Patient Safety and Healthcare Error in the Canadian Healthcare System: A Systematic Review and Analysis of Leading Practices in Canada with Reference to Key Initiatives Elsewhere

Prepared by G. Ross Baker & Peter Norton
For Health Canada

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Table of Contents

• Executive Summary
• Acknowledgements
• 1. Background
  • 1.1 Project Goals and Objectives
  • 1.2 Focus of Inquiry
  • 1.3 Overview of International Efforts:
    • 1.3.1 Australia,
    • 1.3.2 United States,
    • 1.3.3 United Kingdom
  • 1.4 Summary
  • 1.5 References
• 2. Methods
  • 2.1 Literature Review
  • 2.2 The Surveys
    • 2.2.1 Sample for the Mail Survey
    • 2.2.2 Sample for the Telephone Survey
    • 2.2.3 Data Analysis for the Surveys
  • 2.3 Review of Legal Issues
  • 2.4 References
• 3. Results
  • 3.1 Literature Review
    • 3.1.1 Safety and Error: General Texts and Overviews
    • 3.1.2 Epidemiology of Healthcare Error
    • 3.1.3 Identifying and Addressing Errors in Healthcare Organizations
    • 3.1.4 Strategies to Reduce Error
    • 3.1.5 Disclosure of Error
    • 3.1.6 Legal and Ethical Issue
    • 3.1.7 Major Policy Papers and Reports on Healthcare Error and Patient Safety
    • 3.1.8 Professional Education
    • 3.1.9 Lessons From Other Industries
  • 3.2 Mail Survey
    • 3.2.1 Response Rates
    • 3.2.2 Results of the Mail Questionnaire
  • 3.3 Telephone Interviews
    • 3.3.1 Description of Respondents
    • 3.3.2 Telephone Interview Findings
    • 3.3.3 Summary of Main Themes from Telephone Interviews
  • 3.4 Legal Issues Review
    • 3.4.1 Medical Law - definitions and principles
    • 3.4.2 Picard and Robertson Text
    • 3.4.3 The Prichard Report
    • 3.4.4 CMPA Tort Reform Conference
    • 3.4.5 Structured Settlements
    • 3.4.6 Privileging
    • 3.4.7 Selected Other Medical-Legal References
    • 3.4.8 Disclosure
    • 3.4.9 Ethical Obligations of a Physician
    • 3.4.10 References
• 4. Discussion
  • 4.1 Limitations of the Study
    • 4.1.1 Mail Survey
    • 4.1.2 Telephone Survey
    • 4.1.3 Consistency between the Surveys
  • 4.2 Opportunities and Challenges Identified
  • 4.3 Specific Findings
    • 4.3.1 Specific Issues of Concern about Patient Safety
    • 4.3.2 Emerging or Potential Safety Issues Identified by Organizations
    • 4.3.3 Patient Safety Tools, Programs and Surveillance Systems in Use Now
  • 4.4 Leading Patient Safety Practices in Canada
• 5. Conclusions/Recommendations/Next Steps
  • 5.1 Method for Developing the Recommendations
  • 5.2 Report Recommendations
    • 5.2.1 Build Awareness and Set Priorities to Improve Patient Safety in Canada
    • 5.2.2 Develop Better Reporting Systems
    • 5.2.3 Build Skills, Disseminate Knowledge and Implement Systems to Improve Safety
    • 5.2.4 Create Organizational and Policy Level Supports for Patient SafetyEfforts
  • 5.3 Linking Recommendations to a Conceptual Model
  • 5.4 Final Remarks

Appendix F: Glossary Of Terms

The following Appendices are available upon request:

• Appendix A: Final Questionnaires and Telephone Interview Schedule
  • Questionnaire for Healthcare Organizations
  • Questionnaire for Professional Associations and Colleges
  • Telephone Interview Schedule
• Appendix B: List of atient Safety Documents and Materials Sent by Respondents
• Appendix C: Coding for Open Ended Questions on the Mail Survey
• Appendix D: How Data on Adverse Events and Errors Are Collected and Used by Canadian Healthcare Organizations
• Appendix E: Content Analysis for Questions in the Telephone Survey
• Hindsight Bias
• Appendix G: Mail Questionnaire Response Rate Table