Definitions

Adverse Event: An incident that has resulted in harm to the patient as a result of the care provided in the OHP (also known as a “harmful incident”). For specific examples, please see the Advice to the Profession document.

Standards

Preparing for Adverse Events

1. Medical Directors must:
   1. ensure there are written protocols in place to support the recognition and reporting of adverse events and to appropriately manage any adverse events that occur;
   2. ensure there is an established written protocol to facilitate the urgent transfer of patients to the hospital for the management of an urgent adverse patient event;
   3. be available to provide assistance in managing any adverse events, if necessary;
   4. be satisfied that staff practising within the OHP are aware of the written protocols and are capable of managing any adverse events themselves; and
   5. have a communication plan in place to keep informed of any adverse events that take place and any actions taken to manage them.

Managing Adverse Events

2. When an adverse event occurs, physicians involved in the adverse event must take appropriate and timely action, including:
   1. managing any urgent adverse events appropriately by:
      1. providing any necessary care to address the patient’s immediate needs;
      2. ensuring timely initiation of emergency care or services, where necessary (e.g., where the patient is experiencing severe suffering or is at risk of sustaining serious bodily harm if treatment is not administered promptly);
      3. initiating a timely transfer to hospital by appropriate means in light of the patient’s condition, where necessary;
      4. accompanying the patient to hospital, where necessary;
      5. communicating with the receiving physician or premises to notify them of the transfer, where the patient is unaccompanied;
      6. ensuring essential medical information and the referring physician’s contact information is sent with the patient to support continuity of care;
   2. caring for, supporting, and following-up with patients, family, and caregivers as necessary.

Documenting and Reporting Adverse Events

3. When an adverse event occurs, physicians involved in the adverse event must:
   1. document the details of the adverse event in the patient’s medical record;
   2. provide a written report to the Medical Director within 24 hours of learning of the event which includes all relevant information (e.g., date and type of procedure, description of the incident and treatment rendered, analysis of reasons for the incident, outcome);
   3. report the incident, including all relevant details, to CPSO in the form and manner required by CPSO, within 5 business days of learning of the event;
   4. provide CPSO with any relevant medical records and additional information as requested;
   5. ensure appropriate disclosure to the patient, in accordance with CPSO’s Disclosure of Harm policy; and
   6. where a death occurs, make a report to the Coroner.
4. Where an adverse event occurs, Medical Directors must ensure the reporting obligations set out above are complied with (e.g., that the adverse event has been reported to the CPSO within 5 business days).¹

Incident Analysis

5. Once the adverse event has been appropriately managed, Medical Directors must initiate a process with the physician(s) and staff involved in the adverse event to analyze and learn from the event, including:
   1. undertaking an investigation to understand how and/or why the incident occurred;
   2. developing recommendations to help prevent similar incidents from occurring, where appropriate;
   3. sharing the learnings and recommendations with other staff in the OHP, as appropriate.²
6. Medical Directors must ensure that recommendations are implemented within the OHP and are monitored over time to assess their effectiveness.

Analyzing and Learning from Adverse Events

7. Medical Directors must:
   1. critically review all adverse events that have occurred over a 12 month period and evaluate the effectiveness of the OHP’s practices and procedures to improve patient safety;
   2. document the review and any relevant corrective actions and quality improvement initiatives taken; and
   3. provide feedback to all staff regarding identified patterns of adverse

Endnotes

^1. Failure to report an adverse event may result in an outcome of Fail by the Premises Inspection Committee.

^2. Investigations and any corresponding actions need to be proportionate to the circumstances and to the adverse event that occurred. More serious adverse events may require a more in-depth investigation and/or more significant corrective actions.