Rethinking Patient Safety

SAFETY

IS MY

JOB

Rethinking

Patient Safety

A Discussion Guide for Patients,

Healthcare Providers and Leaders

October 2023

Everyone

contributes

to patient safety.

Together we must

learn and act

to create safer

care and reduce

all forms of

healthcare harm.

To improve patient

safety, we must start

by thinking and talking

about it dierently.

After more than 20 years working to improve the state

of patient safety, the healthcare system has made fewer

gains than we had hoped.

1–3

Improving patient safety has

not been as straightforward as expected.

Historically, patient safety eorts have focused mostly

on measuring and responding to harm. However, safety

is much more than the absence of harm. Instead, patient

safety includes looking at the whole system: its past,

present and future in all its complexity.

Healthcare Excellence Canada and Patients for Patient

Safety Canada held many conversations with users of the

health system, people who work in healthcare and safety

scientists (see Appendix). The ideas we collected suggest

a new way of approaching patient safety – where everyone

can contribute to creating safe conditions and where

harm is more than physical.

This discussion guide summarizes what we have learned

so far and captured in this key statement:

Everyone contributes to patient safety.

Together we must learn and act to create safer

care and reduce all forms of healthcare harm.

Below we explain the thinking behind these words.

“Everyone contributes to…”

Everyone who delivers, supports, organizes and funds

healthcare has a duty toward patient safety.

Plus, everyone who seeks or receives healthcare should

be oered the skills and the opportunity to contribute to

their own safety. They also should be made aware of the

degree of risk they face and how they can inﬂuence their

own safety outcomes.

Whether they realize it or not, everyone involved in

giving or receiving care contributes to patient safety.

A patient safety incident is frequently the result of

multiple, complex contributing factors. Blaming and

shaming individuals following an incident does not

improve the safety of care.

5,6

Supporting those involved in an incident is the right

thing to do. It also restores trust and contributes

to psychological well-being, building the path to

patient safety.

“…patient safety…”

“Patient” refers to anyone who seeks or receives care,

including hospital patients, long-term care residents,

home and community care clients and others across

the care continuum.

“Care” includes health and social care, health promotion,

disease prevention and treatment. Care also can take

place in a wide variety of health and social settings.

Patient safety includes all these people and settings,

including the interactions and transitions between them.

Further, the safety of patients is highly dependent on the

safety of those who care for them. Without safety for

essential care partners

, healthcare providers and others

who work in healthcare, patient safety is compromised.

8–10

“Together we must…”

Healthcare is founded on relationships. When we invest

in relationships that foster respect, trust, collaboration,

and open communication, we create a positive culture

of safety.

Within this, courageous leadership is essential to create

environments where patients, essential care partners,

healthcare providers, and sta feel safe to explore, speak

up and act when they see an opportunity to improve safety

or reduce risk.

This responsibility requires psychological

and cultural safety – for everyone.

8,9,11,12

“…learn…”

By adopting an open and curious mindset – and by asking

questions – the people closest to care can discover things

that are working well, while also exploring safety concerns.

In a safe culture, everyone can contribute by paying

attention to what they see, hear, and feel in their gut.

a Essential care partners provide physical, psychological, emotional, and spiritual

support. They can include family members, close friends or other caregivers and are

identified by the patient or their substitute decision-maker.

b We must recognize that those who feel they are in positions without power or

have been systemically disempowered may not currently feel safe to speak up and act.

Historically, many patient safety improvement eorts have

focussed on harm, analyzing incidents and near misses

and looking at factors like compliance to regulations and

standards. These activities are still important.

Yet while global rates of harm remain unacceptably high,

care is usually delivered without incident. So, safety is also

about learning from these experiences: the things that

went well, and the things that could have led to an incident

but did not (yet).

Patient safety eorts traditionally also have involved

reassurance that care is safe. For example, scorecards,

adherence to protocols, and audits are common. However,

these approaches lack the ﬂexibility to identify and

understand new or emerging safety issues.

Additionally, we can learn from informal experiences too

like a short debrief between two people after a care

encounter. We also can learn from larger innovations that

proactively explore safety such as across departments,

people, teams, technologies and processes that support

patient care.

“…and act to create safer care…”

While learning can help us to identify and understand

safety issues and opportunities, actions are then needed –

small and large – to create safer care.

The absence of harm does

not mean that care is safe.

Implementing safety practices has traditionally been the

domain of clinical, quality and safety leaders. However,

everyone needs to feel safe and be given the skills to act

in the service of patient safety.

Some safety actions may involve formal projects or

extra procedures. They also can be as simple as picking

up something from the ﬂoor, having a conversation

with a patient, or regularly participating in a quick

safety huddle, sharing concerns, and then making

improvements together.

Larger actions may include the design, implementation and

management of innovations in technology, care processes

or environments with the guidance of safety scientists and

in partnership with system users.

“…and reduce…”

Managing risk and reducing avoidable harm – its

frequency, severity, and impact – requires us to seize

opportunities for deeper understanding and incremental

improvements.

It also requires us to recognize that the complexity of

healthcare continues to increase due to new discoveries,

new treatments, new technologies, increased patient

volumes, and health human resources’ challenges.

Healthcare will always involve risks, so we must learn

and act to manage them, together.

“…all forms of healthcare harm.”

All types of harm must be considered in the work of

patient safety.

In the past, focus has been mostly on physical harms –

especially those that are easier to measure, such as falls

and healthcare-acquired infections.

But the person who experienced harm is often

best positioned to deﬁne it and describe its impact

on their life.

Examples of other forms of harm that are often

overlooked include under- and over-treatment, wrong

treatment, delayed or incorrect diagnosis, dehumanization,

and psychological harm.

Harm may also be compounded

in the aftermath of an incident because of how it

was managed.

16,17

Plus, widespread societal inequities, power imbalances

and systemic oppression can contribute to healthcare

harm.

18,19

These include racism, ableism, ageism,

sexual and gender discrimination, religious and

class discrimination, and body size and mental

health discrimination.

Additionally, the economic, social, educational, and

environmental inequities faced by various groups and

individuals can lead to healthcare harm. For example,

ongoing colonial impacts and racism experienced by First

Nations, Inuit and Métis in healthcare continue to be

harmful.

20–22

Cultural safety is essential to patient safety.

Bottom line, all forms of harm matter. We must open our

eyes, minds and hearts to this broader concept of harm.

We also must embrace a shared commitment among

patients, care providers, leaders and other key players to

reduce harm, manage risk and create safety in healthcare.

All forms of harm matter.

For reﬂection

As you think about this new approach to patient safety, we encourage you to consider the shifts summarized in this chart.

Moving beyond a singular focus on… to include…

Physical safety and physical harms

All forms of safety, including psychological and cultural safety

and recognizing how systemic inequities contribute to various

forms of harm.

Reacting/responding to past harm Looking upstream. Exploring, learning and acting before harm occurs.

Failures Recognizing when, why and how things go well.

Patients

Embracing safety for patients and their care partners,

healthcare providers, sta and leaders.

Assurance that care is safe

Acknowledging that care involves risks; and focusing on

addressing them.

Safety activities led by managers

and quality departments

Giving patient safety knowledge, skills and responsibility to all.

Patient safety work is perceived

as a project and thus as “extra” work

Seeing safety as a way of thinking, acting and relating to others and

a part of everyday work. Realizing that sometimes simple actions can

have big impact.

“Hard” indicators (e.g., falls rate)

Recognizing “soft intelligence”: perceptions, thoughts, feelings,

observations, ideas and suggestions.

The negative, stressful side of

patient safety

Celebrating the opportunities for relationships and safe care delivery;

being heard and valued; making a dierence; ﬁnding joy at work.

Risk awareness for providers

Sharing information about risks and risk reduction strategies

with patients and their essential care partners.

Safety as separate from equity,

access and other domains of quality

Seeking to understand how other domains of care relate

to safety.

19,25,26

For discussion

We encourage you to think about

questions like the ones below, on your

own or with others. Not only are they

designed to help you begin to take steps

toward improved patient safety, but also

to support you in ﬁnding joy in this work

by helping yourself and others feel valued

and heard:

• What comes to mind when you think

of healthcare harm?

• What does patient safety mean to you?

• How is the presence of safety dierent

from the absence of harm?

• What makes you feel safe?

• Who do you speak to when you have

a safety concern or compliment? How

can you create safe spaces for people

to talk about safety?

• How have you approached safety in

the past? How might you approach it

dierently now? What could you start

doing? What could you stop doing?

• How can you encourage the sharing

of power among patients, caregivers,

communities, providers, sta, and

leaders to enhance patient safety?

• How can action on patient safety

help reduce health inequities? How

can action on health inequities help

improve patient safety?

• How could you use this document to

advance patient safety in your work

or personal life?

Learn more

We invite you to join us on this journey for patient safety

in Canada. Visit our website, access our easy-to-use tools

and resources and learn more about our programs. Explore

how we can go further, together, in helping to shape a

future where everyone in Canada has safe and high-

quality healthcare.

Appendix

How we developed this statement

Our stakeholders told us that a new patient safety

statement needed to be:

• Robust: informed by the latest safety science

and thought leaders.

• Forward-looking: going beyond past deﬁnitions

and approaches and looking to the future of

patient safety.

• Creative: developed using methods that bring out

new ideas from stakeholders.

• Inclusive: involving a diverse set of stakeholders,

such as patients, Healthcare Excellence Canada sta,

front-line care providers, healthcare leaders, safety

experts and thought leaders from other industries

and academic disciplines.

• Useful: based on a solid understanding of how various

end users would interact with and incorporate it.

References

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patient-harm-in-canadian-hospitals-it-does-happen

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doi:10.4324/9781315543543

Our core project team consisted of sta from Healthcare

Excellence Canada and two patient partners from

Patients for Patient Safety Canada. We also worked with

internationally recognized experts in patient safety and

cultural safety, along with communication specialists

throughout the process. Activities included primary

and secondary research, including literature scans,

data collection via diverse methods and engagement

with patient partners, people who work in healthcare,

safety experts, people from other ﬁelds, and Healthcare

Excellence Canada sta.

6. Canadian Patient Safety Institute. Canadian Incident

Analysis Framework.; 2012. Accessed July 10, 2023.

https://www.healthcareexcellence.ca/media/gilnw3uy/

canadian-incident-analysis-framework-ﬁnal-ua.pdf

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Accountability in Your Organization. 3rd ed.

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Klazinga NS. Culture as a Cure: Assessments of

Patient Safety Culture in OECD Countries.; 2020.

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doi:10.1016/s1553-7250(13)39025-4

11. Edmondson AC. The Fearless Organization: Creating

Psychological Safety in the Workplace for Learning,

Innovation, and Growth. Wiley; 2018.

12. First Nations Health Authority. Creating a Climate

for Change: Cultural Safety and Humility in Health

Services Delivery for First Nations and Aboriginal

Peoples in British Columbia. Accessed July 19, 2023.

https://www.fnha.ca/Documents/FNHA-Creating-

a-Climate-For-Change-Cultural-Humility-Resource-

Booklet.pdf

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FullReport-EN.pdf

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content/uploads/2021/07/SCO-Racism-Report-ﬁnal-

WEB-wcag.pdf

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Expertise and Innovation, Reducing Bureaucracy

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Fowler A. Action on patient safety can reduce

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Acknowledgements

Authors

Rachel Gilbert, Maaike Asselbergs, Donna Davis,

Anne MacLaurin, Ioana Popescu, Carol Fancott.

Advisors

Wendy Nicklin, G. Ross Baker, Dr. Alika Lafontaine.

Contributors

Carla St. Croix, Andrea Piché, Denise McCuaig,

Kim Mumford, Hailey Riendeau, James Rebello,

Beatrice Onwuka, Jennifer Schipper at Arc

Communications and Shoshanna Hahn-Goldberg

and team at OpenLab.

We would like to thank all Healthcare Excellence Canada

sta and leadership, HEC community of patient partners

including Patients for Patient Safety Canada and all the

participants in the engagement activities who provided

invaluable insight into this process.

About Healthcare

Excellence Canada

Healthcare Excellence Canada (HEC) works with partners

to spread innovation, build capability, and catalyze policy

change so that everyone in Canada has safe and high-

quality healthcare. Through collaboration with patients,

caregivers and people working in healthcare, we turn

proven innovations into lasting improvements in all

dimensions of healthcare excellence. Launched in 2021,

HEC brings together the Canadian Patient Safety

Institute and Canadian Foundation for Healthcare

Improvement. HEC is an independent, not-for-proﬁt

charity funded primarily by Health Canada.The views

expressed herein do not necessarily represent the

views of Health Canada.

Disclaimer

In the spirit of continuous improvement, we look forward

to our ongoing journey of engaging, learning, reﬂecting

and reﬁning and will update this discussion guide as we

go forward with any new developments.

“If it’s not safe, it’s not care.”

– Dr Tedros Adhanom Ghebreyesus;

World Health Organization (WHO)