CPSI, Root Cause Analysis Workbook - Paediatric Chairs of Canada

18Figure 3: Conceptual Model of Effective System Change StrategySource: Baker, G.R. & Norton, P.Improving Safety through ReportingThe Institute of Medicine’s report To Err is Human (1999) 45 identified the need for a systematic method ofreporting adverse healthcare events. As a result, the U.S. National Quality Forum was asked to develop a listof core events that are considered both serious and preventable in nature. The outcome was the creation of aconsensus report that identified 27 serious and reportable events. The list was modified by Saskatchewan Healthand is described in The Saskatchewan Critical Incident Reporting Guideline, 2004. 17Saskatchewan is an example of a province currently working to systematically improve reporting and patientsafety by provincially sharing lessons learned in local jurisdictions. The process began with the Departmentof Health who, together with regulatory authorities and healthcare regions, reviewed the available optionsfor sharing the lessons learned from RCA reviews. To make provincial reporting and sharing feasible, it wasdetermined that the action items and recommendations arising from an RCA would require additional legalprotection. The findings could then be transmitted to the Department of Health without concerns that thedocuments and/or discussions would be disclosed in a legal proceeding. To create this additional legal protection,the government decided to legislate the investigation and reporting of critical incidents.Saskatchewan Health is committed to broadly disseminating applicable system improvement opportunities ina manner which does not identify individuals or individual facilities (known as being “de-identified”). Followingthe review of a critical incident, any recommendation that may be applicable in other regions is shared provincewidein the form of an Issue Alert. This Alert contains a general, de-identified, description of the circumstancessurrounding the incident and the recommendations that are provincially applicable. The Issue Alert does notinclude any identifying details of the incident or the region inwhich the incident occurred.The Institute for Safe Medication Practices Canada (ISMP Canada) collects and analyzes medication errorreports and develops recommendations for the enhancement of patient safety. ISMP Canada serves as anational resource for promoting safe medication practices throughout the healthcare community in Canada.It accomplishes this through the dissemination of safety bulletins and promotion of safety tools such asMedication Safety Self-Assessment, Analyze-ERR®, and educational workshops and consultations. ISMPCanada is a key partner with Health Canada and the Canadian Institute for Health Information (CIHI) in the newCanadian Medication Incident Reporting and Prevention System (CMIRPS).45Institute of Medicine, Linda T. Kohn, To Err Is Human, (Washington, D.C.: National Academy Press, 2000).