week seven

adverse event

• An unexpected outcome negatively affects patient care

• It results in:

  • Prolonged hospitalization

  • Injury

  • Death

• Often caused by complications in managing patient care

• Also called:

  • Adverse event

  • Critical incident

When an Adverse Event Occurs…

Key people must be informed:

• Patient

• Substitute decision maker (if applicable)

• Healthcare administrators

Nurses should:

• Follow workplace policies

• Understand reporting and disclosure procedures

• Know their role in the process

Reporting vs Disclosure

Reporting

• Information shared with healthcare administrators

• Done by staff involved in or discovering the event

• Used for investigation and prevention

Disclosure

• Information shared with patient or family

• Explains what happened

• Focuses on patient communication

Reporting: Key Points

Reporting usually involves:

• Following employer policies

• Completing incident reports

• Triggering an investigation

• Helping reduce future risks

Examples:

• Reporting adverse drug reactions

• Reporting medical device incidents

• Serious incidents reported to Health Canada

Disclosure: Key Points

Disclosure involves:

• Informing patient or family about the event

• Explaining known facts

• Expressing sympathy or regret

• Explaining investigation steps

Important notes:

• Minor incidents may not require disclosure

• More serious events require full communication

• Some provinces require disclosure by law

Which Comes First?

Order depends on:

• Severity of the event

• Workplace policies

• Legal requirements

Typical process:

1. Initial disclosure to patient

2. Reporting to administration

3. Investigation

4. Follow-up disclosure

Follow-up may include:

• Findings

• Changes to prevent future events

Who Discloses to the Patient?

• A trained healthcare professional

• Someone with strong communication skills

• Possibly:

  • Physician

  • Surgeon

  • Healthcare administrator

Not always the nurse involved.

What Is Disclosed to Patients?

• Known facts about the event

• Effects on care or treatment

• Expression of sympathy or regret

• Explanation of investigation process

After investigation:

• Responsibility may be acknowledged

• A formal apology may be given

All information must be documented.

Do Apologies Prevent Lawsuits?

• Proper reporting

• Timely disclosure

• Appropriate apology

A lawsuit may still occur.

Important note:

• Some provinces have apology legislation

• Apologies cannot always be used as proof of negligence.

Patient safety

reduction and mitigation of unsafe acts within the healthcare system

• using best practices that are proven to lead to optimal patient outcomes

unsafe act

any action or inaction that has the potential to cause harm to a patient

• errors in judgment, lapses in communication, failures in following established protocols

• usually not intentional —> system, flaws, human error, or risky shortcuts taken under pressure

what is patient safety about

• Keeping patients free from harm​

• Providing high quality healthcare​

• Decreasing risks to patients​

• Implementing evidence-based interventions​

Why is Patient Safety Important?​

• 1 in 17 hospital stays (about 150,000 out of 2.5 million) involved at least one harmful event ​

• These events are categorized as: ​

• 47% related to health care and medications (e.g., bed sores, medication errors)​

• 31% related to infections (e.g., surgical site infections)​

• 18% procedure-related (e.g., bleeding after surgery)​

• 4% patient accidents (e.g., falls) ​

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***Note: These figures exclude data from Quebec and patients with mental health or substance use diagnoses.​

inequity in healthcare

quality of healthcare varies significantly across populations influenced by age, gender, race and ethnicity, geography, and socio-eoconomic status

• indigenous people, black communities, LGBTQ2S+, immigrants + newcomers, radicalized groups

is patient safety improving

following covid patient safety was displaced by recovery efforts, workforce burnout, climate change, and heightened political and economic uncertainty

• infection control took precedence

• lack of family presence decreased safety, less experienced staff hired and orientation efforts reduced

What are some of the barriers to patient safety? ​

Safety goes beyond just physical ​

1. Emerging technologies​: AI and EHR can create gaps if not user friendly or replaces rather then supports clinical judgment

2. Resistance to change​: staff may resist new protocols or safety initiatives due to fear of lame, lack of trust in leadership, burnout. creating a culture of safety requires buy in, transparency, psychological safety

3. Communication failures​: one of leading causes, unclear handovers, language barriers, and assumptions made

4. Workload issues​: high patient to nurse ratios, overtime, and staff shortages

5. Training issues​: inconsistent or outdated training can leave staff unprepared for emergencies or new procedures. ongoing education, simulation training, and interprofessional learning

How do we Improve patient safety?​

• Invest in staff education, teamwork, and leadership development.​

• Engage with Patients and Families​

• Strengthening Safety Culture​ —> promote non-punitive environments

• Use Data and Technology Wisely​ —> user-friendly + integrated

• Support the workforce​ (work-life balance)

• Promote Equity and Inclusion​

What is Safety Culture?​

“Culture refers to shared values (what is important) and beliefs (what is held to be true) that interact with a system’s structures and control mechanisms to produce behavioural norms.” ​

“It influences patient safety directly by determining accepted practices and indirectly by acting as a barrier or enabler to the adoption of behaviours that promote patient safety.” Healthcare excellence Canada, 2025. ​

• combo of values, beliefs, and structures to promote pt safety

Components of Patient Safety Culture ​(FIVE DIMENSIONS)

• Informed culture – relevant safety information is collected, analyzed and actively disseminated ​—> staff aware of risk/trends + evidence-based decisions

• Reporting culture – an atmosphere where people have the confidence and feel safe to report safety concerns without fear of blame, and they trust that concerns will be acted upon ​

• Learning culture – preventable patient safety incidents are seen as opportunities for learning and changes are made as a result ​

• Just culture – the importance of fairly balancing an understanding system failure with professional accountability  —> systemic issues

  • wrong med (nurse is at fault) —> also pharm labelling, understaffed, computer glitching

• Flexible culture – people are capable of adapting effectively to changing demands ​

Key Contributors to culture of safety

• Leadership (Board, Directors, Managers)​: sets the tone, reflected in policies, resource allocation, and accountability structures. leaders empower staff to prioritize safety

• Teamwork and communication: interprofessional collaboration, handover reports + shared decision making

• Openness to report and learn from problems and incidents​: organizations must ensure reporting leads to action + feedback (encourages ppl to come forward)

• Proactive organizational learning: ​identifying risks before harm occurs + anticipating problems and evolving practices

• Organizational resources for patient safety: financial investment. safe staffing levels, training programs, and technology

• Priority of safety versus production: safety should not be compromised for speed/cost

organizational culture

beliefs, values, norms, shared by health care staff

• determines behaviours that are rewarded, supported, expected, and accepted

• exists at multiple levels: system, organization, department, unit

just culture

• A framework that promotes fairness, accountability, and learning by recognizing human fallibility and responding to errors in a non punitive way.​

Key Principles​

• Human Error ≠ Punishment: Mistakes are seen as learning opportunities.​

• Accountability with Compassion: Responses are based on the intent behind actions.​

• System Redesign: Focus on improving processes to prevent future errors.​

• Psychological Safety: Staff feel safe to report errors without fear.

The Role of Legislation - QCIPA​

Quality of Care Information Protection Act (QCIPA)​

• Purpose to promote open, frank discussion about quality of care issues without the fear of reprisal​ (before critical incidents occured, but no one reported)

• Includes learning from critical incidents related to patient care delivery​

• Applies to hospitals, independent health facilities,LTC homes, licensed medical laboratories and specimen collection centres​

• Information collected related to speculations, opinions, thoughts are considered quality of care information and cannot be used in legal or disciplinary proceedings nor disclosed to patient/family​

• Decision to use QCIPA is determined by the Quality of Care Committee of the Board​

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what occurs during a QCIPA meeting

critical incident happens, very little discussion abt why/how it happened + how to improve in the future

• hospital administrators can go to the hospital board or QOC committee and ask for QCIPA meeting to be enacted

• if committee agrees then facilitator appointed to ensure all case facts, documentation, and witness statements are analyzed + anyone involved in the situation is interviewed

• at beginning of interview, facillitator will tell nurse (or whoever) that anything shared is covered under QCIPA + cannot be held accountable

• e.g. “could’ve been better prepared, weren’t trained, physician didn’t do a good job and this is why”

• information is confidential but used to make recommendations

***** if info is documented on pt chart it shared w others (pt + family), conversation during meeting is not shared

The Role of Legislation - QCIPA​ - implications

• Cannot discuss the case outside of the review meeting.​

• Anything discussed prior to QCIPA being invoked is not protected​

• Cannot share information that is not factual for learning purposes​ (speculation or opinion-based content excluded from report)

  • “i think other nurse was distracted bc she has a lot going on at home” —> “we were short staffed that day and we each had 2 more pts)

• Limited in what can be shared with patient/family​

• Only actions that have been implemented​

• Cannot link the implemented actions directly back to the case​

  • explain what improvements were made but not necessarily that they were due to a particular incident

Role of Legislation​ - ECFAA​

Excellent Care for All Act (ECFAA) – 2010​

• It helps define quality for the health care sector​ —> places obligation on hospitals and care facilities to always look at QOC

• Reinforces shared responsibility for quality of care​

• Builds and supports boards’ capability to oversee the delivery of high quality of care​ —> encourages creation of quality improvement committees, looking at pt or employee satisfaction surveys etc.

• performance compensation —> higher QOC more money from gov

• Ensures health care organizations make information on their commitment to quality publicly available.​

• critical incidents to be reported to hospital adminstration, Medical Advisory Committee, patient + SDM to improve QOC

Patient Rights​ Disclosure

• Right to know about adverse events and near misses concerning themselves​

• Open and honest communication with families​

• CPSI Canadian Disclosure Guidelines provides a comprehensive overview​

• Disclosure is the process by which a harmful patient safety incident is communicated to the patient (or SDM).​

Patient Safety Incidents​ Definitions

• Patient safety incident = an event or situation that could have or did result in unnecessary harm to the patient​ (all three under are examples)

• Harmful incident = a patient safety incident that resulted in harm to the patient(aka “adverse event”)​ —> wrong med causing allergic reaction

• No harm incident = a patient safety incident which reached the patient but no harm occurred​ —> wrong med no reaction

• Near miss = a patient safety incident that did not reach the patient (aka “close call”)​ —> dispenses wrong med but not given

Disclosure Culture​

Supports patients by:​

• Supporting patients clinically​ (e.g. monitor after wrong med)

• Respecting patients​

• Informing patients​

• Supporting patients psychologically and emotionally​ (esp following traumatic experiences)

• Supporting patients practically​ (able to seek second opinions, access support services, make lifestyle adjustments) —> not left in the dark

Apologies

• Not an admission of guilt or wrong-doing.​

• Help to validate emotions​ and acknowledge their experience

• Display empathy and compassion​

• Help to build and maintain trust​

When to Disclose?​

1. Analysis of event

2. harm from natural progression of med condition VS healthcare associated event (combination can occur)

3. harm resulted from recognized risk of procedure/treatment (would’ve been explained before) VS patient safety incident

4. harmful incident (ALWAYS disclose), no harm incident (GENERALLY disclose, follow organization) , near miss (GENERALLY NEED NO disclose unless ongoing safety risk—> can harm relationship / trust)

Key points for Disclosure​

Identify the team (based on severity of harm and organizational policy)​

• harmful incident that results in death/disability may include hospital administrators, lawyers, doctors, etc.

• no harm may be disclosed by nurse themselves

Meet to plan what and how the disclosure will take place​

Disclosure should not be done alone​

Always document the disclosure in the patient’s record​

Follow up with the patient/family after the meeting to answer any additional

questions or provide more information​