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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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 CPSI Latest News



How often do patients experience harm in a hospital?10725Patient Safety News In 2014-15, one in 18 hospital stays in Canada involved at least one harmful event (138,000 out of 2.5 million hospital stays). Of those, 30,000 (or one in five) involved more than one form of harm. While most patients experience safe care, sometimes harmful events happen that affect patients. Many of these events are preventable. The Canadian Institute of Health Information (CIHI) and the Canadian Patient Safety Institute (CPSI) are working to address a gap in patient safety measurement by collecting data on how often these events are happening and providing information on how these events can be prevented. Through the development a Hospital Harm Improvement Resource and the Measuring Patient Harm in Canadian Hospitals report, system decision-makers, hospital executives, clinicians and policy makers now have access to important information on patient safety in acute care hospitals and how to improve it. The measure and improvement resource comprise a new, readily available tool hospitals can use to improve the safety of their patients and reduce the occurrence of harm. "With the improvement resource, patient safety teams and clinicians can now spend less time researching what to do, and more time planning and implementing changes that are known to work," says Chris Power, CEO of CPSI. "One avoidable harmful event is one too many," says Bill Tholl, CEO of HealthcareCAN, a national organization that speaks for Canada's hospitals and works to foster informed and continuous improvement in healthcare. "HealthCareCAN‎ welcomes the release of this report and working with CPSI and CIHI to pursue the common goal of quality and reliability for patients." This work reflects a new approach in helping Canadian hospitals to measure and improve patient safety. "While most patients experience safe care in Canada, we must continually strive to do better," said the Honourable Jane Philpott, Minister of Health. "High-quality data is an important tool in assisting our improvement efforts, and we thank CIHI and CPSI for working together toward this goal." Why is a measure of harm important? Until now, there has been no single measure that provides perspective on patient safety in Canadian hospitals. The measure is designed to help organizations identify patient safety improvement priorities and track progress over time. Measuring Patient Harm in Canadian Hospitals The Measuring Patient Harm in Canadian Hospitals report provides a summary of the new approach to measuring hospital harm. It provides a big picture view of hospital harm and the status of patient safety in Canada; the number and types of events; and types of patients and their outcomes. The report introduces readers to the Improvement Resource and provides guidance on how to use the measure for improvement. It reinforces the importance of using the measurement data in conjunction with other currently available data. The Hospital Harm measure The Hospital Harm measure was developed jointly by CIHI and CPSI in consultation with leading patient safety experts. The measure represents a new approach to measuring and monitoring harm that occurs in Canadian hospitals. CIHI and CPSI are committed to working with stakeholders across the country to ensure this measure is a useful tool for monitoring and improving patient safety in acute care facilities. The measure is defined as the rate of acute care hospitalizations with at least one occurrence of unintended harm during a hospital stay that could have potentially been prevented by implementing known evidence-informed practices. A key advantage of this measure is that it uses existing data already being submitted to CIHI's Discharge Abstract Database (DAD) — no additional data collection is needed. The DAD captures information on hospital discharges across Canada (excluding Quebec). It is well established, has common standards for data collection and has built-in methods for auditing and assuring data quality. For harm to be included in the measure, it must meet the following three criteria it is identified within the same hospital stay; requires treatment or prolongs the patient's hospital stay; and is one of the conditions from the 31 clinical groups in the Hospital Harm measure framework. The Hospital Harm measure captures unintended occurrences of harm that happen during a hospital stay. The measure is made up of clinical groups that fall under four categories, including Health Care–/Medication-Associated Conditions; Health Care–Associated Infections; and Patient Accidents; and Procedure-Associated Conditions. The measure captures a range of harmful events, from "never events" — things that should never happen and are completely preventable (e.g., retained foreign body) — to events where implementing evidence-informed practices should reduce the incidence of harm but may not prevent every occurrence (e.g., aspiration pneumonia). While not all instances of harm captured by this measure can be prevented, implementing evidence-informed practices can help to reduce the rate of harm. The purpose of measuring quality and safety is to improve patient care and optimize patient outcomes. The measure should be used in conjunction with other sources of information about patient safety, including patient safety reporting and learning systems, chart reviews or audits, Accreditation Canada survey results, patient concerns and clinical quality improvement process measures. Together, this information can inform and optimize improvement initiatives. Hospital Harm Improvement Resource The Hospital Harm Improvement Resource links measurement and improvement by providing evidence-informed resources that will support patient safety and improvement efforts. The Improvement Resource will help to open conversations about patient safety and improvement. For patients and families, like Carole Jukosky, the Improvement Resource provides relevant information to prevent harmful events. Carole's dad Herbert Strasser died unexpectedly in September 2011, after a gruelling six-week hospital odyssey, growing sicker every day. Continuity and follow-through were huge issues that affected his care. "My dad's case is very complex and in the end he had a multitude of issues," says Carole. "It was very confusing to the medical system, very confusing to him and very confusing to our family." Carole had to dig deep through every medical file and lab result trying to make sense of it all. She met with all the facilities to review her dad's case, supported by a coroner's investigation into what was termed "a perfect storm" of miscues and false assumptions. Carole's prodding and inquiries have led to several healthcare improvements. The Hospital Harm Improvement Resource provides information on general patient safety tools and quality improvement resources, how to use the Hospital Harm measure, and references and resources specific to each of the 31 clinical groups. For more information and to access the Improvement Resource, visit or 10/26/2016 9:05:00 AMIn 2014-15, one in 18 hospital stays in Canada involved at least one harmful event (138,000 out of 2.5 million hospital stays). Of those, 30,000 (or10/26/2016 9:04:03 AM296
Celebrate Canadian Patient Safety Week 2016 and get ready to tweet!10646Patient Safety News ​October 24 to 28, 2016 marks the 12th annual Canadian Patient Safety Week (CPSW) and this year we've taken the campaign to a new arena – the social media realm! Ready…Set…Tweet! The theme for Canadian Patient Safety Week 2016, Questions Save Lives, is an opportunity for providers, patients and family members to convey what questions they would ask to make care safer and share them on social media. "Questions Save Lives is more than a theme, it's a thought-provoking statement that engages our audience in a conversation and reminds care providers, patients and families of the important role of conversation in healthcare," says Chris Power, CEO, Canadian Patient Safety Institute. We encourage you to get involved and share on social media the most important questions you believe can save lives." To share your question, Questions Save Lives frames, have been distributed in CPSW packages and a downloadable template is also available on the website, Simply write down your question on the template, take a photo and tweet your question using #asklistentalk. Also on Twitter, on Friday, October 28th, beginning at 1200 Noon EST, Dr. Joshua Tepper, President of Health Quality Ontario will moderate an hour-long CPSW Twitter Talk. Join by following @DrJoshuaTepper or @patient_safety. There will be key influencers chiming in with their perspective on the Twitter Talk topics. Healthcare organizations across the country are taking their celebrations onto social media. Michael Garron Hospital in Toronto has been tweeting #EscapeRoom to create interest in a fun-based, inter-departmental challenge that aims to foster staff engagement. Teams of two to four individuals are stuck in a room and have to work together to quickly identify problems and complete tasks that demonstrate best practices in patient safety, unlocking a key to their escape route. "The Escape Room is like a live board game based on a Halloween theme," says Adnaan Bhyat and Brian Yee, creators of the Escape Room challenge. "We will highlight elements of patient safety through various tasks focused on workplace violence, patient identification, infection control, and hand hygiene. There is a lot of interest from staff and our senior management team have also signed up to participate." "To round out CPSW we have a number of unit-based activities planned, with each day dedicated to a different theme to highlight priorities areas, including speaking up; the patient perspective patient identification; information transfer and communication; and incident reporting," says Narmin Hemani, Patient Safety & Quality Specialist. "Another feature of the week is a presentation from a Patient Speaker from Patients for Patient Safety Canada, who will share the impact that challenges with provider communication had on his wife's health from a patient perspective. CPSW is an action-packed week and we are thrilled to be a part of it!" Don't miss out on this national celebration! We want to know how you are celebrating Canadian Patient Safety Week 2016 and what questions you ask to save lives … and we'll be looking out for your tweets. For more information on Canadian Patient Safety Week, visit www.asklistentalk.ca10/24/2016 2:00:00 PM October 24 to 28, 2016 marks the 12 th annual Canadian Patient Safety Week (CPSW) and this year we've taken the campaign to a new arena – the10/24/2016 4:58:13 PM196
Learning online with the Canadian Patient Safety Officer Course10758Patient Safety News ​Since the Canadian Patient Safety Officer Course online program was introduced two years ago, more than 60 learners have enrolled and 31 have graduated from the program. To be certified as a Canadian Patient Safety Officer, learners complete eight modules in 100 hours of study, delivered entirely online using readings, videos, webinars, discussion forums, and hands-on project work, with expert faculty to provide support and feedback. Learners have 12 months to complete the program. The learners represent a broad mix of those novice to the fields of patient safety and quality improvement, and those with considerable experience in both healthcare and in patient safety/improvement. Some have had ongoing formal roles and others are newly assuming those roles. Three Faculty members, Kristi Chorney, Pauline MacDonald and Barb Saunders, support the learners along their journey. The Faculty act as facilitators and mentors to the learners, grading and providing feedback on their assignments. They also monitor the discussion board and will comment on the student's posts. "The passion we see in our learners in trying to make a difference and increase patient safety in Canadian healthcare is clearly evident," says Kristi Chorney, CPSOC Facilitator. "Typically, this is something that they take on above and beyond their full-time work and the time and energy put into their assignments demonstrates that they are increasing their patient safety knowledge." The Project Plans for final projects being submitted by the learners focus on a variety of clinical improvements (venous thromboembolism prophylaxis, falls prevention, sepsis), communication and teamwork improvements (safety briefings), and patient partnership initiatives (patient and family involvement in hazard identification). Some Project Plans correlate with Accreditation Canada required organizational practices (medication safety and handovers). The topics are well aligned with the current priorities in patient safety. "It is encouraging to see the Project Plans and how the learners are planning to apply new skills at the end of the program, says Kristi Chorney. "It is one thing to gain the knowledge, but it is another thing to translate that knowledge into action. That is what appears to be happening. " The Discussion Forum has generated 19 pages of dialogue with interactions on everything from how to engage people to new approaches like positive deviance and how to use those types of tools. "The interactions on the Discussion Forum have been excellent," says Pauline MacDonald. "Some learners dive right into the discussion forum and contribute new ideas. Their thoughtful questions and posts on the discussion forum reflect their commitment, journal their learnings and foster practical, collegial discussions." Learners are saying that the course is very valuable and they are going to take what they learned back to their work environment in an effort to make change. They are giving the online program high marks for its content, resources and webinars. One participant says, "The course has provided me with the skills and tools to continue my work in the quality field. It is very well designed and relevant to today's healthcare practice and the assignments are great learning opportunities." "Our learners are highly motivated and committed," says Barb Saunders. "They are genuinely concerned about the state of patient safety in healthcare generally and specifically within their organization. They seek opportunities to learn the theoretical concepts to increase their knowledge, as well as to acquire skills to strengthen the culture of patient safety, improve healthcare reliability, and lead sustainable improvements. They have a strong moral compass and strongly believe in, and advocate for, true patient and family partnerships." The Canadian Patient Safety Officer Course is jointly developed and delivered by the Canadian Patient Safety Institute and HealthCareCAN. For more information or to apply for the Canadian Patient Safety Officer Course online program, visit www.patientsafetyinstitute.ca10/20/2016 4:00:00 PM Since the Canadian Patient Safety Officer Course online program was introduced two years ago, more than 60 learners have enrolled and 31 have10/20/2016 4:55:24 PM241
Prescrire addresses medication safety in France10842Patient Safety News Prescrire, a non-profit medication safety organization in France, is committed to better patient care. Prescrire provides clear, comprehensive and reliable information on drugs, therapeutic and diagnostic strategies to enable fully-informed decision-making. The organization also provides continuing education to healthcare professionals, mainly physicians, nurses and pharmacists in the primary care sector. The independent organization is non-partisan and fully funded by its subscribers. "Our aim is to help healthcare providers by providing evidence-based information on products and strategies," says Etienne Schmitt, Head of the Prescrire Programme in France, Éviter l'Évitable ("Preventing the Preventable"), a voluntary medical error reporting programme (including medication errors). "We have created an evidence scale using a risk and benefit approach that advises healthcare professionals on products to avoid where there is not enough assessment. We provide information every time there is a change to products, including the labelling and design of new products." Prescrire's assessment of the harm-benefit balance of new drugs and indications are based on a rigorous procedure that includes a systematic and reproducible literature search, identification of patient-relevant outcomes, prioritisation of the supporting data based on the strength of evidence, comparison with standard treatments, analysis of both known and potential adverse effects, and a systematic assessment of the packaging and the labelling. Prescrire publishes a monthly journal in French and an international edition in English 11 times a year, plus a yearly supplement in French devoted to drug interactions. Prescrire also provides an annual list of drugs to avoid, to help healthcare professionals and patients choose high-quality treatments that minimize the risk of adverse effects. The 2016 review examined medications over a six-year period (from 2010 to 2015) and identifies 74 drugs that are more harmful than beneficial in all the indications for which they have been authorised. In most cases, when drug therapy is necessary, other drugs with a better harm-benefit balance are available. Medication safety issues that are currently top-of-mind in France include over-the-counter (OTC) products, and the confusion between injectables, particularly concentrates and diluted products. "OTC products are gaining in popularity because they are less expensive," says Etienne Schmitt. "There is a lot of confusion with packaging and product names due to umbrella brands, and people don't understand how to use the products appropriately. Health agencies should advocate for a better design of product labels and more clarity in product names. The current consultation launched by the French Drug agency (ANSM) gives Prescrire an opportunity to speak-up on patient safety." Working with regulators on how to prevent medication errors, Prescrire is advocating for better drug formulation and increased transparency from drug agencies, to promote safe labelling and international naming of drugs. Etienne Schmitt says the International Medication Safety Network (IMSN) is a good opportunity to share information amongst members and to get input on their programs. "Working together the IMSN are developing actionable items, providing recommendations and preparing position statements to improve medication safety world-wide. One example is improving the packaging and labelling of vaccines, because vials can be easily confused with other products. Ready to use products, such as prefilled syringes, offer more rigour around the preparation and labelling of vaccines and will contribute to safer care, but are costly and increase the volume storage."10/19/2016 6:00:00 AMPrescrire, a non-profit medication safety organization in France, is committed to better patient care. Prescrire provides clear, comprehensive and10/19/2016 5:28:14 PM68
Sharing ideas to improve medication safety globally10887Patient Safety NewsWhen the International Medication Safety Network (IMSN) meets in Toronto on October 24, 2016, for the 2016 IMSN Global Regulatory Meeting, delegates from 27 member countries, the World Health Organization (WHO) and invited regulators will share their views and concerns on labelling, packaging and nomenclature issues prone to medication errors at a global level. Mr. Wu Tuck Seng, Chairperson of the National Medication Safety Committee, Ministry of Health, and Deputy Director and Head of the Pharmacy Department, National University Hospital in Singapore will be closely following discussions on how to use technology and automation to improve medication safety, specifically bar-coding. Currently, bar-coding of medications is not mandatory in Singapore. They are working towards establishing national compliance, if possible, similar to that in the United States."I want to find out more about bar-coding; the strategies we can employ, what are the challenges, and how we can implement bar-coding at a national level for all drugs," says Mr. Wu. "I want to know how others have worked with the pharmaceutical manufacturers to address bar-coding and medication safety."When it comes to medication safety and medication errors, Singapore uses the root cause analysis methodology to look at what happened, why it happened and what they can do to prevent similar medication errors in the future from a people, process and system perspective. "The majority of medication errors occur at the prescribing and drug administration stage rather than at dispensing," says Mr. Wu. "We need to better understand the opportunities for errors, and learn from our near misses and mistakes and how we can improve our systems, process and people holistically. Healthcare providers can provide insight about where things go wrong before they go wrong. The drugs we use now are more potent and sophisticated. Hence, we need to exercise vigilance even more and involve and work with the staff that are storing, preparing, and administering the drug."Mr. Wu says that the medication errors they commonly see are a combination of the wrong dilution, wrong concentration or the wrong dose being administered. To mitigate this, Singapore hospitals have been using premixes where available. They have been trying to get heparin in pre-mixed doses, but to date, have not been successful.Medication errors involving opioid drugs directly relates to how they are drawn into the syringe and then administered. An ampoule of morphine injection typically contains 10mg. Often times, the prescribed dose is less. For example, if 5mg is needed, only half the volume should be drawn up into the syringe. However, the usual practice is such that the nurse/doctor will draw up the entire 10mg dose into the syringe, and before drug administration the volume not required would be squirted out before the injection. Unfortunately, invariably another staff that is told to administer the medication fails to check the dose or expects the dose to be correct and mistakenly administers 10 mg instead of 5 mg. "This is a practice and process problem, not a drug concentration problem. The objective is to ensure they only administer what is prescribed," says Mr. Wu. For insulin safety, one hospital in Singapore has developed an insulin vial cap device that fits over the insulin vial. Once attached, it cannot be removed. This cap only allows you to use insulin syringes to draw out the insulin from the vial. It will not allow the use of non insulin syringes. This is a forcing function. The device costs approximately $20 per unit in Singapore currency ($20 CDN).The IMSN Global Regulatory Meeting agenda will address manufacturer labelling and look-alike/sound-alike drugs. The IMSN is working with the WHO to develop an international naming nomenclature to address this. "These are important issues pertaining to medication safety that continue to confront us," says Mr. Wu. "We can mitigate medication errors by introducing specific nomenclature for look-alike/sound-alike drugs besides labelling and packaging that can better differentiate them."10/19/2016 6:00:00 AMWhen the International Medication Safety Network (IMSN) meets in Toronto on October 24, 2016, for the 2016 IMSN Global Regulatory Meeting, delegates10/19/2016 5:23:32 PM295

 Upcoming Events



Twitter Talk Event #AskListenTalk5361Twitter 4:00:00 PM10/28/2016 5:00:00 PMThe one-hour Twitter Talk will explore two discussi​on topics moderated by a special guest. Participating in Twitter chats can help you gain followers and influence others by sharing great insights.10/18/2016 8:35:51 PM20 Event
Horizon Health Network’s inaugural Patient and Family Centred Care Experience Conference5322Moncton, New Brunswick 12:00:00 AM11/8/2016 11:59:00 PMThe Canadian Patient Safety Institute is proud to support this event.This event is hosted by Horizon Health4/28/2016 7:09:23 PM14
Health Achieve5329Toronto, ON 12:00:00 AM11/9/2016 11:59:00 PMThe Canadian Patient Safety Institute is proud to support this event.This event is hosted by Ontario Hospital Association5/30/2016 5:09:59 PM9
Award ceremony: 2016 Champion Awards5338 12:00:00 AM11/7/2016 11:59:00 PMHealthCareCAN and the Canadian Patient Safety Institute (CPSI) have partnered to present the Patient Safety Champion Awards to recognize champions of patient safety - volunteer patient or family members and teams or organizations who demonstrated exemplary leadership and collaboration to champion change and achieved safer care through patient/family engagement. 6/22/2016 5:53:03 PM3 Event
Palliative Care Matters5355Ottawa, ON 3:00:00 PM11/9/2016 11:00:00 PMThe Canadian Patient Safety Institute is proud to support this event.This event is hosted by Covenant Health9/20/2016 4:18:33 PM