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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.

A federally funded not-for-profit organization, CPSI offers products and programs focused on four priority areas: medication safety, surgical care safety, infection prevention and control, and home care safety. Its broad range of capabilities includes training safety officers, developing resources for frontline providers, and engaging with patients and their families.​

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Paramedic’s educational framework for patient safety85832Patient Safety News​The Paramedics Association of Canada recognizes the importance of patient safety, both in education and in their day-to-day activities. A reporting mechanism has been put in place where information on adverse events is shared across the country and groups involved in paramedic education recognize patient safety as a key competency for both seasoned practitioners and individuals new to the profession. "As much as we talk about people who are currently practicing and the need for patient safety, we need to grow those individuals where patient safety is part of the framework of how they learn, and for individuals entering into the practice, patient safety is the place to start," says Pierre Poirier, Executive Director of the Paramedic Association of Canada.The National Occupational Competencies Profile for Paramedics framework developed in 2001 and renewed in 2011 identified that patient safety competencies are required in educational content, but the details of those competencies were not explicitly outlined. The Paramedic Association of Canada has since adopted the CanMEDS framework, a competency-based approach to medical education, to align their work and how they will define their profession. "It is more than a skills document that we are creating," says Poirier. "We are looking at competencies from a professional perspective of what are the roles of a paramedic and from that will fall out what are the core concepts, the key capabilities and the enabling capabilities. Two other pieces being developed in tandem are Standards of Practices and a Code of Ethics. These components all fit together to identify how patient safety competencies will be woven into the fabric of paramedic education going forward. "To help determine roles, a group of paramedic PhDs was contracted to solicit key informants and help to define the roles of a paramedic. The Board of the Paramedics Association of Canada has since endorsed those roles and recognizes that patient safety is a cross cutting theme for the capabilities. Work is now underway to ensure that the key and enabling capabilities appropriately address patient safety. A key element going forward is to ensure that patient safety is held as a high priority in how the framework is created and how the profession is defined."Patient safety is not a given and it is not necessarily intuitive," says Poirier. "It is something that has to be learned, reviewed and reinforced. There is a whole pedagogy around patient safety and it is not something that we should ever assume. At the first point of failure if you think that is okay, there is a problem."As a next step, the Paramedic Association of Canada will also look at furthering its professional standing through self-regulating Colleges and baccalaureate degree programs. "In terms of providing safe medical care, the true paramedic professional will understand why they are doing things, as much as being capable of doing them," says Poirier. "That is where you will reap the rewards and have a true understanding of the concepts, and a commitment to patient safety. We are taking a wholesome look so that we have the breadth and depth in the profession and the educational framework to support that." 25/08/2015 6:00:00 PM26/08/2015 8:38:08 PM646http://www.patientsafetyinstitute.ca/en/NewsAlerts/News/Pages/Forms/AllItems.aspxhtmlFalseaspx
University of Ottawa Faculty of Medicine revisits safety competencies mapping85914Patient Safety News​Last year, the Faculty of Medicine at the University of Ottawa participated in mapping of the safety competencies to their undergraduate curriculum. Dr. Amy Nakajima, a clinician-teacher and Zoe Lazaris-Brunner, a medical student at the Faculty of Medicine, are now revisiting the mapping in a different way, from the perspective of the recipient of the intended curriculum, the medical student. The idea to undertake this second mapping project originated from feedback received from third year medical students attending a patient lecture given by Dr. Nakajima; the students indicated that they felt that patient safety teaching is important and their curriculum should include more patient safety content. Furthermore, the students' feedback inspired the submission of a proposal for a pre-clerkship and a clerkship patient safety and quality improvement electives, which were then established in January 2015 and are now available to medical students. These flexible electives allow students to further develop their interests in a chosen clinical area.This year's re-mapping exercise will compare the stated objectives of the undergraduate medical curriculum at the University of Ottawa, through the lens of patient safety, to the students' perceptions of the teaching they received."In particular, we are looking at components of the formal curriculum that are mandatory and lectures that students must attend," says Dr. Amy Nakajima. "At the end of this re-mapping exercise, we will generate some suggestions on how we can incorporate additional patient safety and quality improvement content into our undergraduate curricula." The Canadian Patient Safety Institute Safety Competencies provide an interprofessional, practical and useful patient safety framework that identifies the knowledge, skills, and attitudes required by all health care professionals. For more information, visit www.patientsafetyinstitute.ca06/08/2015 6:00:00 AM06/08/2015 8:26:35 PM500http://www.patientsafetyinstitute.ca/en/NewsAlerts/News/Pages/Forms/AllItems.aspxhtmlFalseaspx
Patient Safety Power Plays - August 201585846Patient Safety Power Plays​​This month’s Patient Safety Power Play goes out to all of our hard-working members of the Canadian healthcare community with a wish to thank you, as always, for your amazing efforts on behalf of others. A career in healthcare, whether on the front lines, behind the scenes, at the policy-making table, or in the home, is one of the most challenging of callings. By definition, healthcare workers think of others’ needs before their own. I urge you all to remember that you have to care for yourselves in order to build the strength to be able to care for others.Our precious Canadian summer months are often a time many choose to take some well-earned vacation. Those able to do so are fortunate to take some time to re-connect with the people, activities and values that make them the valuable workers they are. It is often in the less-structured time of vacation that we have the opportunity to think about how and why we work. Science, technology and knowledge are essential to today’s modern healthcare, however, so too is the ability to communicate with the patients and families accessing this care. Without good communication, effective healthcare is almost impossible. Whether the message is one of instruction, request, or all-important empathy – patients and families need to be able to receive the message correctly.That is why this year’s theme of Canadian Patient Safety Week and Canada’s Virtual Forum on Patient Safety and Quality Improvement is communication – in fact; good communication is good for your health is the slogan in which we here at the Canadian Patient Safety Institute strongly believe.Please have a look at the amazing resources and dedicated speakers all available during October 26 to 30th, 2015 visit www.asklistentalk.caWhat is your organization doing to celebrate Canadian Patient Safety Week? I’d love to hear from you. Email me at cpower@cpsi-icsp.ca Yours in patient safety,Chris Power​​05/08/2015 6:00:00 AM28/08/2015 4:32:58 PM109http://www.patientsafetyinstitute.ca/en/NewsAlerts/News/Pages/Forms/AllItems.aspxhtmlFalseaspx
Patient Safety research projects funded to advance the use of simulation85848Patient Safety News ​Timothy WillettFive innovative projects that will expand the use of simulation to address patient safety and quality at the point-of-care have received funding to advance their work in Ontario hospitals and other healthcare delivery agencies. A total of $47,500 has been awarded for five research projects. Collaborative funding for the projects was provided by SIM-one (Ontario Simulation Network), Improving & Driving Excellence Across Sectors (IDEAS) program, Canadian Patient Safety Institute (CPSI), Healthcare Insurance Reciprocal of Canada (HIROC), and Accreditation Canada. “The diversity of the applications received is truly inspiring,” says Dr. Timothy Willett, Director, Research and Development, SIM-one. “Simulation has become quite established as an educational strategy for pre-licensure healthcare students and medical residents, but has only begun to be used in hospital settings for staff development and to augment safety and quality improvement projects. There is tremendous potential to encourage simulation and to explore and develop the expertise in implementing simulation in a hospital setting.”Congratulations to the recipients! The projects funded include “SOS! A Gamified App to Improve Early Detection of Acute Deterioration in the Frail Elderly” (Raquel Meyer, Baycrest Health Sciences, Ryerson University)The Sensory Observation System (SOS) Simulated Training App will integrate a proven game mechanic that will reinforce learning of pre-existing educational content through interactive task challenges. Through this App, eLearning, eSimulation and gamification intersect to produce a highly engaging game-world and learning environment that motivates learners to improve and apply knowledge and decision-making efficiency in the care of this at risk population. “A simulation-based education module for the accurate diagnosis and safe management of alcohol withdrawal”(Sev Perelman, Schwartz/Reisman Emergency Centre, Mount Sinai Hospital, University of Toronto; John Peter Smith Hospital/JPS Health Network)Accurate administration of the Clinical Institute Withdrawal Assessment (CIWA) scale requires experience, yet there is no training program to teach this competency. This project involves the development, implementation and evaluation of a simulation-based quality/safety improvement program focusing on the correct administration of the CIWA for patients in alcohol withdrawal. “Trauma Resuscitation Using in-Situ simulation Team training (TRUST study) A novel approach to safety threat identification and high-performance team training”(Andrew Petrosoniak, St. Michael’s Hospital)Resuscitation of a critically ill trauma patient occurs in a high-stakes and dynamic environment whereby the ad hoc trauma team must respond quickly to changes in the patient’s status. Using in-situ simulation technology, this project seeks to evaluate the trauma team’s performance during recreated trauma cases. This training strategy will help identify and resolve potential threats to patient safety while providing an opportunity to evaluate the team’s performance. “Assessment of patients receiving complex pain management interventions An educational module of epidural analgesia using standardized patients for Registered Nurses”(Mona Sawhney, North York General Hospital, Queen’s University)Although epidural analgesia, a pain management intervention used to manage pain following surgery, has become a standard of practice, Registered Nurses receive limited education regarding this modality. Simulation education using standardized patients will provide learners with opportunities to practice high-risk skills in a safe environment with the ability to provide constructive feedback, which can prevent mistakes in actual clinical settings. “Improving the quality of team training and performance during interprofessional in situ mock code blue simulations A randomized controlled mixed-methods study”(Catharine Walsh, Hospital for Sick Children, St. Michael’s Hospital, Women’s College Hospital, Alberta Children’s Hospital, University of Calgary)Communication and teamwork failures are the leading causes of errors in healthcare settings. The project will demonstrate that learners who are pre-trained using just-in-time simulation regarding CPR quality and medication administration will exhibit improved performance with respect to these skills during in situ mock codes. Results of this study will provide evidence to optimize in situ simulation-based learning of teamwork skills.The research projects will run until December 31, 2015 and recipients will be encouraged to publish their results nationally. A one-day summit is being planned for 2016, where recipients will present their findings.“This initiative will develop the tacit knowledge on how to make simulation work in a hospital setting,” says Willett. “We will also create a cohort with experience and expertise in simulation who can share their learnings with other healthcare organizations across the country.”05/08/2015 6:00:00 AM05/08/2015 10:27:24 PM671http://www.patientsafetyinstitute.ca/en/NewsAlerts/News/Pages/Forms/AllItems.aspxhtmlFalseaspx
Horizon’s regional approach for VTE prevention85762Safer Healthcare Now!​Page Content ​Alice DamonThe Horizon Health Network in New Brunswick looks for every opportunity to advocate and educate on the importance of safe healthcare practices. Their approach to preventing venous thromboembolism (VTE) was no different. With strong leadership support, Horizon has implemented ​​a program that includes a risk assessment tool, clinical order sets, measurement tools, data analysis, education and communication. When four health authorities joined together to form the Horizon Health Network (Horizon) in 2008, each authority had different processes and ways of doing things. In December 2012, the Horizon VTE Advisory Group was formed to take a regional approach for VTE prophylaxis. The multidisciplinary team of physicians, pharmacy, nursing, and patient safety representatives set out to foster a consistent approach to VTE prophylaxis administration and develop performance indicators to monitor progress. A regional policy and guidelines were put in place and the team looked at best practices that could be adopted. One of the first tasks was to come up with a risk assessment tool that would provide a standardized method of determining which patients were at risk of VTE. The risk assessment tool was shared with physicians and the multidisciplinary teams, and a pocket card was made available in hard copy and on the Horizon intranet for download. The next task was to inventory all clinical order sets for those including VTE prophylaxis. The inventory found surgical services had clinical order sets in place; in medical services there were few order sets where VTE prophylaxis was indicated. Under the leadership of Pharmacy Services, a Medical Inpatients VTE Prophylaxis order set was created that could be adopted across Horizon. A consistent list of medications on the order set ensures consistency and provides options for the physicians to select from. In order to foster a consistent approach across Horizon, it was identified the previous four health authorities, now Horizon Health Network, had variations in medication formularies for VTE prophylaxis. Formulary standardization was required to decrease the patient’s risk of harm and dosing errors. In August 2013, the Horizon VTE Advisory Group sent a letter to the Provincial Chair of the Formulary Review Committee requesting a class review of low molecular weight heparin. In June 2014, the Provincial formulary was standardized to two choices and the Medical Inpatient clinical order set was revised. Next, the team looked at education. VTE Simplified pamphlets for patients and staff information were used to spread the word. “With limited resources and time, we did not want to reinvent the wheel, so we used the VTE Simplified materials to educate patients and staff,” says Alice Damon, Chief Patient Safety Officer, Horizon Health Network. A physician fact sheet was created for distribution from the Regional Medical Advisory Committee to all physicians across Horizon. “We had to develop a consistent process and ensure everyone was on the same page, using the same process,” adds Alice. “Physician champions were identified as means to spread the importance of VTE prophylaxis and educate their peers. Having physician champions will get you further along, as they will talk with their peers one-on-one or in a group setting. It is important to have that in place.” This initiative is a multidisciplinary responsibility although the prescriber is responsible to determine if VTE prophylaxis is ordered. Nursing and pharmacy play an important role in identifying patients that may not been screened for VTE prophylaxis upon admission and bring this to the attention of the prescriber. An online video was created for nurses and pharmacy staff to illustrate their role in relation to the regional approach for VTE prophylaxis and to reinforce patient education. The video is available 24/7 on the intranet to accommodate shift workers. Patient Safety Consultants also visited each nursing floor, asking staff to watch the video and to raise awareness about VTE at the unit level. The final step was measurement. Horizon has adopted a three-fold approach. First, a process indicator was developed for assessing if a patient had a risk assessment done for VTE. The team worked with Health Information Professionals, in the Health Records department, to ensure a consistent method of measuring VTE risk assessment across all facilities. Now, when the Health Information Professionals gather data from patient charts, they also gather information to confirm if a VTE risk assessment had been completed for the patient. This information is used to identify and address areas for improvement. Secondly, the Safer Healthcare Now! audit tool is used for random and periodic sampling to determine if order sets were used and if the appropriate prophylaxis was administered. Patient Safety Consultants, with some assistance from Nursing, complete these audits to reduce some of the burden on the unit staff. Finally, an outcome indicator on deep vein thrombosis and pulmonary embolism combined for medical and surgical in-patients is being reviewed for opportunities for improvement. “As an organization we are constantly looking at ways to get data that is meaningful, and ensure the collection process does not overload staff,” says Alice. Horizon participated in the Safer Healthcare Now​! VTE Audit Day in April 2013 to gather baseline data, and again in October 2014 to monitor any improvement. The Safer Healthcare Now! audit tool is currently used on a quarterly basis to determine if patients are receiving the appropriate prophylaxis. Compliance is at 82 per cent. “To change or transform healthcare practices you need a good change management strategy,” says Alice. “Communication is vital! You will always have resistance and you need to find ways to overcome that. Change takes a long time to happen; it does not happen overnight -- if you think you can do it all in a year, it will take three. To be successful, you need to stay on top of it.”​04/08/2015 7:00:00 AM04/08/2015 7:44:46 PM608http://www.patientsafetyinstitute.ca/en/NewsAlerts/News/Pages/Forms/AllItems.aspxhtmlFalseaspx

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