors in Canada. Canadian Institute for Healthcare Improvement, 2016.

How the Strategy was developed

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The Canadian Patient Safety Institute is regarded as the authority on patient safety in Canada and has steadily provided the foundation for all players in the system to recognize and act on the fact that despite the best efforts of committed providers and leaders, healthcare in Canada remains unsafe. An independent evaluation completed in 2017 found that the Canadian Patient Safety Institute has made significant progress in fulfilling its mandate and that substantial value has been generated from Health Canada’s investment in it. With the independent evaluation recommendations and our own consultations as part of our strategic planning exercise, the Canadian Patient Safety Institute considered two fundamental contextual factors.

First is the increased emphasis on improved performance in healthcare in all dimensions, including quality, safety, patient experience and value for money. Canadians expect their public funding to deliver more than a mediocre system; they deserve high quality and safe care. Second, is the Canadian Patient Safety Institute’s intended impact prospect given its mandate and resources. Without legislative or regulatory levers of its own, the Canadian Patient Safety Institute cannot directly influence pan-Canadian patient safety performance. The Canadian Patient Safety Institute works with partners and through intermediaries across the country to make care safer. Even without direct control of the desired outcomes, our assessment of what we will do is anchored in whether patient safety is improving substantially across the country. We believe our ultimate result is the reduction of preventable harm to patients and its unintended impact on the lives of their families and communities, and to healthcare providers and leaders.

The new strategic directions are based on the evolution of the Canadian Patient Safety Institute and new thinking about its theory of change. Clearly, more robust commitments are required to advance patient safety in Canada and health systems need additional support to complete end-to-end patient safety improvements and to evaluate results. The new strategy focuses on key stakeholder relationships that are critical to demonstrating sustainable improvements safety that are mutually reinforced by strengthening policy and regulation. The new strategy enhances the Canadian Patient Safety Institute’s partnership with its patient-led program, Patients for Patient Safety Canada, empowering patients and the public to advocate for policy, regulatory and other actions to improve patient safety outcomes and the patient experience.

Strategic Key Elements

Patient Safety Right Now will demonstrate best practices in healthcare, but also must strengthen commitment to patient safety in Canada among healthcare providers, healthcare leaders and the public. The strategy relies on two mutually reinforcing key elements. Progress in one element defines further requirements in the other.

Our strategy is to research and deliver measurable, sustainable patient safety improvement practices that are regularly evaluated. These can then be introduced to committed healthcare jurisdictions. In this Annual Report, you will learn more about the progress of our four Safety Improvement Projects - Measuring and Monitoring of Safety, Enhanced Recovery After Surgery, Teamwork and Communication, and Medication Safety at Care Transitions.

Our strategy is to translate evidence of what works into standard practices at all levels of the healthcare system, seeking commitment to and expectations for patient safety in Canada. By doing so, further areas for improvement will be identified. Strengthening commitment is providing the evidence to inspire jurisdictions to adopt stronger patient safety legislation, higher standards for safety, better regulations, and improved organizational level policies to promote safety and protect patients.

The new strategy focuses on key stakeholder relationships that are critical to strengthening policy and regulation and a smaller number of partners with firm commitments to implementation and evaluation of safety improvement interventions. Further, the new strategy enhances our partnership with Patients for Patient Safety Canada (a patient-led program of the Canadian Patient Safety Institute), engaging and empowering patients and the public to advocate for policy, legislative, regulatory, and other actions to improve patient safety outcomes and patient and provider experiences.

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By working with partners to demonstrate what works, we uncover the practices that should be built into policies, standards and regulations. By working to build a more robust commitment to patient safety through mechanisms such as system transparency and reporting, we identify pressing system needs that may require further testing of promising practices whose potential for standardization can be evaluated.

Executing the Strategy

The mechanisms to execute the strategy include these actions:

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Implement – Safety Improvement Projects in priority areas to demonstrate what works.

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Evaluate – embed evaluation in all Canadian Patient Safety Institute activities to assemble evidence of what works.

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Share with purpose – develop concrete strategies to share evidence and improvement knowledge.

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Raise the profile – of patient safety to create expectations for improvement.

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Improve transparency – develop a comprehensive framework that addresses rights and obligations for transparency at all levels.

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Strengthen commitment – to safe care through policy, regulation and accreditation.

Lines of business

The Canadian Patient Safety Institute’s lines of business provide a line of sight between the strategy and the activities that we plan to undertake. By prioritizing our actions, we can determine how to measure our impact. The lines of business provide a guiding framework that links together the 2018-2023 Business Plan, the annual Operational Plan and the Performance Measurement Strategy.

The Lines of Business are:

Safety Improvement Projects

The Canadian Patient Safety Institute has a central role in continuing to build capability and will work with committed partners and stakeholders to embed patient safety science and competencies to better equip health professionals. In addition, we will work with committed partners to implement and evaluate sustainable Safety Improvement Projects that align with pan-Canadian priorities. Our objectives are to:

  • Develop explicit criteria for identifying priorities, committed partners and host organizations to participate in Safety Improvement Projects.
  • Ensure partners and participants meet readiness criteria to ensure they are set-up for success, and have the necessary capability to meet project expectations.
  • Implement Safety Improvement Projects by using an integrated quality improvement/ knowledge translation implementation science methodology and design.
  • Evaluate initiatives to assemble evidence of what works, so that promising results can be replicated by others to impact patient safety outcomes.
  • Develop partnerships to scale and spread those results to health systems and a broader patient safety audience.
  • Develop a knowledge translation and implementation science model that uses a range of mechanisms to transfer compelling messages to targeted audiences.
  • Create a mechanism to gather intelligence from the field and use this information in the Canadian Patient Safety Institute’s priority-setting.

This area of focus encompasses multiple strategic approaches, knowledge translation and implementation science inclusive of research and intelligence gathering, capability building and safety improvement that synergistically aim to develop, deliver, implement and evaluate patient safety practices that will contribute to reducing harm.


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Making Patient Safety a Priority

The Canadian Patient Safety Institute will increase the profile of patient safety among the public and patients, healthcare providers, healthcare leaders and governments, through these actions:

  • Use the patient voice in reporting, campaigns and media to make patient safety a higher priority across healthcare systems.
  • Increase the profile of patient safety in the media.
  • Use compelling patient stories to reach patients and the public.
  • Use a broad array of social media and digital platforms to engage the public, providers and leaders in an exchange of ideas and strategies to help advance patient safety.
  • Build on existing measures to report on the state of patient safety across the country.
  • Take evidence and analysis from other Canadian Patient Safety Institute activities and communicate them to the field.

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Policy Impact

The Canadian Patient Safety Institute will influence policy, legislation, standards and regulations in order to incorporate best evidence to improve patient safety. Our objectives are to:

  • Contribute evidence to inform policies and standards that best support patient safety at organizational and health system levels.
  • Work to embed patient safety requirements in regulations, legislation, standards and accreditation.
  • Influence those who educate and bestow credentials on health professionals so that patient safety is a core competency of all healthcare providers and leaders.
  • Support the development of better measurement, reporting and transparency of patient safety in Canada.

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Alliances and Networks

The Canadian Patient Safety Institute will create strategic alliances and networks with patients, government, industry and other partners who are committed to making care safer. Our objectives are to:

  • Establish a new network of senior decision-makers from all provincial and territorial governments who are committed to improving common patient safety challenges.
  • Engage industry partners in addressing persistent barriers to patient safety.
  • Create new networks of patient groups to share knowledge and experience related to patient engagement.
  • Promote national alignment of healthcare systems around patient safety priorities.

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Impact and Performance Measurement

The Canadian Patient Safety Institute is committed to measuring its impact. The Performance Measurement Strategy helps our organization understand whether we are accomplishing our goals. It is, in effect, a feedback mechanism for our two-pronged approach of demonstrating what works and strengthening commitment as it helps us answer whether we are doing either of these two elements effectively.

An infrastructure for internal reporting of data required was developed to produce our Scorecard and the data table associated with the Performance Measurement Strategy. We also collected data on measures where available, and have laid the groundwork to collect and report on data for other measures that are not yet available, but which will be in 2019-2020 and beyond.

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The Federal Government has been looking at the future role and configuration of Pan-Canadian Health Organizations (PCHOs). The Canadian Patient Safety Institute has been participating in the Implementation Steering Group process and is continuing to work with other PCHOs and federal, provincial and territorial governments to strengthen collaboration and impact.