Domain 1: Related Documents

Last modified by Lisa Stromquist on 2012/11/29 22:29


Contribute to a Culture of Patient Safety

Tools, Resources and Reference Material 


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


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

  • SJHC: the senior leadership come to units on occasion to solicit feedback about certain initiatives.  Leadership reporting of Big AIM/Program Metrics/Access & Flow initiatives to the entire leadership group once weekly in a corridor behind the cafeteria. Each area brings graphs and discusses how they are doing against targets for that week. Feedback is provided, suggestions made, etc.

Patient Safety Accountabilities


Safety climate surveys conducted and assessed on a regular basis


Participate in Patient Safety symposiums, Canadian Patient Safety Week, poster fairs

Provide access to safety tools and resources


Focused education campaigns


Build patient safety language into all position descriptions: professional, non union

Create roles specific to quality and patient safety


Official representation from Patient Safety team in discussions regarding models of care and service delivery



LEAN system improvement methodologies: used to enhance patient safety improvement efforts.  


Evaluate effectiveness of performance indicators through regular audits

  • examples of audit tools, chart review tools, etc; weekly drug library audits; monthly audits, ID Bracelets, safety inspections
  • HSN_Audits_Standards_of Care

Safety indicators and benchmarks have been developed and are reviewed monthly with action plans developed

  • examples of indicators, action plans



Inclusion of family members on various committees

Debriefing of all incidents occur


Develop process/programs to enhance internal learning around quality and patient safety

  •  Introduction of VAD-PICC protocol and 24 hour line placement accessibility for NICU (copy of protocol?)
  • Annual infection control inservices. 
  • Roll out of BPGs - central line insertion and . maintenance (ONIC project), Perinatal infection control standards.NICU/Peds safety initiative roll out will occur in September
  • HSN Skin prep solutions for use in NICU standardized to best practice

Self learning programs; skill maintenance  programs


Multidsciplinary 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 PDSA cycles when introducing change.