The Canadian Adverse Events Study, published in 2004,  revealed that, similar to other countries, 7.5% of all patients admitted to acute care hospitals in Canada experienced an adverse event. Over a third of all adverse events were judged to be preventable; 20.8% of patients with adverse events died. Although this was the first large-scale report of Canadian data, activities to address patient safety concerns in Canada started prior to 2004.
A series of symposia was held annually in Canada to raise awareness of the problems among healthcare professionals, provide information and training to people working in the new patient safety disciplines, import lessons and tools from other countries and industries, and advance the field of patient safety generally. These annual events, known as the Halifax symposia, ran for ten years, commencing in 2001 and concluding in 2010 .
In September 2001, following a one-day forum on patient safety hosted by The Royal College of Physicians and Surgeons of Canada, the National Steering Committee on Patient Safety was first convened. In September 2002, the Steering Committee published Building a Safer System, a comprehensive document listing 19 key recommendations for work that must be undertaken within the national integrated strategy . The report suggested five major objectives, including (i) establishing a Canadian patient safety institute to facilitate a national integrated strategy for improving patient safety; (ii) improving legal and regulatory processes; (iii) improving measurement and evaluation processes; (iv) establishing educational and professional development programs; and (v) improving information and communication processes.
Less than a decade later, much progress has been made in all areas identified by the Steering Committee in 2002, as follows:
A Canadian patient safety institute
The Canadian Patient Safety Institute (CPSI) was established in December 2003 with a mandate from government to build and advance a safer health system for Canadians . CPSI's objectives were to bring innovative solutions to enhance patient safety; facilitate collaboration among governments and stakeholders; support the development of patient safety education programs; provide patients and their families with information and support; and facilitate research in the field.
Improved legal and regulatory processes
Several legislative efforts have addressed potentially contentious issues related to adverse events. The Apology Act is "... a cultural shift, which recognizes that offering a sincere apology or expression of regret is simply the right thing to do," as described by Phil Hassen, former CEO of the CPSI. The Bill provides that "... an apology made by or on behalf of a person in relation to any civil matter does not constitute an admission of fault or liability by the person... does not affect the insurance coverage available to the person making the apology and is not admissible in any judicial civil proceeding."  The first Canadian apology legislation was passed in 2006 by the provinces of British Columbia and Saskatchewan, followed in 2008 by Manitoba. Ontario and Alberta have since introduced similar legislation. The protection afforded by apology laws is similar across Canadian jurisdictions . Similarly, the Evidence Act and related legislation within Canadian jurisdictions have been reviewed and revised to ensure that data and opinions associated with patient safety and quality-improvement discussions are protected from disclosure in legal proceedings. In addition, recent activities by regulatory bodies, provincial governments, healthcare providers, professional associations, and others have provided a foundation for the development of pan-Canadian guidelines for disclosure of adverse events to patients. In 2008, the Canadian Disclosure Guidelines were released by the CPSI . From the regulatory perspective, Accreditation Canada, a not-for-profit, independent organization, provides healthcare organizations with an external peer review to assess the quality of their services based on standards of excellence. Accreditation Canada emphasizes health system performance, risk prevention planning, client safety, performance measurement, and governance . As such, many "best practices" and safety procedures are being sustainably enforced by Accreditation Canada. Finally, the Excellent Care for All Act, passed into law in Ontario in 2010, is a recent milestone . Among other provisions, this act requires all hospitals in that province to develop an annual plan to improve safety and quality, and links executive compensation to the improvement of care. It reflects the aim of the Ontario government to drive accountability for safety and quality up from front-line healthcare professionals to the executive leaders of organizations. Similar bills are now expected in other Canadian provinces.
Measurement and evaluation
In 2005, the CPSI introduced to Canada Safer Healthcare Now,  a campaign based on the American Institute for Healthcare Improvement's (IHI) 100K Lives Campaign (now 5 million lives campaign),  promoting the use of bundles of practices to achieve good clinical outcomes for specific objectives. For example, the first version of the Acute Myocardial Infarction (AMI) bundle, published in 2005, included the following practices: early administration of aspirin; aspirin at discharge; beta-blocker at discharge; timely initiation of reperfusion (thrombolysis or percutaneous intervention); ACE-inhibitor or angiotensin receptor blockers at discharge for patients with systolic dysfunction; and smoking cessation counseling/nicotine replacement/serotonin uptake inhibitor/referral to cardiac rehabilitation program. In 2007, an additional practice, statins at discharge, was added to the bundle. In addition to literature review and educational materials, the campaign provides specific measurement tools for participating organizations to evaluate their performance regarding both processes of care and clinical outcomes. The freely available list of "bundled" interventions and measurement tools promoted by the CPSI is gradually growing and currently includes AMI, medication reconciliation, rapid response teams, and delivery of high-risk medications, as well as measures to prevent nosocomial superbug infections, central line infections, falls, surgical site infections, ventilator associated pneumonia, and venous thromboembolism.
In addition, surveillance systems, including relevant patient-safety indicators, have been developed in Canadian healthcare. The Canadian Institute for Health Information (CIHI)  collects and analyzes information on health and healthcare in Canada and makes it publicly available. Canada's federal, provincial, and territorial governments have created CIHI as a not-for-profit, independent organization dedicated to forging a common approach to Canadian health information. CIHI's data and reports, including the Hospital Standardized Mortality Ratio (HSMR), inform health policies, support the effective delivery of health services, and raise awareness among Canadians of the factors that contribute to good health.
Finally, to facilitate progress and improve the evaluation of various interventions in the area, research granting organizations such as the Canadian Institutes for Health Research  and the Canadian Health Services Research Foundation  have designated competitions dedicated to research in patient safety and quality improvement.
Education and professional development
Multiple healthcare education and professional-development programs for improving patient safety are currently offered by various organizations, including the CPSI, provincial organizations, professional associations, and academic centers. The CPSI, in partnership with the Canadian Healthcare Association, offers a Patient Safety Officer Course . This four-day program is a comprehensive patient safety course designed for healthcare professionals and leaders who have formal responsibility for disseminating patient safety principles and programs throughout their organizations. The CPSI also provides the Patient Safety Education Project,  a partnership with Northwestern University, Chicago, USA. The 2 1/2 day course, built on the training team model, focuses on core patient safety content and teaching approaches to effectively drive patient safety improvement in healthcare organizations. Training programs in disclosure of adverse events to patients are offered by the Canadian Medical Protective Association CMPA  and the Institute for Healthcare Communication-Canada . In Ontario, the Ontario Hospital Association offers a three-day patient safety course where patient safety principles, practices, and tools are presented to assist health care providers and organizations in developing patient safety programs . The University of Toronto Centre for Patient Safety  offers a certificate course in patient safety. In twelve four-hour sessions over six months attendees learn how to plan, implement, and evaluate patient safety and quality improvement projects. Queen's University, Kingston, Ontario, is preparing to launch the first Canadian master's program in patient safety, quality, and risk. Many other education programs are currently available in most Canadian provinces.
Information and communication
Work is currently being done on a shared Canadian electronic medical record system .
Major effort has been made in Canada, as in many other countries, to improve patient safety; however, evidence suggests that improvement occurs gradually, at times quite slowly . Nevertheless, numerous reports have been published by Canadian organizations on improvement in clinical outcomes, such as ventilator-associated pneumonia, central line- and other hospital-acquired infections, secondary to implementation of strategies and techniques promoted by the CPSI . Possibly, different approaches to improvement, such as emphasis on human factors engineering and cognitive psychology to overcome the human limitations in processing data and coping with the ever-increasing demands in health care, are required. Clearly, strong support systems are required to investigate alternatives, implement effective interventions, and ensure their reliable execution. Furthermore, the guiding principle of "no blame", which is the cornerstone of the systems approach to safety improvement,  has been questioned and a stronger role for accountability - both organizational and personal - has been proposed as an important mechanism to effect change . While the validity of this view is highly debatable,  it is well accepted that accountability can be demanded only after profound improvement processes have been implemented in an organization.