Quality improvement and accountability reviews: Learning from patient safety incidents and near misses
Published: August 2009
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Revised: December 2024
Table of contents
About this guide
This guide describes the requirements and processes for reporting and reviewing patient safety incidents and near misses, and how hospitals and other healthcare institutions can foster a culture of safety and learning. This information will be of interest to CMPA members and other healthcare professionals in leadership/management roles and those participating in the reporting and review process.
More resources from CMPA
On disclosure of patient safety incidents
Healthcare providers have an ethical, professional, and legal obligation to disclose harm from healthcare delivery to patients. A disclosure discussion promotes safe and quality medical care and helps maintain trust in the physician-patient relationship.
Read more in the CMPA handbook: Disclosing harm from healthcare delivery: Open and honest communication with patients
On a “just culture of safety”
In a just culture of safety, all individuals can trust that the initial responses to a patient safety incident, as well as any subsequent analyses and proceedings, will be conducted with fairness, and in accordance with the applicable legal frameworks and hospital/institution policies.
Read more in CMPA Good practices: Just culture
On psychological safety
Psychological safety is characterized by a shared belief that anyone on the care team can speak up and share their opinion within a respectful environment and without fear of retribution.
Read more in CMPA Good practices: Psychological safety
