|Patient Safety Power Plays - February 2016||28002||Patient Safety Power Plays|| We all know how busy life can get. Somedays, it feels as though we're more than just busy – we're overworked, exhausted, pushed to our limits. For the thousands of care providers in this country, I'm sure you can relate. Unfortunately, in spite of all the best practices in the world, this hectic, never-ending pace can lead to some pretty significant errors in care. So we're left with a simple question that doesn't have a simple answer how do we get back to the basics? How do we get back to simple? Every year around this time, Bell puts the mental health conversation on the national stage with their Let's Talk campaign. The main goal of the campaign is to end the stigma surrounding mental health issues and to raise money for mental health organizations. I think it serves as a great opportunity to remind everyone of the importance of good mental health, something that can very easily be put in jeopardy by the busyness of the world that pulls us in so many directions at once. Unfortunately, we can't all live in the woods by Walden Pond like American poet and philosopher Henry David Thoreau. One of Thoreau's most famous quotes is, "Our life is frittered away by detail . . . simplify, simplify." It's a wonderful sentiment, and one that we should strive to emulate, sometimes just a few small changes can give some really positive results. Perhaps it's as easy as taking the time to say hello to a colleague, or taking someone out for coffee, where you can converse about anything but work. These brief moments of escape from the pressures and complexities of our daily lives could go a long way towards regaining some simplicity. What do you think? What do you need to get back to simple? How can your organization support you? Send me some of your thoughts and I'll share some helpful ideas with you in next month's Power Play. Email me at firstname.lastname@example.org Yours in patient safety, Chris Power||05/02/2016 7:00:00 AM||05/02/2016 8:28:00 PM||199||http://www.patientsafetyinstitute.ca/en/NewsAlerts/News/Pages/Forms/AllItems.aspx||html||False||aspx|
|Join the “PAD Your ICU” National Initiative||10130||Safer Healthcare Now!|| ICU Improvement teams are invited to join a national initiative to reduce pain, agitation and delirium (PAD) in critically ill patients.
PAD Your ICU is a 10-month program designed and hosted by the Faculty of the Canadian ICU Collaborative and supported by the Canadian Patient Safety Institute and
Safer Healthcare Now!
The deadline to enrol is Friday, February 12, 2016. Delirium is associated with increased mortality and length of stay (LOS) in adult critically-ill patients. Studies have shown that systematic and accurate evaluations of pain and agitation, coupled with "actionable interventions" can provide cost-savings and have a significant impact on patient outcomes, including LOS and complications.
Learn more about PAD!
Up to 80 per cent of critically ill patients in ICU have delirium
or subsyndromal delirium according to validated screening criteria.
Pain and agitation are risk factors for delirium;
pharmacologic treatments may precipitate delirium and are associated with additional risks.
PAD Your ICU participating teams will chose one or two goals to work on for prevention, assessment and treatment of PAD and track their performance through to March 2017. Five webinars will be held over the course of the program (March, May and October 2016) and teams will be also be supported through a series of team calls, list serve, document sharing, monthly reports, assessments, faculty support and data analysis. Participants will also learn novel ways to engage families in the management of the patient's delirium.
PAD Your ICU is a valuable opportunity to track your ICU's performance, and to connect/share ideas with your colleagues across the country!
Click here to learn more or contact Ardis Eliason, Project Coordinator, Improvement Associates Ltd. at
email@example.com, for an information package and to enroll in this improvement initiative. To learn more about Delirium, visit
www.patientsafetyinstitute.ca and click on
Safer Healthcare Now! interventions.||22/01/2016 7:00:00 AM||22/01/2016 4:13:45 PM||384||http://www.patientsafetyinstitute.ca/en/NewsAlerts/News/Pages/Forms/AllItems.aspx||html||False||aspx|
|Update to our Consortium Partners||10279||Patient Safety News|| Together with our partners, CPSI has identified four initial priority areas of focus for a national integrated patient safety strategy, they aremedication safetysurgical care safetyinfection prevention and controlhome care safety These initial priorities will be tested through a multi-year Integrated Patient Safety Action Plan, with patient safety education being a foundational underpinning to advancing improvement. Action is underway in all the areas of the Integrated Patient Safety Action Plan. Read below for a highlight in each area and read the full action plans at http//www.patientsafetyinstitute.ca/en/About/PatientSafetyForwardWith4/Pages/default.aspxHome Care Safety Action Plan Partnering with the Canadian Foundation for Healthcare Improvement (CFHI) and the Canadian Home Care Association (CHCA)) the Canadian Patient Safety Institute (CPSI) is leading a virtual Improvement Collaborative on falls prevention in homecare with the aim of reducing falls and harm from falls. Five home care organizations from across Canada are participating in Wave I of the Collaborative including the Red Cross, Eastern Health Newfoundland, Winnipeg Regional Health Authority, Saint Elizabeth Health Care and the VHA Home Healthcare. The Collaborative runs from October 2015 to March 2016 with the following objectivesIdentifying outcomes for clients at risk of falls;Adapting quality improvement (QI) methods for the homecare environment and increasing QI capacity in this sector; Identifying resources for spread , and;Engaging patients and families in falls risk assessment and prevention. Lessons learned in Wave I will be incorporated into Wave 2 which will be on a larger scale, and is due to start Fall 2016.Infection Prevention and Control Action Plan To address the action item of improving infection prevention and control through the use of strategies known to improve behavior and culture, CPSI's Communication Team, along with dedicated partners, led an innovation competition to drive frontline improvement related to infection control. The entire country rallied around hand hygiene on May 5, 2015 as 1,182 sites took part in STOP! Clean Your Hands Day. Presented in partnership between Accreditation Canada, Infection Prevention and Control Canada, the Public Health Agency of Canada and the Canadian Patient Safety Institute, STOP! Clean Your Hands Day serves as a reminder for care providers, and their patients, about the importance of clean hands. The event was highlighted by the #CleanShots photo contest. Inspired by the BC Patient Safety and Quality Council, we asked healthcare providers across the country to send us their fun and creative photo featuring themselves or their colleague cleaning their hands. You can see the winners here. Medication Safety Action Plan Medication safety actions are progressing well with 87% of 2014-2016 actions underway and progressing towards completion. Co-Lead organizations, the Institute for Safe Medication Practices Canada (ISMP Canada) and the Canadian Institute for Health Information (CIHI), are working on an environmental scan followed by a white paper to identify all reporting systems that could provide medication incident data to a central access point for sharing and learning. An extensive literature search and online surveys have been completed and the Co-Leads are in the midst of key informant interviews with stakeholders and partners across Canada with expertise in medication incident reporting systems. Upon completion in early spring, the white paper will provide a comprehensive review of current medication incident reporting systems in Canada, gaps, and areas of overlap to consider in developing a central access point for all medication safety incident data to contribute to widespread sharing, learning and improvement efforts across Canada.Surgical Care Action Plan The Canadian Medical Protective Association (CMPA) and the Healthcare Insurance Reciprocal of Canada (HIROC) have been hard at work collaborating to enhance learning and sharing to avoid surgical harm. CMPA and HIROC have conducted a retrospective analysis of Canadian surgical harm data between 2004 and 2013. They have synthesized their findings into an information report that has been reviewed for feedback by a number of partner organizations including Accreditation Canada, Canadian Anesthesiologists' Society, Canadian Nurses Protective Society, Canadian Patient Safety Institute, Canadian Institute for Healthcare Information and Patients for Patient Safety Canada. The two page report and an associated appendix are in final stages of review. Watch for the report to be released in 2016. Patient Safety Education Action Plan Work on the Patient Safety Education Action Plan has begun with meetings among lead organizations. On February 11, 2016 contributing partners and lead organizations will come together in Toronto, Ontario to accelerate the momentum of the Patient Safety Education Action Plan including establishing a vision for a Patient Safety Education Network. The lead organizations involved in the Patient Safety Education Action Plan are The Canadian College of Health Leaders, Patients for Patient Safety Canada, SIM – One, Queens University, University of Calgary, University of Toronto, Canadian Medical Protective Association, Health Quality Council Alberta, HealthCareCAN, and Canadian Patient Safety Institute.||18/01/2016 7:00:00 AM||18/01/2016 5:20:47 PM||422||http://www.patientsafetyinstitute.ca/en/NewsAlerts/News/Pages/Forms/AllItems.aspx||html||False||aspx|
|Patient Safety Power Plays – January 2016||10204||Patient Safety Power Plays
Patient Safety News|| As the calendar turns over and we welcome a new year, it's important to take some time to reflect on where we've been and how far we've come in the past 12 months. Personally, I really enjoyed my time at the cottage over the holidays reflecting on the highlights of the past year at the Canadian Patient Safety Institute. It is so incredible to see how much we have accomplished in one year! January 2015 – We hosted the Patient Safety Education Roundtable and started the early conversation on the Patient Safety Education Network. We will host the next Network meeting in Toronto on February 11, 2016. February 2015 – Manitoba Health, Healthy Living and Seniors (MHHLS), on behalf of all regional health authorities and provincial organizations in Manitoba, became a Global Patient Safety Alerts contributor. They are the fifth Canadian organization to do so and hopefully not the last! March 2015 – I started as the CEO of CPSI. What a change to come from an organization of 12,000 to an organization of 35 people. I have never questioned my decision and I have loved every minute of it! We also partnered with Royal College on the release of the CanMEDS 2015 Physician Competency Framework. April 2015 – In partnership with Alberta Health Services, we hosted one of the most successful webinars in CPSI history . . . "When Caring Hurts; Helping Helpers Heal". Nearly 1,000 sites were on the line to learn about the second victim in patient safety incidents. May 2015 – More than 1,150 sites across Canada took part in STOP! Clean Your Hands Day, our annual hand hygiene and infection prevention and control awareness campaign held in partnership with Accreditation Canada, Infection Prevention and Control Canada and the Public Health Agency of Canada. June 2015 – CPSI hosted a roundtable to begin the process of transforming Safer Healthcare Now! in Toronto (set to launch this summer). We also launched an innovation speaker series as a professional development opportunity for staff. July 2015 – After several years of featuring patient accounts of harmful incidents, we turned our lens on healthcare providers. Five courageous individuals came forward to share their stories of how harm directly impacts them in their lives and work. The videos we recorded this month were a well-received highlight of Canada's Forum on Patient Safety and Quality Improvement later that year. August 2015 – After a year and half of consultation and development, we proudly unveiled CPSI's new website, an amalgamation of seven websites into one central location for all things patient safety and quality improvement. September 2015 – We hosted out Annual General Meeting and Consortium meeting in Toronto. We also released our Annual Report and a fresh edition of Hands in Healthcare, our annual Canadian Patient Safety Week companion magazine, as well as the Never Events for Hospital Care in Canada report in partnership with Health Quality Ontario. October 2015 – Patient safety dominated the Canadian healthcare landscape as thousands of sites and healthcare providers took part in Canadian Patient Safety Week (600 packages delivered) and Canada's Virtual Forum on Patient Safety and Quality Improvement (more than 1,100 viewers from 500 plus sites in 7 countries). November 2015 – Seeking greater relations with our fellow national healthcare organizations, members of the CPSI team initiated a series of partnership meetings with some of our closest allies Accreditation Canada, the Canadian Institute for Health Information, the Canadian Foundation for Healthcare Improvement, the Royal College of Physicians and Surgeons and the Canadian Medical Protective Association. December 2016 – With several new board members in the fold, we held a board retreat in Edmonton, allowing our Board of Directors to come together and begin the process of mapping out CPSI's future. WOW! That's an incredible amount of work and it only skims the surface of what we've accomplished this year! I can't wait to see what 2016 brings! Do you have personal healthcare highlight of 2015 to share? I'd love to hear from you. Email me at firstname.lastname@example.org Yours in patient safety, Chris Power||07/01/2016 7:00:00 AM||08/01/2016 6:19:25 PM||612||http://www.patientsafetyinstitute.ca/en/NewsAlerts/News/Pages/Forms/AllItems.aspx||html||False||aspx|
|Falls audit tool a perfect fit for the Saskatoon Health Region||10082||Safer Healthcare Now!
Patient Safety News|| Safety is a priority for the Saskatoon Health Region. The Canadian Falls Prevention Audit Month helped the Saskatoon Health Region (SHR) learn what quality improvement was needed for their fall reduction strategy. Throughout the Saskatoon Health Region safety measures are working well to prevent injuries from a fall, however there are gaps in screening and understanding risk factors, and how to incorporate those components into a safety plan for individual patient and residents. Daphne Kemp, the Regional Falls Reduction and Injury Prevention Coordinator, wanted to demonstrate how standard work could enhance quality improvement and address those gaps. Daphne could make recommendations from a macro level as she knew what was happening from chart reviews, but needed that validity to support improvements and move things forward. She started looking for an audit tool that was best practice, aligned with their strategy, and could be spread across the entire health region. The Canadian Patient Safety Institute's Falls Prevention and Injury Reduction Audit tool was the perfect fit. "We liked the questions, the tool and the information it would provide for us," says Daphne Kemp. For the 2015 Canadian Falls Prevention Audit Month, the SHR chose to focus on long-term care (LTC). There are 30 long-term care homes with about 2,200 residents in the region. Daphne led the audit, with the help of a practicum student to do background leg work. Special Care Project coordinators in each of the LTC homes supported the gathering of data for their residents. The raw data was then faxed to Patient Safety Metrics with Daphne reviewing and doing follow-up. In addition, Daphne chose to audit three areas in acute care and she personally collected data from the convalescent unit, the rehabilitation unit and the transitional care unit. The audit information garnered from those units will help to spread the falls prevention strategy to other areas across the region. One acute-care unit was able to determine from the audit data, that they needed to improve communication. Gaps were identified in recognizing risk factors and communicating when a patient was at risk. The unit chose fall prevention as a Mistake Proofing Project, an approach identifying and preventing mistakes that improve safety and increases staff engagement. It includes setting and tracing both long and short-term goals. Staff champions on the unit are now developing an improvement plan on how to better communicate the risk of falling to the entire healthcare team that may be spread regionally dependant on the outcome. Provincially, Saskatoon Health Region takes a holistic approach to reduce the number of bedrails and restraint use in Long Term Care. Getting buy-in that you don't have to use restraints as it can increase functional decline as well as physical and emotional harm by providing a balance of alternative safety measures is another area where they will use the data. The audit tool has a percentage of use of restraints embedded in it which was another draw for the tool. The SHR recognizes the importance of being transparent. Not only do senior leadership see the results, they are also printed out and sent to each of the LTC homes so the staff can see how they are doing and compare their data with others. The audit results are put together in partnership with Strategic Health Information and Performance Support that are displayed with graphs put together from the raw data so that staff can recognize and visualize where changes need to be made. "People need to see it, visualize it and find value in it – the more transparent you are, the more improvement you will see," says Daphne Kemp. "If staff doesn't see it, they are not engaged in it. To have improvement efforts need to be staff driven and is very powerful; that is my goal down the line." Daphne says that you need to ensure that everyone is aware and knowledgeable about the audit tool, how to do it and to fill out the audit form in its entirety so that you don't have to guess what the auditor meant. The next time they will provide more clarity and do more education with the auditors on how to conduct the audit itself and what information they need to have. "An audit is a big task that can be daunting and overwhelming," says Daphne Kemp. "It is not easy to start and like anything you do for the first time you will always have some glitches. It was a learning process and like any quality improvement initiative, there are going to be challenges and you have to work through them. I could have thrown in the towel, but I saw value in the audit. The next time we audit, we will keep improving and our data will reflect that." ||06/01/2016 7:00:00 AM||08/01/2016 2:50:05 AM||524||http://www.patientsafetyinstitute.ca/en/NewsAlerts/News/Pages/Forms/AllItems.aspx||html||False||aspx|