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:
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.