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Publications & Resources > The Standard > September 2004   

  Last modified August 27, 2004  

The Patient Safety Movement – the basics

The patient safety movement has arrived in Canada. But what is this “movement” about, and how is it affecting the health care sector?

Basic concepts

As a health care professional, you anticipate a positive outcome for your patients when you provide care. The main concept behind the patient safety movement, however, is that human beings, and the systems through which they provide care, are fallible. This means unintended injuries to patients, resulting in prolonged hospitalization or a disability, can occur. These are called “adverse events,” and while some are preventable, others are not. When a patient is harmed by care, it is expected that the situation will be addressed to prevent future injuries.

In this section

CNO’s standards are based on these basic principles of patient safety. For example, in the Professional Standards, you are instructed to take action in situations where client safety and well-being are compromised. You can also demonstrate the Professional Standards by “taking responsibility for errors when they occur and taking appropriate actions to maintain client safety.” In addition, the Ethics practice standard states that promoting client well-being includes “preventing or removing harm.”

These concepts are not new; however, what is new is an emphasis on examining and evaluating adverse events in a system-wide context. Research conducted around the world indicates that the systems through which health care is delivered can contribute to adverse events. Even when a health care provider practises to standards, the complexity of care, technologies, communication systems or organizational factors can contribute to the occurrence of an adverse event. These findings have expanded the scope of examining adverse events beyond just an individual’s actions.

Canadian Adverse Events Study

Earlier this year, Canadian researchers released this country’s first national study related to patient safety called Patient Safety and Healthcare Error in the Canadian Healthcare System. (For more on this study, which is commonly referred to as the Canadian Adverse Events Study, click here.)

The conclusion of the study focused on the positive — that Canada is in a good position to improve its patient safety record, and is no better or worse than several other Western countries (including the U.S. and Britain) when it comes to the rates of adverse events.

At the same time, initiatives for improving patient safety have been launched at local, provincial, national and even international levels. Addressing and improving patient safety, however, requires long-term and coordinated strategies that identify factors that contribute to adverse events and systems that support safe practice by health care professionals.

Researchers have recommended many ways to improve patient safety; however, to be most effective these solutions are often expensive and require across-the-board changes in attitudes, health care delivery systems and behaviours. In other words, the patient safety movement requires health care professionals to rethink what constitutes safe care and what their accountabilities are, and to engage in a whole new learning cycle.

CNO is accustomed to looking at healthcare in a systems context (i.e., through the Practice Setting Consultation Program®) and already has programs in place, such as the Participative Resolution Program, that can address a specific complaint while also incorporating a preventive, system-wide focus.

CNO is committed to engaging with all areas of health care — from individual care providers to administrators to legislators — as it determines what its role will be in the patient safety movement.

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