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Summary of key concepts and good practices

What you need to know and what you need to do.

Patient safety
Key concepts
  • Harm most often reflects the progression of a patient's underlying disease or injury.
  • Sometimes harm results from healthcare delivery.
Good practices
  • Understand the patient safety terminology in your institution.
Key concepts
  • Administrators, healthcare providers, and patients have a responsibility for patient safety.
  • A just culture of safety seeks ways to improve safety and protects patients, healthcare providers, and institutions.
  • A just culture of safety respects everyone's observations and contributions.
Good practices
  • Keep the patient's well-being foremost in your mind.
  • Be alert to threats to patient safety.
  • Be prepared to question policies, practices, and actions that may threaten patient safety.
  • Be honest and transparent when an adverse event (accident in Québec) occurs.
Key concepts
  • The system of care should support patient safety.
Good practices
  • Be alert to threats to patient safety.
Key concepts
  • Healthcare professionals are accountable to patients, work institutions and/or provincial or territorial regulatory bodies.
Good practices
  • Maintain your knowledge and skills.
  • Comply with institutional and regulatory policies and practices.
  • Practise to the standard of care and only if healthy to do so.
Key concepts
  • Continuously improving includes identification, analysis and improving processes to reduce the likelihood of adverse events (accidents in Québec).
Good practices
  • Be prepared to question policies, practices, and actions that may threaten patient safety.
  • Be honest and transparent when an adverse event occurs.
Key concepts
  • Administrators, healthcare providers, and patients have a responsibility for patient safety.
Good practices
  • Practise to the standard of care.
Key concepts
  • Patients who have suffered harm may seek compensation.
  • Most medical-legal actions are based on a claim of negligence(professional civil liability in Québec).
Good practices
  • Practise to the standard of care.
Teams
Key concepts
  • The composition of the team will vary depending on the needs of the patient.
  • Healthcare professionals should understand the scopes of practice of those they work with.
  • The roles and responsibilities of team members should be defined and understood.
Good practices
  • As a member of a team know your own role and each team member's role.
Key concepts
  • Patient care is improved when healthcare providers are committed to working as a team.
  • Good teams have good leaders.
  • The roles and responsibilities of team members should be defined and understood.
Good practices
As a member of a team:
  • Know your own role and each team member's role.
  • Communicate clearly and as often as necessary.
Key concepts
  • A trusting and supportive work culture will foster effective supervision and delegation.
  • When delegating, the supervising physician's primary consideration must be the best interests of the patient.
  • A careful, reasoned approach based on each patient's unique circumstances may help to reduce exposure to the risk of liability for both supervising physicians and trainees.
  • Lack of clarity and false assumptions can obscure communication between supervisors and trainees.
  • Continued safe medical care depends on an honest and accurate assessment of a medical trainee's performance.
  • Supervisors need faculty development and institutional support to be empowered to identify and effectively deal with underperforming trainees.
  • Patients have the right to express concerns about trainees being involved in their care.
  • Patients have a role in helping shape or design training programs for future physicians.
Good practices
  • Trainees need to be mindful of their own level of competence in performing a procedure or clinical task.
  • Supervisors must be aware when more active supervision of a trainee is needed.
  • Supportive communication by supervisors will help trainees feel comfortable and confident.
  • Trainees should be properly oriented as to situations when they should contact the supervisor about a patient.
  • Trainees need to recognize when they do not feel confident supervising more junior residents or medical students.
  • Supervisors should ensure that they provide an accurate and fair assessment of a medical trainee, and openly and honestly report any concerns.
  • Patients should be informed, when appropriate, of the educational status and anticipated role of trainees.
  • Express consent must be obtained from patients when a trainee is performing a medical procedure without direct supervision.
Key concepts
  • Patient care is improved when healthcare providers are committed to working as a team.
  • The composition of the team will vary depending on the needs of the patient.
  • Healthcare professionals should understand the scopes of practice of those they work with.
  • The roles and responsibilities of team members should be defined and understood.
  • Good teams have good leaders.
  • Clear communication within the team is essential for safer care.
  • When tasks or decisions are delegated, both the delegate and delegator have specific responsibilities.
  • Each team member should appropriately document the care they provide.
  • Each team member should have adequate medical-legal liability protection.
Good practices
  • As a member of a team:
    • Know your own role and each team member's role.
    • Communicate clearly and as often as necessary.
    • Know your limitations: accept a delegated task only if you are capable of performing it.
    • Delegate and supervise appropriately.
Communication
Key concepts
  • Good doctor-patient communication is about:
    • fostering understanding
    • recognizing barriers and finding ways to resolve them in a professional manner
    • etiquette and mutual respect
Good practices
  • Be polite.
  • Use language suited to the particular patient.
  • Be alert to non-verbal signs of uncertainty.
  • Confirm your patient's comprehension.
  • Be prepared to get help with translation.
  • Be ready to adapt to cultural differences.
  • Consider alternative communication styles when necessary.
Key concepts
  • Maintaining a patient's personal health information in confidence is an ethical and legal requirement.
  • Confidentiality is central to the doctor-patient relationship because it encourages patients to be frank with their doctor.
  • Breaches of confidentiality can be harmful to patients, physicians, and other health providers.
  • Most breaches are unintentional.
  • In specific circumstances you are required to divulge patient information. Know the legislation in your province or territory.
  • Divulging patient information is permitted if there is an imminent, credible risk of serious bodily harm to a recognized individual or group of individuals.
  • Legal and professional standards for the protection of privacy are equally applicable to electronic communications.
Good practices
  • Protect patient confidentiality.
  • Do not inappropriately access a patient's medical record.
  • Consider who is in the circle of care for your patient before releasing information.
  • Obtain consent before divulging patient information outside the circle of care.
  • Follow the law in your jurisdiction for mandatory reporting.
Key concepts
  • Patients have the right to decide on investigations and treatments (patient autonomy).
  • Mentally capable patients have the right to refuse or withdraw consent for investigations and treatments.
  • Consent must be voluntary and informed.
  • Patients must have the capacity to give consent.
  • The physician is required to provide information that the "reasonable" patient would want or need to make a decision.
  • Elements of informed consent are:
    • diagnosis
    • proposed treatment
    • chances of success
    • risks (material and special)
    • alternative treatments
    • consequences of no treatment
    • answers to questions
  • The consent discussion should be documented in the medical record.
Good practices
  • Discuss the proposed investigation or treatment with the mentally capable patient, including the chances of success.
  • Explain the material and special risks in understandable terms, including the consequences of non treatment.
  • Listen to the patient's concerns and answer any questions.
  • Assess the patient's apparent understanding to make a decision.
  • Respect the patient's decision.
  • Consider relevant legislation regarding minors or mentally incapable patients.
Key concepts
  • Patients need to know:

    • symptoms and signs alerting them to seek further medical care
    • advice tailored to their specific clinical situation
    • they are welcome (made to feel comfortable) to return for re-evaluation
  • When providing discharge instructions:

    • inform the patient who is the most responsible health professional for follow-up care
    • alert those health professionals who are responsible for follow-up care
    • consider the safety of the mentally incapable patient and provide appropriate advice to those who will be with the patient
    • document the discharge instructions provided in the medical record
    • handouts support the informed discharge discussion but do not replace the personal interaction
    • make efforts to provide patients who leave AMA with informed discharge advice and, if possible, obtain a signed AMA form
Good practices
  • Educate patients to recognize the symptoms and signs that should alert them to seek further medical care. Tailor the advice to the patient's specific clinical situation.
  • Encourage patients to feel comfortable and welcome to return for re-evaluation.
  • Involve substitute decision-makers if the patient is not mentally capable at the time of discharge.
  • Support your informed discharge discussion with patient care handouts if available.
  • Inform the responsible healthcare professionals concerning follow-up care.
  • Document your discussion and advice in the medical record.
Key concepts
  • Well-functioning teams deliver superior care.
  • Good teams have a "shared mental model."
  • Good teams communicate "often enough."
  • Team communications should be respectful.
  • The medical record should provide sufficient information for other team members to care for the patient.
Good practices
  • Develop your skill of active listening.
  • As a team leader or member, communicate respectfully, clearly and provide sufficient information in a timely way to help in patient care.
  • Notify the appropriate healthcare provider about a patient's condition, including any changes in that condition.
  • Speak up early if you have patient safety concerns.
  • Review the clinical notes from nurses and other healthcare professionals.
  • Consider using structured communication tools for team communications such as readbacks, SBAR, a surgical safety checklist, or others.
  • Consider the patient's or family's concerns; address or discuss these concerns with a supervising resident or staff physician. Discuss the concerns with the patient, or with the patient's permission, the family. Respond appropriately.
  • Convey the degree of urgency of an order, use standard abbreviations, and keep your writing legible.
  • Document your care carefully.
Key concepts
  • Handovers are high-risk points in patient care.
  • Mnemonics may help structure information.
  • A readback can confirm to-do items, medication orders, lab results and equipment settings.
  • Handovers can provide a fresh perspective on diagnoses and treatments.
  • Transfers of care should be documented.
  • Inform patients or their families of the transfer of care, and, when appropriate, communicate the nature of further investigations, treatments, and follow-up plans.
Good practices
  • Have face-to-face discussions if possible.
  • Avoid interruptions and distractions.
  • Use a structured communication tool, including readbacks.
  • Transfer key information such as the patient's diagnosis, test results, and treatment plan.
  • Ask for further clarification as needed.
  • Clarify roles and responsibilities for further care.
Key concepts
  • All relevant information should be available to both physicians.
  • The reason for the consultation should be clear to both the referring and the consulting physician.
  • Expectations should be clear to both physicians.
  • Responsibility for further care should be explicitly stated.
Good practices
  • Always document requests for consultation and their outcome.
  • State expectations in the request and in the report.
  • Understand the reason for the consultation.
  • Collect and share all relevant information with the other physicians.
Key concepts
  • Medical records are legal documents.
  • Medical records are used to show the thought process leading to a diagnosis and plan of care.
  • Medical records are a means to communicate with other caregivers, whether concurrent or subsequent.
  • Patients have the right to see the content of their medical record, subject to certain exceptions.
Good practices
  • Take care to document every patient encounter whether the encounter is in person or by telecommunication.
  • Record the interaction as soon as reasonably possible.
  • Include all relevant information.
  • Indicate your reasoning and intentions.
  • Write legibly.
  • Use only accepted abbreviations.
  • State the facts using clear and simple language.
  • Consider what a patient will think when reading your notes.
  • When making corrections, be sure to date them and indicate the reason for the correction.
  • Never erase an original entry.
  • Don't alter a medical record after receiving a complaint, threat of a legal action, or a legal action.
Managing risk
Key concepts
  • Arriving at a diagnosis is a complex process involving several steps.
  • A differential diagnosis enables appropriate testing to rule out possibilities and confirm a diagnosis.
Good practices
  • Develop a differential diagnosis.
  • Consider the worst case diagnosis.
  • Reconsider the diagnosis when symptoms or signs persist.
  • Follow up on investigations and patients.
  • Document the rationale for your diagnosis and treatment.
Key concepts
  • Arriving at a diagnosis is a complex process involving several steps.
  • A differential diagnosis enables appropriate testing to rule out possibilities and confirm a diagnosis.
  • Failure to follow up investigations and patients leads to delays in diagnosis or misdiagnosis.
  • The patient's home medications when writing orders at admission, transfer, and discharge should be considered.
Good practices
  • Develop a differential diagnosis.
  • Consider the worst case diagnosis.
  • Reconsider the diagnosis when symptoms or signs persist.
  • Follow up on investigations and patients.
  • Document the rationale for your diagnosis and treatment.
Key concepts
  • Attention to surgical risks in pre-operative, intra-operative, and post-operative care is important.
  • Use of surgical safety checklists improve team communication and may help to decrease the risk of harm related to surgery.
Good practices
  • Determine whether there are appropriate indications for surgery.
  • Conduct and document an informed consent discussion before performing investigations and treatment.
  • Confirm the correct patient, operation, level, and side that is being operated on.
  • Protect vital structures when operating.
  • Use a customized surgical safety checklist.
Key concepts
  • Medication orders and prescriptions should be legible.
  • The patient's home medications when writing orders at admission, transfer, and discharge should be considered.
  • Prescribing opioids and anticoagulants requires particular care.
  • Children and elderly patients are particularly at risk of medication adverse events (accidents in Québec).
  • Medication dosage for children is usually based on weight, age, and clinical condition.
  • Interactions of medications with other drugs, natural health, and food products represent risk.
Good practices
  • Follow proper prescribing practices to help decrease the possibility of medication adverse events (accidents in Québec).
  • Pay particular attention when prescribing for the elderly and pediatric patients.
Key concepts
  • Patient dissatisfaction can stem from an impression that a physician is too busy or simply does not care.
Good practices
  • Maintain a professional demeanor.
  • Take the time to appropriately address any patient concerns or complaints.
Human factors
Key concepts
  • The physical, mental, and emotional state of a provider can affect quality of care.
Good practices
  • Structure your workplace to maximize safety.
  • Be aware of your surroundings and the current situation.
Key concepts
  • Atypical presentations of diseases are common.
Good practices
  • Take an adequate and appropriate history.
  • Review the notes of nursing staff and other healthcare providers.
  • Consider the vital signs.
  • Determine a differential diagnosis.
Key concepts
  • Cognitive biases may adversely influence problem solving and decision making.
Good practices
  • Take an adequate and appropriate history.
  • Review the notes of nursing staff and other healthcare providers.
  • Consider the vital signs.
  • Determine a differential diagnosis.
  • When assuming a patient's care, reformulate the differential diagnosis.
Key concepts
  • Situational awareness involves perceiving what is going on around you, understanding the information, and thinking ahead.
Good practices
  • Be aware of your surroundings and the current situation.
  • Consciously practice situational awareness.
  • Improve self-awareness and mindfulness.
Key concepts
  • Causes of equipment failure include design, maintenance, mishandling and inappropriate use.
Good practices
  • Check equipment prior to use.
  • If concerned, take equipment offline.
Key concepts
  • Care is sometimes provided in less-than-ideal surroundings.
Good practices
  • Structure your workplace to maximize safety.
Key concepts
  • Human factors engineering improves tools, machines, systems, tasks, jobs, and environments.
Good practices
  • Be familiar with the technology you are using.
Adverse events
Key concepts
  • Avoid jumping to the conclusion that a poor clinical outcome is the result of an error.
  • An error is different than an exercise of judgment.
  • Beware the biases of hindsight, learned intuition, self-blame, and others.
Good practices
  • Good physicians learn from mistakes.
Key concepts
  • Effective communication by the healthcare team with a harmed patient can restore trust and improve patient outcomes in the future.
  • The failure to be empathetic and apologize is a leading driver of complaints and legal actions.
Good practices
  • Disclose to the patient if harm resulted from healthcare delivery.
  • Disclose the information in a sincere, caring manner.
  • It is appropriate for physicians to state they are sorry for the circumstances or the condition of the patient at every disclosure meeting.
  • Be aware of the clinical, emotional, and information needs of the patient.
  • Do not abandon the patient.
Key concepts
  • Adverse events (accidents in Québec) will happen to your patients.
  • Harm to patients may result from the underlying medical condition, from the inherent risks of investigations and treatments, system failures, provider performance issues, or a combination of these.
  • Systems thinking — focusing on improving the processes of care — can prevent many adverse events.
  • Many approaches exist to determine the system reasons for adverse events and near misses, including patient safety incident analysis.
  • The best doctors make mistakes.
  • Doctors are accountable to conduct themselves professionally, maintain their knowledge and skills, comply with sound policy, and practice only if they are healthy to do so.
Good practices
  • Keep up to date.
  • After an unexpected clinical outcome, consider whether the outcome should be reported to determine the reasons for what happened.
  • Don't prejudge events.
  • Be prepared to acknowledge and deal with error.
  • Contribute to quality improvement by taking part in system reviews of adverse events (accidents in Québec).
  • Advocate for improvements in the systems and processes of care.
  • Know the clinical care policies in your workplace.
  • Make continuous improvements in your care for patients.
  • Don't use system failures as a way of absolving yourself of appropriate responsibility.
Key concepts
  • Stress is inherent in medicine.
  • Stress occurs following an adverse event (accident in Québec), complaint or legal action.
  • Bad outcomes aren't necessarily reflective of bad care.
  • Statements of claim are not impartial or objective.
  • You are not alone.
  • Avail yourself of the emotional support of colleagues, friends, and family.
  • Do not avoid what needs to be done.
  • It is possible to recover from the distress of a bad outcome.
  • A resilient physician learns by experience, seeks personal help as appropriate, bounces back, and grows.
Good practices
  • Make practice improvements following adverse events (accidents in Québec).
  • Seek and accept support when needed.
  • Derive a constructive lesson from medical-legal problems.
Professionalism
Key concepts
  • Colleges expect a high standard of conduct from physicians which extends beyond the clinical setting.
  • Medical trainees emulate the behaviour they observe from faculty.
Good practices
  • Maintain your professionalism even outside the clinical setting.
  • Practise with integrity, honesty, respect, compassion and altruism.
  • Respect and be honest with patients, peers, supervisors and members of the healthcare team.
Key concepts
  • Attributes of professional behaviour include honesty, integrity, responsibility, competence, respect, compassion, empathy and altruism.
Good practices
  • Practise with integrity, honesty, respect, compassion and altruism.
Key concepts
  • Achieving the ability to accept others' points of view and to adapt your attitude without judgment requires continual conscious effort.
  • A patient's lack of adherence to treatment plans may have roots in cultural diversity.
  • A physician cannot refuse to assess someone on the basis of a conscientious objection.
  • When physicians treat people equally they ignore differences. When physicians treat people equitably, they recognize and respect differences.
  • Physicians are not obligated to provide absolute accommodation in all situations, but rather to reasonably accommodate cultural diversity.
Good practices
  • Treat every patient encounter as potentially cross-cultural.
  • Ask patients to explain how their values, beliefs or religious or spiritual practices influence their preferences for the proposed medical treatment.
  • Fully disclose information in a truthful manner, being diligent yet respectful of cultural diversity.
  • Do not select or exclude patients for reasons other than your clinical competence or expertise.
  • Do not avoid dealing with a healthcare issue because of your own cultural beliefs.
Key concepts
  • Attributes of professional behaviour include honesty, integrity, responsibility, competence, respect, compassion, empathy and altruism.
  • Disruptive behaviour can interfere with team and patient communication, team morale, and may adversely affect patient care and satisfaction.
Good practices
  • Report to the appropriate authority any unprofessional conduct by colleagues. Students should seek assistance from their supervisor, mentor, program director, undergraduate dean, or medical trainee health and wellness program director.
  • Advocate in a professional manner for improvements in patient care.
Key concepts
  • Conflict is normal, understandable, and inevitable.
  • Poorly handled conflict can be destructive.
  • Conflict arises from differences or perceived differences in individual needs, interests, or values.
  • There are different styles of handling conflict. The choice of style depends on the participants, topic, timeline, and desired outcome.
Good practices
  • Address the conflict early.
  • Respect the people, address the problem.
  • Be self-aware: Consider if you are contributing to continued conflict.
  • Clear expectations and clear communication can help prevent destructive conflict.
  • Ensure both sides in a conflict are given equal opportunity to present their case.
Key concepts
  • Respect for both patients and healthcare team members enhances the quality of care.
  • Most serious boundary violations are preceded by boundary crossings.
  • Harm to patients can also be the result of the physician being under-involved in patient care.
Good practices
  • Be aware of when you are crossing a therapeutic boundary.
  • Do not engage in romantic or sexual relationships with patients.
  • Adequately explain intimate examinations, have a chaperone, and appropriately drape the patient.
  • Avoid dual professional and social relationships with patients.
  • Limit how much personal information about yourself you disclose to patients.
  • Avoid treating your family members, friends or business associates if possible.
  • Consider the impact on the integrity of the doctor-patient relationship when patients offer gifts.
Key concepts
  • Social networking sites should be considered public spaces.
  • What you post, whether personally or professionally, reflects your professional identity.
  • Information can spread easily on social networking sites and is often permanent.
Good practices
  • Think before you post on social media.
  • Always adhere to privacy legislation and relevant regulatory guidelines.
  • Monitor what others are posting about you on social media.
Key concepts
  • In some situations it may be necessary and appropriate to report a colleague who is impaired and compromising patient care.
Good practices
  • Report to the appropriate authority any unprofessional conduct by colleagues.