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"Safer patients — every patient, every time"

Approaches to patient safety

A folk tale from India illustrates how safety risks may be identified differently depending on your perspective. The story is about how several blind men try to describe what an elephant is by touching it in only one place. Each man comes away with a much different impression of what an elephant is, describing it as either a wall, spear, snake, tree, or fan.

The elephant of patient safety

Adapted from K. Shojania, 2010

There are a number of different approaches for identifying patient safety risks.

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Click on the spots on the elephant for examples of how diverse approaches can identify different patient safety risks. [REF]
Adapted from Shojania, Kaveh. "The elephant of patient safety: What you see depends on how you look," The Joint Commission Journal on Quality and Patient Safety, September 2010, Vol. 36, no. 9.

Reporting - Systems to report a harmful incident (accident in Québec), a no harm incident or a near miss (incident in Québec) are common but are under-utilized. Traditionally these reports have captured patient identification issues, falls, and medication problems.

Identifying patient safety problems should be both proactive and reactive. Specifically:

  • Multiple methods should be used to identify safety issues.
  • Different approaches identify different risks.
  • Some risks are more readily reduced than others.
  • Prioritization and investment of resources is required.
  • Healthcare provider education and policies can help, but most patient safety problems will not significantly decrease without improvements in the underlying systems of care.