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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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Ten years of putting patients first23529Patient 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 PM27http://www.patientsafetyinstitute.ca/en/NewsAlerts/News/Pages/Forms/AllItems.aspxhtmlFalseaspx
Joint Centres InnovationEX 20173478Patient 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 PM37http://www.patientsafetyinstitute.ca/en/NewsAlerts/News/Pages/Forms/AllItems.aspxhtmlFalseaspx
Patient Safety Power Play: Let’s celebrate!26076Patient Safety Power Plays I have a favour to ask. Please take a few moments out of your day to celebrate someone important to you who is making a difference. Whatever the reason, large or small, take the time and make the effort to celebrate one another. In the workplace, especially one as frantic as healthcare, these can be moments that bring colleagues together and build a stronger culture. In the realm of patient safety, for instance, time is running out to submit your nominations for the Patient Safety Champion Awards. Presented in partnership with our good friends at HealthCareCAN, these awards are your opportunity to recognize both volunteers, and entire organizations, for the work they do to engage with patients and families and ensure they're at the centre of all patient safety initiatives. Not only that, but winners will be flown to the National Health Leaders Conference to accept their award. After the awards ceremony, we're going to host a webinar with the winners and runners-up, where we can share the work they've done with the country and encourage others to follow their example. The deadline to submit your nominations has just been extended to April to give everyone one last chance to submit their nomination. Win or lose, a nomination itself is a tremendous gesture that will leave a lasting impression on someone very deserving. For some inspiration, you can learn all about Johanna Trimble and Michael Garron Hospital, who were the winners of the Patient Safety Champion Awards last year. I for one am looking forward to celebrating our Patient Safety Champions this June at the National Health Leaders Conference. How about you? Any celebrations to share, or people to recognize? I invite you to connect with me at cpower@cpsi-icsp.ca or follow me on Twitter @ChrisPowerCPSI. Yours in patient safety, Chris Power4/11/2017 6:00:00 AMI have a favour to ask. Please take a few moments out of your day to celebrate someone important to you who is making a difference. Whatever the4/11/2017 7:31:19 PM160http://www.patientsafetyinstitute.ca/en/NewsAlerts/News/Pages/Forms/AllItems.aspxhtmlFalseaspx
Niagara Health- Focused on Raising Awareness of Never Events 31287Patient Safety News It was all in the timing. Years before the pan-Canadian list of Never Events was released in September 2015, Niagara Health in Southern Ontario had already begun looking at ways to advance its safety culture. Never Events, named for being incidents that should never happen, can include instances of child abductions, suicides or patients receiving the wrong surgery. Niagara Health recognized that even one Never Event was one too many. With the hospital organization's new strategic plan containing a focus on ingraining a culture of safety and eliminating preventable harm in order to provide extraordinary care, this was seen as a perfect opportunity to embed Never Events within its strategic visioning to combat the challenges in different ways. A report, prepared by the Canadian Patient Safety Institute and Health Quality Ontario with many partners, specified 15 of the most serious known patient safety incidents and offered guidance on how hospitals might avert them. Those guidelines are not binding, so it remains up to healthcare organizations to decide if and how best to develop strategies that will help prevent such incidents. "It was actually the Never Events report itself that triggered the added patient safety attention because we saw it as an avenue to increase awareness, to focus on where we were with this set of 15 and did we need to do something about it," said Marilyn Kalmats, Director of Quality, Patient Safety and Risk Management at Niagara Health. As part of an organization that is focused on continuous learning and improvement, the report prompted the question "Were we missing something?" Niagara Health began reevaluating what it considered to be classified as a never event, prompting clinical staff and administration to take another look at prevention methods. Project teams with a clinical lead and physician lead as well as front-line staff were formed for each of the 15 event types, and were responsible for conducting a gap analysis for each one. A corporate gamification engagement strategy known as "Bridge to Extraordinary" was already in place at Niagara Health to help with education and information transfer about important topics. The organization – which services 430,000 patients from 12 municipalities across six sites was able to use this strategy to bring attention to Never Events in a fun and interactive way. Should a never event happen, they would apply the critical incident process which is already in place and involves a root cause analysis of the factors contributing to the incident, along with the development of recommendations to prevent future occurrences. Monthly reporting to the Executive Leadership Team and the Board Quality Committee are also a key part of this process. "We'd already done a lot of the leg work," said Zeau Ismail, Manager of Quality and Patient Safety at Niagara Health in speaking about the incident review process. "So when the report came out we tied it to the work we were already doing. If we hadn't had the foundation we built, this process wouldn't have been so easy to implement." Raising awareness of Never Events for all hospital staff was key, he said, adding creating a culture of safety, and responding to incidents in a non-punitive, transparent way helped build trust and put the emphasis on prevention. A successful tactic that was part of the Never Events campaign was to have all staff, not just clinical staff, participate in the learning and awareness of Never Events. As part of the corporate gamification strategy "Bridge to Extraordinary" for the month of June the Never Events were highlighted. Coffee cards were handed out as prizes for short quizzes in the monthly Never Events bulletins. Never Events were also discussed as learning opportunities at weekly huddle meetings – face-to-face gatherings of all staff at every site in public settings where anyone can listen in. "We talk about what we are focusing on and how we are going to improve in front of the general public," said Ismail. "It can be uncomfortable at times, but if we don't talk about this, we're not going to improve." If you would like to share your story on how your organization is focusing efforts to reduce never events, please contact the Canadian Patient Safety Institute at nationalconsortium@cpsi-icsp.ca 3/17/2017 6:00:00 AMIt was all in the timing. Years before the pan-Canadian list of Never Events was released in September 2015, Niagara Health in Southern Ontario3/21/2017 6:56:46 PM492http://www.patientsafetyinstitute.ca/en/NewsAlerts/News/Pages/Forms/AllItems.aspxhtmlFalseaspx
Q3 National Patient Safety Consortium Update31273Patient Safety News The Steering Committee is pleased to report that 68% of Consortium actions are complete, 21% of actions are started, 5% are scheduled to start later, and the remaining 5% is expected to start but delayed. A key action is the evaluation of the National Patient Safety Consortium and the Integrated Patient Safety Action Plan. The Evaluation Framework was presented at the Consortium meeting in September 2016. The Canadian Patient Safety Institute is pleased to announce that Vision & Results Inc., with the leadership of Dr. San Ng and Ms. Jean Trimnell will conduct the evaluation of the Consortium and the Integrated Patient Safety Action Plan. Dr. Ng is the founder of Vision & Results Inc. with a PhD from the University of Toronto. Ms. Trimnell has had an extensive career in Ontario's health sector including CEO and Vice President of several sites. Dr. Ng and Ms. Trimnell will be utilizing a collective impact model throughout the evaluation with preliminary findings anticipated for October 2017. 3/15/2017 6:00:00 AMThe Steering Committee is pleased to report that 68% of Consortium actions are complete, 21% of actions are started, 5% are scheduled to start later,4/3/2017 9:00:57 PM217http://www.patientsafetyinstitute.ca/en/NewsAlerts/News/Pages/Forms/AllItems.aspxhtmlFalseaspx

 Upcoming Events

 

 

Making it stick: when asking, telling and begging just isn’t enough 23067WebExhttp://www.patientsafetyinstitute.ca/en/Events/StopCleanYourHandsDay/Pages/Making-it-stick.aspx5/4/2017 4:00:00 PM5/4/2017 5:00:00 PMChanging practice through knowledge translation and implementation science4/3/2017 7:35:34 PM13http://www.patientsafetyinstitute.ca/en/Events/Lists/Events/calendar.aspxFalseWebcast
STOP! Clean Your Hands Day5193Canadahttp://www.patientsafetyinstitute.ca/en/Events/StopCleanYourHandsDay/Pages/default.aspx5/5/2017 12:00:00 AM5/5/2017 11:59:00 PMIt's time for patients and providers to come together for clean hands – STOP​​! Clean Your Hands​ Day returns Friday, May 5, 2017.2/8/2017 6:03:54 AM17http://www.patientsafetyinstitute.ca/en/Events/Lists/Events/calendar.aspxFalseCampaign
15th Annual Northwest Patient Safety Conference5181Marriott, SeaTac International Airport: 3201 S. 176th St. Seatac, Washington 98188http://www.wapatientsafety.org/news-events/patient-safety-conference5/11/2017 12:00:00 AM5/11/2017 11:59:00 PMThe Northwest Patient Safety Conference is presented annually by the Washington Patient Safety Coalition. The only event of its kind in the Western United States, it brings innovative, stimulating, and challenging ideas to a broad audience. Presentations and discussions will be of interest to patients and family members, providers from all settings, and others interested in and responsible for patient safety.12/13/2016 10:50:44 PM10http://www.patientsafetyinstitute.ca/en/Events/Lists/Events/calendar.aspxFalseConference
Patient Safety Trainer Session: May 16-17, 2017 [Toronto, ON] 5168Toronto, Ontariohttp://www.patientsafetyinstitute.ca/en/education/patientsafetyeducationprogram/patientsafetytrainer/pages/session-may-16-17-2017-toronto-on-2016-11.aspx5/16/2017 12:00:00 AM5/17/2017 11:59:00 PMThe Ontario Hospital Association (OHA) with support of the Canadian Patient Safety Institute (CPSI) is excited to announce that the "Become a Patient Safety Trainer" course, a high impact, 2-day comprehensive train-the-trainer patient safety education program will be offered in Toronto, Ontario.11/8/2016 8:16:14 PM14http://www.patientsafetyinstitute.ca/en/Events/Lists/Events/calendar.aspxFalseConference;Workshop
Canadian Patient Safety Officer Course 5155Ottawa, ONhttp://www.patientsafetyinstitute.ca/en/education/psoc/Pages/default.aspx5/29/2017 12:00:00 AM6/1/2017 11:59:00 PMThe Canadian Patient Safety Institute is proud to support this event.9/20/2016 7:25:04 PM3http://www.patientsafetyinstitute.ca/en/Events/Lists/Events/calendar.aspxFalseWorkshop