Patients, families, and care providers affected by patient safety incidents expect there
will be learning and improvement so that others will not suffer. For that, countries need mature data systems and a culture of safety that includes improving by learning from reporting hazards, harm, and near misses, as well as learning from situations and organizations where safe care is delivered consistently over time, which is in most cases.
While systems are in place to support incident reporting, sharing, and learning from a variety of sources, in Canada truly national incident reporting is limited to medications, adverse drug reactions, and device failures. However, there are other pan-Canadian and
grassroots efforts to advance reporting and learning from patient safety incidents that are complementary. System and contextual factors influence the ability to improve safety, learn, and report. An important one is the COVID-19 pandemic, which resulted in limited or delayed patient safety reporting and some scaling back of improvement projects.
The best systems incorporate reporting from multiple sources (patient feedback, coroner reports, etc.) and engage all people involved in care, especially patients and families, in their design, implementation, and continuous improvement. Patient groups,
like Patients for Patient Safety Canada (PFPSC), provide the perspective of patients and families with lived experiences that can effectively improve safety. PFPSC contributes to the development of Canadian patient safety strategies, policies, and programs, and innovates and co-leads initiatives that matter to patients and the public.
The World Health Organization’s Global Patient Safety Action Plan includes patient safety incident reporting and learning systems to “ensure a constant flow of information and knowledge to drive the mitigation of risk, a reduction in levels of avoidable harm, and improvements in the safety of care” objective.
