Abstract

Morgan outlines some important elements necessary for improving patient safety in Canadian healthcare. But these steps are likely to require considerable time and resources and may be difficult to implement. In the light of the evidence of adverse events in Canadian hospitals, all Canadian healthcare organizations need to begin to measure the numbers and types of adverse events experienced by their patients and clients. Staff need to learn new skills for investigating and improving care. A variety of tools and resources are available for these tasks. Leadership both in senior management and on the front lines must learn to shift the focus from blaming individuals to improving systems of care. Leaders must also acknowledge that most healthcare organizations have failed to gather the necessary information on adverse events, and they must invest in building knowledge and implementing practices that reduce the current levels of injury.