Research from around the world has identified patient safety as an important issue. Improving patient safety is a priority for Manitoba Health, Seniors and Active Living and all those who deliver health care services.
When striving to improve safety within the system, it is important to consider how health care is delivered and the complexity of the health care system. The previous practice of focusing on the actions of individual health care providers when errors occur did not take this into account . We need to find ways to examine the system more broadly and consider how it may contribute to incidents when they happen and how to make changes to prevent their recurrence.
As early as 2003, Manitoba Health developed a provincial policy to encourage the voluntary reporting of critical clinical occurrences (now referred to as “critical incidents”) where learning might occur from seemingly isolated errors. In 2006, legislation was introduced for mandatory no-blame critical incident reporting across the health system to support a culture of learning and openness. Manitoba was the second province to introduce mandatory reporting and investigation of critical incidents. There are several initiatives underway in the health care system to improve patient safety, including making changes to deliver safer care, to better enforce infection prevention and control measures, and to facilitate better communication between health care providers and patients and their families.