Canadian Incident Analysis Framework

1 SaskatchewanMinistry ofHealthCanadian Incident Analysis Framework Canadian Incident Analysis FrameworkCanadian Patient Safety Institute Suite 1414, 10235 - 101 StreetEdmonton, AB, Canada T5J 3G1 Toll Free: 1-866-421-6933 Phone: 780-409-8090 Fax: 2012 Canadian Patient Safety InstituteAll rights reserved. Permission is hereby granted to redistribute this document, in whole or part, for educational, non-commercial purposes providing that the content is not altered and that the Canadian Patient Safety Institute is appropriately credited for the work, and that it be made clear that the Canadian Patient Safety Institute does not endorse the redistribution.

2 Written permission from the Canadian Patient Safety Institute is required for all other uses, including commercial use of Citation: Incident Analysis Collaborating Parties. Canadian Incident Analysis Framework . Edmonton, AB: Canadian Patient Safety Institute; 2012. Incident Analysis Collaborating Parties are Canadian Patient Safety Institute (CPSI), Institute for Safe Medication Practices Canada, Saskatchewan Health, Patients for Patient Safety Canada (a patient-led program of CPSI), Paula Beard, Carolyn E.

3 Hoffman and Micheline Citation: Incident Analysis Collaborating Parties. Canadian Incident Analysis Framework . Edmonton, AB: Canadian Patient Safety Institute; 2012. This publication is available as a free download at: additional information or to provide feedback please contact Canadian Patient Safety Institute would like to acknowledge funding support from Health Institute for Safe Medication Practices Canada would like to acknowledge funding support from Health Canada through the Canadian Medication Incident Reporting and Prevention System (CMIRPS).

4 The views expressed here do not necessarily represent the views of Health (print): 978-1-926541-44-0 ISBN (online): 978-1-926541-45-7 Canadian Incident Analysis Framework The Framework was developed collaboratively by the Canadian Patient Safety Institute, the Institute for Safe Medication Practices Canada, Saskatchewan Health, Patients for Patient Safety Canada (a patient-led program of the Canadian Patient Safety Institute), Paula Beard, Carolyn E. Hoffman and Micheline canadien pour la s curit des patientsBureau 410, 1150 chemin CyrvilleOttawa, (Ontario) K1J 7S9T l phone: 613-730-7322T l copieur: 613-730-7323 Canadian Incident Analysis FrameworkWORKING GROUP MEMBERSM embersPaula Beard, ACP, MAJulie Greenall, RPh, BScPhm, MHSc, FISMPCC arolyn E.

5 Hoffman, RN, MNSharon Nettleton, BA, MAIoana Cristina Popescu, MBAM icheline Ste-Marie, MDDonna Walsh, RN, BScN, FISMPCJ ennifer White, BSc, MEDesCurrent AffiliationsAlberta Health ServicesInstitute for Safe Medication Practices CanadaAlberta Health ServicesPatients for Patient Safety Canada (a patient-ledprogram of the Canadian Patient Safety Institute) Canadian Patient Safety InstituteMontreal Children s Hospital of the McGill University Health CentreInstitute for Safe Medication Practices CanadaSaskatchewan Ministry of HealthDISCLAIMERSThis publication is provided as information only.

6 All examples are provided as illustrations. This publication is not to be used as a substitute for legal advice. It is not an official interpretation of the law and is not binding on the Canadian Patient Safety Institute (CPSI). THANK YOUT hank you to patients, families, providers, operational leaders, regulators and funders for your passion and commitment to improving the safety of patient care. We invite you to share your successes and challenges on this Incident Analysis Working Group would like to acknowledge the many individuals who have generously contributed their expertise to the development of the Framework , including: the partnering organizations and authors of the Canadian Root Cause Analysis Framework for building the foundation for this document (partners.)

7 The Canadian Patient Safety Institute (CPSI), the Institute for Safe Medication Practices Canada (ISMP Canada) and Saskatchewan Health; co-authors: Carolyn Hoffman, Paula Beard, Julie Greenall, David U, Jennifer White), participants of the March 2010 International Roundtable Meeting on Event Analysis for their early guidance on content for the Framework ; staff of Fraser Health for graciously taking the time to pilot and improve initial revisions to the Framework ; members of the Recommendation Management and Patient Engagement Focus Groups; representatives of Ministries of Health, Health Quality Councils, CPSI voting member organizations; and the participants of the public consultation survey for helping the working group understand some of the challenges facing organizations across Canada as they endeavour to improve healthcare.

8 Additionally, the working group would like to thank: John Lewis, Donna Davis, Anne Findlay, Robert Johnston, Deborah Prowse, Sabina Robin, Cindy Winfield, Michelle Dionne, Mary Marshall, Laura Lin Gosbee and Ross Baker for their important expert advice and contributions. Canadian Incident Analysis FrameworkTABLE OF CONTENTSC laire s Story 5 Executive Summary 7 Introduction Background Key Updates The Evolution of Incident Analysis Incident Analysis and Management from a Patient/Family Perspective 14 The Essentials of Analysis .

9 Principles, Concepts and Leading Practices Principles Concepts Leading Practices Avoiding Cognitive Traps 25 The Incident Analysis Framework Incident Analysis as Part of Incident Management When to use the Framework Before the Incident Immediate Response Prepare for Analysis Analysis Process Methods of Incident Analysis - Overview Selecting a Method of Incident Analysis Comprehensive Analysis Concise Incident Analysis Multi- Incident Analyses Developing and Managing Recommended

10 Actions Follow-Through Implementation Monitor and Assess the Effectiveness of Recommended Actions Close the Loop 68 Continuous Organizational Learning and Sharing Results 68 Reflecting on and Improving the Quality of Analysis and Management Processes 70 Conclusion 71 References 72 Appendices 80 Team Management Checklist 81 Challenges and Strategies During the Incident Analysis Process 82 Analysis Team Membership, Roles and Responsibilities 83 Sample Analysis Team Charter 85 Sample Confidentiality Agreement 86 Checklist for Effective Meetings with Patient(s)/ Families 87 Incident Analysis Guiding Questions 89 Creating a Constellation Diagram 92 Incident Analysis Report Template 99 Case Study - Comprehensive Analysis : Elopement from a Long-term Care Home 100 Case Study - Concise Analysis .