Domain 1: Contribute to a Culture of Patient Safety

Last modified by Lisa Stromquist on 2012/11/23 15:30



- Commit to patient and provider safety through safe and competent, high quality practice -

- Describe the fundamental elements of patient safety -

- Maintain and enhance patient safety practices through ongoing learning -

- Demonstrate a questioning attitude as a fundamental aspect of professional practice and patient care -



Healthcare Professionals who contribute to a culture of patient safety understand:

  • Key patient safety concepts, , such as adverse events, close calls, no-harm events and just culture
  • Key patient safety processes, including the reporting of adverse events, methods of analyzing how an adverse event occurred, system improvement processes, and the institution of structures to ensure accountability within a system
  • The creation, application dissemination and translation of patient safety principles, practices, behaviours attitudes and knowledge
  • The potential risks presented by one’s own daily practice, and ways to minimize those risks
  • Types of organizational cultures, as well as the characteristics of high reliability organizations and how they relate to health care
  • The contribution of system failures and provider performance to adverse events and close calls
  • Systems-based approaches to reducing system failures


  • Recognize and respond appropriately to potential and actual unsafe clinical situations
  • Work within their own limitations


  • Commitment to patient safety as a key professional value and an essential component of daily practice
  • Value professional learning as a life-long process requiring self-assessment and self-directed education
  • Demonstrate a questioning attitude in routine and non-routine activities



Policy statements support safe competent practice: 

  • disclosure
  • incident reporting
  • infection control
  • medication safety
  • consent
  • transmission of information    
  • Standards of care are developed to include safety standards. All paediatric staff are familiar and accountable to them 
  • Review and update policies and procedures every 3 to 5 years based on new learnings

Patient Safety articulated as a key strategic directions 

  • Development of a Patient Safety Strategy Map 
  •  Safety is an item on key agendas, Board, Board Quality, Unit level teams, Partnership Councils
  • Patient Safety Leadership Rounds
  • Town Hall or Break Time with Senior leaders
  • Patient Safety Accountabilities

Process to assess the safety culture in the organization

  •  Safety climate surveys conducted and assessed on a regular basis

Develop clear position descriptions that address patient and provider safety

  • Patient safety language built into all position descriptions: professional, non union, 

Opportunities for participation in external knowledge exchange activities and continued patient safety training  and education

  • Participate in Patient Safety symposiums, Canadian Patient Safety Week, poster fairs, etc
  • Provide access to safety tools and resources
  • Focused education campaigns

Develop resources and create opportunities for experts to support  and advise on patient safety practices


  • Create roles for Medical Director  for Patient Safety, Medical Director for Quality & System Improvement, Director of Quality and Patient Safety
  • Official representation from Patient Safety team in discussions regarding models of care and service delivery
  • Patient safety leadership rounds
  • Patient safety acountabilities
  • Focus on compliance with ROP's for accreditation 
  • LEAN principles informed the layout and flow in our Laboratory redesign 
  • LEAN system improvement methodologies: used to enhance patient safety improvement efforts.  Using LEAN involves clarifying team roles, improvement communication and using data for decision making.  Qualified facilitators work with unit based teams to focus on patient safety improvements and ensure that all decisions for improvement have patient safety as a priority.

Process in place to evaluate effectiveness of patient safety mechanisms and address gaps

  • Evaluate effectiveness of performance indicators through regular audits
  • Safety indicators and benchmarks have been developed and are reviewed monthly with action plans developed

Opportunities for family members to contribute as stakeholders on policy and procedure reviews

  •  Inclusion of family members on various committees

Process in place to provide opportunities for staff to share and learn from internal patient safety reports

  • Debriefing of all incidents occur
Process in place to ensure all staff maintain clinical competencies
  • Develop process/programs to enhance internal learning around quality and patient safety
  • Self learning programs; skill maintenance  programs

Emphasize continuous monitoring of quality indicators


Organizational support for training to analyze factors affecting quality & patient safety

  • Multidisciplinary teams and training for prospective analysis .  Specific team members called on by QAC to lead or contribute to sentinel event reviews
  • M&M rounds occur 
  • Use of PDSA cycles when introducing change
Created by Lisa Stromquist on 2012/07/16 17:05