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Critical patient safety incidents reviews: Shifting gears towards patient and family centred model

Fraser Health has implemented a novel approach for managing critical patient safety incidents. Our journey started with new emerging process for timely response from leadership to initiate an SBAR T-con call for critical incidents, with focus on patient and family immediate needs. The Regional Quality Review team was formed to standardize the methodology and tools utilized in the review process. The Patient Event Journey Map tool was developed to guide the incident review through patient and family lens. Our quantitative data analysis shows that our system recommendations has increased in terms of recommendation effectiveness in comparison to the old model. The results achieved are: 50 % increase in standardization of clinical care processes, significant increase in engagement of Leadership in patient safety reviews, there 50 % decrease in recommendation with low effectiveness score i.e. Training, educations, studying, and analysis. 



Hamze Jomaa – Fraser Health 

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