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Specific Action Plans:

To help UHN create solutions for improving patient and workplace safety, action plans have been developed for the following four major streams of activity:

  1. Reduce Hospital Acquired Conditions (HACs)
  2. Increase reporting and analysis of Serious Safety Events (SSE)
  3. Reduce the number of incidents that result in preventable harm to workers
  4. Foster a culture to promote speaking up for safety by learning and implementing error prevention tools, recognizing the role of patients and staff.
  • Build a foundation of resilience by embedding safety behaviours, error prevention tools, and harm prevention strategies into daily practice
  • Develop a comprehensive approach to identifying and learning from patient and worker safety events
  • Create a culture where staff and patients can embrace safety as a core value
  • Engage patients and caregivers in HAC (Hospital Acquired Conditions) implementation plans
  • Complete the first phase of HAC implementations
  • Improve reporting and classification of Serious Safety Events (SSE): develop an education program to emphasize the importance of reporting events
  • Continue to develop and implement a comprehensive workplace injury prevention program
  • Foster a culture which promotes speaking up for safety, by learning and implementing the error prevention tools, and recognizing the importance and the role patients and staff play in the process

This quarter, we developed a three-year Caring Safely plan to ensure high-quality patient safety practices are sustained long-term at UHN. Educating our staff and leaders continues to be a key component of this—more than 6,000 staff have been trained in error prevention tools and we’ve delivered six leadership training modules. Another key to Caring Safely’s success is ensuring that we are communicating results and sharing our learnings across the organization. One such example is Toronto General Hospital’s root cause analysis (RCA) pilot for patient safety events, which is reported at the Safety and Quality Committee of the Board meeting. Further work is underway to evaluate the RCA framework after all pilots have been completed. We’re also communicating workplace Serious Safety Events to UHN leadership on a monthly basis through newly developed summary reports. Moving forward, we will be making it easier for unit managers to request workplace safety data for their areas by creating a standard process for them to follow. Finally, in support of the education component of Caring Safely, we will be rolling out the Safety Coach program to all sites.


  • Developed our three-year plan in collaboration with Caring Safely streams
  • Completed two out of four root cause analysis (RCA) pilots for patient safety events
  • Developed Healthcare Performance Improvement (HPI) Summit presentation on UHN’s cause analysis program in collaboration with Worker Safety, Patient Safety and Human Factors
  • Introduced clinical management strategies to mitigate violence-related risk
  • Trained more than 6,000 staff in error prevention tools (since May 2017)
  • Implemented huddles in all clinical and most non-clinical areas

Attention Needed

  • Complete development of standard of work for patient SSE debriefs
  • Define roles, responsibilities and process for the application of UHN’s cause analysis framework to worker safety events
  • Develop a musculoskeletal injuries risk assessment framework and pilot preventative strategies
  • Ongoing support needed for leaders to implement High Reliability Leadership Toolkit

Past Reports:

Charlie Chan (Lead)

Interim President and CEO

Mike Nader

Executive Vice President and Chief Operating Officer

Emma Pavlov

Executive Vice President Human Resources and Organizational Development, and Michener Operations

  • Emily Musing
  • Wing-Si Luk
  • Brenda Perkins-Meingast
  • Jeanette Maclean
  • Diana Elder
  • Michelle Lorello
  • Kerseri Scane
  • Laura Williams
  • Dan Girard
  • Shirin Ansari-Tadi
  • Michelle Benitez

*names are still being added/confirmed