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Canadian Patient Safety Institute

Safe care....accepting no less​

The Canadian Patient Safety Institute (CPSI) has over 10-years of experience in safety leadership and implementing programs to enhance safety in every part of the healthcare continuum.​

SHIFT to Safety


Improving patient care safety and quality in Canada requires everyone’s involvement—SHIFT to Safety gives you the tools and resources you need to keep patients safe, whether you are a member of the public, a provider, or a leader.


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Our Programs​

 CPSI Latest News



Patient Safety Power Plays: Are we still talking about clean hands?8954Patient Safety Power Plays I've been involved in healthcare for a long time, from many different vantage points, and I like to think I've seen it all and that nothing could phase me – even though I know that is not the case. However, when STOP! Clean Your Hands Day rolls around every May 5, I'm confronted by something that I just can't believe we haven't solved yet clean hands! On the one hand, it's troublesome that something that is so simple to do, and that can save and protect so many people is still a major problem. On the other, I know that change can be slow and that even though it's taking longer than I'd like, I believe we are heading in the right direction. Let's look at a pair of other public health issues for some context Smoking. It's taken a couple of generations, but we've gone from smoking in schools and on airplanes, to prohibiting smoking in most pubic spaces. Per Stats Canada, fewer people are heavy smokers today compared to a decade ago, and smoking rates among teens has fallen more rapidly than any other age group. Anecdotally, I see fewer smokers on the street than I did even five years ago and it's a very positive sign. Seatbelts. Most people have a story from their childhood where the entire family crammed into Grandpa Joe's station wagon, with not nearly enough seatbelts (if there were any) to go around. Today, we know that's unacceptable and that even a quick trip around the block requires you to buckle up. Transport Canada reports that seat belt use has increased in the past two decades and that 95 per cent of Canadians are using their seat belts in a vehicle. As seat belt use is rising, fatalities are declining. STOP! Clean Your Hands Day is our attempt to highlight the dangers in not cleaning your hands, not only in healthcare, but in our communities, as well. It's our opportunity to declare that it is unacceptable and that we must change the current rates of hand hygiene dramatically. With that, let's all take a moment to clean our hands, and encourage our friends and family to do the same. Yours in patient safety, Chris Power​5/8/2017 6:00:00 AMI've been involved in healthcare for a long time, from many different vantage points, and I like to think I've seen it all and that nothing could5/8/2017 4:40:48 PM267
Documenting delirium in the ICU: a simple, yet effective approach 9026Patient Safety News Up to 80 per cent of critically ill patients in an ICU will have delirium or subsyndromal delirium; pain and agitation are risk factors for delirium. While pharmacologic treatments are used to manage symptoms, they may precipitate delirium and are associated with additional risks. Studies have shown that a systematic evaluation of pain and agitation, coupled with "actionable interventions" can provide cost-savings and have a significant impact on patient outcomes, including length of stay and complications. Last year, ICU teams from across Canada, including 10 paediatric teams and 31 adult acute care teams participated in an initiative to learn more about pain, agitation and delirium. During the PAD Your ICU National initiative, teams shared ideas and knowledge, set specific aims, implemented iterative tests of change, measured progress and shared successful methodology for organizational change. Taking the time to highlight the word delirium on the patient's 24-hour care sheet has made a significant impact on patient outcomes at the Royal Inland Hospital in Kamloops, British Columbia (RIH Kamloops). Over the course of a year, the practice of documenting delirium assessments has increased from 40 to 85 per cent. The Confusion Assessment Method for the ICU (CAM-ICU) is a widely-used instrument for the assessment of delirium in the ICU. The RIH Kamloops team set an aim that 80 per cent of ICU patients would be identified and documented every shift (q shift) and as needed (prn) with the use of the CAM-ICU by March 31, 2017. ​ ​RIH Kamloops PAD team (left to right) Brad Holowachuk, Physical Therapist; Tina Chard, Occupational Therapist; and Holly Delitzoy, Registered Nurse "The CAM-ICU assessment takes less than a minute to complete," says Tina Chard, Occupational Therapist at RIH Kamloops. "Some of the staff did not understand the purpose behind the CAM-ICU and how important it is to the patient's care and therapy. This information is critical for physical, occupational and speech-language therapists. In order for a patient's cognition to be addressed by OT, they have to be CAM negative for at least two to four days." Starting in January 2016, surveys at RIH Kamloops indicated that only 40 per cent of ICU charts had delirium identified (+ or -) on the patient's chart. A number of changes were implemented to increase awareness, including Patient Care Coordinator rounds; educational emails from the nurse educator; and whiteboard posters. Through these changes, 50 per cent of charts had delirium identified by June 2016. "In November 2016, we then implemented daily reporting over an 11-day period and found that while staff where reporting CAM-ICU scores to the Patient Care Coordinators when asked, the scores were still not being documented on the patient's care record," says Tina Chard. "We started highlighting delirium on the record sheet; placed posters in staff washroom displaying a cartoon with key facts; attended bi-weekly huddles; and the ICU Educator sent educational packages to the nursing staff. By January 2017, we were proud to report that 85 per cent of records had a score for delirium recorded." The PAD team continued to highlight delirium on the record sheets until April 1, 2017 and will conduct another survey in June 2017 to see if the practice of recording delirium is being maintained. The team is also looking at ways to spread their work to other hospitals across the Interior Health region and continue the work to increase awareness of the PRISME tool to identify the underlying factors that lead to and perpetuate delirium; and to narrow down the options to three to five steps on how to improve delirium. PAD Your ICU was designed, delivered and hosted by the Faculty of the Canadian ICU Collaborative and supported by the Canadian Patient Safety Institute. Over the 10-month period (February to December 2016), the program consisted of five webinars and 11 team connection calls where participants were provided with clinical content, coupled with improvement science on how to go about making changes. Participating teams chose one or two goals to work on for the prevention, assessment and treatment of pain, agitation and delirium, and to track their performance through to March 2017. "Through the support of the Canadian Patient Safety Institute, together with the Canadian ICU Collaborative, we were able to connect medical staff from different systems," says Bruce Harries, Improvement Associates Ltd. and Director, Canadian ICU Collaborative. "The ability to learn from faculty experts was invaluable in sharing information that was not well-known across the group. Participants also told us that it was great to talk to their Canadian colleagues who have similar issues and to make some progress on addressing delirium, pain and agitation." "One of the themes that the teams worked on was teamwork and communication," adds Bruce Harries. "We want to pull together a one-pager on the outcome of that work to provide guidance on things that you could be doing. Participants had different approaches on how you can make this work on your unit." There was a fairly active discussion group that was created through the Pad Your ICU National initiative. The group will be migrated to the Critical Care Canada Google Group, so that they can stay connected with their colleagues in ICUs across the country. 5/5/2017 6:00:00 AMUp to 80 per cent of critically ill patients in an ICU will have delirium or subsyndromal delirium; pain and agitation are risk factors for delirium.5/4/2017 9:47:29 PM295
Partnerships help pave the road in developing an Enhanced Recovery After Surgery strategy9179Patient Safety News This article is the first in a series on Enhanced Recovery After Surgery. As the national strategy evolves, information for the public, providers and leaders will be posted to Click on the link to learn more and watch for upcoming articles! Enhanced Recovery After Surgery (ERAS) consists of a number of evidence -based principles that support better outcomes for surgical patients including an improved patient experience, reduced length of stay, decreased complication rates and fewer hospital readmissions. "We want to take the ERAS learnings and evidence that has been acquired internationally and within Canada, and develop a strategy that can be moved across the country," says Carla Williams Patient Safety Improvement Lead, Canadian Patient Safety Institute. To start the ball rolling, a face-to-face meeting with key stakeholders was made possible through the generous support from 3M and Medatronics. "3M organizes its perioperative business around surgical best practices and has developed a number products and solutions for enhanced surgical care," says Lisa Mackie, Business Manager- Infection Prevention Division at 3M Health Care. "Developing an ERAS strategy involves many healthcare disciplines and collaboration across all the groups, and including industry is the key to success. This is a first step and it was a privilege to be involved." "The synergy and level of engagement of our partners at the meeting was amazing," says Carla Williams. "You could feel the passion, energy and commitment in the room. It would have been difficult to foster the rich conversations we had at the table and build the same momentum virtually. And, we could not have accomplished what we did without our industry sponsors." The inaugural S3A-Surgical Care Safety Best Practices Partners meeting, held in Calgary, Alberta, on January 29, 2016, has created a burning platform for the development of a dissemination and implementation strategy to advance the evidence-informed principles of ERAS in Canada. Some 24 organizations were invited to attend the face-to-face meeting, including representatives from Patients for Patient Safety Canada, the Royal College of Physician and Surgeons of Canada, Canada Health Infoway, various surgical specialties (Canadian Association of General Surgeons, Society of Obstetricians and Gynecologists Canada, Canadian Anesthesiologists' Society), provincial quality councils and allied health organizations (Dieticians of Canada, Canadian Physiotherapy Association, and Canadian Society of Hospital Pharmacists). Representatives from both 3M and Medatronics were also invited to attend the meeting and contribute to the discussions. "In addition to patient engagement, the ERAS principles also involve pain management, mobility and enhanced nutrition guidelines so we wanted to ensure the contribution of all relevant stakeholders," says Carla Williams. "The value of all of our partners working together is essential to achieving great outcomes with ERAS." A number of sites of excellence have already embraced ERAS principles, including Alberta Health Services (AHS), British Columbia Patient Safety & Quality Council and the Doctors of British Columbia, Eastern Health, McGill University Health Centre, and University of Toronto Best Practices in Surgery. During the meeting, AHS, McGill and the University of Toronto shared their learnings. Based on input from the meeting, a project charter has been developed to incorporate seven ERAS principles in all surgical carePatient engagement and awareness of the ERAS principles.Nutrition guidelines (pre and –post-op) that include no NPO (fasting at midnight), carb-loading pre-op, and feeding on post-op day zero.Intra-operative fluid management.Pain management and opioid sparing.Minimization of nausea and ileus.Minimization of tubes and drains.Early post-operative mobility. It was also agreed that data collection and measurement would be an integral part of this work. "The discussions during the meeting were very powerful," says Lisa Mackie. "Dr. Claude LaFlamme and Carla Williams did a fantastic job in setting up the day and leading the group discussions to scope out a plan to take this initiative forward." The identification of emerging best practices in surgical care safety along with a plan to spread and implement these best practices is one of the actions reflected in the Integrated Patient Safety Action Plan for Surgical Care Safety. Given the improved patient outcomes, ERAS principles emerged quickly as the logical choice. ERAS was originally developed exclusively for colorectal surgeries, however, the learning and evidence indicate that the same principles can be applied to any type of surgery. For more information on ERAS initiative, contact Carla Williams cwilliams@cpsi-icsp.ca5/1/2017 6:00:00 AMThis article is the first in a series on Enhanced Recovery After Surgery. As the national strategy evolves, information for the public, providers5/8/2017 5:17:14 PM699
Ten years of putting patients first9288Patient Safety News From the depths of a parent's worst nightmare, Theresa Malloy-Miller has emerged as a tireless advocate for the patient's voice in Canadian health care. As one of Canada's original patient safety champions, Theresa Malloy-Miller is also a full-fledged member of a club that no-one wants to belong to. It's a sad fact that most of this country's strongest voices for improved patient care draw strength for their advocacy from a frequently tragic personal experience with the health delivery system. Theresa is no different. She and her husband Tim took their 17-year-old son Daniel to a London, Ontario hospital in January 2003 with what they suspected was a severe case of the flu. Four days later their boy was dead. An autopsy confirmed myocarditis, a heart infection that can cause rapid onset of heart failure. That hospital experience left the Millers reeling with shock and grief, but also confounded by a succession of missed signals, poor communication and medical mistakes they fervently believe reduced their son's chances of survival. The hospital stonewalled at first, but the couple's ongoing search for answers eventually culminated in the first patient safety conference ever held in London. It also opened the doors for Theresa to become one of the two patient advisors on the Quality and Patient Safety Committee and the Co-chair of the Patient Experience Committee. After numerous internal and external reviews of Daniel's death, hospital procedures were modified and communication guidelines strengthened. It took four years and a change in hospital administration, but the Millers finally received an apology. Daniel's story is still used at London Health Sciences Centre in staff education sessions. Theresa was still burdened with a mother's grief in 2006 when she first heard, almost by accident, about a conference being held in Vancouver later that year to create Patients for Patient Safety Canada, a group of committed individuals charged with promoting the patient and family voice in the health care system. "Daniel had passed away in 2003; it was three years later," Theresa recalls over the phone from her home in Delaware, Ontario. "You know, your life stops, you search, and I was at that point of needing to do something." She contacted one of the conference organizers, Ryan Sidorchuk, then Canada's first global patient safety champion who was selected for a multi-national summit with the World Health Organization's World Alliance for Patient Safety in London, England, in 2005. He invited her to attend the inaugural Vancouver meeting. Theresa did and she's been an active member of Patients for Patient Safety Canada ever since, working on quality control and the patient experience at her local level while spearheading research and knowledge transfer initiatives nationally. "I was really reaching for something," she says of those early days. "I think when you lose a child it just turns your life upside down. So my life was nothing like what it was before anyway. It was in disarray. "I think Patients for Patient Safety brought me back to a more similar style of how I approach things. Always if I set a goal and I have a plan I'm comfortable in that space. It brought me probably to a more familiar place at a time when nothing was familiar." Working alongside other volunteers, many of whom had suffered similar adverse experiences, was a healing experience for her. "You can't move forward in patient safety by yourself. The task is too large. So being part of a group is just more effective. You get inspired by what other people are doing and the group opens up opportunities." The patient safety work also gave her a way to channel some of the anger she was still carrying, Theresa adds, "absolutely. The anger is indescribable. Anger that I never envisioned could be possible. Certainly it gave Daniel a voice which was really important to me." Ask her what the most encouraging development she's seen in health care over the last 10 years is and Theresa is quick to answer. "The central thing I see is the acceptance and the need for a patient family voice in health care. It is so central now in how health care is going to progress." Allowing that the person who has the health needs to be at the centre of the health care equation is just a dramatically different approach from the way it used to be", Theresa says. At the time of Dan's ER visits Theresa felt that their views and information were not considered. "We knew a lot about Daniel and all of the people who interacted with us never wanted to hear our view. And it was the crux of why it didn't work out. The only way forward in health care is for the person who has the health need to be at the centre of that circle." If she had but one message to pass on to health care providers, it would be, "as people we all have health needs and we're all on the same team. There's only one team when it comes to health." Unlike many of her patient safety counterparts who regularly weave their personal loss into their public advocacy work, Theresa stopped telling Daniel's story at patient forums a few years ago. It was just too difficult for her. Every time she revisited the story she'd need weeks to recover. But she has no doubt that Daniel, who was always a peacemaker among his friends, would be proud of the positive force for change that his mom has become. Theresa has recorded Dan's story in video form, a long version with her husband Tim and a shorter version with the help of CPSI. Both of these videos continue to be viewed. Theresa has put her focus into contributing to patient safety issues. She is the chair of the Knowledge Transfer Working Group of PFPSC. This group of PFPSC members, with the help of CPSI staff and in partnership with the WHO, has been able to bring many topics related to patient safety to an international audience. At a local level, she brings a patient voice to hospital safety and quality projects and measures. As part of the hospital-based Patient Experience Committee, she is able to add input into hospital policies like disclosure and family visiting, as well as contribute to local patient safety education sessions. There are many ways to contribute to patient safety. When Theresa reflects on what pushes her to continue to be involved in patient safety, Dan's voice comes to her quickly. "His favourite thing that he'd always say to me was, 'you are so annoying,' Theresa says, with a little laugh. "It's something that's stuck in my head. As much as I was devastated, at those really low points I would hear him say that. 'You are so annoying.' I think he would expect me to do something positive and not just sort of wallow in the pit." Being part of PFSC has provided Theresa with a positive meaningful and way to contribute to patient safety.4/24/2017 6:00:00 AMFrom the depths of a parent's worst nightmare, Theresa Malloy-Miller has emerged as a tireless advocate for the patient's voice in Canadian health4/24/2017 9:58:56 PM448
Joint Centres InnovationEX 20179107Patient Safety NewsInvitational Forum on Reducing Harm - April 5, 2017 Transparency and culture change key to patient safety See the patient in front of you as an individual, care for them to the best of your abilities and apologize to them directly in a timely manner if you make a mistake. That is a distillation of some of the patient-centred advice provided at a comprehensive review of patient safety and reducing harm in hospitals provided by a range of participants at the forum held in conjunction with the 4th annual InnovationEX of the Joint Centres for Transformative Health Care Innovation held at Markham-Stouffville Hospital. Markham-Stouffville is a member of the Joint Centres along with Mackenzie Health, Michael Garron Hospital, North York General Hospital, Southlake Regional Health Centre and St. Joseph's Health Centre. In addition to this year's focus on patient safety, the event also showcased innovative work at the six hospitals aimed at improving quality, safety and bringing more value to the health care system. "You're doing innovation in the best way. You're doing innovation as it's touching patients," said Dr. Bob Bell, Deputy Minister of Health and Long-term Care in his introductory remarks. In his presentation, Bell focused on how the revised Quality of Care Information Protection Act, to be proclaimed this summer, will increase transparency in dealing with preventable errors in hospitals. As keynote speaker at the forum, Chris Power, CEO of the Canadian Patient Safety Institute (CPSI) provided a comprehensive overview of the status of patient safety in Canada today. "We know that in health care things go wrong despite our best efforts. But most times we get it right," she said. However, Power said someone in a Canadian acute care hospital dies from a preventable event every 17 minutes and this statistic has not changed much in recent years. Whether it is possible to totally eliminate such errors depends on your perspective, she said, with other speakers in the meeting opining that while total elimination of error was not possible much more could be done to reduce the impact to patients of such incidents. With communication breakdown identified as the main cause of preventable errors, Power said, the key to changing the situation lies in creating a safety culture, and improving teamwork and communications. Power then talked about work being done at CPSI to identify the "winning conditions" for improving patient safety. These conditions includeImproving the reliability of human decision-making – currently seriously underdeveloped in Canada because of a very strong tradition of clinical autonomy and suspicion of standardized work.Developing a sense of urgency about the issue – a sense that Power says that "appears to have waned" in recent years.A commitment to good governance and management commitment. Power and others talked about "pockets of excellence" in Canada while the governance capacity overall for system performance has not improved greatly.Access to reliable data of a granular nature that will be useful for individual clinician. Power said with the increased cadre of sophisticated patient-advocates "patients and the public are going to be the ones that transform health care. Not us." This was a theme that continued through the panel discussion that followed which included input from panel member, Diane McKenzie, patient and family advisor at St. Joseph's. The other major focus of the panel discussion was the comparison between managing patient safety in hospitals with how safety is dealt with in the aviation and space industries. Insights were provided by former astronaut and emergency room physician and now CEO of Southlake, Dr. Dave Williams, and Samuel Elfassy, managing director, corporate safety, environment and quality for Air Canada. The panel discussion was moderated by Dr. Joshua Tepper, president and CEO of Health Quality Ontario. Safety is one of the six dimensions of quality that defines a high quality health care system and drives the work of Health Quality Ontario. Comparing and contrasting safety in the hospital sector with that of the aviation industry is a long-standing fixture in patient safety debates and from the panel discussion it was clear clinicians still need to do more to embrace the culture ingrained in pilots and astronauts. Elfassy said changing the culture in hospitals will require a lot of transparency, data and personal story telling. Williams evoked the power of story-telling and shared the impact that unexpected outcomes let alone medical errors can have on clinical staff when he spoke of becoming tearful recently while giving rounds at Southlake discussing an incident from 30 years ago where no errors were made but there was a very tragic outcome. Williams noted those in the aviation industry have an extensive exposure to a terminology and culture of safety that is only just starting to be embraced by medicine. While Williams and Power focused on the need for more standardization in health care, McKenzie added that providers need to account for the individual needs of patients at the same time. The discussion briefly touched on whether fiscal restraints on hospitals had an impact on patient safety. Power and others noted all variables impacting patient care in hospital such as bed shortages should be viewed through a safety lens. Hospitals will continue to need to provide the highest quality and safest care within the constraints of their funding envelopes. The discussion concluded by returning to the focus on individual patient care to improve patient safety and reduce medical error. McKenzie noted that while developing standards of care are very important there must also be recognition that some patients will not fit the care models that are developed and there must be a process to ensure they also receive optimal care. "We promise patients the highest quality of care and we will build their trust when we fulfill that promise," said Tepper. Dr. Tim Rutledge, Chair of the Joint Centres, wrapped up the forum and set the tone for continued work on the issue of reducing harm by reiterating "we need a culture of trust, a culture of learning and a culture of collaboration". He noted there was a palpable sense this existed in the organizations who participated in the forum.4/19/2017 6:00:00 AMInvitational Forum on Reducing Harm - April 5, 2017 Transparency and culture change key to patient safety See the patient in front of you as an4/19/2017 4:42:41 PM100

 Upcoming Events



Atlantic Health Quality & Patient Safety Learning Exchange 20175388Charlottetown, PEI 2:00:00 PM5/31/2017 10:00:00 PMThe Atlantic Learning Exchange 2017 is a must-see and must be seen event that you do not want to miss! Join leaders and patient safety champions who will be gathering for a two-day quality and patient safety knowledge exchange. 9/20/2016 7:26:46 PM23
PSEP – Canada’s Innovations in Patient Safety Education Award5439 12:00:00 AM6/2/2017 11:59:00 PMThe Innovations in Patient Safety Education Award recognizes organizations, groups or individuals that demonstrate exemplary practices in patient safety education and quality improvement work using the PSEP – Canada program.4/25/2017 8:44:51 PM10 Event
2017 National Forum on Simulation for Quality & Safety5432Edmonton, AB 2:00:00 PM6/8/2017 10:00:00 PMThe Canadian Patient Safety Institute is a proud sponsor of this event.This event is presented by SIM-One3/3/2017 6:24:43 PM8
National Health Leadership Conference 5413 12:00:00 AM6/13/2017 11:59:00 PMThe Great Canadian Healthcare Debate offers health leaders a unique opportunity to debate and pass policy resolutions that reflect the current Canadian health system context and address the most pressing issues facing the healthcare system and health leaders today.12/15/2016 6:13:24 PM15
Summer Institute 2017: A Spotlight on Patient-Oriented Research5430University of Alberta 2:00:00 PM6/27/2017 10:00:00 PMThe Canadian Patient Safety Institute is proud to support this event.This event is presented by Alberta Innovates, Alberta SPOR Support Unit, CIHR2/23/2017 5:15:02 PM6