Hamilton Health Sciences Centre Healthy Hands campaign

The Healthy Hands campaign/program entered by the Hamilton Health Sciences Centre (HHSC) for the Stop! Clean Your Hands Day What’s Your Hand in It? competition was truly a team effort. The poster campaign is the brainchild of the HHSC McMaster Children`s Hospital Nursing Council for Pediatric Critical Care Unit (PCCU). 

“The campaign was unique in that it was not a top-down approach to hand hygiene,” says Cindy O’Neill, Manager, Infection Prevention and Control. “The staff came up with the idea, took the ball and rolled with it.  It was unique to the individual and what motivates them. As a result, we are seeing a cultural shift with improved teamwork where everyone is excited about the program.”

The Healthy Hands campaign/program for staff and families was created to increase awareness and hand hygiene rates on the PCCU. This program provides families an opportunity to participate in their child’s care and empowers them to discuss and encourage hand hygiene with the healthcare team.

A personalized poster (pictures of children of the PCCU staff taken by HHSC in-house photographers, with the message to "please wash your hands" and the reasons why) is included in each patient’s admission package. The admitting nurse writes the patient’s first name on the poster which is then displayed at the head of the bed/crib or a highly visible area for all hospital staff to view. In addition, there is large collage (approximately 8 x 5 feet) of hand hygiene poster photos (which portrays children of PPCU staff) that hangs above the parent/visitor area to promote good hand hygiene practices; and another poster with the children’s photos and the message “thank you for washing your hands” in every room above the sink.

Education is provided to every admitted patient and their family. “Family members are encouraged to use the personalized poster as a resource to remind staff to clean their hands,” says Cheryl Munroe, Registered Nurse. “The program has expanded into the community as a number of families have taken their poster home to display outside their child’s bedroom as a reminder to Home Care providers to clean their hands prior to administering care.”

To increase understanding of the 4 Hand Hygiene Moments, the Infection Control Practitioner dedicated time with each nurse to conduct one-on-one observational audits using an electronic tool to highlight common missed hand hygiene opportunities. This understanding further authorized and promoted a “gatekeeper model” to enhance good hand hygiene and support a patient safety culture.

“We did a lot of education around use of the audit tool and how staff should audit their peers,” says Connie Gittens Webber, Infection Control Practitioner. “That helped to provide a comfort level and understanding by the staff as to what was required.”

Within six months of implementation, hand hygiene rates increased by 42 per cent for Moment 1 (before Patient/Patient environment contact); and by 47 per cent for Moment 4 (after Patient/Patient environment). The unit has sustained rates of more than 85 per cent for Moment 1 and Moment 2 since the program was initiated in March 2012.

Positive feedback from the “Quality Counts” postcard (patient satisfaction survey) have also improved, particularly related to the question, "Have you been informed about the importance of Hand Hygiene.” “Families are part of our team and we involve them in what we do,” says Barb Jennings, Manager.  “Asking families for feedback on how well we educated them on hand hygiene helps to build on our partnership with families.”

“The program has helped to break down the traditional silos that you encounter in large organizations,” adds Barb Jennings. “Everyone is involved and everyone is engaged. The Healthy Hands program certainly has legs and although it started in the PCCU, other units are now working together to introduce the program.”  A SharePoint site has been set-up to compile unique ideas and measurement data that other units can utilize to promote hand hygiene.

“Implementing a program such as this is a long process, but so worth the effort,” says Cindy Rogers, Hand Hygiene co-ordinator.  “Being recognized for our work in hand hygiene speaks volumes and we look forward to spreading our program across the country.”

STOP! Clean Your Hands Day was celebrated on Monday, May 6th, 2013, to coincide with the World Health Organization (WHO) global campaign to improve hand hygiene, SAVE LIVES: Clean Your Hands. The fourth national Canadian event was designed to support the global campaign, with a focus on evaluation and monitoring to increase the knowledge and perception of healthcare-associated infection and the importance of hand hygiene; and to profile patient participation in hand hygiene promotion and improvement activities.

Promotional packages containing 4 Moments Cards, Patient and Family Hand Hygiene Guides, post-it notes and more were distributed to 1,003 Canadian healthcare organizations that registered for STOP! Clean Your Hands Day. The package also included flyers promoting the use of the WHO Hand Hygiene Self-Assessment tool and a new data collection process to support organizations in their hand hygiene observations.

In the weeks leading up to STOP! Clean Your Hands Day, four webinars were presented to help healthcare organizations learn from experts in the field on how to improve hand hygiene practices. The topics included Ten Barriers to Hand Hygiene (a French presentation); Patient and Visitor Involvement: The Hand Hygiene Missing Link; Patient Involvement in Hand Hygiene; and Hand Hygiene Measurement and Patient Safety Metrics.  The one-hour webinars were recorded and have been posted for viewing at www.handhygiene.ca

A key component of STOP! Clean Your Hands Day 2013 was the “Dragons’ Den” style What’s Your Hand In It? competition to showcase innovative ideas to promote hand hygiene that involved patients and families and demonstrated improvement; 18 entries were received from healthcare organizations across the country.  Five organizations were then invited to pitch their approach to improving hand hygiene to a panel of judges and over 90 webinar participants. The panel asked questions of the presenters and critiqued the presentations to determine the winning entry based on patient and family involvement, staff engagement, and monitoring and feedback of results.

Congratulations to Hamilton Health Sciences Centre (HHSC) for their winning entry, a personalized poster with visuals of the children of HHSC staff that reminds patients and their families and staff to clean their hands. The personal touch and the involvement of the patient and family in the design resulted in a dynamic and exciting campaign that can be applied to various care settings. The Canadian Patient Safety Institute will now work with Hamilton Health Sciences Centre on ways to spread their work across the country.  See the sidebar article What’s Your Hand In It? for more information on the HHSC entry.

Kudos to the other finalists whose innovative ideas included various  elements for improving hand hygiene such as the LIFE Hand Hygiene bundle (Leadership, Innovation, Family and patient engagement and Education); and a patient driven initiative to improve hand hygiene compliance with patients and families. Click here to view the webinar and presentations from the finalists.

“I can certainly speak for my fellow Dragons (judges) when I say that we were blown away by the quality of the pitches we heard, highlighting the tremendous work that is happening across Canada to improve hand hygiene in both healthcare and community settings,” says Hugh MacLeod, CEO, Canadian Patient Safety Institute.

Tools and resources to support STOP! Clean Your Hands Day are available on the website www.handhygiene.ca   The Canada’s Hand Hygiene e-learning module provided healthcare workers and volunteers with information on hand hygiene and how to improve hand hygiene in their organization.  The online learning module was developed by the Canadian Patient Safety Institute and Discovery Campus.  The module can be accessed in English and French for individuals in Canada and internationally, at http://cpsi.discoverycampus.com/

During STOP! Clean Your Hands Day, organizations were asked to tell us how they were celebrating. Tweets and email submissions collected on “What’s Happening Across the Country” included many creative ideas, including pop quizzes, stories, photos, comments, and the launch of a website. The real-time sharing contributed to another successful national hand hygiene event across Canada.

STOP! Clean Your Hands Day participants were also entered into a draw to receive a GOJO care package.  Congratulations to Alice Amero, Tideview Terrace (Digby County, NS), Margie Foster, Grand River Hospital (Kitchener, ON) and Denise Erskine, Peel Manor LTCC (Brampton, ON).

STOP! Clean Your Hands Day was presented by the Canadian Patient Safety Institute in partnership with Accreditation Canada, CHICA Canada, and the Public Health Agency of Canada; and sponsored by GOJO.

Now in its fourth year, the Office of Continuing Medical Education, University of Calgary, is offering an on-line certificate program in Patient Safety and Quality Management for healthcare professionals to expand their working understanding of patient safety and quality management concepts and learn from experts in the field.  This one-of-its-kind program is conducted through four in-person education days at the University of Calgary and 13, two-hour real-time online sessions delivered between September 2013 and March 2014. Participants also complete a patient safety/quality improvement project with the guidance of an experienced mentor.

The program has attracted participants from across Canada and to-date more than 70 healthcare professionals have received certificates in patient safety and quality management.  The interdisciplinary program is designed for physicians, residents, nurses, pharmacists and managers who want to focus on workplace improvement to advance a quality and safety culture.

The program will help participants to:

• Distinguish and describe the components of a healthcare safety and quality model;
• Describe core principles of patient safety and quality;
• Identify key strategies for designing and delivering safer/higher quality healthcare;
• Explain the critical role that microsystem and macro system leadership has for patient safety and quality;
• Describe how a healthcare system should respond when the outcomes of healthcare design and delivery are not optimal; and
• Develop and present a patient safety/quality improvement project.

Registration is limited to 25 participants.  Visit www.patientsafetycourse.ca for more information. Register before August 10, 2013 to receive the reduced rate of $2,250; the registration fee for students and residents is $500.

Continuing education credits are available from the College of Family Physicians of Canada, Royal College of Physicians and Surgeons of Canada, the Alberta College of Pharmacists, and the College of Health Services Executives.

The Patient Safety and Quality Management Certificate program is offered through W21C (Ward of the 21st Century), the Health Quality Council of Alberta and the University of Calgary’s Office of Continuing Medical Education.

The Patient Safety Education Program Canada (PSEP – Canada) core curriculum has been enhanced to include five new modules focused on patient safety in mental health. A ‘first of its kind’, the modules address the unique issues that people dealing with mental illness face every day when receiving care. 

The mental health modules identify specific safety issues facing persons with mental illness, including suicide and self-harm, violence and aggressive behavior, seclusion and restraint use, and absconding and missing patients.  The objective of each module is to raise awareness of individual and system factors that contribute to these safety issues, and to identify the steps and strategies for their prevention.

The modules look at how the care approaches that are linked to safer outcomes, such as recovery-orientated, client-centred and trauma-informed care promote client and staff safety. The mental health modules were developed in collaboration with the Ontario Hospital Association (OHA) and the Canadian Patient Safety Institute. 

“The diverse modules provide guidance based on the best available evidence and articulate safety for the mental health client population in various care settings” says Ann Pottinger, Discipline Chief for Nursing and Manager of Nursing Innovation, Centre for Addiction and Mental Health and a member of the expert faculty that helped to develop the modules.  “The modules look at the individual and systemic factors in your practice, in your team and at an organizational level that are needed to promote safer outcomes.”

“When it comes to mental health, care promoting a trauma-informed and least restrictive setting where you can balance freedom and choice with safety and security, leads to safer environments,” adds Ann Pottinger.  “The user-friendly modules are a rich source of information and can be customized to enhance both basic and complex quality improvement and safety discussions throughout your organization.”

PSEP – Canada helps healthcare organizations to strengthen quality improvement and patient safety initiatives within their facilities. It is delivered as a two-day, peer-to-peer education event that certifies members of inter-professional teams as patient safety trainers. The curriculum is comprised of core patient safety content and effective teaching approaches to enable certified trainers to share their acquired knowledge and skills with others members of their team and organization. For more information, visit www.patientsafetyinstitute.ca and click on Education.

The legendary Alberta advantage is cited here in everything from tax rates to relative amounts of sunny blue sky.

Alberta’s medical system is also highly regarded. Perhaps it’s no surprise. The province’s commitment to quality, safe care is even writ in legislation, in the Health Quality Council of Alberta Act.

The legislated council therefore enjoys unique authority in doing detailed system reviews of even politically sensitive issues in healthcare.

Its commitment is to release all review findings to the public.

But it also contributes to a groundbreaking public alert system launched in 2011 by the Canadian Patient Safety Institute (CPSI).

The Global Patient Safety Alerts system is a searchable, web-based clearinghouse of healthcare information and advisories gleaned from contributors’ patient safety incidents. The system is gaining traction, but its impact relies on health regions and health organizations generously sharing lessons from patient safety incidents.

Dr. John Cowell, CEO of the Health Quality Council of Alberta, was with it from the beginning and has overseen a dozen system reviews.

Reviews were done on everything from emergency- room wait times to the province’s ground ambulance system. The council even conducted a review over allegations that Alberta physicians were being deterred from advocating on behalf of patients.

“We made strong recommendations to Alberta Health Services that it needed to develop and walk the talk around a just culture, where individuals would feel safe to speak out,” said Dr. Cowell. They also reviewed and made recommendations pertaining to the value of trust in relationships among staff members, as well as between staff and leadership levels.

As Dr. Cowell adds, those recommendations were a bit unusual in that they were philosophical in nature. Typically, patient safety concerns are more technical.

But this again speaks to the authority given to the council to recommend improvements to healthcare in Alberta

“We’ve got many, many recommendations out there that are in play,” says Dr. Cowell.

Alberta’s role in sharing information with other healthcare stakeholders and organizations is music to the ears of Wendy Nicklin, CEO at Accreditation Canada, which sets national standards for health care. Nicklin was also a board member at CPSI when Global Patient Safety

Alerts were first discussed.

“It’s important in healthcare that we learn from each other,” said Nicklin. “I think we have a professional responsibility to inform our colleagues around the world of some risk or caution that is required, as well as the potential steps to address it.”

In Alberta, the Health Quality Council is ready and willing to take on controversial issues.

The council also reviewed the province’s response to the H1N1 influenza pandemic, as well as a case where the wrong mother's breast milk was delivered to an infant. The issues were headline-making news for months.

Cowell says the council’s work is far from done. Reviewing and improving the policies, practices and human interactions in a system as vast and complex as health care is a task without end.

“This is long, hard, detailed and relentless work over time,” says Dr. Cowell. “This is shifting culture from one that gave less

service to quality and safety, to one which actually understands that it’s highly pragmatic, central to the well-being of citizens and is very measurable.

“All high performance corporations have figured out what their dimensions of quality are and how to perform against it.” Performance, however, does not equate to perfection, adds Dr. Cowell.

“In a highly complex system that is a combination of great science and imperfect science, where trained individuals try to do their best for those who suffered some tragedy, mistakes will be made,” he says. “People will fail.”

As he says, that’s why healthcare needs a mechanism like Global Patient Safety Alerts to report and share the findings from patient safety events.

It’s not about naming individuals, says Dr. Cowell. It’s not about blaming or shaming anyone.

It’s about improving healthcare, system by system.

That’s the way they do it in Alberta. It’s an advantage.

​This past March, 26 members from Patients for Patient Safety Canada (PFPSC), a patient-led program of the Canadian Patient Safety Institute (CPSI), met for a powerful two-day in-person meeting. For many, it was like coming home. They felt they were being heard and that their experience and insight was valued. The members of the program left the two-day event feeling hopeful that their unique perspective can make a difference in the healthcare system.

The meeting goals were to build further knowledge and understanding about the important relationship between CPSI and PFPSC, foster strong relationships between PFPSC members and to increase confidence as advocates for patient safety. A WHO workshop was held in conjunction with the meeting, where 11 additional PFPSC members qualified for the WHO Patients for Patient Safety (PFPS) Champion designation.

Hugh MacLeod, CEO of the Canadian Patient Safety Institute, kicked-off the meeting relaying his personal experience as a patient and reinforced the important role patients and family members play in the healthcare system. CPSI recognized the importance and the necessity of the two-way relationship with PFPSC, including the patient voice within CPSI

“I now have a clearer understanding of how CPSI supports PFPSC and how they value the insight that can be provided from our vantage point,” says Tanya Barnett, a new PFPSC member. “CPSI truly appreciates our experience and how our stories can drive change in the healthcare system.”

Nittita Prasopa-Plaizier, WHO PFPS Program Manager, shared the new PFPS strategy and highlighted the need to demonstrate the impact of patient engagement and to find ways to maximize the effectiveness of the program’s work.

Kim Neudorf, a PFPSC member since 2009, found Nittita’s presentation very powerful. “Nittita reinforced how the patient is the only constant, as they are present at every point in time during their care. It raised the question of how can the healthcare system not involve them?”

Barbara Balik, Principal of Common Fire Healthcare Consulting and Senior Faculty at the Institute of Healthcare Improvement, shared her insights about patient-centred care and safety. She referred to our work as “disruptive innovators”, challenging the status quo in a positive way.

“Barbara’s inspirational message focused on the importance of storytelling,” says Theresa Malloy-Miller, a PFPSC member since 2006. “She provided some great tips on how to stay focused and be clear about what you want to achieve when telling your story.”

Stephanie Newell, who heads PFPS Australia, outlined how legislation is mandating consumer representation on federal committees. The requirements for consumer partnership in the new National Safety and Quality Standards have created more opportunities for public participation. 

 “The networking opportunities were priceless and the meeting built a sense of team,” says Phil Capone, a PFPSC member since 2012. “The energy and passion for change demonstrated by the PFPSC members attending was truly remarkable and a testament to how deeply committed we are to advancing patient safety.”

Presentations by PFPSC members, small group discussions and question and answer sessions unleashed some great exchanges. The flurry of positive comments received from those who attended confirmed that the in-person meeting was a great success.

​We are humbled by the responses to the Ghost Busting in Healthcare essay series. In particular, we are overwhelmed by the feedback from care providers, middle management and patient advocates. Because of this feedback, we have decided to create another series of essays dedicated to these three groups. They are important voices that bring a balance of the current reality and signs of hope for the future.

We want all of the front line providers, middle managers and patient advocates, to consider these questions and would like to invite them to co-author a 500-word essay and include what you see as the Ghost of Healthcare Consciousness.

1. What will it take for us to achieve a new dynamic wholeness in the healthcare system?
2. What will it take to build a system that is cohesive, flexible, interconnected, cost-effective, orderly and that values the patient voice?

Deadline date for submissions is April 23, 2013. All material submitted is subject to editorial review and acceptance by Longwoods. We will be in contact with those chosen to collaborate on their essay submissions. Send your submissions to thepublisher@longwoods.com.

​If you walk down the halls of the Cardiac Science units at the Alberta Health Services Mazankowski Alberta Heart Institute and CK Hui Heart Centre in Edmonton, you can’t help but notice the reminders to clean your hands.  Alberta Health Services have challenged healthcare facilities in each of their five zones across the province to come up with a plan for 100 per cent hand hygiene.

The Mazankowski and CK Hui sites had the advantage of a head start on developing their plan.  Last year, they joined the Safer Healthcare Now! Stop Infections Now Collaborative (SINC). Their hand hygiene compliance rates were at an all-time low – about 26 per cent and they wanted to help influence change.  As a result, in the last year, compliance rates have at times reached 76 per cent at the Mazankowski site and 80 per cent at the CK Hui site. 

“We have been able to integrate many of the ideas and our work from the Collaborative to our zone meetings and we are thrilled that the work we started is now spreading throughout the Edmonton zone,” says Darlene Bartkowski, Clinical Nurse Educator at the Mazankowski Alberta Heart Institute. “Some of the things we are doing are not revolutionary, but it is the sharing that makes the difference.  You realize that you are not the only one with that problem.”

The AHS SINC team produced buttons for staff that say, “You can ask me to clean my hands”, in an effort to get patients and families more involved in their care. They invited all staff from the Edmonton zone to participate in a flash mob and music video to promote effective hand hygiene.  The AHS Edmonton zone is using hand hygiene observation as a way to improve things, rather than a way to punish people for not doing something.  And, they have a formed a working group to look at cleaning of equipment. 

“It can be difficult starting a process like this and initially we did not have as much frontline representation as we would have liked to have,” says TobieGuinez, Clinical Nurse Educator. “Once the frontline staff got involved, we started to see change.  Frontline staff are now more diligent about cleaning their hands, and they are asking questions about the observations and getting more involved in them.”

“For the Collaborative, we formed a multidisciplinary group and that really changed the team dynamic,” says Inger Eakin, Project Manager.  “There is a lot more engagement.  In fact, one physician responded to a question in a recent engagement survey that being part of this Collaborative was the first time he felt engaged and part of the team.”

The AHS multidisciplinary team includes representatives from Medical staff (physicians), nurses, educators, environmental services, diagnostic imaging, laboratory, respiratory services, food services, protective services, a service attendant and more.  

The Edmonton zone has set targets in education and hand hygiene compliance and meets bi-weekly to talk about the various methods to reach their goals, and to discuss issues and problems.  Overall zone compliance has gone up and the Edmonton zone leads in provincial hand hygiene compliance.

The Stop Infections Now Collaborative was led by experts from the University Health Network (IGNITE ) in conjunction with other behavioural change consultants from Canada and the U.S. To learn more about the Stop Infections Now Collaborative, visit www.saferhealthcarenow.ca.  For information on effective hand hygiene, visit www.handhygiene.ca

​When the Canadian Patient Safety Institute (CPSI) invited Patients for Patient Safety Canada (PFPSC) members to become Master Facilitators for the Patient Safety Education Program – Canada (PSEP – Canada)  PFPSC Co-Chair, Donna Davis, and Membership Chair, Dale Nixon, were quick to apply.  Since Davis and Nixon were selected to become certified Master Facilitators, their journey has just begun. As PSEP – Canada Master Facilitators, Davis and Nixon will join a cadre of trained leaders that help members of inter-professional teams become Patient Safety Trainers to guide patient safety education in their home organization.  

 “As patient safety advocates we need to broaden our approach, and the PSEP – Canada program provides the opportunity to expand our involvement from a personal experience to educating a broader audience,” says Donna Davis. “Every day you have ‘teachable moments’ with your patients, co-workers and even yourself.  Through my experience with the patient voice and my journey as a patient safety advocate, the face of the patient is forefront and I want to bring that perspective to the PSEP – Canada program. That is what makes it real.” 

“Hearing the stories of heartache because of harm resonates with people,” says Dale Nixon.  “It puts a face, not just the written word, on those that have been harmed. It is something healthcare providers remember long after the session is over and it helps them become a voice for improving safety.”

In November 2012, Davis and Nixon attended a two and half day PSEP – Canada “Become a Patient Safety Trainer” conference in Newfoundland to begin their training as certified Master Facilitators.  The next step is to attend a Professional Development Workshop, taught by faculty from Northwestern University out of Chicago, Illinois, to refine their teaching and practice improvement skills and then they will co-teach during a PSEP – Canada conference later this year.  Once certified, Davis and Nixon will be able to teach as Master Facilitators in the PSEP – Canada program.

Designed to strengthen internal capacity, grow quality improvements and patient safety initiatives, the PSEP – Canada program is built on a train-the-trainer team model that provides a peer-to-peer educational framework. With an emphasis on creativity and excellence in educational techniques, the program focuses on applying human factors in the workplace, scientific methods for improving safety, organizational culture and dealing with change, understanding teamwork, moving beyond blame to systems thinking, and how to teach and implement patient safety. As Master Facilitators, Davis and Nixon will ensure that the patient’s voice forms a foundation throughout these modules.

“CPSI has once again demonstrated its commitment to truly make a difference and include patients and families in improving patient safety in Canada,” says Dale Nixon.  “I am excited about the opportunity to bring the patient voice to the patient safety education program.”

Visit www.patientsafetyinstitute.ca for more information on the Patient Safety Education Program – Canada.

​Intensive workshop designed by physicians, for physicians

The Canadian Patient Safety Institute and the Royal College of Physicians and Surgeons of Canada are co-sponsoring ASPIRE, a four-day workshop designed by physicians, for physicians to promote patient safety in residency education. The Advancing Safety for Patients in Residency Education (ASPIRE) workshop will take place April 14 to18, 2013 in at the Royal College of Physicians and Surgeons in Ottawa, Ontario.  

The program is targeted to medical educators in speciality and family medicine.  It will focus on patient safety topics relevant to helping residents acquire entry to practice abilities. At the end of the workshop, participants go away with an education plan for their institution. In addition, they will be equipped to serve as instructors, faculty resources and champions for the dissemination of patient safety curricula throughout their post-graduate educational program.

A host of dynamic speakers will deliver sessions on patient safety including competencies, teamwork and communications, human factors, patient safety incidents, risk management, resources and much more.  Click here to download the program.

Participants will receive a copy of Educational Design: A CanMEDS Guide for Health Professions, a     how-to guide for creating education programs and the Patient Safety Education Program – Canada (PSEP – Canada) curriculum that includes core patient safety content and effective teaching approaches based on adult learning principles. 

Don’t miss this patient safety focused learning event!  The registration fee for the four-day workshop is $1500; register before February 25th to take advantage of early bird savings.  Participants will qualify for ASPIRE certification and Royal College Maintenance of Certification (MOC) credits on completion of the program.  

To register, visit www.royalcollege.ca. The workshop is offered in English only.

If patient safety is your passion, the Canadian Patient Safety Officer Course is for you.  The four-day course focuses on the fundamentals of patient safety and will provide you with the latest information, tools and techniques to develop a patient safety program in your organization. The 2013 session runs April 23 to 26, at the Fairmont Chateau Laurier in Ottawa, Ontario.

The Canadian Patient Safety Institute has partnered with the Canadian Healthcare Association to provide this comprehensive program to advance patient safety competencies in healthcare organizations. The Canadian Patient Safety Officer Course provides the basics to take your patient safety programs to the next level.

“This is a must-attend course for healthcare providers wanting to be make an impact on patient safety in their organization,” says Hugh MacLeod, CEO of the Canadian Patient Safety Institute.  “It is your commitment to patient safety that will advance the movement toward safer care for all Canadians.”

Learn how to influence and enhance a patient safety culture; incorporate human factors;  foster communication, teamwork and organizational culture related to patient safety; build physician engagement strategies; understand high-risk clinical processes; and recognize system-induced patient safety incidents.

Register today! Visit www.cha.ca or click here to access the course details and registration form. Cost for the four-day course is $3,975/participant. An early bird saving of $375 can be applied if you register before February 22, 2013.

How do you govern quality in primary care?

The Effective Governance for Quality and Patient Safety program has been customized to assist board members and senior management in Ontario’s primary care sector to develop and implement evidence-informed approaches to governance and leadership and to share innovative health governance practices, resources and tools.

“This is a must-attend workshop for primary care board members and senior management to lead, support and sustain a culture of quality,” says Kim Stelmacovich, Ontario Senior Regional Director, Canadian Patient Safety Institute. “The Effective Governance for Quality and Patient Safety program provides a common evidence-based platform of key governance principles to support the quality agenda in Ontario’s primary care sector.  The program is endorsed by the Ontario Ministry of Health and Long-Term Care to ensure that primary care boards have an understanding of their role in quality to support successful partnerships and implementation.”

Seven, one-day learning sessions have been scheduled throughout the province for both English and French audiences.  Learning sessions will be held in Toronto (February 27); Ajax (March 2); Ottawa (March 6); London (March 27); Hamilton (April 13); Sudbury (April 20) and Mississauga/Toronto Airport (April 24).  Organizations invited to participate are: family health teams, community health centres, aboriginal health centres and nurse practitioner-led clinics. It is recommended that each organization register three participants to attend one of the seven sessions scheduled, including: the board chair, chair of the board quality committee (or other board representatives) and senior management (executive director or clinical lead).

Click here to register for an upcoming session.  There is no registration fee for these sessions. Click on the link for more information on the Governance for Quality in Primary Care learning sessions.

The Effective Governance for Quality and Patient Safety program was developed by the Canadian Patient Safety Institute (CPSI) and the Canadian Health Services Research Foundation (CHSRF) to help healthcare boards understand and implement effective governance practices and processes for quality and patient safety. CPSI has partnered with the Association of Family Health Teams (AFHTO), the Association of Ontario Health Centres (AOHC) and Nurse Practitioners’ Association of Ontario (NPAO) to customize the Effective Governance for Quality and Patient Safety program for Ontario’s primary care sector.  

For more information on the Effective Governance for Quality and Patient Safety program, visit www.patientsafetyinstitute.ca

​Webinar outlines how to determine the cost of adverse events and the cost-effectiveness of patient safety improvement strategies

In November 2012, the Ontario Hospital Association partnered with the Canadian Patient Safety Institute (CPSI) to host a webinar to present the findings from a recent study on the Economics of Patient Safety in Acute Care.

During the webinar, Lead Investigator Dr. Edward Etchells, Associate Director of the University of Toronto Centre for Patient Safety, identified the important elements of economic evaluations. He explained in simple terms, how to determine the cost of adverse events and the economic attractiveness of patient safety improvement strategies.  In addition, Dr. Etchells outlined a five-step plan in determining the economic burden of adverse events:

1. Define the target of concern/burden;
2. Define the economic perspective (hospital budget/societal issues such as patient or family/different outcome, etc.);
3. Decide what to count and count it;
4. Assign a unit cost to each element; and
5. Attribute costs to safety. 

Dr. Etchells also summarized the patient safety improvement strategies that the study found economically attractive, including: pharmacist-led medication reconciliation, chlorhexidine for vascular catheter site care, standard counting strategy for detecting surgical foreign bodies, and Keystone ICU patient safety program to prevent central line-associated blood stream infections.

 “You need to have a good understanding of the costs and benefits when faced with tough decisions,” says Dr. Etchells.  “Given the right information, policy and decision makers will be better informed to make wise choices and do the right thing.”

Commissioned by CPSI and released in 2012, the Economics of Patient Safety in Acute Care study estimates the cost of preventable patient safety incidents at $397 million.  Calculating the estimated economic burden of preventable patient safety incidents in acute care can help policy and decision makers to explore ways to improve patient safety and avoid unnecessary healthcare expenditures.

Click here to view the webinar, or visit www.patientsafetyinstitute.ca for a link to the site. The webinar is available in English only.

Click here to download a copy of the Economics of Patient Safety in Acute Care report, or to learn more about the research study visit www.patientsafetyinstitute.ca and click on Research.

​Research study validates web-based tool for independent double check

Dosing errors are the most common type of paediatric drug errors, with over-dose out numbering under-dose errors. Morphine is the high-alert drug most frequently administered in error, due to distractions, interruptions and high stress that are a common occurrence in a busy clinical environment.  Paediatric drug calculations are typically weight-based and nurses administering medications ascertain the accuracy and appropriateness of the dose using the patient’s weight.  An independent double check (IDC) where two nurses independently verify the patient, medication, drug concentration, dose, time and route can help to detect and avert medication errors at the point-of-care. Despite these measures there continues to be a significant number of patient safety incidents related to medication causing harm to paediatric patients.

A research study supported and funded by the Canadian Patient Safety Institute, the University of Ottawa School of Nursing and Sandoz International, Preventing Medication Errors with High Alert Drugs: Testing a Computerized Double Check, looked at the utility and usability of a web-based tool called the iDoseCheck for preventing morphine dosing errors, as compared to the standard paper, pencil, calculator double check. The iDoseCheck is a graphical calculator developed to assist nurses with the IDC. The iDoseCheck aids in verification of both the mg/kg dose and the volume of morphine to be administered.  The web-based tool displays strategically placed error messages to provide information about over- and under-dosing.

“The independent double check is often an interruption for the checker, even though it is intended to detect and avert medication errors,” says Dr. Jacqueline Ellis, Children’s Hospital of Eastern Ontario (CHEO) and lead of the study, Preventing Medication Errors with High Alert Drugs: Testing a Computerized Double Check.  “With so many distractions and interruptions in our day-to-day work, medication errors can and do happen.  The iDoseCheck is a useful visual tool that will help to keep our patients and nurses safe.”

The iDoseCheck was developed collaboratively by nursing, pharmacy, information technology and human factors engineering professionals. The application was tested in the University of Ottawa, Nursing Simulation Lab, at the Canadian Association of Pediatric Health Centres annual conference and at CHEO, on a post-operative care unit and an emergency department.  Participants in the research study included 112 nurses, 29 nursing students, 13 hospital administrators, two pharmacists, two physicians and one physiotherapist.

“The study participants found the iDoseCheck easy to learn with minimal training,” adds Dr. Ellis.  “The iDoseCheck was preferred over the usual paper, pencil, calculator method of dose calculation and nurses were confident that it was accurate and provided them with one more check in the process of preparing and administering IV bolus morphine.”   

Dr. Ellis cautions that the iDoseCheck is not a substitute for drug calculations, rather an additional method to check the accuracy of the calculation.

At this time the web-based tool provides calculations for 2 mg of intravenous morphine only, however, screens are being developed to include 5 and 10 mg of intravenous morphine. Further developments under consideration include 11 other opioids, rapid sequence intubation medications and paediatric resuscitation medications.  A mobile application will also be developed to provide access to calculation support at the point-of-care.

Click on the link to access a copy of the Preventing Medication Errors with High Alert Drugs: Testing a Computerized Double Check report, , or visit www.patientsafetyinstitute.ca and click on Research to learn more about the study.  To view a demonstration of the web-based tool, visit www.idosecheck.com

Interprofessional education in patient safety

In partnership with the Northern Alberta Institute of Technology (NAIT), the Patient Safety Education Program – Canada (PSEP – Canada) held a session in Edmonton, Alberta in May 2012. The group included 46 healthcare educators and representatives from Alberta Health Services, to expand their patient safety skills and advance patient safety education within their respective organizations. The two and a half day educational event certifies members of interprofessional teams as patient safety trainers. 

Dr. Cheryl Pollard is an assistant professor in the Bachelor of Science Nursing Program at Grant MacEwan University. Dr. Pollard has an interest in patient safety in both her clinical and academic work and is always looking for ways to more tightly align patient safety issues within the curriculum.  Since being certified as a patient safety trainer, she has incorporated patient safety learning into the classes that she teaches, including: mental health (where they look at the incidence of medication errors within a mental health context and ways to analyze the system components that contributed to those errors); a nursing leadership class (sessions specifically related to incident analysis); systems thinking; support for patients that have experience an error and implications for staff that make those errors; and a fundamentals of nursing research class where they look at issues from a general context such as repeating patterns and  engaging students to look at research through a patient safety lens.

“This PSEP – Canada program combines a pedagogical component and a content component and most courses are not facilitated in that manner,” says Dr. Pollard.  “Being able to link some of those ideas is very useful.”

Martie Grant is an instructor in the Diagnostic Medical Sonography Program at NAIT’s School of Health Sciences and is developing curriculum that integrates interprofessional education (IPE) where students from different program areas learn with, from and about one another to provide collaborative patient-centred care.  Martie is developing a 45-hour course to be delivered over 15 weeks to medical, dental and animal health students. Through curriculum mapping she has combined the Canadian Patient Safety Institute safety competencies and the Canadian Interprofessional Health Collaborative (CIHC) competencies to create NAIT outcomes that demonstrate safe patient care.  The new program will be launched for the medical faculty in 2014, starting with Diagnostic Medical Sonography, Medical Laboratory Technology, Medical Radiologic Technology and Dental Technology. The following year the program will be rolled out to respiratory therapy and paramedic students. NAIT is also developing an online version of the course for combined laboratory XRAY and magnetic resonance imaging students.  

“When you are developing curriculum, you want a solid background and best practices behind the information,” says Martie Grant. “The PSEP – Canada program provides valuable educational tools such as techniques to communicate and different ways of working together that can be easily incorporated into our courses.”

Both Dr. Pollard and Martie Grant say that the toolkit provided to attendees at the end of the PSEP – Canada program provides an on-going wealth of information that can be tailored to deliver a message that fits your audience.  Dr. Pollard is using components of the toolkit to augment her teachings and Martie Grant is drawing on the information and incorporating it into the courses she is developing.

The Patient Safety Education Program – Canada, developed for interprofessional teams, focuses on applying human factors in the workplace, scientific methods for improving safety, organizational culture and dealing with change, understanding teamwork, moving beyond blame to systems thinking and how to teach and implement patient safety. To learn more about or to bring a PSEP – Canada program to your area, visit www.patientsafetyinstitute.ca/education.

​Role playing helps healthcare providers rehearse for patient safety

Taking their cue from real-life patient safety situations and events, healthcare students and practitioners in Manitoba are using role playing to learn safety lessons. Learn to be Safe – A Simulation Learning Experience was developed by the Manitoba Institute for Patient Safety (MIPS) to enhance effective communication and collaboration within healthcare teams, including patients and their families, to improve patient safety. Two scenarios have been developed and a toolkit provides character briefings, character photos, props and resources for participants to re-enact the simulations.

Dr. Harold Nyhof, Head of Family Medicine Services at the Northern Regional Health Authority in Thompson, Manitoba is utilizing the “Gene’s Story” scenario as a powerful tool to facilitate learning in apology and disclosure. Dr. Nyhof delivers the session to groups of eight to 13 healthcare providers from interdisciplinary teams, where he asks the participants to step outside their current role and take on a character that is often outside of their comfort level. Dr. Nyhof reinforces the value of including frontline healthcare providers on the interdisciplinary teams.

“The participants become very engaged and the learnings provide multiple perspectives to learn from,” says Dr. Nyhof.  “At first the participants often say that it is the physician’s role to apologize, but they quickly learn that this is a team approach and not to assign blame. The discussions reinforce how to approach an apology and who needs to be at the table.”

Susan Lessard-Friesen, Deputy Registrar of the Manitoba Pharmaceutical Association is utilizing the “Maureen’s Journey” scenario in the classroom for 4th year pharmacy students to highlight the underlying causes of poor communication and the difficulties that can arise around shared decision-making. The simulation session will be rolled into a continuing professional development program for pharmacists in the spring of 2013.

Lessard-Friesen says that you get diverse perspectives when you ask healthcare providers to take on a different role and how a conscious or unconscious bias can cloud their perceptions. “When a pharmacist is asked to play the role of a nurse or physician, you can see how conflict develops within the team and how that results in barriers to communication. The participants learn about communication and ways to improve communication, and ways to address conflict within a team. When we ask the participants to take on the role of the patient, it brings a new dimension to their learning and reinforces the role of the patient within the healthcare team.”

The Manitoba Institute for Patient Safety established a working group from a wide array of health disciplines to develop the Learn to be Safe Simulation Learning Experience. Developing a program based on simulation was relatively new to most of the working group members, but from the start they decided it had to mimic situations that were as close to real life as possible and it had to be fun, interactive and involve interdisciplinary groups. The scenarios were pre-tested with key healthcare providers and tweaked to replicate realistic situations and events. The program materials are based on the safety competencies developed by the Canadian Patient Safety Institute, interprofessional principles and competencies recommended by the Canadian Interprofessional Health Collaborative, and required organizational practices of Accreditation Canada.

“To improve healthcare safety, we need to encourage teamwork, effective communication and patient and family-centred care,” says Laurie Thompson, Executive Director of MIPS.  “Patient safety is not something we learn once; it is something that we continually need to work on to improve.  The kit focuses on opportunities to practice and learn important safety lessons.”

Thompson and Lessard-Friesen are involved in a network of partner organizations that is promoting interprofessional continuing professional development for health professions in Manitoba.  The goal of the Interprofessional Continuing Professional Development Network for the Health Professions in Manitoba (iCPD Manitoba) is to plan, develop and deliver competency-based interprofessional CPD programming to meet the learning needs of health professionals and facilitate the emergence of collaborative patient-centred care.

“The concept of participating in interprofessional education opportunities to facilitate the provision of collaborative patient-centred care is not well understood by healthcare providers, especially those in community practice,” says Lessard-Friesen. “Evidence exists to demonstrate that interprofessional collaborative practice improves patient health outcomes and safety; however, continuing professional development programming continues to be designed and developed predominantly for only one health profession. The bottom line is, if we are going to work better together to improve patient outcomes and safety, we need to learn together and it is programs like Learn to be Safe that will help us to do that.”

The Learn to be Safe Simulation Learning Experience is a valuable tool for educators in healthcare profession education, healthcare service delivery and continuing professional development.  For more information, visit www.mbips.ca, or contact the Manitoba Institute for Patient Safety at (204) 927-6477.

Notice is hereby given that the Annual Business Meeting of the Canadian Patient Safety Institute (CPSI) will be held at the Westin Hotel, December 7th, 2012, 12:30-14:30 ET, at the Westin Hotel, Newfoundland/Nova Scotia Room, 11 Colonel By Drive, Ottawa. The business to be transacted at this meeting includes the following:

Business Meeting Agenda 

1. Receipt of the report of the Board of Directors and the report of the Chief Executive Officer;
2. Receipt and approval of the financial statements of CPSI for the period ending March 31, 2012, and the report of the auditors;
3. Appointment of auditors for CPSI and authorization for Board of Directors to establish remuneration for the auditors;
4. Election of Directors;
5. Ratification of all acts and proceedings of directors and officers since the date of the 2011 Annual Business Meeting, and;
6. Such other business as may properly be brought before the meeting or any adjournment.

A Voting Member of CPSI may be represented at the meeting by the designate in that Voting Member’s application for membership or in any subsequent update.  If that representative is unavailable, or if the Voting Member wishes to have a different representative for this year’s Annual Business Meeting, the Voting Member may, and is encouraged to, complete and return the provided proxy form appointing another person to act and vote on behalf of the Voting Member.  A Voting Member may appoint anyone it wishes to act as proxy.  To be recognized as valid for the meeting, a signed proxy form must either:

• Be returned to CPSI at the following address by fax, mail or delivery by December 3rd, 2012 to the following address:

Suite 410, 1150 Cyrville Road
Ottawa, Ontario, K1J 7S9
Attention: David H. Hill, Board Secretary
Fax 613-730-7323

OR; 

• Be presented by the proxy holder immediately prior to the meeting at the registration desk established by CPSI for that purpose at the location of the meeting.

CPSI strongly encourages the return of completed proxies.  Without more than 25% of the Members represented in person or by proxy, the meeting cannot proceed.  We cordially ask for the cooperation of the members in this regard.

The accompanying information circular forms a part of this notice.

Dated at the City of Edmonton, in the Province of Alberta, this 23rd day of November, 2012, by order of the Board of Directors. 

An integrated plan to Learn-Act-Communicate-Improve

The Capital District Health Authority (CDHA) has developed a Patient Safety Plan, "Patients First – Learn-Act-Communicate-Improve", to promote a patient safety and quality improvement culture within the health authority in Nova Scotia

“With a strong commitment of the board and the Quality and Patient Safety Committee of the board, the Patient Safety Plan was developed with a focus on what the patient’s voice brings to quality and patient safety,” says Catherine Gaulton, Vice-President Performance Excellence and General Counsel. “Our commitment to quality and patient safety is the cornerstone of all strategies and priorities developed for patients and others that we serve, including families and the community.”

About 18-months ago, the Quality and Patient Safety Committee of the CDHA Board led a strategic initiative to look at what constituted good governance in terms of quality and patient safety, using the Canadian Patient Safety Institute Effective Governance for Quality and Patient Safety Toolkit as their guide. The board’s commitment to quality and patient safety was formalized with a list of recommendations and a “to do” list to ensure all obligations would be met. The committee now provides diligent oversight and the board dedicates at least 25 per cent of their monthly agenda to quality and patient safety, regardless if an issue is present at the time.

The guiding principles and philosophy of patient safety at CDHA are first organized following the six domains of the Canadian Patient Safety Institute Safety Competencies framework. The competencies are then overlaid on each of the Accreditation Canada Required Organizational Practices (ROPs) and both are further mapped to the Canadian Medical Protective Association “Good Practices Guide” to create a Practices Map.

“Our board is committed to fulfilling its mission, vision and values in a strategic, goal-oriented and measurable way,” says Dr. Daniel O’Brien, CDHA Board Chair. “Improvement in quality and patient safety are at the forefront of our work and, in our view, are simply non-negotiable. The Patient Safety Plan incorporates and aligns the Canadian Patient Safety Institute’s safety competencies, Accreditation Canada's required and respected parameters and our own strategies complete with their evaluation and accountability mechanisms. This plan overwhelmingly supports our work as governors and our full commitment to improving quality and patient safety.”

Gail Blackmore, Director, Performance Excellence Program at CDHA and her team, Beth Kiley and Kitty Grant (Risk Management and Patient Safety Leaders in Performance Excellence) are responsible for linking education, accreditation and physician engagement into the performance excellence framework. Mapping these levers together shows how each drives quality improvement and patient safety practices for better, more effective planning and without duplication of effort.

“The Patient Safety Plan links expectations, resources and education,” says Gail Blackmore. “It is a live document that we update regularly and use to continually track our progress. This truly is a team effort and the integrated approach reinforces that patient safety is a shared responsibility that requires a commitment from everyone in the organization.”

The CDHA has established quality and patient safety teams that meet regularly and report back to a district Quality and Patient Safety Council and a Physician District Advisory Quality Committee.  Much work is underway to engage with patients in patient safety and bring the patient’s voice to the table. Using a three-prong approach to foster meaningful engagement of patients and families, the CDHA is providing education sessions for quality leaders on how to engage patients, developing recruitment strategies for meaningful participation, and providing education and support for patients and families participating as Healthcare Experience Advisors.    

The CDHA Patient Safety Plan supports patient safety and reduces risk to patients by creating and sustaining a safe environment that ensures the recognition and acknowledgement of risks to patient safety; initiation of actions to reduce these patient safety issues and risk; internal reporting of patient safety issues and corrective actions taken; a focus on processes and systems; organizational learning about patient safety; and supporting and sharing knowledge about patient safety within CDHA and other healthcare organizations.

The CDHA Patient Safety Plan is available at www.cdha.nshealth.ca/about-us/quality-and-patient-safety.  For further information, contact Gail Blackmore at gail.blackmore@cdha.nshealth.ca

​The Credit Valley Hospital and Trillium Health Centre is the recipient of the 2012 Patient Safety Education Program – Canada (PSEP – Canada) Innovations in Patient Safety Education Award, recognizing their work in fostering a culture of patient safety.  The PSEP – Canada Innovations in Patient Safety Education Award was presented to the Credit Valley Hospital and Trillium Health Centre on November 1, 2012.

“The Innovations in Patient Safety Education Award recognizes organizations that demonstrate best practices in patient safety and quality improvement,” says Hugh MacLeod, CEO of the Canadian Patient Safety Institute.  “Credit Valley Hospital and Trillium Health Centre have effectively adapted the PSEP – Canada program to foster peer-to-peer spread in advancing a patient safety culture throughout their organization. They are truly a deserving recipient of this award.”

“This award is a further validation and confirmation that we are on the right track in making patients a priority in everything that we do,” says Michelle DiEmanuele, President and CEO of the Credit Valley Hospital and Trillium Health Centre.  “Awards like this serve as a reminder of the enormous responsibility we hold and the need to push the bar even higher.”

DiEmanuele says that fostering a culture of patient safety is something that needs to be on your agenda every day.  Leaders need to walk through the hospital and address issues as they see them on a day-to-day basis. With this active leadership model she reinforces that by looking at policy and practices you can really define your culture of patient safety throughout your organization. “How much bureaucracy you have and how many layers in decision-making have an impact,” says DiEmanuele. “The more agile, nimble and flexible the organization can be, greatly increases your ability to respond effectively to patient safety needs.”

The patient safety education program was offered at two Trillium sites in two concurrent streams:  Lunch and Learn workshops were open to all staff and PSEP – Canada Ambassador training sessions for a targeted group of 45 individuals across the organization.  The PSEP ‒ Canada materials formed the foundation of these two streams.  The program  was delivered by Dr. Amir Ginzburg, Physician Director, Patient Safety and Quality at the Trillium site, who is a PSEP ‒ Canada Master Facilitator, and an inter-professional team from Trillium that are certified as PSEP ‒ Canada Patient Safety Trainers. The train-the-trainer program is taking hold and staff are using their PSEP ‒ Canada training to deal with difficult issues, develop feedback mechanisms, improve communication and promote critical thinking.

During Canadian Patient Safety Week (October 29 to November 2, 2012), the PSEP – Canada Ambassadors profiled poster presentations on projects that they have undertaken to improve patient safety over the past year. 

Credit Valley Hospital and Trillium Health Centre is the second recipient of the Innovations in Patient Safety Education Award.  The inaugural award was presented to Bridgepoint Health last year.

For more information on the PSEP – Canada and the Innovations in Patient Safety Education Award, visit www.patientsafetyinstitute.ca and click on the PSEP – Canada link.

​Good Samaritan Society learning event

Governing quality and safety for various sectors across two provinces can be a challenge. The Good Samaritan Society (GSS) has over 54 sites and programs across Alberta and British Columbia that serve more than 6,000 individuals in complex/long-term care and assisted/supportive living, as well as provides other specialized healthcare services for the elderly and the physically and mentally challenged.

To increase their knowledge and ensure effective governance of quality and safety, the Good Samaritan Society had the Canadian Patient Safety Institute Effective Governance for Quality and Patient Safety (Governance) program customized to encompass a long-term care focus and meet their diverse needs. The program is based on seven drivers that focus on improving quality, performance and patient safety through the use of evidence. The May learning event was delivered to a group of 24 at the Good Samaritan Society, including board members, executive and regional directors of operations.

The GSS wanted to better understand the board’s role in governance. They learned their role is more than fiduciary and it is equally important for the board to spend half of its time on quality and safety within the organization as their core work. The program helped raise awareness of the role and level of engagement needed from the board and how the board can contribute to better results.

During a debriefing session following the learning event, the board and staff talked about what they learned and what was relevant to the GSS.  “It underscored the importance of identifying and reporting performance measures to the board and sharing that information on a regular basis,” says Carla Gregor, GSS CEO.  “This was an affirmation of what we were doing and that it was aligned with what we could and should be doing.”

One of the challenges identified was measurement and ensuring the right measures are selected to report to the board.  “What is quality and how do you find meaningful measures of quality so that you are not overwhelming your stakeholders with too many indicators, but acknowledging those indicators that will make vital improvements in key areas and result in meaningful change?” says Gregor. “In a widely distributed organization such as ours, it is having consistency across programs and sites and ensuring that we have a vehicle to share best practices.  When you are doing good work over 30 of the sites, it can be difficult to share that in a meaningful way.”  The board and staff talked about how they could make use of client stories as an opportunity to highlight achievements and areas for improvement and work that into facilitated discussions at the board level and for the staff as well.

 “The program provided the scope and breadth of what we need to do both operationally and from a board perspective for the effective governance of quality and safety,” says Cheryl Bilous, Vice-President of Operations.  “I found it to be an excellent program and altogether one of the best packages available. We walked away with relevant and timely examples and templates that we can adapt for our use.”

“This program was organized and customized and it is one of the best board experiences that I have been part of,” says Don Storch, the former Board Chair of the Good Samaritan Society. “Everyone has a story and this was a very good way to bring people together to understand one another and build relationships within the board and beyond. This structured time helped the board to better understand some of the operational issues and the kind of things to watch for.”

Storch praises the Governance Toolkit he received at the learning event as an encyclopedia full of useful information. He has been able to use the tools and resources from the manual to ensure effective governance for other boards that he serves on, unrelated to healthcare.

Through the program, the GSS determined that a more effective board mechanism was needed to deal with safety and quality. A board task force has been formed to develop terms of reference for safety and quality to identify roles, responsibilities and membership. A specific board-focused committee is being created to oversee quality and safety within the organization, that is supported by the Vice-President (VP) of Medicine and the VP of Operations, who is responsible for all GSS care programs. The Governance program has also helped bring more clarity to the planning process and raise the level of discussion at the board level and across the organization to ensure a more cohesive and systemic approach to governance, in a more planned and organized way.

The Effective Governance for Quality and Patient Safety program can be tailored for your needs.  For more information on the program visit the Canadian Patient Safety Institute website, www.patientsafetyinstitute.ca 

​Canada’s Virtual Forum on Patient Safety and Quality Improvement

The fifth and final session of Canada’s Virtual Forum on Patient Safety and Quality Improvement provided presentations and panel discussions focused on the question,” Is healthcare safer?”  The five-day Virtual Forum provided 20-hours of presentations that drew 4,286 unique registrants from 1,687 sites in 22 countries, saving over 668 tonnes of CO2 emissions. All presentations have been archived; click here to view or to download sessions at your convenience.

The opening presentation on day five provided an overview of the processes involved in inquiries and reviews, focusing on recent reports coming out of Alberta and British Columbia. Dr. John Cowell (CEO, Health Quality Council of Alberta) discussed the HQCA Quality Assurance Reviews and Inquiries, and Dr. Doug Cochrane (Chair and Provincial Patient Safety & Quality Officer, BC Patient Safety & Quality Council) provided detail on Investigation into Medical Imaging, Credentialing and Quality Assurance.  Based on their findings, both Dr. Cowell and Dr. Cochrane reinforced that robust quality assessment systems that monitor competence and justly address performance issues, credentialing and privileges and communicating with patients and families in ways that are timely and respectful are key to supporting quality care for patients.

As board members and healthcare executives, Maura Davies (Board Chair, Canadian Patient Safety Institute and CEO, Saskatoon Health Region) and Wendy Nicklin (former board member of CPSI and current President and CEO, Accreditation Canada) discussed the most significant patient safety improvements in Canada over the last 10 years.  They talked about their “a-ha” moments, balancing patient-centred care with fiscal restraints and opportunities to share rather than reinvent patient safety strategies. They reinforced how much we can learn from one another when it comes to the perspective of patients and families, or stealing shamelessly from other healthcare providers in order to enhance quality and patient safety initiatives.

The French presentation was provided by Ariella Lang (Research Scientist, VON Canada), who reviewed research on home care safety, and the differences between safety in this environment and current research in institutional care.

The Resources to help you succeed presentation highlighted the Canadian Incident Analysis Framework.  Key enhancements to the framework include the inclusion of the patient/family perspective, multiple methods to analyze incidents, placing analysis in the incident management continuum, innovative diagramming and a new section on developing and managing recommended actions.  Information on learning modules and upcoming information calls was also provided.

During a panel discussion to reflect on the question, “Is healthcare safer?”,  Andre Picard (Health Report, The Globe and Mail), Dr. Doug Cochrane (BC Patient Safety & Quality Council), and Donna Davis (Co-Chair, Patients for Patient Safety Canada) had a thoughtful conversation and provided perspectives on  the value of the patient’s voice and the barriers, challenges and opportunities to advance patient safety and quality.  They encouraged broader discussion with an open and honest conversation, the value of measurement and indicators to demonstrate if we have moved the bar, more training and education in patient safety, reinforcing a safety culture amongst provides, sharing knowledge and learning and to be “plan-full”, not “react-full” when designing systems.

Hugh MacLeod, CEO of Canadian Patient Safety Institute, closed the Virtual Forum thanking everyone who participated.  Particular appreciation was extended to Carol Kushner, Anne Findlay, Johanna Trimble, Judy Duchscher and Bernie Weinstein, the family members who provided the emotional patient narratives that set the stage for each day’s presentations.

MacLeod praised the 1,800 healthcare organizations that participated in Canadian Patient Safety Week and showcased some of the activities that demonstrate the commitment to patient safety and quality improvement. He summarized the essence of the Virtual Forum’s 35 sessions delivered and invited participants to continue the conversation online.  With the mantra, Ask.Listen.Talk., MacLeod reinforced that context is everything and that we have a better understanding of patient safety and quality improvement and, with a leadership commitment, we have the capacity and readiness to change; denial is our greatest threat and we need to address the gap between outcomes and experience; the value of relationships and culture that supports an open and honest dialogue; and listening to, encouraging and respecting the voice of the patient/client/resident.

The winner of the The Med Safety Goes Viral: 2012 Medication Safety Video Competition was announced.  The 14 Med Safety videos entered in the competition were profiled throughout the week and received 16,827 views on YouTube.  The overall winner was the Trillium Health Centre submission, Bring Your Own Bottle.  The Philippines Heart Centre medication safety video received the most views, with 4,553 hits. The Virtual Poster Presentations also showcased the great work in quality and patient safety that is being undertaken across the country. 

Highlights of the Virtual Forum were tweeted steadily by those in attendance or watching the video stream (#patientsafetyforum).  Participants are encouraged to share what they have learned and we want to hear your perspective! Ignite the conversation and send your thoughts, ideas and patient stories to info@cpsi-icsp.ca.

Canada’s Virtual Forum on Patient Safety and Quality Improvement

What are you doing to reduce healthcare-acquired infections?  The importance of infection prevention and hand hygiene were the topics featured during the fourth day of Canada’s Virtual Forum on Patient Safety and Quality Improvement.  Over 1,800 participants from more than 700 sites joined the sessions over the first three days of the five-day Virtual Forum.

The fourth day opened with a panel discussion that included perspectives from two health regions that have faced C.Difficile outbreaks: Cape Breton District Health Authority, and the Niagara Health Region. Looking at the incidents, public perception and communication strategies, and the follow-up and organizational changes, these regions outlined what they learned about both infection control and the culture necessary to make large-scale changes, as well as how to regain public trust when an outbreak occurs. The panel included Brady Wood (Chief Communications Officer, Niagara Health Region), and from the Cape Breton District Health Authority, Dr. Diane Calvert Simms (Chief Executive Officer) and Martha McLean (Director, Acute Care and Infection Prevention and Control). The frank discussion highlighted how trust and transparency drives relationships and reputation.

During a two-part session on hand hygiene, Jim Gauthier (President, Community and Hospital Infection Control Association – Canada) outlined why, after multiple campaigns and educational tools, hand hygiene continues to elude organizations as a regular practice; and  Dr. William Jarvis provided an overview of the basic science of alcohol and alcohol-based hand rub (ABHR) antimicrobial activity and introduced an ‘in-use efficacy’ hand hygiene model. Jarvis also reviewed data around the relative influence of alcohol level, formulation and application volume on ABHR efficacy. Both speakers reinforced having the front-line involved in developing solutions, using a multi-modal approach and the importance of leadership support and engagement in the auditing process.

Patricia King (Manager, Program Practice and Education, Residential Services) and Joanne Baines (Leader, Infection Prevention and Control) provided details of an audit tool developed by the Vancouver Island Health Authority to track and review hand hygiene compliance in residential care centres. With strong leadership support, a hand hygiene policy has been developed and monthly auditing and immediately sharing the results have helped to reinforce compliance. The session also reviewed statistics and a collaborative approach to deal with outbreaks. Toolkits and algorithms have been developed for staff dealing with C. Difficile, influenza and influenza-like outbreaks.

The daily French presentation focused on establishing a culture for infection prevention, presented by Yolaine Rioux (Directrice des programmes de santé publique, des soins infirmiers et des pratiques professionnelles, CSSS Richelieu-Yamaska).

Resources to help you succeed profiled Global Patient Safety Alerts, an online tool to search and browse over 650 and growing patient safety incident advisories, alerts and recommendations. This one-stop searchable database provides quick, actionable information to make patient care safer.

It`s not too late to join the conversation!  The final day of the Virtual Forum is packed with more poignant patient narratives, thought-provoking discussions, valuable insight and useful information on patient safety and quality improvement. Click here to view the program and register.

Are you sharing what you’ve learned?  Send your questions, comments and patient stories to: info@cpsi-icsp.ca or tweet chat to #ptsafetyforum.

​The program for day three of Canada’s Virtual Forum on Patient Safety and Quality Improvement was dedicated to medication safety.  Communicating effectively about medications is a critical component of delivering safe care across all sectors of the healthcare system. 

Neil Johnson (Vice-President, Cancer Services, London Health Sciences Centre) provided a synopsis on implementing medication reconciliation in an acute care multi-site academic hospital.  His presentation focused on leadership and change management to effectively implement medication reconciliation across the continuum of care. Johnson says that to drive change you need to ensure you have the right leaders on the bus from the get-go. He also described what he called his secret sauce for sustainability: craft a vision that has clear goals and objectives; identify leaders; develop influencing strategies; dedicate the right resources; and ask questions that engage an approach of ‘would you help me to …’ and ‘this is what I need from you’.

Cathy Szabo (CEO, Client Services, Central Community Care Access Centre) outlined how technology is helping to improve patient care and transitions at community care facilities in Ontario. Using leading practices in e-health and health assessment technology that supports evidence-based decision-making and outcome-based care,  the CCAC has developed and implemented resource matching, an e-Referral system and medication management to reduce duplication and better manage transitions for the betterment of their clients and patients.   

The Medication Safety in Family Practice and Primary Care session explored barriers and enablers for medication safety in the primary care sector. Patsy Smith (Health Care Consultant, PLS Consulting) and Dr. Ruth Wilson (Board Chair, Institute for Safe Medication Practices Canada and Associate Director of Health Policy, College of Family Physicians of Canada) demonstrated how teamwork, e-prescribing and drug information systems, and accreditation can improve medication safety. The presenters discussed issues around over-the-counter drug availability, herbals and supplements, illegal procurement, financial barriers, lists of side effects, allergies and intolerance, and the enablers and barriers to e-prescribing. 

Co-lead of the National Medication Reconciliation Strategy Marie Owen (Medication Reconciliation Co-lead, Canadian Patient Safety Institute) provided an update on the priorities for medication reconciliation (MedRec) in Canada.  MedRec is a challenging and complex component of patient safety and continuing collaboration on the development of technology, tools and resources, education, teamwork and communication will help advance safe medication practices. Owen profiled some of the endeavours undertaken to build awareness, including social media and consumer engagement.

Author and physician, Dr. John Sloan and patient narrative family member, Johanna Trimble described their personal experiences in the session Safe Prescribing for the Frail Elderly. Both Sloan and Trimble reinforced how invaluable the perspective of a loved one can be when unexpected results occur as a result of new, additional, or changes to a drug regime. When describing drugs for the elderly stereotyping continues to be a problem and the presenters say that you need to look at the person not the population. To provide the best care possible, they suggested igniting a conversation with the question, ‘How do you want to live the rest of your life?’

Alain Biron (Performance Measurement Advisor, McGill University Health Centre) provided the French presentation on Medication Safety: Centralizing data effectively in an organization. Biron discussed some of the challenges associated with measurement strategies (self-reporting, trigger tools, observation), along with characteristics of high-performing organizations that have successfully integrated the use of measurement to drive improvement at the micro-system level.

The Resources to help you succeed session profiled the Improving Care Search Centre, a Google-like search network that has summarized information on patient safety and quality improvement from over 600 websites.  Virtual Focus Group sessions will be held on November 13, 14 and 15 to gather input on improving the website.  To join a virtual Focus Group, email info@cpsi-icsp.ca

Throughout the week, videos have been broadcast to promote medication safety.  The Med Safety Goes Viral: 2012 Medication Safety Video Competition challenged healthcare organizations to create short videos that promote and demonstrate medication safety in healthcare or community settings. Fourteen videos were submitted from healthcare organizations worldwide and the videos have been viewed over 14,000 times on YouTube!  View the Med Safety videos on YouTube and vote for your favourite!

The Virtual Forum continues until Friday, November 2nd, with more patient stories, presentations and panel discussions to come.  Click here to view the program and register. Send your questions, comments and success stories to info@cpsi-icsp.ca, or tweet chat to #ptsafetyforum.

​Canada’s Virtual Forum on Patient Safety and Quality Improvement

The second day of the five-day virtual forum on patient safety and quality improvement, hosted by the Canadian Patient Safety Institute, focused on falls prevention, with four key presentations highlighting tools and innovative strategies to prevent falls and injuries from falls.

Angela Muzyka (Accreditation and Patient Safety Coordinator) outlined the rollout of a falls prevention initiative in the Cypress Health Region.  This southern Saskatchewan health region has integrated community, mental health, home care, acute care, long-term care and EMS into their falls prevention initiative. An integrated approach has led to a reduction in injuries from falls through falls champions in long-term care, as well as using data and team huddles to make improvements. Collaboration amongst healthcare disciplines and community engagement are the foundation that have created a tidal wave of awareness and support for this initiative.  

The Saskatchewan Falls Collaborative, formed in April 2011 to reduce falls in long-term and home care by 20 per cent by March 2012, has made great strides in reducing injuries from falls. Dr. Jenny Basran (Assistant Professor, Head of Clinical Gerontology, University of Saskatchewan) summarized the strategies that are being used to sustain and spread fall prevention programs in Saskatchewan and provided valuable tools and resources available to support falls prevention initiatives. The five strategies outlined include: a universal falls prevention program; screening all patients; multi-factorial assessments for all patients at risk; creating personalized care plans; and to document, evaluate and educate.

A presentation by the BC Injury Research and Prevention Unit outlined the economics of falls prevention amongst seniors by focusing on the cost of falls and falls-related injuries and the current evidence on cost-effective interventions and available resources. Dr. Vicky Scott (Senor Advisor on Fall and Injury Prevention) says that falls are the leading cause of injury-related deaths and hospitalization for British Columbia seniors. Each year, more than 200,000 B.C. seniors will experience one or more falls, resulting in over 12,000 hospitalizations and more than 950 direct and indirect deaths. Scott advocated the need for integrating cost-effective, evidence-based fall prevention programs into existing services for seniors, such as making physical activities and exercise programs more affordable and accessible to all older adults.   

The French presentation was provided by Helene Riverin (Physical Therapist/Safety and Improvement Advisor, Safer Healthcare Now!) with an overview of the falls prevention strategies implemented by CSSS de la Vieille-Capitale and lessons learned that can be valuable for other groups building falls prevention programs.

Patient narratives set the stage for each day’s sessions. The emotional and touching stories from patients and their families reinforce the importance of the voice of the patient in advancing patient safety. Click here to view the collection of patient narratives being profiled throughout the week and during last year’s forum. 

The daily Resources to Help You Succeed presentation provided details on the 2012 Finding Balance campaign, launching on November 1st. This month-long falls prevention initiative provides education and awareness for seniors to check their medications, keep active, watch their step and speak up about dizziness.  Liza Sunley summarized the falls prevention tools available from Finding Balance Alberta, an initiative coordinated by Alberta Centre for Injury Control and Research.

Canada’s Virtual Forum on Patient Safety and Quality Improvement provides the opportunity to learn from thought-leaders who share the latest best practices.  It’s not too late to register to join just one or all of the sessions – and it’s free – all you need is an Internet connection. To view the program and register, click here.  Join the conversation and tweet chat to #patientsafetyforum, or send your comments and questions to info@cpsi-icsp.ca.

​Canada’s Virtual Forum on Patient Safety and Quality Improvement

Canada’s Virtual Forum on Patient Safety and Quality Improvement kicked off on Monday, October 29 with a robust registration of more than 1,500 unique registrants from 26 countries.  The five-day virtual forum on patient safety and quality improvement, October 29 to November 2, is open to all health disciplines and the general public, and the entire program is available on the Internet through a live video stream. Themes for the program focus on leadership and culture, falls, medication safety, infection control and “Is Healthcare Safer?" -  Inquiries, reflections and progress.

In the opening remarks, Hugh MacLeod (CEO, Canadian Patient Safety Institute) and Dr. Micheline Ste-Marie (Associate Director of Professional Services at the Montreal Children’s Hospital of the McGill University Health Centre) welcomed the online audience and officially launched Canadian Patient Safety Week.  Over 1700 sites have registered to participate in Canadian Patient Safety Week 2012, a 37 per cent increase over last year. Edmonton’s Mayor, Stephen Mandel, provided greetings and saluted participants of the virtual forum.

An executive leadership panel discussion with Vickie Kaminski (President and CEO, Eastern Health), Chris Power (President and CEO, Capital Health), Karima Velji (Vice-President, Clinical and Residential Programs and CNE, Baycrest) and Marga Cugnet (CEO, Sun Country Health Region) provided valuable reflections and advice on leadership and culture. The panel outlined how strategies, such as Lean®, are helping to advance the patient safety culture in their organizations. They emphasized the importance of listening to patients and their families and effectively sharing those learnings.

Looking at the perspective of middle management, taking the goals set out by leadership and the challenges in implementing them at the frontline, views were provided by Debbie Walsh (Manager, Peri-Operative Program, Eastern Health), Suman Iqbal (Director of Care, Apotex Jewish Home for the Aged, Baycrest), Joy Tarasuk (Health Services Manager, Capital Health Cancer Care Program), and Leila McClarty (Community Health Services Manager, Bengough Health Centre, Sun Country). The panel discussion reinforced asking, listening and giving a voice to the frontline when implementing changes that will enhance the safety culture in the organization.

A session on culture highlighting safety and the mental health facility was provided by the Centre for Addictions and Mental Health. Rani Srivastava (Chief of Nursing and Professional Practice) and Shawn Lucas (Manager, Spiritual and Religious Care) utilized clinical vignettes to highlight the unique issues inherent in the culture of mental health and the associated challenges and opportunities for patient safety. Both speakers reinforced that culture matters – the culture of the healthcare provider and the system matters as much as the culture of the individual.

Each day of the forum opens with a short video where the perspectives of patients and their families are provided through patient narratives that provide poignant recollections of unnecessary harm.

At 2:00 p.m. EST each day, a presentation in French will be provided.  Monday’s presentation, delivered by Dr. Ste-Marie centred on how leadership influences the culture of patient safety, while stressing the importance of intergenerational collaboration and the development of a patient/family partnership with clinical teams.

At 3:50 p.m. EST daily resources to help you succeed will be profiled.  The first day highlighted Patient Safety Metrics - Measuring to Reduce Harm, an online data and measurement reporting system that is an invaluable tool for healthcare organizations looking to build performance monitoring into their patient safety frameworks. Patient Safety Metrics tracks over 70 process and outcome measures.

Don’t miss out on the valuable insight and discussion ‒ join any or all of the sessions continuing throughout the week.  Click here to view the program and register. Send your questions, comments and patient stories to: info@cpsi-icsp.ca or tweet chat to #ptsafetyforum.

​

Claire Friedman was not the mother-in-law of sitcoms and punchlines.

She was active, vibrant and loved by friends and family.

So when Bernie Weinstein walked into the hospital that day in 2002 and saw his mother-in-law restrained in a chair, he was shocked.

“My mother-in-law was a patient in the Jewish General Hospital, recovering from cancer surgery,” says Bernie. “She was a very active person, constantly walking the corridors, talking to people.”

That Friday evening, Bernie and wife Sandy had stopped by the hospital to check on Claire.

“When we arrived, we found her sitting in a chair, strapped down, pretty much comatose,” says Bernie. “She’d been in good shape Thursday.”

The couple approached a nurse for an explanation of why Claire, who loved to be up and about, was strapped down. They were assured Claire was fine.

“Your mother-in-law is over 80 years old,” said the nurse. “She has low blood pressure. This is quite normal. This happens all the time.”

The nurse also assured them that Claire would be fine to leave the hospital on Sunday for Mother’s Day visiting. Claire was more herself on Saturday and by Sunday she was much better.

Bernie says he remained suspicious about the matter, but set his concern aside. But on a subsequent visit, another nurse pulled him aside and said his mother-in-law’s temporary stupor was caused by a medication error.

“She was given the wrong medication and they lied to us and told us it was normal,” says Bernie. “I really got upset, and I'm not a very quiet person.”

After several drafts — toned down in editing, by Sandy — Bernie sent off a letter to the Jewish General Hospital’s ombudsman. Soon after, Dr. Joseph Portnoy, the hospital’s director of professional services, phoned Bernie to explain the details of the error and the steps being taken to ensure it wasn’t repeated.

But what really shocked Bernie was Dr. Portnoy’s humility.

“On behalf of the staff, we are sorry,” Bernie recalls him saying.  “We’re sorry because of what happened and we’re sorry we didn’t tell you the truth.”

Then the doctor asked Bernie if he would be interested in sitting as a community representative on the hospital’s Quality and Risk Management Committee.

Bernie, who is now also a member of Patients for Patient Safety Canada (a patient-led program of the Canadian Patient Safety Institute), has gone on to help implement a number of positive changes at the hospital.

The medication error in his mother-in-law’s care prompted inquiries with the pharmaceutical company, which then changed the appearance of the medication to be more distinct.

The case was an example of where the health provider wasn’t at fault, says Bernie. It was a technical or system error that, as it turned out, had caused other patients harm.

“The system had to be changed and that’s the sort of approach taken by the Quality and Risk Management Committee,” he says.

The Jewish General also implemented a disclosure policy and Bernie became involved with the hospital’s Speak Up program.

The program is part of the three-pronged approach at the hospital to improve communications between clinicians and patients.

“It encourages patients to speak up in an open and respectful manner, whenever they don't understand what they have been told or are uncomfortable about what is happening around them,” says Bernie.

The Speak Up program works with clinicians to improve their communication and stresses listening closely to what patients and their families are telling them.

“In general, when you went into the hospital as a patient you lost all your power,” says Bernie. “You could be the biggest corporate magnate and lose all your power.

“But having patients and their families be part of the medical team will make the entire system better.”

Claire died a couple of years after the incident, in January, 2004, at age 81. Bernie still thinks about her often.

“She was a very special person,” he says. “She was very much loved by her children and grandchildren. She will be very well remembered.”

Bernie deeply appreciates the action of the Jewish General Hospital in making amends to Claire’s loved ones. The problem with the initial coverup, he said, is that it created a divide between the hospital and the patient’s family.

“We felt like they didn’t trust us,” he says. “It made us feel unimportant.”

The sincere apology acted to restore the trust and connections.

“An apology and explanation of what’s being done makes you feel like you’re part of the process and that something good, something positive came out of the incident.”

Claire’s experience in healthcare reminds us that when patients and their families are included in the medical team it makes the system safer for everyone.  Canadian Patient Safety Week, October 29 to November 2, 2012, is an opportunity to raise awareness that “Good healthcare starts with a question.”  To find more information on Canadian Patient Safety Week, please visit www.asklistentalk.ca.

​

The lingering deaths of two loved ones continues to inspire  Carol Kushner, a champion of compassion in healthcare.

Carol’s best friend died gracefully this year, after weeks of love and laughter. Carol’s  father’s death, almost 30 years ago, was cruel by comparison.

“Heaven and hell,” says Carol, a health policy analyst and co-chair of Patients for Patient Safety Canada (a patient-led program of the Canadian Patient Safety Institute), whose views are informed by the two intimate experiences.

“My father was a hunting and fishing, good old boy,” says Carol. “He loved to laugh. He loved to cook. He loved gardening.”

Ken Wilson, she says, was one of those people blessed with a full grasp on life. He was healthy and hearty until he reached the age of 60, in December 1971, when he was diagnosed with bowel cancer.

The initial treatment seemed successful, but by the spring of 1972 he began noticing bone pain in his legs and spine.

“It was pretty clear that this pain was going to continue until he died,” says Carol. “Unfortunately, his pain was very badly controlled.”

Ken wanted to die at home and his wishes were granted. But extensive at-home support for patients and families was rare in those years.

Ken was in agony. He developed a huge bed sore at the base of his spine that might have been prevented if the family had been taught about the need to turn him frequently. He was only given Aspirin and 292s for his pain. Carol, her mother and her aunt were frustrated and helpless.

“I can’t tell you how terrible we felt because he was suffering so much,” says Carol. “I can’t describe the stress. He was in such pain that he wanted us to kill him. He wanted to kill himself, but he no longer had the strength.”

In his final four weeks, Ken was finally given morphine and some peace came for him and his family.

“My best friend, Lorraine Brown, died the end of January of this year,” says Kushner. “She had terminal cancer — she knew well in advance that she wasn’t going to survive — and wanted to die at home.”

This experience was markedly different, says Carol. First, there was a team of nurses and personal support workers who taught Lorraine’s loved ones how to keep her comfortable and safe. Lorraine’s family doctor, head of palliative care for the region, also visited her once a week.

Lorraine’s condition was grave, at least in physical terms. She could no longer eat or go to the bathroom. She was hooked up to a pain pump, a gastric pump and lines to provide nutrition and medications.

Carol moved into Lorraine’s home and helped administer care, including injections, and helped turn Lorraine when she could not longer moveindependently. Friends and family knew they needed to be  scrupulous about hand-washing and hygiene.

“It may sound strange but my friend Lorraine and I — and my husband and her husband — had a lot of fun in those last five weeks,” says Kushner. “I am very

proud that she had no infections and no skin breakdowns when she died. She was pain free and that was an extraordinarily uplifting experience compared to the difficult journey with my father.”

Carol expected Lorraine would want to talk about old times, all the things she’d done and places she’d been. But that wasn’t the case.

“What she wanted to talk about was the here and now,” says Carol. “That was so interesting for me because it taught me how to be right in the moment and not dwell on the past or on what was going to come.”

The laughter was over silly things, says Carol. For example, Carol called the swabs used before injections Chemo Swabby. “She’d crack up over that,” says Carol. Two weeks after arriving home from the hospital, Lorraine asked that her nutrition line be discontinued. Everyone knew the consequences, but they were okay with it, says Carol.

“People need choices around where they die and how they die,” says Carol.

The healthcare system is properly aimed at saving and extending life. But Carol says it must also be intimately involved with death itself. “I want the healthcare system to be more humane, more empathetic — kinder,” says Carol. “We are all human beings.

We all deserve to have the best possible death. We now know a lot more about how to make that happen. It’s not easy. It’s time consuming and it’s hard, but it’s so rewarding to make a difference to someone at such a crucial time.”                  

After experiencing the death of her father and later the death of her friend, Carol Kushner knows first-hand the importance of a kind healthcare system.  In an effort to promote quality improvement in healthcare, Canadian Patient Safety Week, October 29 to November 2, 2012, is sharing the message that “Good healthcare starts with a question.” For more information on Canadian Patient Safety Week, please visit www.asklistentalk.ca.

​

To her loved ones, it was as if their beloved Fervid vanished overnight.

Yes, Fervid Trimble was 87 years old. She was ill with an apparent flu. Yet she’d been sharp as a tack just days before, living independently in her own apartment.

A worried phone call from Fervid had been enough of a concern for family to initially take her to an emergency room for assessment. She was dehydrated, so she was given fluids and sent home.

The next day, with symptoms persisting, Fervid was transferred to the healthcare centre attached to her seniors’ complex to recuperate. Everyone expected she’d be back home in no time.

“What actually happened is she started getting a lot worse,” says Fervid’s daughter-in-law, Johanna Trimble. “When I say worse, I mean cognitively.”

Fervid was lucid one moment, hallucinating the next. She suffered coordination problems and repetitive arm movements.

“Sometimes we would arrive, find her in her bed and could not wake her up,” says Johanna. “It was not a normal nap.  We honestly could not wake her.”

At other times, Fervid was delirious. She talked of just visiting Seattle with her husband, who died years before.

This mysterious descent into dementia was puzzling. Johanna finally inquired about Fervid’s prescriptions — pain medication, as well as an anti-depressant — and then used her library-science background to research the drugs. Each, it turned out, affected serotonin levels in the brain and the combination could cause an adverse drug interaction, known as serotonin syndrome. The syndrome’s symptoms matched Fervid’s.

Johanna says the anti-depressant prescription was a shock to family members. Fervid was not depressed in the days before her flu.

More likely, she was grieving about being away from her home, friends and neighbours in her apartment complex. And the delirium, Johanna suspected, was due to an adverse drug interaction.

The facility’s psychiatrist, though, was about to put Fervid on another drug — one used in treating Alzheimer’s.

“The big problem, looking back, is that these psychiatrists don’t know the patients well,” says Johanna. “All they see is the state they’re in at the moment.”

To physicians, Fervid was displaying symptoms of depression and dementia. But this wasn’t the Fervid known to her friends and family.

Fervid was brought up on a dirt-poor wheat farm in southern Alberta. Her family moved south to the U.S. and Fervid eventually put herself through the University of Idaho, earning a masters degree in education.

“This was back in the early 1940s,” says Johanna. “This is the kind of woman we’re talking about. She was a force to be reckoned with.”

As it turns out, so are Fervid’s loved ones. Johanna, with her research documented, teamed up with her husband Dale and his sister Kathie to meet with the facility’s medical staff.

“My husband conducted the meeting because he’s a skilled conflict-resolution professional,” says Johanna, smiling. “I tend to get hot-headed.”

The medical staff listened closely to the family’s findings and concerns. Immediately, a decision was made to change Fervid’s medication.

“It took somewhere between three and six weeks for her to come back,” says Johanna. “She was right back to normal, sharp as she ever was.”

Unfortunately, the news wasn’t all good. The adverse drug reaction had resulted in Fervid being bed-ridden for months. In frail elderly people, this often results in rapid loss of muscle strength.

When she was finally released, Fervid required a wheelchair for mobility.

About five years later, Fervid became ill with a recurring bacterial infection. Though she became weaker over time, her mind remained clear.

“Something happened to us as a family,” says Johanna. “I can only say that I think Fervid knew that she wasn’t going to be there very long, and we started having these incredible conversations with her.

“Fervid shared all of the wisdom and experience she had in her life. She told us how much she loved us.”

One day near the end, Fervid said something profound. Johanna can’t remember the words, but doesn’t need them to remember the message.

“It was like she passed the torch, or passed the baton,” says Johanna, who made it her mission to work on behalf of elders in care.

“I feel inspired to go forth and see that what happened to us doesn’t happen to other people.”

Johanna joined Patients for Patient Safety Canada (a patient-led program of the Canadian Patient Safety Institute), as well as a number of other patient advocacy organizations. She is also on a working committee developing continuing physician education on the overuse of drugs in treating the elderly.

“Everyone has the best intent, but we have to look much more carefully at how we’re prescribing for frail elders, who have half the liver function and half the kidney function of somebody under 75.”

She also can’t stress enough the importance of involving family members in patient care. If the facility staff don’t ask, it’s up to a patient’s loved ones to step up, and with respect, ask questions and provide input.

“This is not completely without self interest,” says Johanna, smiling. “I have four grandchildren. I’m looking at needing the healthcare system someday myself.”

The story of Fervid’s experience in care emphasizes the importance of being an advocate for our loved ones, when they are unable to do so themselves.  Canadian Patient Safety Week, October 29 to November 2, 2012 is an occasion to raise awareness on patient safety and quality improvement with the message that “Good healthcare starts with a question.” To find out more information about Canadian Patient Safety Week, please visit www.asklistentalk.ca.

​

Anne Findlay struggled to make sense of the scene in front of her.

There was an elderly woman in the bed. Her face was badly swollen and bruised. Her lip was stitched and her knee gashed.  She looked like an assault victim.

“I looked at her and could hardly believe it was my mom,” says Anne. “She was that badly bruised. She looked awful.”

Her mom was conscious, but terrified, says Anne. She couldn’t speak much, because her tongue was swollen.

How could this happen? Anne had been with Beth all day and left her in good care, sleeping soundly in a Calgary hospital.

“I was horrified,” says Anne. “I was horrified because you don’t expect somebody to be injured in a hospital. When you go there you expect things to be safe.”

Beth, 84, was not in good health. She had suffered a stroke two years earlier. She had a history of heart problems and recently developed swelling in her face and abdomen, as well as a shortness of breath.

So Anne took her mom to hospital and spent a long day waiting to get Beth into care. Finally, Beth was admitted and an X-ray of her lungs was ordered.

Beth was asked to stand for the initial X-ray. She barely managed it because she was so weak.  When a second X-ray was ordered later that day, Anne asked that Beth not be made to stand. The technician performed the X-ray with Beth propped up on a gurney.

That evening, Anne stayed with her mother until she was safely off to sleep. What Anne didn’t know was that, after she left for the evening another X-ray was ordered.

During the procedure, for reasons still not clear, Beth rolled off the gurney and dropped to the floor. Paramedics were called and transferred her to the emergency department where she was treated for her injuries.

When an emergency room doctor phoned Anne at home, he wasn’t too optimistic.

“This does not look like a good outcome,” he said.

Over those early hours and in coming days, Anne sought answers to the most obvious question: What happened?

The emergency room doctor said he’d been told the wheels on Beth’s gurney were not properly locked down.  The nurses looking after Beth, though clearly upset, couldn’t provide any answers.  No one seemed to know the exact reason why the gurney had moved, resulting in Beth’s fall.

“I went home and I documented everything that happened from when we first went into the hospital three days before,” says Anne, who then contacted the Patient Concerns Office.

A meeting was arranged with the Patient Concerns’ manager and the manager of Diagnostic Imaging. Anne gave her notes to the managers, who promised to follow-up.

“Our concern at the time was just being there with mom, obviously,” said Anne, who credits the nurses and the doctors with tremendous care and compassion over the following days.

Anne says it’s likely her mom wouldn’t have lived much longer because her heart and kidneys were failing, regardless of the injuries from the fall.

“But to see somebody you love — that badly injured in the hospital and not dying peacefully — and for that to be our final image of her, is really hard to take.”

Anne was asked to meet with Calgary Health Region staff several weeks after her mom’s death.  At the meeting, she was told that the Velcro strips on the gurney pad used that night for Beth’s X-ray weren’t aligned properly with the gurney frame and the mattress slipped.

But what about the gurney’s wheel brakes not being locked? Hospital officials were kind. They apologized. But Anne said it all felt scripted and she was left with many unanswered questions.

Three months later, Anne gathered her family to talk about the possibility of legal action. They felt it might be the only way to get complete answers.

But in the end, they felt Beth wouldn’t want a lawsuit. So they tried to let their feelings go.

However, nine months after Beth’s death Anne saw a news item about the Halifax 5 Patient Safety Conference and a new disclosure policy in the Calgary Health Region. Again she decided to pursue answers.

Anne met with the same hospital official from the previous meeting.  This time he talked more openly about Beth’s accident and was able to answer many of the questions which hadn’t been dealt with before.  Although an investigation wasn’t able to pinpoint an exact cause for why the gurney had moved and why Beth had fallen, Anne felt that now there was an honest effort to provide some answers.

Also, Anne learned of the new policies and procedures developed in the Calgary Health Region to prevent another accident like Beth’s.

“That’s what I needed to know,” said Anne. “When somebody is injured in the hospital, if you don’t feel that the people involved are being honest with you about what happened, you lose trust.  You’re this individual, or this family, and you feel like you’re up against a huge system. Trust is all you’ve got to go on.”

Anne also decided to get involved as a volunteer.  Beth’s legacy carries on in a daughter who is now an advocate for patient safety. Anne sits on Alberta Health Service’s Patient/Family Advisory Group, the Health Quality Council of Alberta’s Patient/Family Safety Advisory Panel, and is a member of Patients for Patient Safety Canada (a patient-led program of the Canadian Patient Safety Institute).

“I wish you could have met my mom,” she says. “She was a very strong woman. She was gracious. She was intelligent and she was compassionate. I’ve been told I’m a lot like her. I couldn’t receive a higher compliment,” says Anne. “I know my mom would be proud of what I’m doing.”

Anne knew the importance of being actively involved in her mother’s care. During Canadian Patient Safety Week, October 29 to November 2, 2012, thousands of healthcare providers, patients and family members will help spread the message that “Good healthcare starts with a question.”  To find out more information on Canadian Patient Safety Week, please visit www.asklistentalk.ca.

The quintessential nurse stood by her dying father’s bedside and uttered a bitter pledge to her family. “I will never enter a hospital again,” said Judy Boychuk Duchscher, who had seen her father suffer countless and needless indignities in previous days.

Judy never kept her pledge. She did not give up on nursing. In fact, she threw herself into a PhD and into the causes of patient safety and patient-centred care, vowing to find a way to honour her father and others like him.

To do so, she spent several years reflecting on the underlining issues that had permitted the grievous errors, flights of ego and apathetic care her father endured. During that time, she also gradually let go of the guilt she felt, that she had somehow failed her father.     

Victor Boychuk, Judy’s dad, was a career educator. He taught high school chemistry and physics for years and served as a principal before retirement.  Victor was ever-engaging with an endearing wit and a demonstrative sense of humour.

Victor and his wife wintered in Arizona and during one of Judy’s annual visits, in the winter of 1997, something happened that changed all of their lives. This trip marked Judy’s first encounter with a true sense of vulnerability at the hands of the healthcare system, a feeling that would become all too familiar.

Victor had a persistent cough that he dismissed as a common cold, for which his family physician had given him preventive antibiotics. But Judy’s keen clinical eye told her that this was not a simple cold, but the ominous sign of heart failure. She took his pulse and noted an irregular heart rhythm. She then took him to a cardiologist in Phoenix who prescribed Digoxin to regulate his heartbeat.  But Judy was surprised that her dad wasn’t also given an anti-coagulant to prevent clots from forming in his heart. 

After leaving the cardiologist, Judy had increasing concern that her father was not given an anti-coagulant.  Judy decide to phone the cardiologist, who was unconcerned because the Boychuks were returning in a few days to Canada where Victor’s family physician could follow up on the situation.

“A week after my father returned home he had a massive stroke,” says Judy. “Over time he became a shell of the man he was.” Judy felt guilty for years, feeling that if she had pushed the cardiologist harder for the proper medication, Victor’s stroke could have been prevented. The family rallied around Victor, and Judy says there were many moments of love, laughter and intimacy in the family.

But about eight years after the stroke, Victor began to experience bleeding. He went to the hospital and a colonoscopy was done, which revealed some suspicious nodules, which turned out to be cancerous. Victor and his family were left with a decision. He’d lost considerable weight after the stroke and he wasn’t much more than 100 pounds. “Honestly, I think he lived on Werther’s caramel candies and cigarettes,” says Judy, chuckling at the memory. “He wasn’t the kind of person you’d want to take for major surgery.”

But given the options, her dad decided to undergo major surgery to remove the section of bowel that contained the tumour. Judy worked with the hospital’s nutrition team to get him ready. The surgery was performed and, as Judy feared, her dad struggled to recover from this major event. Soon after the surgery, Victor’s health began to fade.

“The challenge for him was that he was so nutritionally depleted.”

As she explains, the worry in cases like her dad’s is that healing requires proper nutrition. Without it, infection sets in and the infection burns up the body’s scarce resources.

Judy met numerous times with the hospital dietician and the two talked about Victor being fed intravenously. Judy knew that the I.V. supplement carried its own risks, but Victor’s post-surgical body was in dire need of fuel.

After several unsuccessful attempts by the dietician to collaborate with the surgeon, Judy requested a face-to-face meeting to discuss her father’s deteriorating condition. “I think that was the nail in the coffin, quite honestly,” says Judy, who described the doctor as insulted by her input. “He got angry that we were suggesting care that he was clearly capable of deciding by himself.”

In the days following, Victor’s condition continued to deteriorate. He developed a fever and was projectile vomiting. Things went from bad to worse. Victor was supposed to get up and walk for therapy each day. His hesitancy to “get up and move”was interpreted by his caregivers as his being uncooperative.  But Judy says he was just simply exhausted. Judy arrived one day to find Victor being walked, though he was clearly out of breath and terribly pale. Victor was being encouraged to push himself a little more, while he gasped for breath.

Judy assessed him and sure enough, his heartbeat was irregular and his oxygen level was dangerously low. His heart had suffered a critical blow during this activity, and shortly after Victor was placed in coronary care. Judy went into the critical care unit to find her dad in distress and because of her nursing experience she noted clear signs of heart injury. Judy drew the staff’s attention to these signs and with her encouragement, steps were taken to diagnose that Victor was, in fact, having a heart attack.

Victor’s malnourished body continued to battle infection with the help of antibiotics, but his kidneys were failing. Judy’s watchful eye and insistent voice brought attention to Victor’s changing status, but for Judy it all seemed too little too late. With the assistance of a caring physician who was on-call, they discussed the reality of the situation.

Things were not changing; the treatment the physicians had prescribed was not working. Victor slipped into a coma and the next 48 hours were like a slow countdown to the inevitable.  One moment gave Judy reprieve. She was sitting with her mom holding vigil over Victor’s bedside when he suddenly laughed out loud. His face lit up with joy. He was animated and clearly talking to people that neither Judy nor her mother could see.

Judy and her mother were mesmerized by what they were witnessing. It seemed that Victor was telling them he was ready to move on and that helped them decide that it was time to discontinue support. Judy called the physician to tell him of their decision.

“Well, I’m not going to do that,” said the doctor. “We haven’t given it enough time.”  Judy was devastated. This decision, by Judy and her mother, was excruciating to make, but loving and respectful of Victor’s dignity. To them it was about the quality of his life and the integrity of his death.  Judy called in the hospital administrator. The order was signed and Victor died in the hospital’s palliative care unit two days later.

Judy returned to Edmonton to complete her school term.  Her days spent working and studying, her evenings spent in grief. Judy not only grieved the loss of her father, but the loss of respect and belief in the healthcare system that she had devoted her life to. Growing bitterness motivated her to pledge to never enter a hospital again.

“I just didn’t think I could face the institution that had so disappointed my father and me. But it wasn’t long before I realized that would be a travesty,” Judy adds with a smile. “I realized that would not honour my father. I needed to tell his story and I needed to be able to change something about the system so this didn’t happen to somebody else.” Judy threw herself into teaching student nurses. She launched an organization called Nursing the Future, where new nurses can come for support and guidance on how to become the type of nurse they want to be.

She’s also speaks on patient safety and offers her 33 years of nursing experience in helping the Canadian Patient Safety Institute.“This idea of patient-centred care can’t just be a phrase,” says Judy. “It can’t be a marketing idea. It has to be real. The patient and their family needs to be the centre of whatever we’re doing. They have to be involved.”

If she has another message, it’s that healthcare, at its foundation, is not about technology and science. “We need to practice compassionately,” she says.

The story of how Judy continued to advocate for her father’s care shows the importance of family involvement in healthcare.  Canadian Patient Safety Week, October 29 to November 2, 2012, is an occasion to increase awareness that, “Good healthcare starts with a question.” To find out more information on Canadian Patient Safety Week, please visit www.asklistentalk.ca.

​The foundation begins with an apology 

Claire Smith was only 10-years-old when she unexpectedly died in a Pediatric Intensive Care Unit (PICU).   Claire died following a planned surgery to correct a malformation at the base of her brain which was causing her spine to erode and curve significantly, and a myriad of other severe neurological signs and symptoms.  Claire’s tragic death was ultimately attributed to serious issues in care and in the system. Her parents, Raeline McGrath and David Smith, openly talk about what happened, not to find fault, but rather to bring about positive systemic and cultural change.

Raeline and David asked for and then invited to participate in an external analysis of Claire’s death. The analysis team met with them first to learn from their perspective before interviewing others. When the findings were about to be released, the process was structured to have the report shared with Claire’s parents first.  The meeting opened with an apology and that formed the foundation for the post-analysis disclosure about what happened, how and why it happened and what will be done to make care safer. “For us as Claire’s parents, it acknowledged our place in the process,” says Raeline. 

“The analysis process was objective, thorough, accurate and startlingly candid which enabled us to have an open, clear and honest understanding of the events that led to our daughter’s death,” adds Raeline. “This disclosure led to further apologies and opened up a series of other actions and meetings with the people directly involved in Claire’s care that resulted in improvements in the safety of care at the hospital.”

Raeline reinforces the importance of sharing information as openly and quickly as possible and to involve families in the discussion as to what happened. “With everything we did, we wanted to ensure it would not compromise another analysis.  We set out to find where the system and the processes went astray and to make it better for those who would come behind.  The apology is foundational.  With the  analysis and follow-up we were able to move to the next phase ‒ taking Claire’s 16-day episode of care and looking at it as a catalyst for change.”

Raeline and David applaud the Eastern Regional Integrated Health Authority in Newfoundland and Labrador for carrying out a timely and fulsome review of what happened and why, fully sharing the report’s contents, and implementing the recommendations.

Effective management and analysis of patient safety incidents provides an opportunity to make care safer.  The learning gained from a potentially very difficult situation can lead to something positive by reducing the likelihood of recurrence. The Canadian Incident Analysis Framework is a valuable resource that individuals and organizations can use to analyze and learn from patient safety incidents.

Originally developed as a Root Cause Analysis Framework in 2006, the revised Canadian Incident Analysis Framework contains lessons learned from practitioners and researchers, and better reflects the realities and needs of healthcare organizations to analyze and manage patient safety incidents. Key enhancements to the framework include: the patient/family perspective, multiple methods to analyze incidents, placing analysis in the incident management continuum, innovative diagramming, and a new section on developing and managing recommended actions.

The Canadian Incident Analysis Framework and supporting resources can be found by visiting www.patientsafetyinstitute.ca.  The framework can be downloaded for free and printed copies are available for purchase.  Feedback and questions are welcome via email at analysis@cpsi-icsp.ca.  Send comments and questions related to medication safety to analysis@ismp-canada.org

Quality and safety best practices help to enhance policy and programs decisions

As a board member of the Canadian Patient Safety Institute, Keith Dewar was intrigued by what others around the table were saying about the Effective Governance for Quality and Patient Safety (Governance) program.  As the CEO of Health PEI, Dewar works with a newly formed 11-member board appointed mid-2010. Health PEI delivers the majority of health services to the 144,000 residents of PEI.  

Dewar pitched the idea of bringing the Governance program to the Health PEI Board as one of their first developmental activities, to help shape the board’s role in the effective governance of safety and quality. The board is committed to using quality and safety best practices to guide its policy and program decisions.

“Quality and safety is the primary driver and touchstone for decision-making and the board has dedicated 25 to 30 per cent of their meeting agenda to directly or indirectly discuss quality and safety,” says Dewar.  “We wanted our board to see first-hand how other boards govern for quality and safety and this program provided the opportunity to do just that.”

“Your board may be at different stages in their development and this program helps you to take your governance program to the next level,” adds Dewar.  “Whether you have a new or a long serving board, this program can help challenge where you are at and where you need to grow. It can also forge a relationship between the board and the senior team and underscore that the board understands and is taking governance seriously.”

Dr. Donna Murnaghan, chair of the Board’s Quality and Safety Committee, says that the program provided an educational opportunity for board members to reconnect and to have a deeper appreciation for governance. She would like to see the Governance program delivered again for new board members and those who were unable to attend the initial session, held in the spring of 2012.

“Governance can be a slippery slope because you can’t allow yourself to go too far down into operations and it is difficult to know when you have reached that fine line,” says Dr. Murnaghan.  “When you are setting policy for governance you must truly engage in setting the direction and guidelines that allow your CEO and staff to do their work effectively.  This program provided for the flexibility that is needed for an effective governance model and that context really does matter.  How you work on a partnership engagement level in PEI is different from that in Nova Scotia or Ontario.  Part of a strong governance model is getting to understand the culture of the governance model that will work in a particular area.”

Murnaghan equates the process used to customize and deliver the Governance program for Health PEI to a well-oiled machine.  She participated in developmental meetings to determine what was wanted and what was needed. The topics covered during the program were married with engagement, discussion and work underway. “It was very interactive and intuitive as to what is needed in the system and the information provided was based on useful examples and best evidence. The expertise around the table from the team of educators was welcoming and informative, with a willingness to share their experience and knowledge going forward.”

At the end of the program, participants are provided with a comprehensive toolkit that includes a wealth of templates and models that they can adapt, modify and use.  Murnaghan says that the toolkit is a wonderful resource that they can refer to and draw on the examples to enhance their governance program. 

Health PEI has established a comprehensive governance program that includes the critical tools, strategies and insights needed to ensure effective board governance. By educating board members on the importance of quality and safety, they are working to provide leadership that makes decisions that respect and honour quality.

The Board’s Quality and Safety Committee has set up a quality and safety agenda and have planning meetings so that they can stay on top of things. This three-member committee have instituted quality and safety tours to look at the dimensions of quality, connecting with staff and the patient/resident/client to better understand issues and recognize progress on the frontline. Other board members are invited to participate in these walking tours to reinforce a well-rounded understanding and the value of quality and safety.

The Effective Governance for Patient Safety and Quality Improvement program can be customized for your organization.  To learn more, visit the Canadian Patient Safety Institute website at www.patientsafetyinstitute.ca and click on Education.​

This one-year research degree provides a strong foundation in:

• Improvement science theory and research methods
• Measurement methods and tools
• Best practices in implementing quality improvement and patient safety
• Systems thinking
• Theory and tools for leading change

The Msc(QIPS) is designed for high performing administrators, physicians and health professionals. The modular format allows students to earn their degree in one year without interrupting their career. The initial cohort of 25 students began their courses in September 2012. The students represent a range of health professionals and health sectors and generously add their knowledge and experience to class discussions.   

The deadline for applications for the 2013-14 academic year is November 15, 2012. Courses begin in September 2013.  

The program’s faculty are recognized national and international leaders in the fields of improvement science, patient safety, risk management and healthcare leadership and bring a diverse mixture of professional, clinical and managerial backgrounds: 

• Ross Baker Full Professor, IHPME, with 20 years of experience,  more than 50 relevant publications in quality improvement and patient safety, author of the book High Performing Healthcare Systems – Delivering Quality by Design, and one of the founders of the Dartmouth Faculty Symposium on Quality Improvement held annually since 1994;
• Kaveh Shojania, Associate Professor, Department of Medicine, is the Director of the University of Toronto Centre for Patient Safety and holds a Canada Research Chair in Patient Safety and Quality Improvement; published over 100 peer reviewed articles including in leading journals, such as the New England Journal of Medicine, Lancet, the Journal of the American Medical Association, and the CMAJ.; lectured widely on issues related to the scholarly advancement of patient safety and quality improvement, including twice delivering invited lectures to the US Institute of Medicine; and Editor of the BMJ Quality & Safety, the leading journal in the field;
• Ed Etchells, Site Director, Sunnybrook HSC site for U of T Patient Safety Centre; Associate Scientist at Sunnybrook Research Institute has  70 peer reviewed publications, including being on the Canadian Adverse Events study and recent publications on the economics of patient safety, and principal investigator or co-principal investigator on numerous grants from CIHR and Canadian Patient Safety Institute on patient safety informatics and medication safety issues;
• Paula Blackstien-Hirsch, Quality and Patient Safety Consultant supporting a broad range of healthcare organizations, and Associate Faculty, NHS Institute for Innovation and Improvement; has led system level improvement provincially and nationally as Senior Director, Canadian Patient Safety Institute, Executive Director, Centre for Healthcare Quality Improvement, and Director, Hospital Report Research Collaborative, UofT.
• Polly Stevens, Vice President, Risk Management, Hospital Insurance Reciprocal of Canada (HIROC), has led hospital wide improvements and risk management as Director of Quality and Risk Management at the Hospital for Sick Children and American Hospital Association Patient Safety Fellow with a focus on assessing macro system risks and learning from low frequency, high severity events.  
• Chris Hayes, Critical Care Physician, Medical Director Quality and Patient Safety St. Michaels’ Hospital, Medical Officer for Canadian Patient Safety Institute, Graduate of IHI Patient Safety Executive Officer Training Program, member CPSI/ RCPSC Safety Competencies project; Scientist in the Keenan Research Centre of the Li Ka Shing Knowledge Institute of St. Michael's Hospital; and
• Lianne Jeffs, Assistant Professor Lawrence S. Bloomberg Faculty of Nursing, Director of Nursing Research at St. Michael’s Hospital where she has led and collaborated on nursing and interprofessional quality improvement and safety knowledge translation and education strategies involving action learning projects.

For more information on the MSc Quality Improvement and Patient Safety contact Elaine Aimone by email at e.aimone@utoronto.ca or by phone at 416-946-5608. Program details are available on the IHPME website at http://www.ihpme.utoronto.ca/.

​Canada’s Virtual Forum on Patient Safety and Quality Improvement is fast approaching.  Don’t miss out on this free online forum, available live over the Internet!  With 20-hours of presentations, videos and panel discussions delivered by experts in healthcare and patient safety, the forum is taking place from October 29 to November 2, in conjunction with Canadian Patient Safety Week.

“Whether you are in the comfort of your office or your home, the Canadian Patient Safety Institute looks forward to welcoming you when we go live on October 29th,” says Hugh MacLeod, CEO.  “We have an outstanding line-up of speakers and I encourage you to check out the program and join our virtual audience for any or all of the sessions.”

Each of the five days is themed to profile key topics, including: leadership and culture; falls reduction strategies; medication safety; infection control; and patient safety across the board, probing the question, ‘Is healthcare safer?’. With four hours of programming a day, three presentations will be delivered in English and one in French each day. Poignant patient narratives will be profiled daily to set the stage for the presentations.  You can also tune-in for a 10-minute recap of tools and resources available on each topic at the end of the each day’s session. Click here to view the detailed program.

More than 1,100 individuals have already registered for this year’s forum. Sessions from the inaugural forum held last year were viewed by more than 2,500 registrants from 17 countries around the world. 

We invite individuals and organizations to join in the engaging, compelling and informative discussions. Mark your calendar and register today for Canada’s Virtual Forum on Patient Safety and Quality Improvement at asklistentalk.ca.

HSERC’s Nightmare on Main Street focuses on interprofessional communications

Nightmare on Main Street is a fun and creative project being undertaken during Canadian Patient Safety Week (CPSW) by the Health Sciences Education and Research Commons (HSERC) for healthcare students from eight faculties at the University of Alberta in Edmonton. On Wednesday, October 31st, the HSERC area, including two simulation rooms, will be set up as a Nightmare on Main Street. One room will resemble a patient room on a hospital ward or intensive care unit; the other will be set up in the “smart condo”, a simulation of an apartment much like you would see as part of a home care visit.

Sharla King (HSERC Director), Joe MacPherson (HSERC Simulation Specialist) and Diane Aubin (Project Manager at the Canadian Patient Safety Institute) are developing the scenarios for the Nightmare on Main Street to profile issues that could cause patient safety incidents.  

Students are being asked to pre-register to participate in the Nightmare on Main Street at http://www.hserc.ualberta.ca/. They will be grouped in interprofessional teams of three to visit both the patient room and the “smart condo” where they will engage in a short, five to 10 minute interaction performed by standardized patients (actors portraying the role of a patient, doctor, nurse, occupational therapist, etc.). Each team will then debrief on what they observed and prizes will be awarded to those with the keenest eye for identifying issues that could cause patient safety incidents.

“We took our inspiration for the Nightmare on Main Street from a successful endeavor at the Queen’s Joanna Briggs Collaborative for Patient Safety in Kingston, where a room of horrors has been a regular feature of CPSW for the past two years,” says Aubin.  “The Nightmare on Main Street is reaching out to the student population to increase awareness of patient safety. We hope to have good student participation for this first-time event.”

Information booths will also be set up in the foyer outside the simulation rooms where students can learn more about Canadian Patient Safety Week and Canada’s Virtual Forum on Patient Safety and Quality Improvement and participate in an activity to promote effective hand washing.

Canadian Patient Safety Week is fast approaching and packages containing posters, tent cards, magazines and promotional items are available to help healthcare organizations promote this year’s theme, Good healthcare starts with a question.  Join us in celebrating Canadian Patient Safety Week, October 29 to November 2, 2012. To register and learn more, visit www.asklistentalk.ca

About the Health Sciences Education and Research Commons (HSERC)

Providing care to increasingly complex patients within an evolving health system requires a new approach to health science education. HSERC is committed to equipping the next generation of health workforce with the skills to provide such care. HSERC is a shared resource among eight faculties with two essential parts. First, HSERC is the home of the interprofessional curriculum with a focus on supporting the development and evaluation of team-based learning experiences for all health science faculties. Second, HSERC has a suite of simulation learning environments and simulation services (e.g. Standardized Patient Program) to support curriculum development/delivery and education research.

​The Faculty of Health Sciences, in collaboration with School of Nursing and Department of Anesthesiology and Perioperative Medicine, Faculty of Law, Faculty of Engineering and Applied Science, School of Business and School of Policy Studies, has launched a Master of Science in Healthcare Quality program at Queen’s University. 

“The Healthcare Quality program is the first of its kind to specialize in linking theory and practice in quality, risk and safety in healthcare,” says Dr. David Goldstein, Co-Director of the program.  “We are excited to offer this program to law, engineering, business, healthcare, administration, and policy professionals who are working to advance quality and safety in the healthcare system and related fields.”

This new graduate program in quality, risk and safety in healthcare has been designed as a distance-learning, two-year, part-time program for professionals who wish to continue their education, while continuing full-time employment.  With only two mandatory intensive weeks held on campus, the majority of the program will be delivered via live online seminars, with real time interaction with professors and other students, and independent learning.  This method allows students to fully participate in graduate level seminars, without having to take time off work for repeated weekly travel.  This flexible structure also makes the Master of Science in Healthcare Quality accessible to students from all over the globe.

The Master of Science in Healthcare Quality has been specifically designed with an interdisciplinary curriculum that links theory with practical knowledge on how to conceptualize, design, implement, and measure effective change in a healthcare setting.  Expert faculty, drawn from business, law, engineering, medicine, nursing, and policy, will provide a comprehensive program that will prepare students to make lasting changes in the real world.  An international elective, offered at Herstmonceux Castle in the United Kingdom, will give students the opportunity to explore how quality, risk and safety are conceptualized and actualized around the world via the ability to learn from international experts in the field.

The application deadline for the 2013 admission cycle is February 1, 2013.  For more information on the Master of Science in Healthcare Quality, contact Briana Broderick by email at briana.broderick@queensu.ca, or by phone 613-533-6000 ext 75370. Program details on the Master of Science in Healthcare Quality are posted to the website www.hqrs.queensu.ca

​How will you celebrate Canadian Patient Safety Week?

Covenant Health has selected the theme, “Working together for patient and resident safety” to profile ways that patients, residents and families can ASK.LISTEN.TALK. and get involved in their own care. Focusing on safer care, such as medication reconciliation, falls prevention and hand hygiene, sites and departments at 18 Covenant Health facilities across 12 Alberta cities and towns have been invited to participate in a poster display competition.

“We held a poster competition last year and the excitement and creativity was really outstanding,” says Meaghan Ellis, Clinical Quality Consultant for Covenant Health. “We want to build on that enthusiasm and get more staff, patients, residents and their families involved in promoting safe care.”

Last year, Covenant Health formed a working group with key representatives from across the organization to ensure everyone was included and to help disseminate information throughout the widespread sites. This year, the working group has invited senior leadership to evaluate and judge the poster displays.

The quality team is helping to organize the poster display competition and has ordered Canadian Patient Safety Week (CPSW) promotional packages for each site to use. They are also promoting Canada’s Virtual Forum on Patient Safety and Quality Improvement and providing information, tools and resources that their sites can use to promote CPSW.

“The poster display competition really allows people to use their imagination and get engaged in Canadian Patient Safety Week,” adds Ellis.  “In the past, some units profiled projects they were working on and one unit took an innovative approach and included words of wisdom from their rehabilitation patients on their display. The poster competition provides for great teambuilding and ties everything together to promote our common goal of safe care for all.”

Ellis is looking forward to seeing this year’s poster display entries and will be visiting the sites and taking photographs to capture ways that Covenant Health is getting everyone involved to celebrate Canadian Patient Safety Week.

The theme for Canadian Patient Safety Week 2012 is Good healthcare starts with a question. The Canadian Patient Safety Institute will send registrants free posters depicting medication reconciliation, falls prevention, hand hygiene and communication. Register now to receive your free CPSW package of posters, tent cards, magazines and promotional materials to use at your site. Visit the website www.asklistentalk.ca  for presentation templates, tips sheets, activity ideas promotional items and more.

Enter the Medication Safety Video Competition: Med Safety Goes Viral.  The deadline for submission of three minutes or less videos profiling medication safety in healthcare and community care settings is September 28, 2012.

Join Canada’s Virtual Forum to learn about the latest in patient safety and quality improvement from an exciting line-up of experts. This week-long event is free and can be accessed through a computer and internet connection.  Click here to check out the program.

The Effective Governance for Quality and Patient Safety program was delivered on April 3-4, 2012, bringing Nova Scotia board members, CEOs and senior staff together to have important conversations around the board’s role in quality and safety of care. The program provided participants with evidence-informed approaches to governance and leadership that can be used in setting goals, monitoring improvements and achieving results in the quality of care and patient safety.   

Nova Scotia’s health services are governed by volunteer boards in nine district health authorities and the IWK Health Centre. The program focused on governance in the acute care sector, with 33 participants attending a day and a half learning event in Dartmouth. Through the use of videos clips, case studies, engaging peer-led discussions and a candid guest speaker, the session helped the participants to capture two or three key actions they would take back to their organization to begin their quality and patient safety journey.

“The sessions provided the opportunity for candid conversations and information sharing, and the participants received some wonderful resources that they can share with their larger boards,” says Carla Anglehart, Director of Organizational Development, Health Association Nova Scotia.  “This program brought us to a different depth in dialogue and provided an important piece of education for our boards to fulfill their governance role in patient safety.”

Janette Sears, a board member with the Pictou County Health Authority says the program provided a tremendous amount of information that underscored the complexity of governing quality and patient safety. Sears chairs the Pictou Board’s Quality and Patient Safety Committee and is now using the program resources to develop a plan to measure and monitor patient safety indicators.  Since attending the sessions, Sears has expanded the committee to include medical staff and community members.

“Most often quality and patient safety plans are cumbersome and try to address everything,” says Sears.  “The program helped to reinforce that we can keep it simple initially and take a more straightforward approach. The information was timely, appropriate and provided an excellent starting point to develop a plan that will effectively address our role in the governance of patient safety.”

Both Anglehart and Sears agree that more education on the board’s role in quality and patient safety still needs to be done and they are exploring ways to make that happen. Anglehart is looking to provide governance training for continuing care health boards, while Sears encourages people with experience in health governance to share their knowledge and apply for a position with their local health board. 

The Effective Governance for Quality and Patient Safety program offers a unique opportunity to explore evidence-informed approaches to governance and leadership and to share innovative health governance practices, resources and tools.  To learn more about the program or to schedule a learning event in your area, visit www.patientsafetyinstitute.ca/education

Developed by the Canadian Health Services Research Foundation and the Canadian Patient Safety Institute,  the Effective Governance for Quality and Patient Safety program supports boards in their efforts to improve governance for quality and patient safety. The program includes a toolkit and education session to help healthcare boards understand and implement effective governance practices and processes for quality and patient safety.

​This is the third article in a three-part series on how the Patient Safety Education Program – Canada  (PSEP – Canada) is helping to advance the patient safety culture at Bridgepoint Health in Toronto, Ontario.  Learn more from the participants and their work projects.

The PSEP – Canada train-the-trainer model is being used by Bridgepoint Health to revamp their approach to patient safety education. Using the PSEP – Canada framework, the Bridgepoint Health Patient Safety Education Program was developed to help participants learn about applying human factors in the workplace, scientific methods for improving safety, organizational culture and dealing with change, understanding teamwork, moving beyond blame to systems thinking, teaching others about patient safety, and implementing patient safety initiatives that will result in improvements. During the program, participants worked in teams to apply their learnings to a work-based project. Here are highlights of four of the projects and the impact the program has made in improving patient safety on the frontline.    

Addressing safety and quality issues

Respecting Bridgepoint’s no-restraint policy, one team looked at the use of transponders with patients experiencing changes in behaviour that include wandering or  being at risk of getting disoriented and lost. The team reviewed the literature, their current processes and policies, and reflected upon the characteristics of clients requiring a transponder. They then developed criteria to assess use of a transponder and validated why the restraint was required for the client. They came up with a decision tree/flow chart, case studies, an easy-to-remember mnemonic for staff to use, and training materials to provide guidance on what to look for when assessing the client and the things to do once the decision is made that a transponder is required. 

Richard Kellowan, an Occupational Therapist on the team says that the PSEP – Canada program has opened up an avenue to discuss things more freely with the frontline staff.  “It provides a structured platform to identify and address safety and quality, without the stigma associated with being a ‘whistleblower’,” says Kellowan.  “When reporting a risk or a problem, it is about being comfortable to speak up about it and engaging others to get their input.  The main thing is that it makes it easier to address issues of safety and quality without preconceptions and there is no blame with any of the issues.”

Learning from different perspectives

Patricia Ruiz-Skol, Patient Care Manager, found the Plan-Do-Study-Act (PDSA) cycle a practical and useful tool that provided concrete results and illustrated how it would impact behaviour.  Her team used the PDSA cycle to create a protocol and clear guidelines to follow on their unit when a patient requires a transponder.  An inter-professional approach provided knowledge and experience from different perspectives and she says they all learned from each other. 

“The program helped me to be more aware of patient safety and the importance of it and how everyone plays a role,” says Ruiz-Skol. “We are more organized, informed and aware so that we can always be vigilant and look for anything that may harm the patient so we can step in and correct it. To report near misses is a new way of thinking and this program reinforced that patient safety is a priority and not to be hesitant to report or identify issues that compromise patient safety.”

Effecting change for patient safety

In the fast-paced environment of the inpatient and outpatient neuro-rehab programs, the team focused on information that was important in terms of handover to outpatient services. Through interviews and a staff survey, they determined what information was frequently missing or undocumented on the referral form.  This project focused on whether the Ministry of Transportation (MTO) had been notified as to whether the patient’s condition could impact their ability to drive (in which case their driver’s license could be suspended). They found patients were sometimes driving to their appointments and the outpatient staff was unsure if a letter had been sent to the MTO, if their license had been suspended, what had been discussed while they were an inpatient, or even if it was safe for the patient to drive.

“We wanted to know what had been discussed on the unit so that we could better advise our patients for their safety and the safety of everyone on the road,” says Sandy Duncan, Occupational Therapist.

First they had to determine who was discussing what with patients and if the information placed on the record was difficult to find.  The process implemented now has the discussion taking place during the patient’s inpatient intake meeting, with their family and the full team present, and documented in a way that is very clear so that everyone knows that a letter has been sent to the MTO.  Unit Clerks and administrative support staff have been instructed where to file copies of the sent letter and the referral form has been updated, adding a box to check if the matter had not yet been discussed with the patient.

“The Bridgepoint Patient Safety Education program gave legitimacy to the changes we were making and having a program and tools behind the project really helped to push it forward,” says Duncan. “Often you feel you won’t be able to do anything that will result in change, but this program has changed the way I approach things.  I know I can effect change and it is important for the safety of the patient.”

Speak up! Patient safety is everyone’s role

As an Interprofessional Education Specialist, Elizabeth Hanna knows how incredibly valuable it is when people at different levels of the organization learn together.  She says that PSEP – Canada is a well-designed program where interaction was a priority and that it provided a good balance between didactic teaching, small group work and the work-based projects.

Elizabeth’s team focused on the transfer of information for clients with head injuries, to ensure that the Ministry of Transportation is appropriately notified. “There was confusion around the process with both staff and the patients,” says Hanna.  The group did a needs assessment and a survey before designing and implementing a tool, but recognized that they had to do more; they continue to do chart audits to ensure the new process is working.

“What resonated with me during this program is that it is as much about leadership as it is about patient safety and you need to speak up,” says Hanna.  “Do not think that it is someone else’s role to raise an issue, either small or large, about patient safety.  The program focuses on leadership, how you manage a project, involving your stakeholders and how you manage change.  These all go together and are important aspects to sustain change.”

Click here to link to the first article in the three-part series on how Bridgepoint Health has customized the Patient Safety Education Program – Canada to advance patient safety in their organization. To link to the second article in the three-part series which focuses on the perspectives of the participants and profiles of their work-based projects, click here.

For more information on the PSEP – Canada program offered by the Canadian Patient Safety Institute please click here.

​This is the second article in a three-part series on how Bridgepoint Health tailored the Patient Safety Education Program – Canada (PSEP – Canada) to create an internal education program that would result in long-term advancements in patient safety.  This article focuses on the perspectives of the Bridgepoint participants and provides a short profile of their work projects to advance patient safety.

Improving the efficiency and effectiveness on the frontline

To participate in the Bridgepoint Patient Safety Education Program teams identified work-based projects to improve patient safety. The teams then had the opportunity to apply the learning and tools from the patient safety program to these projects. The processes the teams followed to develop improvement strategies were all similar in style. They conducted staff surveys and interviewed staff for input and feedback; completed a variety of audits, both pre- and post implementation; and compiled literature reviews to learn from what others were doing and to seek out best practices.

The teams quickly learned to start small and focus on one aspect of the change they would like to implement.  Many of the unit-based projects have since been expanded into larger projects, but more importantly, the teams now have the knowledge and the tools and feel empowered to effect change that will improve the efficiency and effectiveness on the frontline.  Here are profiles of three of the work-based projects:

Using a systems thinking approach

The medication room in the palliative care unit was a catch-all.  It was used to store medications and equipment and it was also used for charting; it was cluttered and unorganized.  “We did not have what the patient needed, when they needed it,” says Danielle Lapointe, Registered Practical Nurse.

As part of a larger project a separate room was established providing more space for charting, and the toasters, coffeemakers, microwaves, refrigerators and snacks for patients were moved to a newly created nutrition centre – thus freeing up space to reorganize the medication room. The team then simplified, standardized and organized the medication room.  “Everything was cleaned and everything was given a spot on a medication cart,” says Lapointe. “We have assigned people to replenish the medication carts on a daily basis to ensure everything is in the right spot and we have everything we need, when and where we need it.”

Lapointe says that the Bridgepoint PSEP – Canada training gave her the ability to identify potential patient safety hazards and how to act on them.  “It provided a systems thinking approach so that there is no blame if something goes wrong,” says Lapointe. “If we have a medication error, we don’t blame the person, we look at what are the factors that led to the error.”

Sharing the knowledge

Lapointe received a Bridgepoint Good Catch Award for identifying a potential safety hazard where mouthwash, chlorhexidine swabs and mouth swabs were all housed in the same container, separated by a small plexi-glass partition, which could lead to using chlorhexidine as a mouth swab by accident. 

“This program taught us to identify issues, what to look for, how to address them, and how to educate your colleagues to share in the education,” adds Lapointe.  “Bridgepoint did not teach us about patient safety so that the information would stay only with us; it is shared throughout the facility so that all health disciplines can share our knowledge.” As soon as Lapointe reported the issue of the chlorhexidine swab placement, every unit on the hospital was checked and every medication cart was changed.

Lapointe says that once you have been trained in systems thinking you learn how to make changes and that the PSEP – Canada has a ripple effect that is changing the culture at Bridgepoint. “Bridgepoint is so supportive and takes patient safety seriously,” says Lapointe. “Programs like this go a long way in supporting frontline workers who can quickly identify issues and provides the opportunity to make a difference.”

Gaining the confidence to make a change

Another project focused on eliminating missing medication orders in an inpatient Neuromuscular Program.  Information was gathered to determine: Was it because the staff is too busy? Was it due to a heavy caseload? Was the writing on the medication orders illegible?  An education program was instituted and signage posted in various locations, including the medication room, nursing stations and areas where charts are checked. Follow-up emails are sent to staff on the unit to remind and encourage them to ensure all medication orders are complete. 

Prior to the pilot study, there were about two or three missing orders every month; since the interventions were implemented last year, there has only been one missing order. The team concentrated on ongoing staff education and the provision of signage in appropriate locations to help eliminate missing medication orders.  “This is not rocket science, it just takes some extra energy and attention,” says Ken So, Occupational Therapist.  “The training I received through the program has given me the confidence to enhance my working environment and to make changes. I realized that I don’t need a huge research grant; I can simply conduct a survey, do some preliminary audits and provide education for the team – it is small, useful, specific and effective.”

Applying the learning in everyday practice

Staff on one unit did not find the cardex system useful as the information was often out-of-date and messy, or the card lacked enough space to write. The team found it would be unrealistic to revamp the cardex system within the timeline of the program, so they focused on the allergy section of the card; another team of allied health professionals is now looking at revising the entire cardex system for the unit.

Once allergies were identified as a focus, an audit of the cardex cards was completed and compared with the online documentation system to see if there were inconsistencies. They found a huge gap where allergies documented on the cardex were not necessarily the same ones that were documented on the computerized document system, and that was a major patient safety concern.  An allergy sticker was developed that can be affixed on each cardex card and they made it everyone’s responsibility to update the allergy section for their patients.

“The Bridgepoint PSEP – Canada program provided us a framework to work with, gave us tools to use that were easy to follow, and brought an increased awareness of patient safety,” says Maya Nikoloski, Registered Nurse and Nurse Educator.  “It provides you with a safety lens that you can apply to micro or macro level initiatives from unit-based projects to hospital-wide programs. It has changed my perspective on how I approach a project and it has really allowed me to apply the learning in my everyday practice.”

Click here to link to the first article in the three-part series on how Bridgepoint Health has customized the Patient Safety Education Program – Canada to advance patient safety in their organization.

For more information on the PSEP – Canada program offered by the Canadian Patient Safety Institute, click here.

​Bridgepoint Health (Bridgepoint) is taking an innovative and empowering approach to advance patient safety throughout their organization. Based on the Patient Safety Education Program – Canada (PSEP –Canada) train-the-trainer model and framework, Bridgepoint has developed a customized patient safety education program that is having a ripple effect and changing their patient safety culture.  

Kate Wilkinson, Director of Quality and Patient Safety at Bridgepoint and a PSEP – Canada Master Facilitator, was instrumental in bringing the PSEP – Canada program to Bridgepoint.  Kate, along with three facilitators, Steve Hall (Allied Health Education Specialist), Carla Gibson (Nurse Educator) and Zahir Hirji (Advanced Practice Nurse, Infection Control) customized the PSEP – Canada curriculum for Bridgepoint in order to make practical changes in attitudes, behaviours and knowledge around patient safety.  “We needed to broaden our base of expertise; it could not just come from one individual,” says Wilkinson.  “The PSEP – Canada model provided the opportunity to develop a broader group of individuals at the facilitator level and is structured so participants can become patient safety trainers.”

The inaugural Bridgepoint patient safety education program trained 40 staff; another 48 are currently going through the program.  To take part in Bridgepoint’s program, there was an application process where participants outlined a work-specific project they would implement to advance patient safety and make a positive impact on patient care.

In developing a patient safety education program, Bridgepoint wanted to enhance the content to make it more meaningful for their participants. Tailoring the PSEP – Canada curriculum specific to their needs and interests involved a lot of time and commitment. However, incorporating Bridgepoint examples into the modules was a way to increase an understanding of what was in place and to help participants learn what was really important in terms of patient safety.

Each of the facilitators were assigned modules to develop, based on their interests. “We liked the fact that we could take the PSEP – Canada modules and instill our own flavour and a local spin on them,” says Gibson.  “We made conscious decisions on what we wanted to deliver, what was important, how would it work, how to deliver and what tools to use,” adds Wilkinson.  “We also created pre- and post- tests as a way to understand knowledge translation and evaluate the course from an outcome perspective.”

There was some innovative thinking within the group about labelling each session with a theme and connecting a safety aspect to it.  For example, a Formula One racing theme was incorporated into a session on teamwork.  “When we used distinct examples from our experiences for the case studies and role plays, it really brought home the message and “Bridgepointized” the content for the participants,” says Hall.

Four one-day sessions were developed; the sessions were designed to build on one another, not repeat content. The facilitators wanted to ensure that the sessions were interactive and relevant for the participants, and activities were frequently switched-up to keep learners engaged with the material.  Each session was peppered with a good balance of role plays and case studies. “We developed the modules we would introduce over the four days; however, we re-jigged the content as we went along based on the feedback we received from each session and the needs of the learners,” says Wilkinson.

Prior to each session, participants were provided with a package that contained two or three relevant articles and these pre-course materials were used in the sessions to tie the content together. Understanding adult learning principles, the facilitators recognized that not everyone would read the articles, however some people like to have them ahead of time. By sending information out prior and using it during the sessions, the facilitators demonstrated the value of the pre-course material.

Each session was introduced with a plenary designed to get people’s attention, hold their attention for the rest of the day, and help participants to understand the real importance of the work that they are doing.  “We kept the plenary short and focused less on the breadth of the content, but rather to really go for that shock and “ah” factor,” says Wilkinson. 

Some of the modules were delivered using co-Facilitators, partnering to deliver the education. The facilitators say that this approach takes more time upfront to plan because you have to work together, rather than individually.  “In a way, we were modelling interprofessional behaviours within our team and the sessions were much more dynamic with co-facilitation,” says Hall.  “It is a lot for one person to deliver the content, facilitate and manage questions. This approach really worked well and we had a lot of fun working as a team. ” 

The facilitators quickly recognized that the more interactive the sessions, the more people responded and participated.  “When we went through the role plays we set up an environment that was safe, where people felt supported,” says Gibson. “They became engaged in the process and that is the biggest tell that you are doing something right.”

For some sessions, guest lecturers were brought in and paired up with the facilitators; some guest lecturers were from the audience and others were external. Having experts within your facility to speak about patient safety provides a refreshing opinion or view and gives variety to the lectures.

The facilitators reinforced that sending people to a course is not enough; to be effective you need leadership support and dedicated people in the organization who are good at facilitating and also have an interest in patient safety.  Having work-based projects incorporated into the program helped them to keep in touch with the participants and provided much needed skills in problem-solving on the frontline. 

All of the teams prepared poster boards on their projects and made presentations during clinical rounds.  Two of the teams presented their projects to Board members and hospital executives.  “It is not often when you have Board members engaged and asking questions of staff where there is a common theme of patient safety,” says Hall.  “To sit back and watch that evolve was very rich and both sides learned from that interaction.”

“Participants learn a lot about how and what to do to improve patient safety in their practice and they now know what they would do differently in a situation when patient safety is compromised,” says Wilkinson.  “The bottom line is that they now feel empowered to do something.”

In the spring of 2013, Bridgepoint will move to a new state-of-the art facility; the hospital will go from 10 to 14 units, the units are smaller and the teams will be changing. They are now looking at the training and education needs for every staff member to make the transition. With more teams and a different bed configuration there are many teamwork and communications challenges to address from a patient safety perspective.  “We need to integrate patient safety education into that orientation and whether it is a standalone four-hour component, or integrated as a common theme that winds its way through the entire content is yet to be decided,” says Wilkinson.  “Our goal is that each direct care staff member will have a core patient safety education program that will include teamwork and communications, technology and human factors, and systems-thinking.”

This is the first article in a three-part series on how Bridgepoint Health has customized the Patient Safety Education Program – Canada to advance patient safety in their organization. Click here to learn more about the participants and their work-based projects.

​Almost a million Canadians visit hospital emergency each year for heart-related problems. Many are treated and released quickly, but when complications arise, the consequences can be serious and devastating. A new study is looking to enhance patient safety for people with heart-related problems.

The Canadian Institutes of Health Research has awarded the Ottawa Hospital Research Institute (OHRI) a research grant of $428,829 to create patient-safety enhancing solutions that address healthcare associated complications for people with heart-related problems. Adverse Events among Patients Discharged with Sentinel Cardiovascular Emergency Department Diagnoses is a three-year study that will look at the common heart-related reasons when patients present in emergency, including fluid on the lungs (heart failure), heart rhythm problems (atrial fibrillation) and fainting (syncope). The goal of the study is to determine what systemic and patient factors increase the risk of preventable healthcare-related complications among emergency patients, age 50 and over, with heart-related problems.

The study will follow 6,500 patients across 10 Canadian emergency departments, including The Ottawa Hospital (Civic and General campuses), Kingston General Hospital, Mount Sinai (Toronto), the Foothills, Peter Lougheed and Rockyview hospitals (Calgary), University of Alberta Hospital (Edmonton), Centre Hospitalier Affilié Universitaire de Québec (Enfant-Jésus, Quebec City), and Hôpital du Sacré-Cœur (Montréal). Using health record reviews and telephone interviews, teams of emergency doctors will review the records of patients who subsequently died, were admitted to hospital, visited emergency, saw their own doctor, or felt worse 14 days after their first visit to emergency. The team of experts will identify complications related to the healthcare received on the initial emergency visit. 

“The study will provide a broad view of the continuity of care for heart-related problems. We will look at the effect of different strategies, such as quick referral to a specialist through rapid referral clinics, are making a difference to reduce harmful incidents,” says Dr. Lisa Calder, Attending Physician in Emergency Medicine (The Ottawa Hospital), Associate Scientist Clinical Epidemiology Program (OHRI) and Principal Investigator for the study. “This is a great step toward reducing healthcare associated complications for people with these heart-related problems.”

“The Canadian Patient Safety Institute would like to congratulate Dr. Calder for making such a significant contribution to patient safety through this important research,” says Hugh MacLeod, CEO of CPSI. “This is great news for patient safety and we applaud the efforts of Dr. Calder and her team to improve the outcomes for people with heart-related problems.”

​Adverse events create a significant economic burden on the Canadian healthcare system. In an effort to understand the true financial costs of preventable adverse events, extensive research has been conducted to examine the economics of patient safety in acute care. The Economics of Patient Safety in Acute Care report, released in July  2012, was funded by the Canadian Patient Safety Institute and led by principle investigators Dr. Edward Etchells, Associate Director of the University of Toronto Centre for Patient Safety and Dr. Nicole Mittmann of Sunnybrook Health Sciences Centre.

An article recently published in the BMJ Quality and Safety Journal, entitled “Comparative Economic Analyses of Patient Safety Improvement Strategies: A Systematic Review”, set the stage for the release of the report, highlighting the results from the literature review of economic studies related to patient safety improvement strategies.  The full report provides more detail on the methods used in the study and explains the concepts associated with economics research.

The Economics of Patient Safety in Acute Care report includes:

• Estimates of the total economic burden of patient safety in acute care in Canada in 2009/2010.
• Preliminary estimates of the cost of safety issues, including the cost per case of:
• Hospital-acquired infections (including nosocomial bloodstream infections);
• Nosocomial falls;
• Clostridium Difficile-associated Disease (CDAD);
• Methicillin-Resistant Staphylococcus aureus (MRSA infections);
• Vanconmycin-Resistant Enterococci (VRE); and
• Surgical Site Infections (SSI).
• Guidelines and a framework for performing or assessing economic research in patient safety.
• Recommendations for future research in the economics of patient safety.

The report reinforces the need to continually evaluate the costs of adverse events to the entire healthcare and social system; however, more importantly it strongly advocates conducting methodologically sound research to determine the best interventions and strategies for improving patient safety.

For more information on the Economics of Patient Safety in Acute Care report, visit http://www.patientsafetyinstitute.ca/English/research/commissionedResearch/EconomicsofPatientSafety/Pages/default.aspx 

A new resource to support healthcare renewal, transformation and innovation

Visit: www.eihrportal.org    

As health system policy makers and stakeholders in settings across Canada work to transform healthcare, they need reliable, accessible evidence on healthcare financing, governance and sustainability. The Evidence-Informed Healthcare Renewal Portal (EIHR Portal) is a single window into a continuously updated collection of reliable evidence that can guide healthcare leaders in their timely pursuit of health system renewal, transformation and innovation.

As a contributing partner in the EIHR Portal, the Canadian Patient Safety Institute is pleased to announce the launch of this new resource for policy makers and stakeholders for healthcare renewal evidence. 

What is the EIHR Portal?

The EIHR Portal is a gateway within the McMaster Health Forum’s Health Systems Evidence to important policy contributions on healthcare renewal in Canada. A wide range of evidence is easily searchable and accessible.  It contains 24 types of documents, including jurisdictional reviews, stakeholder position papers, toolkits and intergovernmental communiqués.  The documents address priority areas identified by federal, provincial and territorial governments, such as primary healthcare, patient safety, health human resources and performance indicators (e.g., timely access).

Who contributes the evidence contained in the EIHR Portal?

The EIHR Portal, an initiative of the Evidence-Informed Healthcare Renewal Roundtable, is managed through a collaboration between the McMaster Health Forum and the Canadian Institutes of Health Research (CIHR).

The following EIHR Roundtable organizations contribute documents and have provided financial support to make the EIHR Portal possible: 1) Alberta Innovates – Health Solutions; 2) Association of Canadian Academic Health Organizations; 3) Canadian Agency for Drugs and Technologies in Health; 4) Canadian Health Services Research Foundation; 5) Canadian Healthcare Association; 6) Canadian Institute for Health Information; 7) Canadian Institutes of Health Research; 8) Canadian Nurses Association; 9) Canadian Patient Safety Institute; 10) Health Canada; 11)  Health Council of Canada; 12) Institute of Health Economics; 13) Manitoba Health; 14) Northwest Territories Department of Health and Social Services; 15) Nova Scotia Department of Health and Wellness; and 16) Ontario Ministry of Health and Long-Term Care.

Documents and other resources contained in this Portal have been generated by and/or contributed by these organizations. The details for these documents within Health Systems Evidence are provided in English and French. All documents within the EIHR Portal undergo an independent review and must meet specific inclusion criteria. New content is continually being added.

How Can You Access the Evidence-Informed Healthcare Renewal Portal?

For free, unlimited access to the EIHR Portal, and to receive a monthly customized evidence service that will email you new evidence updates specific to your pre-defined areas of interest, visit www.eihrportal.org and log in (or register if you haven’t already done so) then click on Canada’s Evidence-Informed Healthcare Renewal Portal.

For more information about the EIHR Portal, join us for a Webinar:

September 13, 2012

• 11:30 a.m. – 12:30 p.m. EST (English)      Register Now
• 1:00 p.m. – 2:00 p.m. EST (French)            Register Now

or contact: Jennifer Campbell, Senior Advisor, Knowledge Translation, Canadian Institutes of Health Research Jennifer.campbell@cihr-irsc.gc.ca  / (613) 941-080​

​With over 80,000 hip and knee replacement surgeries performed annually in Canada an unprecedented collaborative effort is being made to help reduce preventable complications in hip and knee surgery.

The Canadian Orthopaedic Association National Standards Committee, the Canadian Institute for Health Information, Accreditation Canada, and the Canadian Patient Safety Institute have jointly developed a public position statement, Improving Safety and Outcomes for Canadians Undergoing Hip and Knee Replacement Surgery, which promotes the adoption of a surgical safety checklist prior to commencing surgery and submission of a minimum data set to the Canadian Joint Replacement Registry after surgery. The participating organizations are promoting the protocol, as it combines the safety checklist before surgery and data submission to the registry as part of the post-operative debriefing, to help hospitals to comply with mandatory accreditation standards that improve patient safety. 

The safety checklist requires that critical steps be completed for all surgical patients to confirm that the surgical team has taken preventative measures and is properly prepared for potential complications or emergencies.  Data submission to the joint replacement registry, which occurs electronically during the surgery, makes it possible to match patients with an implant should problems surface with a particular device. The cumulative data is helping clinical researchers to develop more effective evidence-based care and track the performance of different types of hip and knee devices.

The Canadian Joint Replacement Registry (CJRR) was launched in 2001, to provide information on the use, effectiveness, safety and outcomes of hip and knee replacement surgery in Canada; currently the registry captures data from about 45 per cent of hip and knee replacements. To improve patient safety and outcomes, the collaborating organizations are promoting full use of both the Surgical Safety Checklist and the Canadian Joint Replacement Registry by all hospitals performing hip and knee replacement surgery.

To download a copy of the Surgical Safety Checklist, visit www.patientsafetyinstitute.ca. Click here to download a copy of the position statement, Improving Safety and Outcomes for Canadians Undergoing Hip and Knee Replacement Surgery.  For more information, contact Doug Thomson, CEO of the Canadian Orthopaedic Association at (514) 874-9003, ext. 5.

The Northern Alberta Institute of Technology (NAIT) School of Health Sciences is bringing the Patient Safety Education Program – Canada (PSEP – Canada) to Edmonton.  The Become a Patient Safety Trainer education conference is being delivered in Alberta for the first time, as a pre-conference course to SIMFEST 2012: Celebrating Simulation in Health Sciences Education. SIMFEST 2012 and the PSEP - Canada pre-conference session is targeted for all healthcare professionals and educators who are interested in enhancing their use of simulation-based education as well as becoming a patient safety trainer.

The PSEP – Canada Become a Patient Safety Trainer education conference is a two and a half day train- the-trainer session being delivered by the Canadian Patient Safety Institute, in partnership with Northwestern University.  The pre-conference course, scheduled for May 28 to 30, 2012, is designed for all healthcare professionals, including clinical teams and individuals from local healthcare organizations, along with healthcare faculty.  With an emphasis on creativity and excellence in educational techniques, the PSEP – Canada program will prepare attendees to deliver a high-impact, comprehensive patient safety curriculum utilizing effective teaching approaches based on adult education methods to promote effective fundamental patient safety practices in their organization, and foster a culture of patient safety.  The $960 registration fee includes the train the trainer session, a full patient safety education curriculum in both hard copy and electronic format, trigger tape vignettes on DVD, case-based learning tools and customizable presentations for you to implement a patient safety program in your organization.

SIMFEST 2012: Celebrating Simulation in Health Sciences Education is a two-day conference for healthcare educators who want to further enhance and showcase their use of simulation-based education.  SIMFEST 2012 will be held at the NAIT South Learning Centre from May 31 to June 1, 2012. The program includes four world-class keynote speakers, several interactive workshops, poster and podium presentations, exhibitor/vendor booths and many great networking opportunities. Sessions will focus on human factors and stress, interprofessional education, debriefing and feedback, authentic assessment strategies, design, simulation research, teamwork and communication and much more! The early-bird registration fee for the two-day conference is very affordable at $150, which includes meals!  Daily registration is also available. 

For more information, or to register for the SIMFEST 2012 Conference and PSEP – Canada pre-Conference, visit www.nait.ca/simfest2012.  Click here for more information on the PSEP – Canada program.

​The Institute of Health Policy, Management and Evaluation (IHPME) at the University of Toronto, in consultation with the Centre for Patient Safety, have launched a Master of Science (Quality Improvement and Patient Safety).

The new MSc concentration in Quality Improvement and Patient Safety provides students with the opportunity to focus their research and learning on all aspects of improvement science, current issues in healthcare quality and safety and relevant leadership and influencing skills. The program is offered in a modular format to allow individuals to earn this research degree in one year without interrupting their careers. Apply now for the Fall 2012 program; applications are due by May 15, 2012.

The transdisciplinary curriculum provides a solid foundation in quality and safety improvement theory and research methods as they apply to the current Canadian healthcare context. Students will also explore best practices in implementing quality improvement and develop the necessary leadership and change management skills to lead improvement across the system. Key areas of study include:

• Improvement science theory and research methods
• Measurement methods and tools
• Best practices in implementing quality improvement and patient safety
• Systems thinking
• Theory and tools for leading change at the macro, meso and micro levels

The new concentration in Quality Improvement and Patient Safety links theory to practice. Students will lead and evaluate a sustainable quality improvement initiative within the workplace. 

The new MSc concentration in Quality Improvement and Patient Safety is designed for high performers who wish to develop their expertise and lead quality improvement research or initiatives within their organizations or the broader healthcare system, including:

• Early-career health professionals or physicians who are completing their residencies and looking for an area of specialty to advance their academic/research careers
• Mid-career physicians or health professionals (e.g., clinical managers, professional practice leaders, educators) with administrative responsibilities in acute care, rehab/CCC and community hospitals, primary care or long-term care facilities
• Mid-career administrators (e.g., program directors, VPs) within acute care, rehab/CCC and community hospitals, long-term care facilities, LHINs or CCACs
• Policy-makers/planners involved in quality improvement initiatives

Contact Elaine Aimone, Project Lead at e.aimone@utoronto.ca, for more information or to explore whether this degree is right for you.

​Adverse events create a significant economic burden on the Canadian healthcare system. In an effort to understand the true financial costs of preventable adverse events, extensive research has been conducted to examine the economics of patient safety in acute care. The Economics of Patient Safety in Acute Care report, to be released in May 2012, was funded by the Canadian Patient Safety Institute, 3M Health Care, and Baxter Corporation and led by principle investigators Dr. Edward Etchells, Associate Director of the University of Toronto Centre for Patient Safety and Dr. Nicole Mittmann of Sunnybrook Health Sciences Centre.

An article recently published in the BMJ Quality and Safety Journal, entitled “Comparative Economic Analyses of Patient Safety Improvement Strategies: A Systematic Review”, sets the stage for the release of the report, highlighting the results from the literature review of economic studies related to patient safety improvement strategies.  The full report provides more detail on the methods used in the study and explains the concepts associated with economics research.

The Economics of Patient Safety in Acute Care report includes:

• Estimates of the total economic burden of patient safety in acute care in Canada in 2009/2010.
• Preliminary estimates of the cost of safety issues, including the cost per case of:
• Hospital-acquired infections (including nosocomial bloodstream infections);
• Nosocomial falls;
• Clostridium Difficile-associated Disease (CDAD);
• Methicillin-Resistant Staphylococcus aureus (MRSA infections);
• Vanconmycin-Resistant Enterococci (VRE); and
• Surgical Site Infections (SSI).
• Guidelines and a framework for performing or assessing economic research in patient safety.
• Recommendations for future research in the economics of patient safety.

The report reinforces the need to continually evaluate the costs of adverse events to the entire healthcare and social system; however, more importantly it strongly advocates conducting methodologically sound research to determine the best interventions and strategies for improving patient safety.

For more information on the Economics of Patient Safety in Acute Care report, visit www.patientsafetyinstitute.ca

​Implementing a patient safety education program at The Credit Valley Hospital and Trillium Health Centre is key to enhancing patient safety culture, and the Patient Safety Education Program ‒ Canada (PSEP ‒ Canada) is the tool that has been deployed to develop solutions and strategies for widespread changes that are mindful of and improve patient safety.

The patient safety education program is being offered at two Trillium sites in two concurrent streams:  Lunch and Learn workshops that are open to all staff and PSEP – Canada Ambassador training sessions for a targeted group of 45 individuals across the organization.  The PSEP ‒ Canada materials form the foundation of these two streams.  The program is delivered by Dr. Amir Ginzburg, Physician Director, Patient Safety and Quality at the Trillium site, who is a PSEP ‒ Canada Master Facilitator, and an inter-professional team from Trillium that are certified as PSEP ‒ Canada Patient Safety Trainers. The train-the-trainer program is taking hold and staff are using their PSEP ‒ Canada training to deal with difficult issues, develop feedback mechanisms, improve communication and promote critical thinking.

Elena Holt, Manager of Cardiac Surgery, is one of Trillium’s inaugural PSEP – Canada Ambassadors, a term used to describe the end-users from Trillium’s local deployment of PSEP ‒ Canada.  Holt says that the patient safety education program provides an opportunity to be interactive with her staff and the immediate feedback she has received is that it has effectively filled an educational gap.  “This is a relatively new role for me and some of the staff is also new.  We have the opportunity to tap into the PSEP knowledge and bring it to the frontline staff.  We just trained about 50 staff from our cardiac surgery ward specifically around patient safety and they just loved it. They are now talking about patient safety, really engaged in it and asking for more.  Our department is going through a number of significant changes and this opportunity to be interactive around patient safety really inspired our staff during a time when they may have buckled under pressure from everything that they are going through.  It brings them back to why they came into healthcare and provides a framework that they use in their day-to-day work to enhance the patient experience.”

Heather Ead, Surgical Clinical Educator and a Trillium PSEP – Canada Ambassador has been able to very quickly deploy many of the PSEP – Canada core concepts in real world situations.  “A few days after our session on medication safety and human factors an opportunity came up in an improvement initiative to use the information I learned.  I was able to bring new ideas and enhance the implementation of safe medication practices on my ward,” says Ead.  “The frontline really can give you valuable information and are very open to tell you when something is not working well.  When you give them information to reframe their concerns using a patient safety lens, it empowers them and reinforces that they should and can speak up; changes can be made.  It changes the culture.”

Suzi Laj has been a clinical nurse educator for about five years and recently transitioned to a Quality and Patient Safety Advisor role.  “The Patient Safety Education Program – Canada really makes you look at things differently.  When I am facilitating a workshop for the PSEP Ambassadors, I want them to be able to take both a retrospective and prospective look at potential safety issues and risks so that they can make a change before we have an adverse event.”  

As the Inter-Professional Coordinator for medical learners, Laj is also taking modules of the PSEP – Canada  curriculum to present at a four-hour workshop on patient safety to undergraduate students from the University of Toronto in May 2012.  The workshop topics will focus on communication and teamwork, gaps in patient safety and partnering with patients.  Laj says that the PSEP ‒ Canada format and materials met all of the criteria to be accredited as an interdisciplinary education program.

One of the sessions offered in the patient safety education program is focused on communication and teamwork to reinforce direct, consistent information transfer between healthcare professionals.  “Nursing and allied staff sometimes see things quite different from physicians,” says Dr. Ginzburg.  “Communication at two in the morning or in high stress circumstances can often be challenging.  The participants learn structured communication techniques and use case-based scenarios and role play with a physician in a safe environment to solidify the concepts.  Participants have told us they feel more confident in their ability to effectively communicate across professional silos when those phone calls need to be made for the safety of the patient.  The opportunity to practise with a physician has been a great opportunity and very empowering.” 

“Patient safety is not a just a nice thing to do, but the way we should be thinking all of the time,” says Dr. Ginzburg.  “It is more than patients being safe; as an industry we are opening our eyes to recognize that enhancing patient safety is a core value in how we deliver healthcare and a state of patient safety mindfulness needs to be part of our everyday clinical practice.  We feel we are on the right track with our patient safety education program and we hope to have some innovative and impactful results to share in the future.”

This article is the second in a series on the Patient Safety Education Program – Canada, to highlight how healthcare organizations have adapted the curriculum to advance the culture of patient safety.  Click here for more information on PSEP ‒ Canada or visit www.patientsafetyinstitute.ca

​Patient safety is viewed as everyone’s role at The Credit Valley Hospital and Trillium Health Centre, located in the Mississauga-Halton Local Health Integration Network (LHIN). The Trillium Health Centre site is using the Patient Safety Education Program ‒ Canada (PSEP ‒ Canada) to bring patient safety education into the clinical domain and plant the seeds to enhance their patient safety culture.

Dr. Amir Ginzburg, Physician Director, Patient Safety and Quality at the Trillium Health Centre site became a PSEP ‒ Canada Master Facilitator in 2010. Over the last year, members of an interprofessional team from Trillium were certified as PSEP ‒ Canada Patient Safety Educators to build the resources needed to launch a patient safety education program locally.  Based on a needs assessment to identify high yield educational opportunities, a 14-hour curriculum was developed that is being delivered in two different streams in a concurrent timeframe. 

The first stream is a series of Lunch and Learn sessions open to all staff, where the curriculum is being offered in 45-minute to one-hour sessions; the second stream is the development of a cadre of 45 PSEP ‒ Canada Ambassadors from across the various health systems at Trillium, to whom the course is deployed in three half-day sessions over a four-month period.   During Canadian Patient Safety Week in November 2011, the PSEP ‒ Canada program was launched at two Trillium Health Centre sites, located in Mississauga and West Toronto.

“We have reached about 300 people in the organization thus far and it has snowballed in an organic way that is very exciting,” says Dr. Ginzburg. “There has been a lot of peer-to-peer spread reinforcing that this education is of high value.  We are using techniques aimed at adult learners and our staff are walking away from the sessions with two or three usable concepts that translate into changes in behaviour and practice.”

Dr. Ginzburg says that the amount of energy and planning that goes into rolling out the curriculum is quite significant. They ensure that the information presented is appropriate for the diverse inter-professional experiences of their participants; and when delivering the program they try to blend different teaching styles every 15 to 20 minutes to reach adult learners where they live.  “A lot of preparation goes into making this work, both for the organization as a whole and for the outcomes we are expecting to materialize, but also to make it a high quality event for the participants and the learners,” says Dr. Ginzburg.

The Lunch and Learn sessions, held twice per month, are attracting 35 to 60 people at the Mississauga site and another 20 to 30 at the West Toronto site.  Topics have included gaps in patient safety, patient safety and leadership, organizational culture, patients as partners, human factors, medication safety, falls, teamwork and communication, and the effects of technology on patient safety.

The Trillium PSEP ‒ Canada Ambassadors come from each Health System within the organization and are being trained to act as a safety net for the entire organization.  “The robust PSEP ‒ Canada accordion curriculum provides enough material to really galvanize interest,” says Jo-Anne Copeland, Quality and Patient Safety Advisor. “You have trigger tapes to help spark some of the topics and discussion, as well as some creative interactive tabletop exercises to choose from.  The PSEP ‒ Canada materials provide a good core to start with, so that you can pick and choose and customise it to reach your audience. You certainly see a difference using the adult education model as it gives you several different tools for people to learn from and there is significantly more interaction.  As a presenter, it helps me keep it fresh for the participants.”

Sonya Pak, Director of Quality and Patient Safety, reinforces that physician engagement upfront is critical to the success and rollout of their education program.  “Trillium has the luxury of having Dr. Ginzburg as a Master Facilitator and that has been extremely helpful,” says Pak.  “Having physician leadership that is visible as an educator and someone we can bounce ideas off just enriches the program.”

Pak says that the program has surpassed their expectations. “The conversations that have emerged from the PSEP – Canada Ambassador program and the Lunch and Learn workshops have been very stimulating. And we are now doing things on the frontline to move in a positive direction and advance the culture of patient safety.”  

The program educators are now looking at ways to sustain the momentum and use the training materials throughout the entire organization.  The focus moving forward is to put the right structure behind those that have been trained to ensure that they are supported to continue the culture change that has been initiated.  During Canadian Patient Safety Week 2012 this fall, the PSEP ‒ Canada Ambassadors will be asked to share their stories through poster or verbal presentations on what they have done in their respective areas based on the knowledge gained through the PSEP ‒ Canada program.

“We are looking for peer-to-peer spread of the concepts and some of our ambassadors are motivated to provide in-services on the wards to their colleagues or other staff,” adds Dr. Ginzburg.  “We plan to do walk-arounds with middle and senior leaders to showcase the lens that the ambassadors are now bringing to their care areas and to deal with safety issues in real time.  PSEP ‒ Canada is the vehicle that we feel will help take our patient safety culture to the next level.”

This article is the first in a series on the Patient Safety Education Program ‒ Canada to highlight how healthcare organizations have adapted the curriculum to advance the culture of patient safety.  Click here for more information on PSEP ‒ Canada or visit www.patientsafetyinstitute.ca

The Canadian Patient Safety Institute and Safer Healthcare Now! congratulates the winners of the British Columbia Patient Safety and Quality Council (BCPSQC) Third Annual Quality Awards.

“We are pleased to recognize the efforts of the BCPSQC Quality Award winners for their efforts in improving medication reconciliation practices and preventing venous thromboembolism,” says Hugh MacLeod, CEO, Canadian Patient Safety Institute.  “On behalf of the Canadian Patient Safety Institute and Safer Healthcare Now! we applaud the leadership and passion of these healthcare providers for their efforts in implementing positive, sustainable changes to advance patient safety across the BC healthcare system.”

The Across the Province Award recipient is the British Columbia Provincial Renal Agency.  Using the clinical information database (PROMIS), the 13-member team implemented medication reconciliation for all dialysis patients in BC, preventing miscommunication and improving care to patients. The project was led by Dan Martinusen, Clinical Pharmacy Specialist – Nephrology, Royal Jubilee Hospital, BC Provincial Renal Agency.

The runner-up was the BC Venous Thromboembolism (VTE) Prevention Collaborative.  This mentored quality improvement implementation project is designed to optimize VTE prevention for hospitalized patients across BC.  The combined percentage of appropriate prophylaxis has increased from 58 per cent to 93 per cent, according to the program’s audit strategy. The award was presented to the leadership team, including Dr. Steve Ligertwood (Fraser Health Authority), Dr. David Wilton (Vancouver General Hospital) and Dr. Rod Tukker (Vancouver General Hospital), along with the representatives from the 11 participating sites.

Launched in 2009, the awards program recognizes individuals, healthcare teams and facilities that have implemented measures, or engaged in initiatives to improve the quality of care in BC.  Click here for more information on the British Columbia Patient Safety and Quality Council Third Annual Quality Awards.

The Client Safety Learning Event was adapted from the Effective Governance for Quality and Patient Safety Program, which recognized client needs in the community across the healthcare continuum.  This learning event, delivered for the first time in November 2011, was designed for board members of healthcare organizations and their leadership teams to improve quality of care, healthcare system performance and client safety through the use of evidence. The Canadian Patient Safety Institute (CPSI) worked with an advisory committee to customize and adapt the core program to meet the needs of the community sector, adding pragmatic tools and examples of innovative practices from the community experience to the already extensive program materials.

In November 2011, the Mississauga Halton Community Care Access Centre (MH CCAC) joined forces with the Metamorphosis Network (an independent network of community support service providers and mental health and addiction agencies in Central Ontario) and the Canadian Patient Safety Institute, to deliver the Effective Governance for Quality and Client Safety Program as an education stream at the Metamorphosis Annual Conference.  The one and a half-day workshop, funded by the Mississauga Halton LHIN, drew 64 participants from 29 organizations from the Local Health Integration Networks (LHIN) of Mississauga Halton and the Central West.

During the workshop, the participants learned about concepts, tools and resources to advance their governance efforts to improve quality and client safety; and they developed a next step Action Plan.  The key focus of this planning exercise was to identify strategies, tactics and governance practices that will influence enhanced effective governance for safer, quality client services at the board table.  The EGQPSP toolkit, customized workbook, GAP analysis tool and Action Plan provides participants with a varied selection of knowledge transfer strategies. T he participants were encouraged to take the learnings and materials to their next board meeting.

“The program team from CPSI, the core program peer facilitators and the advisory committee worked very hard to customize materials that would be relevant for the community sector and the feedback from the conference participants was extremely positive,” says Jutta Schafler Argao, Vice-President, People, Quality and Planning at the Mississauga Halton CCAC and one of the key organizers of the workshop. “The materials resonated with the participants and the spirited discussion made the topics come alive. There was a lot of positive energy in the room and the board members and senior management left the workshop with renewed energy for the challenging work that they do.” 

Jutta attended the workshop along with the CEO and seven board members from the Mississauga Halton CCAC. “Our board and senior team are highly focused on quality and it is part of our strategic plan,” says Jutta.  “Our Action Plan developed at the workshop focused on advancing the quality and client safety journey that our board has been on and it served to validate the work that was already in progress.”

Working with partners for greater collaboration and synergistic services planning was one of the topics indentified in the Mississauga Halton CCAC Action Plan and there have been subsequent conversations on how that might occur.  Following the November workshop, the Metamorphosis Network and the Mississauga Halton CCAC developed a local leadership partnership to continue the governance for quality and safety agenda. Management of the Metamorphosis Network and the Central West and Mississauga Halton CCACs met in December 2011 for a half-day planning session, reviewing strategic plans to look at areas of collaboration and how they could leverage their work.

“To have the community sector develop common quality measures, engage in cross-board conversations and develop activities to guide the work to achieve common measures, whether it relates to issues like falls or interdependencies, adds a lot of value that goes beyond the community healthcare sector,” says Jutta. “Over the next few months we will be delving into what that might look like, what are the measures and how to put in place measurement and quality improvement capabilities that would be required. If community healthcare is coordinated and when measuring quality outcomes are aligned with the provincial healthcare focus on quality, patients /clients and families really benefit. Ultimately, the goal is to have the community and the acute care sector working together to align resources and deliver results that achieve the best results for patients /clients.”

Click here for more information on the Governance for Quality and Patient Safety Program. To arrange for the Governance program to be delivered to your board and senior management, send an email to governance@cpsi-icsp.ca

​The Canadian Patient Safety Institute (CPSI) and Queen’s University School of Nursing and Department of Anesthesiology and Perioperative Medicine, Faculty of Health Science joined together to offer the Patient Safety Education Program (PSEP – Canada ) Become a Patient Safety Trainer conference at Queen’s University in Kingston, Ontario in January 2012. 

The PSEP-Canada conference-based education program uses a curriculum-driven approach. The adaptable curriculum has been built to educate participants on both patient safety and quality content and how to disseminate it.  This train-the-training team approach is grounded in adult learning theory and embedded in social structures to facilitate behaviour change. 

 “For the first time, we offered a classroom to practice learning event where academics who are expert in this content interfaced with clinical teams from local healthcare organizations,” says Abigail Hain, Acting Director of Education for the Canadian Patient Safety Institute. Participants included 19 representatives from five hospitals and 28 faculty members from Medicine, Nursing, Health Sciences and Rehabilitation at Queen’s University.

“I do feel we now have a critical mass in the university and in our Local Health Integration Networks (LHIN) to make patient safety initiatives happen and become part of everyday business,” says Jennifer Medves, Director School of Nursing and Vice-Dean Health Services at Queen’s University. “The PSEP – Canada  Conference is a first step to develop healthcare professionals for the future who understand the complexity of patient safety and become advocates for quality care that keeps the safety of patients central to our care.”

Dr. Charles T. Low, an Anesthetist at Brockville General Hospital attended the conference and was inspired by the two and a half day program. “I’m very energized and can’t stop thinking about it,” says Dr. Low.  “... I am so much closer to being able to help guide others back at home in a positive direction.”

Dr. David Goldstein, Associate Professor, Department of Anesthesiology and Surgery at Queen’s University-Kingston General Hospital says the program will help save Canadian lives: “We are now moving forward to use this experience to guide curriculum design for student health professionals, as well as those at the sharp end.”

The PSEP – Canada  curriculum and dissemination method, originally developed by Northwestern University by American and International patient safety experts, has undergone extensive customization by Canadian safety experts for the Canadian healthcare provider audience.  For more information or to schedule a conference in your area, visit www.patientsafetyinstitute.ca, or send an email to psepcanada@cpsi-icsp.ca

CPSI applauds the Canadian Association of Gastroenterology 

​The Canadian Association of Gastroenterology (CAG), in partnership with the Canadian Partnership Against Cancer (CPAC) and the Canadian Institutes of Health Research (CIHR) has developed the Consensus Guidelines on Safety and Quality Indicators in Endoscopy to promote greater safety and quality in endoscopic services to Canadians. There are more than 1.6 million endoscopic tests performed in Canada every year.

“We applaud the leadership of the Canadian Association of Gastroenterology in developing these guidelines that promote patient safety for Canadians undergoing endoscopic tests,” says Hugh MacLeod, CEO of the Canadian Patient Safety Institute (CPSI).  “Patient safety transformation is a collaborative effort and we acknowledge the work of the CAG in the collective task of improving patient safety.”

“If one looks at endoscopy service delivery, particularly from a patient point of view – which is access to services, rapid access, high quality services, feedback and an ability to respond to how they perceive endoscopy service delivery, there really was nothing in place,” says Dr. David Armstrong, Chair of the Endoscopy Committee and the Consensus Guideline Committee. “These guidelines say what should be monitored and what processes have to be in place from a patient point of view. The Consensus Guidelines provide the framework for quality improvement programs to monitor how services are delivered.”

The Consensus Guidelines were developed by a group of 35 Canadian, European and U.S.-based participants, who reviewed more than two decades worth of research to develop 23 evidence-based recommendations that address quality and safety indicators, quality assurance, training and credentialing and ethics in endoscopy.  Focus groups and patients in Calgary, Hamilton and Montreal were also involved in reviewing the Consensus Guidelines.

The new national Consensus Guidelines will provide those who deliver service with new ways to measure and benchmark practices.  The Canadian Association of Gastroenterology will work with its members, its partner the Canadian Partnership Against Cancer, provincial gastroenterology associations and other stakeholders to promote broad implementation of the Consensus Guidelines across Canada. 

For more information visit the Canadian Association of Gastroenterology website,  www.cag-acg.org.

Effective teamwork and communication are critical for the safe delivery of health care. The Canadian Framework for Teamwork and Communication is now available as a resource to help decision-makers and healthcare providers select a course of action to support teamwork and communication within their organization. Components of the framework include the following:

• comprehensive literature review of effective teamwork and communication in Canada and internationally;

• results of a needs assessment to understand the status of teamwork and communication within Canadian healthcare organizations;

• review of teamwork and communication training programs, providing a high level overview of the purpose, content, methodology, learning principles, expected outcomes and applicability to the general Canadian healthcare context; and

• synopsis of key lessons learned through consultation with national and international quality and patient safety experts, for improving knowledge of teamwork and communication in healthcare.

Effective teamwork and communication in safe patient care is an essential and ongoing process. It requires cultural change within an organization to sustain the knowledge, skills and attributes that are the key elements of effective teamwork and communication.  Good communication is defined as the accurate and unbroken transmission of information that results in understanding and teamwork is defined as the interaction or relationship of two or more health professionals who work interdependently to provide care for patients.  This framework is a starting point to encourage conversation that will ultimately transform discussion to action, creating a culture of safety to support the safe delivery of patient care.

The Teamwork and Communication Working Group, comprised of quality and patient safety leaders and experts, was formed in 2009 to develop the framework for effective teamwork and communication to advance patient safety. The Working Group was co-chaired by Jane Mann, Quality Improvement and Patient Safety Consultant, Fraser Health (Vancouver, BC) and Cathy O’Neill, Director of Quality and Patient Safety, Quinte Health Care (Belleville, ON). The Canadian Patient Safety Institute provided secretariat and funding support to the Working Group.

Visit www.patientsafetyinstitute.ca for more information, or click here to download a copy of the Canadian Framework for Teamwork and Communication.

​How do you ensure that the information you are presenting is engaging to your audience?  That is the challenge that inspired Barbara Saunders, Managing Consultant of Operational Improvement and Accreditation, Quality Improvement and Patient Safety at Fraser Health in lower mainland British Columbia to sign up to become a Master Facilitator for the Patient Safety Education Program (PSEP-Canada).  Barbara is one of the 23 PSEP-Canada Master Facilitator’s helping healthcare professionals become Patient Safety Trainers and guide patient safety education in their home organization.

When Barbara first learned about PSEP-Canada, Fraser Health was developing an educational framework for quality and patient safety that would include formal education, online learning and self-directed learning.  “We were trying to develop a more comprehensive and effective approach as to how we were providing coaching and education, says Barbara. “The PSEP-Canada caught my eye because it focused on adult learning principles. I’ve worked in the quality and patient safety field for many years, so it was not the content of the program that was appealing, rather it was the style in which the program was being delivered and the skills that I would be able to learn to do a better job of providing an environment that would foster that learning.”

Barbara says that it took a while to realize what was different about the PSEP-Canada program. When she signed up to become a Master Facilitator, she thought she was going to learn adult learning principles in a more traditional way: “As Master Facilitators, I think all of us were a little confused at first, because we saw the curriculum being taught in a non-linear way and we didn’t at first appreciate that the impact of the program is not only content, but the purposeful manner in which it is delivered. It took us a bit of time to make sense of what was being presented to us. What we quickly came to realize was that it not about the content of the curriculum, it is about learning how to convey that to others in a way that will support them to adopt, to learn, and to apply. The curriculum provides the core content, but it is the method of acquiring that makes the PSEP-Canada program unique. It is a way of presenting any material that will enable the learner to make sense of it, to shift their attitude, to acquire new knowledge, and to practice their development of new skills.”

The PSEP-Canada program provides a comprehensive way of encouraging, assisting and supporting people to adopt and apply learning to their situation that will change behaviours, change the way  healthcare services are structured and delivered, and change the outcomes that patients, families, residents, clients will experience for the better.  “That whole change will shift our healthcare system to be more effective and safe,” adds Barbara. “That is what makes the PSEP-Canada program different from other educational programs.  It is creating this cadre of leaders at two levels, master facilitators and trainers who are capable facilitating, coaching, mentoring, and assisting healthcare practitioners to move toward a more effective, efficient healthcare system that is truly supporting patient outcomes and a culture of safety and quality improvement.”

To learn more about the PSEP-Canada program, or to bring the program to your area, please visit the Canadian Patient Safety Institute website, or email: psepcanada@cpsi-icsp.ca.

​The Ottawa Hospital is a large academic centre with two tertiary care campuses, the General and the Civic, each with about 500 beds. Four units across the continuum of care (including intensive care, main operating room, geriatric assessment unit and surgical ward) were selected to participate in a pilot project to use the CPSI Safety Competencies to create a culture of patient safety. A modular training program was later developed, in part using the Patient Safety Education Program (PSEP-Canada), centered on two of the Safety Competencies: creating a culture of patient safety and communications and Teamwork. About 80 staff were trained and participants completed a patient safety cultural assessment prior to and at the end of the training program. 

 “We looked for the statistical difference in where they thought they were in terms of core patient safety knowledge and concepts before and again after the sessions,” says Linda Hunter, Director, Quality and Patient Safety, The Ottawa Hospital.  “At the same time we monitored patient safety indicators particular to their domain of work over the entire year of the project.  What we are trying validate in our hypothesis is that education, coupled with mentoring, training, real life practicality and doing an initiative for quality and patient safety will over time engrain measureable change in the patient safety culture at the unit level. Results from the initial patient culture assessment will be compared to confirm if there is a change and if it is sustained.”

An eight-hour patient safety training program was developed, which includes six modules, each varying from 30 to 90 minutes.  The sessions include a general introduction to patient safety, what is patient safety, patient safety competencies, an introduction to quality improvement measures, teamwork, and communications.  All presentations, with the keynote address and video vignettes, have been posted to the hospital’s InfoNet for staff to access. 

Hunter completed a literature review and also used the PSEP-Canada material to develop the learning modules:  “Organizations are very well-intentioned, but have limited time for preparation for just-in-time education. PSEP-Canada is excellent to use as a basis for education materials as the pre-work is already completed. The role-playing and modelling games, vignettes and CDs, information on PowerPoint rather than PDF so that one can pull what is pertinent is extremely valuable.” 

“It is very important to align a program to how the organization looks at quality and patient safety,” adds Hunter.  “Our program supports our quality framework, our definition of quality, and other initiatives we are doing so that staff see the practicality.  We had created a plan for patient safety education prior to incorporating the PSEP-Canada into our program and it was interesting to see how the work aligned.  We had the idea, we had the plan, but we did not have the resources to implement.  PSEP-Canada provided the ability to develop internal capacity and get more staff trained to understand that patient safety is a science and with sound understanding behind that we can create a culture of patient safety.”

Hunter has completed both the Patient Safety Officer Course and the Patient Safety Education Program. “The PSEP program is very strong in facilitating and understanding the instructional techniques of being a train-the-trainer, however there are basic concepts that you need to learn first.  The Patient Safety Officer Course teaches core competencies and it is important to have staff in your organization who understand the concepts of patient safety. If you don’t have anyone in your organization trained to be a Patient Safety Officer, have them take that course first,” advises Hunter.  

Click on the link for upcoming sessions and more information on the PSEP-Canada program.

​A revised draft version of the Canadian Root Cause Analysis Framework, provisionally titled the Canadian Framework for Managing Patient Safety Incidents (Framework) is now available for stakeholder input. 

Two national webinars have been scheduled to outline the changes to the Framework and launch the open consultation. An English session will take place on Tuesday, November 22nd and a French session on Thursday, November 24, 2011 from 12:00 pm to 1:30x pm EST.  Click here to register.

A survey will be sent to those that participated in the national webinars and other stakeholders to gather input and feedback on the draft Framework. A survey report will be compiled by the end of the year and this information will be used to finalize content for the new Framework.  The Canadian Framework for Managing Patient Safety Incidents will be released in early 2012.

This Framework is a resource designed to support organizational learning and quality improvement. It is intended to help individuals and organizations across the healthcare continuum determine, prioritize and manage the factors that contribute to a patient safety incident, develop and implement more robust and precise recommended actions, evaluate outcomes, and share learning for system improvement.

Key enhancements to the Framework will:

• Replace the term “root cause” with “contributing factors”, to better reflect how incident analysis fits with other activities surrounding a patient safety incident.
• Introduce concepts related to complexity and interconnections that better reflect the realities of the current healthcare system.
• Provide two methods for analysis of individual incidents (concise, comprehensive) and two methods for analysis of multiple incidents (cluster and aggregate) to allow effective use of limited resources dedicated to incident analysis.
• Offer guidance on how to effectively develop, synthesize, prioritize and manage recommended actions across the organization to ensure those with the most impact are being implemented.

Under the guidance of the Canadian Framework for Managing Patient Safety Incidents Working Group, a draft Framework was created and initial consultations have taken place with Canadian experts, including healthcare leaders, Deputy Ministers, patient safety and quality improvement professionals, and patients and families. The feedback and recommendations received have been integrated into the revised draft of the Framework.

This is your opportunity to provide feedback!  We value your input and look forward to hearing your thoughts on the revised Framework through the survey.  For more information on the Framework, webinars and the survey, contact Ioana Popescu ipopescu@cpsi-icsp.ca.

The Canadian Patient Safety Institute (CPSI) and the Canadian Health Services Research Foundation (CHSRF) are recipients of the Ted Freedman Award for Innovation in Education, recognizing their work in Effective Governance for Quality and Patient Safety.  This prestigious award recognizes organizations that inspire, advocate and enable education in health, health services and healthcare management.  The Award was presented during the Health Achieve 2011 Conference in Toronto on Wednesday, November 9th.

“It is truly an honour to be recognized for our efforts to create and sustain pan-Canadian governance capacity that drives continuous improvement in patient safety,” says Hugh MacLeod, CEO, Canadian Patient Safety Institute. “This initiative was a first of its kind in Canada and has become a valuable resource for healthcare governing boards and senior leaders in supporting organizational efforts to improve quality and patient safety.”

To ensure the Effective Governance program resonates with a wide reach across various organizations and regions, CPSI and CHSRF have partnered with others, including the Ontario Hospital Association (OHA) and the Ontario Ministry of Health and Long-Term Care, who were responsible for bringing the program to Ontario to help hospitals meet the legislative requirements of Excellent Care for All Act in Ontario. Through the involvement of CPSI’s valued partners, the program is customized and tailored for a range of contexts and sectors.

The Effective Governance for Quality and Patient Safety program, which includes an education session and toolkit, helps boards and senior leaders to understand and support front-line patient safety related activities, and develop a board quality and patient safety plan that builds on successes and aligns patient safety efforts across the organization. Commissioned research led by Dr. G. Ross Baker (2010), Effective Governance for Quality and Patient Safety in Canadian Healthcare Organizations, identified a number of interdependent drivers that enable boards to fulfill their responsibilities for quality and patient safety. That framework formed the basis for the Effective Governance for Quality and Patient Safety initiative and the Governance toolkit and education sessions were then developed, providing strategies and tools that foster accountability and improve patient safety practices. 

The Effective Governance for Quality and Patient Safety program is offered in partnership with health regions and organizations. If you are interested in bringing the program to your area, please contact governance@cpsi-icsp.ca or visit www.patientsafetyinstitute.ca for more information and to access the online toolkit.

The Ted Freedman Award for Innovation in Education, created in 2000, is presented annually by the Ontario Hospital Association and Healthcare Quarterly. The award recipient is selected by an independent panel led up Dr. Louise Lemieux-Charles from the Department of Health Policy, Management and Evaluation, University of Toronto. 

​

Canada’s Virtual Forum on Patient Safety and Quality Improvement, held in conjunction with Canadian Patient Safety Week, adopted the theme ASK. LISTEN. TALK in the fifth and final session, to promote good communications in healthcare.  The Forum reached out to more than 2,000 unique registrants at more than 700 sites in Canada and 17 countries around the world, with 428 tonnes of CO2 emissions saved by participating virtually.

Hugh MacLeod, CEO, Canadian Patient Safety Institute applauded and thanked everyone for their participation and commitment to patient safety and showcased the passion and activities during Canadian Patient Safety Week.

Friday’s session featured presentations focused on patient safety research, safety in home care, and suicide risk prevention. Chris Perlman (Homewood Research Institute) reviewed a suicide risk assessment guidebook and framework developed for Canadian healthcare organizations.  This is a joint initiative of the Canadian Patient Safety Institute and the Ontario Hospital Association.  Diane Doran (University of Toronto Faculty of Nursing) described the Pan Canadian Home Care Study and the five sub-projects that will inform the learnings of patient safety in home care.

Dr. Doug Cochrane (British Columbia Patient Safety and Quality Council) and Stéphane Robichaud (New Brunswick Health Council) provided an overview of their respective Quality Councils and the panel discussion centered on where future funding and research priorities should be directed. Dr. Dave Williams (Southlake Regional Health Centre) used the metaphor of a space environment to reinforce that normalization of deviants and a culture of safety is critical for both space programs and healthcare. The panel agreed that a different approach and an inter-professional model is required to enhance a culture of safety.

Regis Blais (University of Montreal) provided an overview of research studies in progress and proposed areas and opportunities for future research that will address knowledge gaps in patient safety; the presentation was delivered in French.

During the week, 14 hand hygiene videos were profiled as a fun and creative way to promote good hand hygiene.  It was a close race and the winner of the Hand Hygiene Video Competition was the SICK TEAM (Thunder Bay Regional Health Sciences Centre), with Mrs. A (Chatham-Kent Health Alliance) receiving the most likes on Facebook for their video presentation.  At the close of the competition, 1,025 votes were cast, 1080 comments posted, and the videos were viewed over 2900 times on Facebook and 550 times on YouTube.

The Virtual Forum highlighted some of the work that is underway in patient safety, including disclosure, education, engagement, medication safety, infection control, just culture, research, hand hygiene and more.  The poignant and emotional patient narratives set the tone for each day as participants learned about the patient experience and the importance of including patients and their families in the patient safety agenda. MacLeod acknowledged the individuals for their courage to tell their personal stories and their commitment to improve safety for all patients.

The Virtual Forum closed with a commitment to take the insight and learning from the five-day program and continue the conversation. Hugh MacLeod encouraged participants to use the information to spread the word and push the patient safety and quality improvement agenda forward. The Forum ended with a two-minute video on hope that sets the stage for advancing patient safety and quality improvement.

Copies of all presentations are available to view and download at the Canada’s Virtual Forum website.   Send us your thoughts on the Forum – what resonated most with you and what you would like to know more about; and tell us your patient safety and quality improvement stories.  Send an email info@cpsi-icsp.ca. 

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​The program for the fourth day of Canada’s Virtual Forum on Patient Safety and Quality Improvement showcased presentations on infection control, hand hygiene, just culture and healthy workplaces.

Dr. Michael Gardam (University Health Network) opened the day with a profile of results from a Canadian Patient Safety Institute funded study of using positive deviance to decrease healthcare associated infections. He stressed the importance of using positive outliers that already have the answers to complex problems to address patient safety issues. The Vancouver Island Health Authority is using a risk-based approach to infection prevention to improve access, patient  flow and patient dignity; Martin Wale shared how the results of a pilot project have been implemented island-wide and the sustainable cost savings that have been achieved. Mark Wells, AUPE presented clips from a “Superbugs” video that illustrates the importance of a team approach, how cleaning staff are an important element in infection prevention and control, and that employee stability and engagement translates into better patient outcomes.

Creating a just and trusting culture in healthcare is a daunting task and Mark Fleming (Saint Mary’s University) provided some helpful tips on how to bring healthcare teams on board. He challenged all healthcare teams to use the patient narratives as a valuable learning tool to reflect on their own team culture, how they would do things differently and any barriers for improvement.

Dr. Denny LaPorta (Jewish General Hospital) looked at the challenge of implementing hand hygiene programs, outlining how to empower staff, engage leadership, measure, and provide feedback; the presentation was delivered in French; slides will be available in English.

Other presentations focused on work and care. Patsy Smith (Capital Health) explored safety issues and concerns outlined in the Patient Safety in Primary Care in Canada research report that looked at solutions and strategies and the impact of expanding collaborative teams in primary care. Lisa Ashley (Canadian Nurses Association) discussed findings from research on nurse fatigue and patient safety.  Pamela Fralick (Quality Worklife Quality Healthcare Collaborative) highlighted the work of the Collaborative and the continuing need for a focus on healthy healthcare workplaces. This initiative is an invaluable resource for change management and knowledge exchange.

An overview on the Safer Healthcare Now! interventions and the Patient Safety Metrics measurement tool were provided, with an invitation to join upcoming virtual learning opportunities.

It’s not too late to join the conversation! Click here to join for the final day of the Virtual Forum to hear courageous patient narratives, interactive presentations, and thought-provoking discussion. Questions and comments are encouraged; send an email to info@patientsafetyinstitute.ca.   

“The Patient Safety Officer Course teaches core competencies and it is important to have staff in your organization who understands the concepts of patient safety. If you don’t have anyone in your organization trained to be a Patient Safety Officer, have them take that course!” -- Linda Hunter. Director, Quality and Patient Safety (The Ottawa Hospital)  

The Canadian Patient Safety Institute and the Canadian Healthcare Association (CHA) are partnering to deliver two sessions of the Canadian Patient Safety Officer Course in 2012.  The four-day course is targeted to professionals and leaders who understand the fundamentals of patient safety and have a formal responsibility for disseminating patient safety principles and programs throughout their organization.

Providing information, tools and techniques to advance leading patient safety practices and build a strong patient safety culture in your organization, the course includes interactive workshops, case studies, teambuilding activities, networking, reflective analysis and coaching by patient safety leaders.  Emerging topics in patient safety will be examined and participants will acquire the skills to:

• Build on basic notions of patient safety and safety culture;
• Define measurement tools and indicators;
• Create, implement and maintain a rigorous and focused patient safety program within their organizations;
• Develop detailed, customized patient safety strategies and implementation plans; and
• Incorporate patient safety concepts into their inter-professional curriculum.

Courses will be held in Vancouver, British Columbia from February 21 to 24, 2012 and Ottawa, Ontario from April 24 to 27, 2012. 

Book early to reserve your seat! Early-bird registration at a discounted rate of $3500 is available until January 10, 2012 for the Vancouver session, or March 1, 2012 for the Ottawa session; the registration fee after those dates is $3900. Register Now!

For more information, visit www.cha.ca or www.patientsafetyinstitute.ca , or send an email to safety@cha.ca

​It was National Medication Safety Day at Canada’s Virtual Forum on Patient Safety and Quality Improvement with sessions focused on medication safety across transitions of care during the third of the five-day virtual program. 

Medication Reconciliation Co-leads Canada, Marg Colquhoun (ISMP-Canada) and Marie Owen (Canadian Patient Safety Institute) opened the day with an overview of the national commitment to optimizing medication safety and next steps for the National Strategic Advisory Group in advancing communication, leadership accountability, inter-professional engagement, accreditation, IT support and research.  The Cross Canada MedRec Check-Up interactive map summarizes medication safety initiatives underway across Canada.

The Canadian Medication Incident Reporting and Prevention System (CMIRPS) is a collaborative program for healthcare providers to report and prevent harmful medication incidents in Canada. Bonnie Salsman (ISMP-Canada) and Margaret Zimmerman (Health Canada) provided examples of reporting for near miss, no harm and harmful incidents; consumers can now report medication incidents at www.safemedicationuse.ca.  The Canadian Patient Safety Institute information-sharing resource to help prevent and mitigate patient safety incidents was also highlighted; www.globalpatientsafetyalerts.com  provides an in-depth analysis of almost 700 patient safety incident advisories, alerts and recommendations.

The four panel presentations provided an overview of a number of innovative projects to improve medication safety. Elaine Wong (Eastern Health) outlined tools introduced to support safe opioid medication practice in paediatrics. Allen Huang (McGill University) described the Right RX research trial currently underway to develop a medication reconciliation process at discharge that ensures the right medication from hospital to home. Winchester District Memorial Hospital has achieved 100 per cent medication reconciliation compliance and Lynn Hall says that making MedRec a strategic priority, being creative and keeping it simple resulted increased patient safety and staff satisfaction and decreased readmission rates and length of stay. Deb Gordon and Gail Hufty (Alberta Health Services) reviewed the strategies used to develop and implement a comprehensive medication reconciliation program province-wide. The panel discussion centered on bridging the communication gap in improving medication safety through educational strategies, tools, context and culture, and patient involvement.

The French session focused on medication reconciliation in long-term care and highlighted the tools created and partnership established by a health region in Quebec.  All sessions are archived and can be viewed at your convenience on the Canada’s Forum website.

The Virtual Forum continues through Friday.  Click here to register and view sessions in real-time.  Join the conversation and send you questions, comments and stories to: info@patientsafetyinstitute.ca

The second day of the week-long Canada’s Virtual Forum on Patient Safety and Quality Improvement focused on doing the right thing. Participants world-wide attended today’s virtual sessions focused on patient empowerment, disclosure, and self-advocacy.

In the presentation, Truth Talk: We have a duty to the patient, Michael Millenson (Health Quality Advisors) reinforced that while we know what to do to and can advert harm, it will take consciousness, culture and cash. To see things differently, we must see things we have not noticed before and ask questions we have not asked before. Strong cultural change is manifested by being able to ask questions.

During the panel discussion focused on Disclosure, What’s working and what’s not, Dale Nixon (Eastern Health) provided an emotional and courageous recount of the loss of her son, and how failure to disclose the details of this harmful incident affected her family. Catherine Gaulton (Capital District Health Authority) emphasized the importance of taking a proactive approach and having a policy around disclosure, outlining who is involved and how to disclose; and talking to patients and their families and saying you’re sorry.  Carolyn Philip (Fraser Health Authority) says that rather than asking patients/families if they have questions, ask if you have met their expectations; let them share their experience and tell their story. Bruce MacLeod (Alberta Health Services) emphasized that disclosure is a process, not a single conversation and as an important first step, involve patients/families in the discussion, acknowledge their concerns and apologize. The Canadian Patient Safety Institute will launch the new Disclosure Guidelines: Being Open with Patients and Families later this week.

The Manitoba Institute for Patient Safety showcased their new web-based SAFE (Self-Advocacy for Everyone) Toolkit, created to provide basic information, tips, tools and resources on patient safety.

A French-only presentation is also available daily for participants.  Monday’s session focused on governance strategies to support an organization’s safety culture; in today’s session, the Jewish General Hospital outlined how quality indicators help patients know more about the performance of the hospital. All English and French presentations are archived and available on the Canada’s Forum website.  Watch the Patient narratives and vote for your favourite hand hygiene video on Facebook.

The Virtual Forum continues daily until Friday, November 4th, with more patient stories, presentations and panel discussions to come.  Click here to register and send your questions, comments and success stories to: info@cpsi-icsp.ca

​More than 1670 people from over 500 sites in 17 countries saved over 215 tonnes of carbon emissions by participating in Canada’s Virtual Forum on Patient Safety and Quality Improvement that kicked-off on Monday, October 31, 2011.   The first of the five-day Forum provided presentations and panel discussions focused on patient safety: what does it mean; what does it take?

Hugh MacLeod, CEO, Canadian Patient Safety Institute welcomed participants to the global conversation as they inspire extraordinary improvement in patient safety and quality improvement. MacLeod also officially launched Canadian Patient Safety Week in his opening remarks. 

In the opening presentation, Martin Hatlie, President of Partners for Patient Safety, says that 75 per cent of things that go wrong are routine, but to make progress and make transformational change in the healthcare culture, we can learn from patient safety stories. He also noted that trustworthiness is a powerful concept emerging in patient safety discussions that is resonating with many audiences. Hatlie outlined an overarching model that identifies four domains of patient safety (recipients of care, providers, systems for therapeutic action and methods) and described 11 elements that fall within these domains.

The Senior Executive Leadership panel discussion provided honest and impactful insights from Chris Power, President and CEO, Capital District Health Authority; Vickie Kaminski, President and CEO, Eastern Health; Robert Howard, President and CEO, St. Michael’s Hospital; and Rheta Fanizza, Senior Vice-President of Saint Elizabeth Health Care.  These leaders talked about the perils and pearls of implementing patient safety and quality improvement initiatives in their organizations, reinforcing staff/physician/citizen/patient engagement and staying true to their vision for a transformation in culture to take place. This candid discussion brought much comment and questions from the Forum participants.

Monday’s program also included patient narratives, reinforcing the importance of including the perspective of patients and their families in patient safety discussions; a summary of changes to patient safety classifications and five new words to be used to describe patient safety incidents in healthcare conversations; and an overview of the Patient Safety Education Program-Canada and how the program has been implemented at Bridgeport Health.

Click here to register, learn more or hear the presentations from Canada’s Forum on Patient Safety and Quality Improvement.  Join the conversation and send your questions, comments and patient stories to: info@patientsafetyinstitute.ca.  There are many more patient stories, presentations and panel discussions to come; the Virtual Forum continues daily until Friday, November 4th.

​Two days after his car accident, Vance Davis was struggling in a Regina hospital.

His mom Donna was out of the room when Vance asked what seemed like a strange question.

“Am I going to die?”

“Not on my watch,” said the duty nurse, chuckling. 

The staff were well aware of Vance’s head injury. But they repeatedly said it was minor — barely more than a concussion.

His mom, Donna, wasn’t so sure. Vance’s behaviour — at times aggressive and at other times unresponsive — was out of character.

The Vance they knew was always on the go. At age nine he was Carievale, Saskatchewan’s pony express, delivering newspapers on his horse. At age 19, the oilfield worker had already purchased his own home.

“He was the fixer around town,” says Donna. “He’d shovel elderly people’s sidewalks, or mow their lawn. He always had to be busy.”

Now he was unconscious and to his mom, a nurse, slowly slipping away.

Vance’s ordeal began on a rural road in the wee hours of a March morning. Vance lost control of his truck for reasons we’ll never know. He phoned police, waited, then walked six kilometres to shelter.

He was eventually found, semi-conscious, in a trailer and taken to a local health centre, then transferred to Regina.

Upon arrival, Vance was seen by a neurosurgeon, taken for a CT scan and admitted to the surgical intensive care unit.

Donna says she heard staff talking about Vance as a drunk driver. She told them the RCMP ruled alcohol out as a cause of the crash.

“But that was really the beginning of staff not hearing what we said,” says Donna. “They stereotyped Vance as a 19-year-old man who had obviously been drinking and driving.”

Given staff assurances Vance only needed time and rest, his dad went home. But as the hours passed, it became more and more obvious to Donna that her son’s condition was getting worse.

“I mentioned my concern to the staff many, many times over the next three days,” says Donna, who watched in frustration as Vance was moved out of intensive care to a ward.

Finally, Vance’s condition caught the staff’s attention. Donna was called back to the hospital at 3 a.m. and met with the on-duty neurosurgeon. He was frustrated. He’d been in hospital each day of Vance’s stay, but was never told of the case.

Surgery was finally performed. But when the doctor walked into the room, he fought for the right words.

“He’s brain dead, isn’t he?” said Donna.

Having lost trust in those providing care, she demanded a profusion scan be done to confirm the worst. The two technicians on duty seemed oblivious to the family’s pain, laughing and even performing a high-five during the process of the scan.

“I just remember dying inside, watching how they treated our beloved son,” says Donna.

In their agony, the family decided to donate Vance’s organs. They went home to grieve. But in the following weeks and months, Donna began to seek answers.

The Davis family, she said, wanted Vance’s death to have meaning. They wanted to see the hospital take responsibility and change its procedures.

It took almost six years, but Donna and Jack Davis got a disclosure meeting with the hospital.

Changes resulted, including a protocol called Vance’s Stop Sign that allows anyone involved with a case to initiate a review. Now, a patient will not be discharged of transferred until the concern is addressed.

Communication and ‘handoff’ procedures were also improved. Families are also now included in medical rounds in the ICU. A provincial alert was sent out, too.

Donna’s message to health professionals is this: Please listen to patient families because they know their loved one best.

Donna says Vance remains with her always, especially in her work as co-chair of Patients for Patient Safety Canada.

“Every time I tell Vance’s story I’m honoring his life,” says Donna. “Vance was a fixer in life. Now he’s a fixer in death. I’m hopeful, really hopeful, that things are changing”

Vance’s story emphasizes the importance of open communication between healthcare providers, patients and families.  Canadian Patient Safety Week, October 31 to November 4, 2011, encourages both healthcare providers and patients to share the message that “Good healthcare starts with good communication.”   To find out more information on Canadian Patient Safety Week, please visit www.asklistentalk.ca .

​Terri Sabo had places to be and people to see. Terri was a go-getter.

At age 43 she began feeling tired. She’d huff, puff and perspire after walks up hilly Nanaimo streets.

Terri saw her doctor and was sent to an allergist. Her G.P. blamed an allergy to the family dog.

The staff at her Vancouver Island business school, however, remained concerned with her barking cough. Terri returned to her doctor, who diagnosed a cold.

Terri’s staff was adamant she demand a chest X-ray. So she returned to her doctor, who relented.

On the night of her son Joey’s seventh birthday, Terri received a message about needing an ECG.

After the test, she was sent to hospital, where doctors gave her unusual news: You’re in heart failure, they said.

“That was the start of things that could go wrong, did go wrong,” she says. “First, a whole year of being misdiagnosed and ending up in heart failure.”

Both her grandmother and mother died before 40 of heart failure. Terri told every doctor about her family history.

“No one took that into consideration the whole year,” she says.

Terri spent a week in hospital and was then referred to a cardiologist. Tests revealed that Terri’s cardiac ejection fraction — a rating of heart efficiency — was 20 per cent. In healthy hearts, it’s closer to 60.

The good news? Medications to lower heart rate and blood pressure would allow her heart to recover. Terri was put on beta blockers, ace inhibitors, diuretics and tranquilizers.

“I went to sleep,” says Terri. “I was probably in bed for 22 of 24 hours.”

But she tried to always be up and dressed when her son came home from school, to ease his worries.

“The treatment actually worked phenomenally well,” she says. “When I went back a year later my ejection fraction was up to 50. And a year after that it was 60. It was hurray, this is great.”

Terri was told she could begin to halve her medications in stages, over time, as long as her blood pressure and heart rate remained at safe levels.

She took the instructions to her G.P. and things began to unravel. At appointments, her doctor rationalized Terri’s readings as mood related, or from coffee intake.

Do you want to go back on full doses of your meds? Terri declined, fearing another year of virtual hibernation.

Eventually, Terri went back to the cardiologist, who was upset. Terri’s blood pressure was high and tests showed it had been too high for ages. Her medications, meanwhile, were far below prescribed levels. Her cardiac ejection fraction was back down to 28.

“I had no idea I could get to this point again,” says Terri. “I had no idea my blood pressure was skyrocketing again.”

It wasn’t easy, but Terri changed doctors and approached her health the way she would business, with goals and teamwork. Her ejection fraction is back up to 45, but at the price of low energy and a far less active lifestyle.

“There is this big push for patient self management,” says Terri, now a patient-safety advocate. “What I want to get across is you can’t ask patients to self manage. That’s a cop out. That’s not everybody taking ownership.”

Yes, patients and doctors need to work as a team, she says. But family doctors, specialists and pharmacists must join and communicate with each other, she says.

If her cardiologist and doctor had communicated even periodically during Terri’s initial course of medications, her heart would be healthier today and her life much different.

Terri is especially saddened by how her illness affects her loved ones. Family activities are curtailed or cancelled. She lost her business and was forced to file for personal bankruptcy.

 “There is no turning it around this time,” she says. “There is no third chances for me. I thank God everyday that I’m alive. I know how lucky I am. But sometimes I don’t feel so lucky.”

Terri’s experience highlights the importance of communication in healthcare. During Canadian Patient Safety Week, October 31 to November 4, 2011, thousands of healthcare providers, patients and family members will help share the message that “Good healthcare starts with good communication.”  To find out more information on Canadian Patient Safety Week, please visit www.asklistentalk.ca.

Little Sophia Maron never lived outside her mother’s womb.

She was but 18 weeks old when her mom, Tania, delivered the stillborn girl into a place of confusion, fear and bureaucratic technicality.

Hospital policy was that any baby under 20 weeks wasn’t human. Yet Sophia’s legacy is all too human and speaks to the true nature of humanity.

Sophia’s story began with her mom experiencing an apparently normal and healthy pregnancy. A routine doctor’s visit at 18 weeks shattered Tania. The baby had no heartbeat.

Tania was given a prescription for a labour-inducing drug, Cytotec. The doctor assured Tania he’d be there to provide the support to make her as comfortable as possible.

He provided a note for hospital staff to call him when Tania arrived. So she inserted the Cytotec and after five hours of pain and bleeding went with her husband Oliver to the local hospital.

She and Oliver were placed in a room off the E.R. — Tania inserted more Cytotec — and the hospital called her doctor.

“Not only did he not come, but it took three hours to get a return phone call,” says Tania.

But because he’d given the hospital instructions, no on-duty doctor was assigned. Tania, therefore, wasn’t given any medication or intravenous fluids.

Even worse, emergency room nurses didn’t seem to know what to do with Tania. They delivered a laundry hamper and stack of towels.

“We were told to just clean up our own blood and mess,” says Tania. “We were told not to bleed on the floor.”

Every 30 minutes or so, Oliver would get more towels. He pleaded for help, but staff were waiting for Tania’s obstetrician. Oliver was told that Tania took the Cytotec off-site, so her care was not hospital responsibility.

“I was incredibly dehydrated from blood loss,” says Tania. “It sounds melodramatic, but we were afraid I would die as well. The blood was terrifying. I was feeling incredibly light-headed.”

A young nurse, new to the profession, was compassionate but caught between Tania’s agony and the attitudes of more senior staff. She would later file a complaint against colleagues and was offered trauma counseling, as well as Tania’s blessing.

Sophia finally delivered and a senior nurse arrived. She tugged on the umbilical cord.

“It’s still alive — it’s moving,” said the senior nurse, who upon realizing her mistake, threw a towel over Sophia.

Tania was taken for a D-and-C. Afterwards, she asked that Sophia’s body be turned over for cremation. She was told it wasn’t hospital policy and that stillborn babies under 20 weeks were treated as medical waste.

Tania, who now wears a locket with Sophia’s ashes inside, won that battle. And she’s won many more.

“When you lose a baby you lose part of you — you lose the dreams you have for the baby,” says Tania. “It should not be judged as anything less than a loss and have other people’s support and compassion.”

Tania approached the hospital to ensure they remembered her case, and in the hope of changing policy.

The key was that she didn’t go in fighting and instead pitched the idea of making the hospital a model of care for stillbirth deliveries.

Now, all women given Cytotec will be treated in the labour-and-delivery ward of the hospital, if they choose. A grief and loss pamphlet is now available for families suffering these losses.

Parents of a stillborn baby in the second trimester will also be given the option for cremation. Tania was also asked to sit on a new Perinatal Bereavement Committee at the hospital.

Her advocacy, including work with the Canadian Patient Safety Institute, has been healing, says Tania.

The changes at her local hospital, Tania hopes, will spread across Canada. Sophia’s legacy is in teaching all of us to be a bit more human.

“Sophia has already had a huge impact,” says her mom. “She will always be important.”

Although Sophia’s life ended before it began, her message that everyone deserves safe care is still being heard.  In an effort to promote safe care and quality improvement in the Canadian healthcare system, Canadian Patient Safety Week, October 31 to November 4, 2011, is sharing the message that “Good healthcare starts with good communication.”  To find out more information on Canadian Patient Safety Week, please visit www.asklistentalk.ca.

​Sabina Robin is ever grateful for a doctor’s tale of immortal love and how it softened her family’s journey through grief.

Sabina’s three young children waited with relatives in a quiet hospital room when she and the doctor walked in to deliver the news.

The doctor sat down, arranged the kids around him, and began the story. It was about waterbugs and dragonflies, but really it was about their sister Mataya, who was taken to hospital a few days earlier.

Mataya’s story began on a Sunday in March of 2004 as Sabina rushed around her central Alberta farmhouse, getting four children and husband Michel ready for church.

“I go get Mataya and see she’s got what I think is an ink spot on her cheek,” says Sabina.

Within 24 hours Sabina and Mataya were in a specialist’s office in Calgary. The pediatric hematologist said Mataya had ITP, or bleeding from an unknown source.

He prescribed Prednisone and told Sabina she could take her daughter home. But Sabina, a nurse, was worried about Mataya’s condition, as well as the distance — more than two hours — between home and hospital.

She dug in her heels and asked that Mataya be admitted to Calgary’s Alberta Children’s Hospital. The doctor only agreed to admit Mataya to one of the city’s general hospitals.

That dynamic — of caregivers dismissing Sabina’s concerns — played out over the next 40 hours in hospital as Mataya’s condition worsened. More bruising appeared. She became more and more lethargic. She stopped feeding and was vomiting.

Staff declined to call the attending physician on several occasions and instead called a resident, who became frustrated with Sabina’s demands for attention.

The staff were convinced Mataya’s condition was minor; that the baby was just tired and suffering a stomach bug.

Yet there was blood in her urine. Mataya’s chart showed a number of troubling indicators. Sabina panicked. She asked that an I.V. be started. The resident refused.

“Whatever I said it wasn’t sinking in with anyone,” says Sabina, who reluctantly lay down with Mataya and fell briefly asleep. She awoke to find her daughter unresponsive. She rang for the nurses. Again, she was treated like a hysterical mother.

She threatened to leave the hospital. One nurse mentioned calling security.

Finally, morning arrived with the promise of the attending doctor. But just then, Mataya was struck with a seizure.

“She coded,” says Sabina. “I pulled the call bell and they all started coming — residents, nurses and the attending physician. But it was a gong show.”

Sabina demanded Mataya be taken to Children’s Hospital. The transfer took four hours but when the ambulance arrived a team of 13 staff was on hand.

The infant was rushed into surgery and the doctors stopped the bleeding and removed a clot from Mataya’s brain. Over the following hours, though, Sabina watched in silent grief as the pressure on her little girl’s brain went up and up and up until she died.

In the intervening years, Sabina Robin became a force in patient safety, involving herself in the W.H.O. and Patients for Patient Safety Canada.

She helped Calgary hospitals improve their procedures and communication. She still wants more open disclosure in patient harm cases. She believes hospitals and staff must be accountable to patients and make direct apologies.

“It’s important for organizations to recognize they can inflict a second type of harm on patients and families when they don’t step up and acknowledge responsibility,” she says.

“For families, that’s the most important thing. They want to know they have done everything in their power to make sure this doesn’t happen to anyone else.”

Sabina ensures Mataya is not forgotten. Just as the doctor’s magical tale is not forgotten by the Robin family. The story offered them something to hold onto.

The story was about how one little waterbug transformed into a dragonfly, soaring over a beautiful, magical realm.

Never able to return to her family. But waiting for them in the light at the top of the world.

Mataya’s mother knew the importance of not holding back, but advocating for her daughter’s health.  Canadian Patient Safety Week, October 31 to November 4, 2011, promotes awareness on patient safety and quality improvement in healthcare with the message, “Don’t hold back.  Good healthcare starts with good communication.”   To find out more information on Canadian Patient Safety Week, please visit www.asklistentalk.ca.

​They tried to close the file on Martha Murray soon after the autopsy and toxicology reports came back.

The Ontario Chief Coroner’s office concluded Martha’s death, at age 22, was natural. No recommendations were made.

What wasn’t natural, at least for the coroner’s office, was in dealing with a family unwilling to accept its findings.

“People don’t just go to bed and not wake up the next day,” says Martha’s mom, Maryann.

So the Murray family began a seven-year battle for answers and changes to the system. When politely asking wasn’t enough, they demanded. When demands didn’t work, they talked to politicians and journalists.

In the end, errors were found, processes were changed and a family was better able to grieve. Martha Murray’s name will not soon be forgotten in Ontario. Nor should it be forgotten.

Martha was discovered in her bed on a September morning in 2002. She went to sleep and died in the night.

After the coroner’s findings, the family began sleuthing through Martha’s records. They knew she’d been prescribed Lithium for bipolar disorder in recent months. The dosage was increased just 11 days before her death.

In her patient file was a recommendation against prescribing Lithium because of chronic low potassium. Lithium, the family later learned, is also contraindicated in patients with cardiac issues.

A psychiatrist, knowing of Martha’s low potassium, wrote the Lithium warning. But her latest psychiatrist didn’t agree and prescribed the drug without informing Martha of the concern.

Martha had also undergone numerous EKGs in the years before her death, experiencing bouts of accelerated heart rate. Anxiety was often blamed and the test results were then viewed as “normal” for her.

But Maryann sent Martha’s EKGs to the coroner’s office. Investigators examined 17 ECGs and concluded Martha had a congenital heart defect.

Maryann also discovered Martha visited a cardiologist a year before her death. He’d ordered tests that confirmed the heart defect.

But the cardiologist never read the tests. The office never phoned Martha to inform her. Nor was a cardiac warning about Lithium added to her records.

Standard practice at the cardiologist’s office was to wait for the patient’s return visit before reading the tests. Except patients like Martha can assume no news is good news and not return.

After lobbying by the Murray family, the Ontario College of Physicians and Surgeons sent an “educational dispensation” to the cardiologist citing a duty to read test results and follow-up. 

It frustrates Maryann to this day that the college didn’t send out a warning to all its members. The coroner’s office, though, did recommend that patients prescribed psychotropic drugs be first given a cardio check-up.

“I think it was important for us to understand that Martha did everything she could to get better,” says her mom. “She was within the health care system to get well. And a series of mistakes kept happening that ultimately cost her her life.”

The coroner’s office also changed its procedures. It was not reporting adverse drug reactions to Health Canada until Martha’s death and the Murrays’ fight for truth.

Martha was Maryann and Paul Murray’s eldest. She had four younger siblings, whom she doted on. Her illness inspired her to study nursing, with the goal of helping others.

Maryann says a culture of cover-up and denial existed in the Ontario health system. She fought for Martha, but she also fought for other patients who lost their lives without proper disclosure or reporting of lessons learned.

“People have given their lives, or they’ve suffered, and the least we can for them is to report what happened and allow the analysis to occur so we can prevent it from happening again,” says Maryann.

“My daughter wasn’t able to get married, have children and enjoy the normal legacy we do,” adds Maryann. “I kept pushing because I wanted to know what had happened to our daughter.”

“No one wanted a 22-year-old to die. No one intended to cause any harm. But when the harm occurred, the system didn’t do its job to examine what went wrong and to figure out ways of prevention.”

Martha’s experience in the Canadian healthcare system illustrates the importance of clear communication between healthcare providers and patients.   Canadian Patient Safety Week, October 31 to November 4, 2011, is an opportunity to raise awareness that “Good healthcare starts with good communication.”  To find out more information on Canadian Patient Safety Week, please visit www.asklistentalk.ca. 

Raeline McGrath risked everything to fight in Claire’s memory.

​Claire, her nine-year-old, was gone. Now friendships were at stake, along with the nursing job she loved in a Newfoundland hospital.

“I knew what the fallout would be,” she says. “I knew, without a doubt, I’d be labeled as ungrateful — seen as a mother struggling unsuccessfully to blame someone for her daughter’s death.”

Raeline tried to bury her concerns about Claire’s death. After all, she worked as a nurse at the same hospital.

It would be easier for everyone if Raeline forgot her nagging concerns, grieved for a time and came back to a hospital full of supportive, caring colleagues.

“I see these same people every day, in the cafeteria, in the corridors, across the bed. I knew this would not end well.”

But Raeline and her husband David were too committed to Claire in life to abandon her in death. Claire was born with a genetic condition, Trisomy 13, and had severe developmental delays.

Claire walked with difficulty. She did not talk, but communicated with pictures, gestures and actions. Her care was constant and began often at 4:30 in the morning.

“We took great pride and interest in ensuring she was safe and healthy,” says Raeline.

Claire died in March of 2008, after 16 days in intensive care, following surgery to repair a malformation in her skull. After surgery, Claire was placed in a deep sleep and on a ventilator. She eventually succumbed to complications, including pneumonia.

When Raeline quietly began to look into the death, she discovered information on possible causes; among them, improper management of the endotracheal tube and ventilator. She took her concerns to the regional health authority, Eastern Health, which then ordered an external review, in mid 2008.

The review found that ventilator management was below accepted standards. It also revealed Claire’s death was precipitated by an abrupt rise in carbon dioxide. The most common cause is a blocked endotracheal tube. The review deemed Claire’s death as preventable.

Tensions were already high in the hospital after Claire died, especially with Raeline seeking a review. A picture of Claire in the pediatric intensive care unit was taken down.

“They were devastated when Claire died,” says Raeline. “It was one of their own. They felt they’d done everything they could and were frustrated I didn’t see that side of things.

“As the mother I needed answers. But as a nurse I needed answers, too. I worked in the same critical care division. I needed to feel comfortable that we did everything we could for Claire.”

The review finding of a preventable death was the worst possible outcome for everyone — for staff and for Claire’s family. The health authority, though, held a forum with staff, communicated openly with Raeline and David and apologized for her death.

Changes in policies and procedures were made. The pediatric ICU is now more open to family members. But Raeline felt she had to leave the hospital for another nursing position in the health region.

“I’ve asked myself if it was worth it,” says Raeline. “I don’t think I had a choice. If we’re going to move ahead — if Claire’s death is going to have meaning — then I did what I had to do ... to make it better for the next Claire.”

She wants her former colleagues to know of her deep belief in openness and accountability in health care. She’ll never forget the apology one nurse made to her.

“If I have done something that unknowingly has contributed to Claire’s death,” said the woman, “I am really sorry.”

Raeline and David were deeply touched. Raeline thought to herself: “We are so privileged to have had this nurse care for Claire.”

And then she knew in her heart that she had turned Claire’s care over to the right people.

“So would I do it again? Yes,” she says. “I’d hand Claire over the same people. Same people. Same place. All over again.

“I wish they had done things differently. I wish they could accept that things can be done differently. But I do not blame them.”

Claire’s battle highlights the importance to fight for safe care and to accept no less.  Canadian Patient Safety Week, October 31 to November 4, 2011, is an occasion to raise awareness on patient safety and quality improvement with the message that “Good healthcare starts with good communication.”  To find out more information on Canadian Patient Safety Week, please visit www.asklistentalk.ca.

​New Disclosure Guidelines support openness with patients and families

“Disclosure is a process of open communication and information sharing, rather than a single conversation so that improvements to patient safety can be effective. Disclosure is needed for healing and patients and families must receive an apology for what has happened. It is the responsibility of all healthcare providers and the right of every patient.” (Donna Davis, Co-Chair, Patients for Patient Safety Canada)

The Canadian Patient Safety Institute, with the support and involvement of many participating organizations, has released an updated version of The Canadian Disclosure Guidelines: Being Open with Patients and Families. The revised Guidelines will continue to support individuals and organizations in developing or enhancing disclosure policies and practice as a core element of a patient safety culture. The Guidelines were revised to reflect progress made in the evolution of a patient-centered and safety-focused culture of healthcare has made significant progress since the disclosure guidelines were first published in 2008.

“We hope the revised guidelines will create new conversations about disclosure, clarify how best to meet the needs of patients and families, and help align disclosure policies across Canada,” says Hugh MacLeod, CEO, Canadian Patient Safety Institute.

 “The guidelines emphasize the importance of a clear and consistent approach to disclosure, regardless of the reason for the harm,” says Brent Windwick, Chair of the Disclosure Guidelines Working Group.  “Through these guidelines, we hope to support and encourage individuals and organizations to develop or enhance disclosure policies and practice, incorporating and adapting the core elements respective to their needs.”

Underpinning the new Guidelines is the philosophy of supporting disclosure through a just culture. While a healthcare organization’s culture is vital to encourage and sustain safer patient care, the addition of the word “just” reflects a fair and supportive system where the emphasis is on creating a safe learning environment to learn from harmful incidents, bringing about system changes to improve patient care, and if appropriate, the education of providers.

The Canadian Disclosure Guidelines: Being Open with Patients and Families reinforces the importance of providing an apology as a genuine expression of being sorry for what has happened; and outlines the guiding principles and steps involved in the disclosure process.  Some of the major changes include:

• Clarification of terminology: The new Guidelines introduce new patient safety terminology derived from the International Classification for Patient Safety, developed by the World Health Organization (WHO), including five terms relevant to disclosure, which will provide clarification and consistency:
• Healthcare associated harm:  Harm arising from or associated with plans or actions taken during the provision of healthcare, rather than an underlying disease or injury.
• Patient safety incident: An event or circumstance which could have resulted, or did result, in unnecessary harm to a patient.
• Harmful incident: A patient safety incident that resulted in harm to the patient. (Replaces “adverse event”)
• No harm incident: A patient safety incident which reached a patient, but no discernable harm resulted.
• Near miss: A patient safety incident that did not reach the patient. (Replaces “close call”)
• Supporting Patients: The new Guidelines emphasize the importance of remaining sensitive to the needs of the patient and family, and taking steps to keep them apprised of actions taken in response to the event; supporting patients clinically, providing psychological and emotional support when they experience harm during a patient safety incident; and ensuring practical and timely access to further healthcare treatment and professional support. 
• Expense reimbursement: There are new guiding principles on providing expense reimbursement for patients/families to attend disclosure meetings, when the harm a patient suffers is not part of the patient’s underlying condition. These costs may include travel expenses, parking, meals, accommodation, child care and fees for obtaining medical files pertinent to the event.
• Supporting Healthcare Providers: The new guidelines also emphasize the importance of ensuring emotional and practical support is made available to healthcare providers involved in patient safety incidents or disclosure discussions; and providing education and training to healthcare providers in how to effectively participate in a disclosure discussion.

A draft of the updated Guidelines was initially released in June 2011 for input. Individuals and organizations participated in a national information webinar on the draft document and approximately 250 individuals and organizations participated in a survey consultation process, offering their feedback and recommendations on the draft document.  The Canadian Disclosure Guidelines: Being Open with Patients and Families can be downloaded from the Canadian Patient Safety Institute website:  www.patientsafetyinstitute.ca

Discussions on disclosure and the revised document will take place during Canada’s Virtual Forum on Patient Safety and Quality Improvement.   Click here to see the program and to register.

​The Canadian Patient Safety Institute has recognized Bridgepoint Health with a leadership award for their outstanding contribution and commitment to improving patient safety and quality improvement practices, experiences and outcomes for their patients, residents and clients.

Jane Merkley, Vice President, Programs, Services and Professional Affairs (CNE) and Kate Wilkinson, Director, Quality and Patient Safety accepted the newly established Innovations in Patient Safety Education Award on behalf of Bridgepoint Health at the launch of the Patient Safety Education Program (PSEP-Canada), in Toronto, on September 14, 2011. 

As a Master Facilitator with the PSEP-Canada program, Kate Wilkinson is leading the delivery of a patient safety education program at Bridgepoint.  “Bridgepoint’s vision is to be Canada’s leader in the care for patients with complex chronic disease and rehabilitation and with a focus on education and research in this area the PSEP-Canada program really aligned with our patient safety strategy and educational initiatives,” says Kate. “We developed a framework to build our knowledge and understanding of the science of patient safety and Jane Merkley was quick to come on board as our Executive sponsor. With that support we are creating a community of people who have a common understanding, interest and passion, and they are starting to build capacity within their teams. They are the ones starting the discussion and dialogue to influence their peers.”

 “The Innovations in Patient Safety Education Award recognizes organizations that demonstrate best practices in patient safety and quality improvement work,” says Hugh MacLeod, CEO, Canadian Patient Safety Institute.  “Bridgepoint has embraced the PSEP-Canada program and is making great strides in implementing the train-the-trainer model to advance learning in their organization.”  

“From the boardroom to the boiler room, we are committed to making patient safety our priority and equipping our staff with the knowledge, tools, resources and support to make Bridgepoint Health become a leader in patient safety,” says Marian Walsh, CEO, Bridgepoint Health. “The Award acknowledges our efforts and to be recognized as a leader in our field is an honour for both our hospital and our faculty.”

Some 43 healthcare professionals, representing all inpatient and out-patient areas, will graduate from Bridgepoint’s seven-month patient safety course in November 2011. The course includes four, one-day sessions and teams work on small scope projects to utilize the methods and tools they learned during the program. “Our clinical teams are undertaking process improvement projects and their work will be highlighted in poster presentations that will be displayed during Canadian Patient Safety Week in November,” says Kate.

Kate says to advance patient safety you have to build knowledge at the frontline.  “As a master facilitator, I have the opportunity to interact with people that have the same vision and desire to create something different at the frontline.  This is one of those tactical things an organization can do to focus on the people that matter the most, those who interact with patients. As we have more and more people trained as facilitators and master facilitators, we won’t have to recreate things. The PSEP-Canada program provides the tools to articulate the problem, the issues and the solution.”

PSEP-Canada is offering the Become a Patient Safety Trainer program throughout the fall. If you are interested in bringing the PSEP-Canada program to your area, please visit the Canadian Patient Safety Institute website, or email: psepcanada@cpsi-icsp.ca.

Photo caption:   Bridgepoint Health recognized for leadership in patient safety education (left to right): Steve Hall, Zahir Hirji, Carla Gibson, Kate Wilkinson, and Jane Merkley

​Since its launch on February 15, 2011, frontline healthcare providers around the world have come to rely on Global Patient Safety Alerts for access to information on patient safety incidents, from causes, to solutions and recommendations.

Developed by the Canadian Patient Safety Institute, Global Patient Safety Alerts is an innovative web-based information-sharing resource to help you prevent and mitigate patient safety incidents in your organization and help others succeed.

There are currently more than 650 patient safety incident advisories, alerts and recommendations to help organizations recognize, respond to, and reduce patient safety incidents. Learn what works and share your own insights and solutions with healthcare providers, healthcare organizations, patients, and the public. We are continuously adding new alerts so check back often.

The Canadian Patient Safety Institute has also partnered with the Armstrong Institute for Patient Safety and Quality/Quality and Safety Research Group to provide a third-party evaluation of Global Patient Safety Alerts as a mechanism for sharing and learning. This will ensure the ongoing reliability and value of Global Patient Safety Alerts for healthcare providers around the world.

For iPhone and iPad users, the Canadian Patient Safety Institute is also preparing for the launch of a mobile app, providing access to Global Patient Safety Alerts in the palm of your hand.

Click here for more information and to access the latest alerts. 

​It’s that time of year again! Canadian Patient Safety Week, October 31-November 4, is just around the corner and participants from across the country are busy planning events and activities in their organizations and regions.

The national annual campaign is held to create awareness and to help inspire extraordinary improvement in patient safety and quality. Working together thousands of healthcare professionals, patients, residents, clients and their families help spread the message that “Good healthcare starts with good communication.” The week encourages everyone involved in healthcare delivery, or those receiving care to ask questions, listen carefully and talk openly.

Those who register for the week at www.asklistentalk.ca will receive regular updates and a free package of promotional materials, including posters, tent cards, buttons, notepads and more. Promotional items are also involved in the Canadian Patient Safety Week online store.

Based on last year’s feedback, the Canadian Patient Safety Institute (CPSI) is also offering registrants with the option of customizing their posters, tent cards and meal tray placemats by having their organizational logo added.

As a result of the success of a series of webinars on patient safety and quality improvement held during last year’s Canadian Patient Safety Week, this year CPSI is pleased to present Canada’s Forum on Patient Safety & Quality Improvement. Each day during Canadian Patient Safety Week, the Virtual Forum will deliver three-and-a-half hours of content and presentations from a broad spectrum of experts via webinar. Healthcare professionals, patients, residents and clients and anyone interested in improving patient safety and quality are encouraged to attend and to bring the Virtual Forum to their organizations. Registration for the Virtual Forum is free and enables you to participate in all presentations throughout the week.  

The Canadian Patient Safety Institute also invites organizations to endorse Canadian Patient Safety Week. Your endorsement illustrates your support for Canadian Patient Safety Week and its message as well as your organization’s commitment to inspiring extraordinary improvement in patient safety and quality. Click here to find out more.

Tools and resources, including games, quizzes, tips sheets and more will be added to the Canadian Patient Safety Week site, www.asklistentalk.ca, in September.

Questions? Please email us at cpsw@cpsi-icsp.ca

​The Canadian Pharmaceutical Bar Coding Project is a joint initiative of the Canadian Patient Safety Institute and the Institute for Safe Medication Practices Canada (ISMP-Canada) to implement standardized bar codes on all aspects of pharmaceutical labeling to enhance medication safety.  The Canadian Pharmaceutical Bar Coding Project is a unique opportunity for all stakeholders of the Canadian medication system to collaborate nationally and internationally, from industry to healthcare providers, within both institutional and community care, on a comprehensive strategy for enhanced medication labeling to improve patient safety. International health jurisdictions have embraced medication label bar coding requirements as a critical first step toward improved public safety, through the increased use of smart systems that utilize automated identification (AI) methods of assisting healthcare practitioners in their administration of medication.

ISMP Canada and the Canadian Patient Safety Institute have facilitated a collaborative strategy with over 50 participating organizations to address the technical approach to bar coding, adopting the GS1 global AI standard.   This multi-phase project developed and issued technical requirements in 2010 for Canadian pharmaceuticals that have been marketed for use within Canada.  The standard provided guidance to all health sectors, outlining recommended bar code components and symbologies, product database elements, medications to be included in the bar coded categories, and packaging levels and bar code placement.  To view the Joint Technical Statement on Pharmaceutical Automated Identification and Product Database Requirements, click here.  The Joint Technical Statement is due to be updated later in 2011, to address additional recommendations for pharmaceutical automated identification system improvements.

The project leads recently met with the Federal, Provincial and Territorial Deputy Ministers of Health to provide an update and outline potential areas of synergy. The Canadian Association of Paediatric Health Centres (CAPHC) Patient Safety Collaborative hosted a webinar where Ian Sheppard, ISMP Canada Project Lead for the Canadian Pharmaceutical Bar Coding Project explained how evidence shows that many errors are preventable through medication bar coding and related patient care systems improvements.  To access a copy of the webinar presentation, visit the CAPHC Knowledge Exchange Network website: www.ken.caphc.org and click on Patient Safety.

To learn more about the Canadian Pharmaceutical Bar Coding Project, visit the ISMP Canada website:

www.ismp-canada.org/barcoding

CPSI and CAPHC formalize a working relationship

​The Canadian Patient Safety Institute and the Canadian Association of Paediatric Health Centres (CAPHC) have signed an agreement to formalize their relationship and build on the collaborative efforts to advance patient safety for Canadian infants, children and youth across the continuum of care.

“CAPHC is a recognized leader and advocate for advancing the improvement of healthcare for Canada’s children and youth and this partnership builds on the work we have been doing in recent years and further strengthens our efforts to align priorities to make healthcare safer,” says Hugh MacLeod, CEO, Canadian Patient Safety Institute. “By working together we can leverage our collective resources to maximize outcomes and minimize duplication of efforts toward a safer healthcare system for all Canadians.”

“With increased coordination and partnering we can ensure a sharper focus and better integration to improve patient safety in paediatric healthcare organizations,” says Elaine Orrbine, President and Chief Executive Officer, CAPHC.  “Formalizing our relationship with the Canadian Patient Safety Institute will help to advance the work we are doing in patient safety and further engage in programs, strategies and initiatives to ensure safe care for the Canadian child and youth populations.”

CAPHC and the Canadian Patient Safety Institute agree to promote and integrate each other’s work.  The Canadian Patient Safety Institute will support CAPHC patient safety initiatives including the paediatric trigger tool; medication safety interventions such as high alert medication delivery, opioid safety, and paediatric medication reconciliation; and the patient safety listserv.  CAPHC will lead or participate in specific Canadian Patient Safety Institute programs and projects related to children and youth, such as Safer Healthcare Now! interventions, engage in demonstration projects related to Governance, the Patient Safety Education Program (PSEP-Canada); integration of the Safety Competencies into practice environments, and adoption of bar coding technology in paediatric health centres.

Education sessions held for Ontario Hospital Boards on quality and patient safety

The Effective Governance for Quality and Patient Safety Education Program and Toolkit, developed by the Canadian Patient Safety Institute and the Canadian Health Services Research Foundation, are proving to be  effective tools in supporting Boards to improve governance for quality and patient safety.

The Canadian Patient Safety Institute and the Canadian Health Services Research Foundation partnered with the Ontario Ministry of Health and Long-Term Care and the Ontario Hospital Association to adapt and provide the Effective Governance for Quality and Patient Safety Education Program to support implementation of the Excellent Care for All Act, which was passed in the Ontario legislature in June 2010.  This progressive legislation has placed increased emphasis on hospital board accountability for quality and patient safety.

Six sessions were held between March and May 2011, in five Ontario communities, including London, Toronto, Ottawa, North Bay and Thunder Bay.  The program helped participants to more fully understand a board’s core functions related to quality and patient safety; identify approaches to measure quality of care; recognize how a culture of quality and patient safety within an organization can be led, supported and sustained by the Board; and identify tools, structure, processes and priorities that will assist in enhancing their organizations’ governance practices related to quality and patient safety. At the end of the sessions, participants developed Action Plans for implementation in their home organization.

Joan Dawe, former Board Chair of Eastern Health in Newfoundland and Labrador and a member of the Faculty that developed the Effective Governance for Quality and Patient Safety Education Program and Toolkit led some of the Ontario sessions. “Historically, Boards have focused more  on financial  performance and accountability, leaving quality and patient safety to medical staff and administration, however today their engagement and level of discussion is much broader and more complex,” says Joan.  “Evidence indicates that devoting at least 25 per cent of the board’s time to quality and safety will result in better outcomes for patients. To foster a culture of quality and patient safety and fulfill their oversight role, Board members need to know how to ask the difficult questions that will help them fully understand what is happening in their organizations and make decisions that will ultimately improve quality of care for the people they serve. This program is invaluable in helping Board members fully understand the core functions related to quality and safety with a special emphasis on the Excellent Care for All Act.”

The Canadian Patient Safety Institute is looking to partner with health regions and the provinces to deliver the Effective Governance for Quality and Patient Safety Education Program.  This approach ensures that a critical mass of leaders within a region or organization gain a common skill set and knowledge that is tailored to specific local circumstances.  For more information, contact Abigail Hain, ahain@cpsi-icsp.ca.

The Improving Care Search Centre is connecting websites around the world to improve the availability and accessibility of patient safety information. This tool is changing the way information is shared, searched and gathered. 

“There is no shortage of great work that we can learn from and the Improving Care Search Centre provides the tool to share what is happening across the country and worldwide,” says Dr. Ben Chan, CEO of Health Quality Ontario.  “This site is incredibly important to have a crisp and clear way of getting information like guidelines, how-to manuals, training materials, best evidence, and practical ideas to advance the patient safety agenda. It will help us understand results from leaders that we should emulate and lean about the constructive role patients can add to improving care. ”

“Improving patient safety and quality assurance in healthcare has become the aim of many countries,” says Roisin Boland, CEO of the International Society of Quality in Health Care (ISQua). “The Improving Care Search Centre will provide easy online access to patient safety and quality improvement information, and any tool for healthcare providers with this focus will result in better care. It supports the culture shift to one of patient safety and quality as a priority in the minds of healthcare management and staff at all times.”

ISQua is one of the nearly 200 Improving Care Alliance members sharing patient safety and quality information around the world and building the wealth of knowledge we have to learn from. Membership in the Improving Care Alliance is free of charge and open to organizations involved in patient safety and quality, from hospitals, long-term care homes and community care centres to regulatory bodies, health authorities and quality councils.

Alliance member websites will be indexed through the Improving Care Search Centre. Anyone using the search centre to find information on patient safety will be able to access member sites in their search. Members are also able to contribute to the Patient Safety Crosswalk - a place to quickly share and find the latest in patient safety news, events, projects, research and more.

“Patient safety is something we strive to ensure and I feel that being active in the Improving Care Alliance will enable us to provide the best possible patient care,” says Roxanne Gillam, an Infection Control professional at the Dr. C.L. Legrow Health Center, Western Regional Health Authority in Newfoundland and Labrador.  “This is a great network that is full of good ideas, information, activities and projects that you take and make your own. They are supported with best practice evidence, which makes them easier to implement.  We are in a rural area and I don’t have the same back-up and resources that larger institutions have, so I can use the information accessible on the Improving Care Search Centre to make informed decisions.  In particular, I found the hand hygiene information extremely useful in guiding our quality and patient safety initiatives and meeting accreditation standards for our hospital.”

The Improving Care Search Centre allows users to create a profile and customize their home page with the patient safety and quality information feeds they want to receive.  These feeds then provide alerts to the most recent Twitter conversations, Patient Safety Crosswalk news items and more.  Users can also browse through the list of Improving Care Alliance members, viewing information each organization has shared on the Patient safety Crosswalk and link directly to their websites. Visit the Improving Care Search Centre website and register to customize your experience! To become a member of the Improving Care Alliance, click here.

Esther Fung, Director of Pharmacy Operations and Drs. Ludwik Fedorko, Joseph Fisher and Rita Katznelson, researchers and anaesthesiologists with the University Health Network (UHN) in Toronto, Ontario were recently awarded the Ian White Patient Safety Award for Best Paper in Patient Safety by the Canadian Anesthesiologists' Society (CAS). The award, presented at the CAS annual conference in June, was given in recognition of their work on a point-of-care barcode aided medication process for anesthesia caregivers. The process helps to verify ampoule dispensation, produce accurate syringe labels and aid verification of each syringe prior to administration. This research project was partially funded by the Canadian Patient Safety Institute in 2008.

“We are honoured to be recognized by our peers for this economical solution to improve medication safety in operating rooms across Canada,” says Esther Fung.  “The medication bar-coding system recognizes the vigilance required by anaesthesiologists to ensure proper administration of medications in the operating room and incorporates safety factors that will reduce the risk of errors.”  

This Pharmacy and Anesthesia collaborative project was implemented in all 20 operating rooms at the Toronto General Hospital (one of the three hospitals that form the UHN) in January 2010. Previously, medications were provided to the operating rooms through a tray exchange and stock replenishment process.  Medications were not in a patient-specific, unit-dose, ready to be administered format. Within two weeks of implementation, all of the hospital’s anaesthesiologists voluntarily adopted the new process. After 18 months, over 134,000 medications were dispensed for over 12,000 cases using the new process and no medication identification error incidents were reported.

The bar-coding system provides accurate syringe labelling and independent ampoule/syringe verification throughout the dispensation, premixing, administration and documentation process. The process was designed to enable real-time documentation of medications, fluids, infusions and urine, blood loss with the use of touchpad like monitor user interface. The design reduces interactions with the computer to an absolute minimum and makes computer data entry easier and faster than manual paper reporting.  Electronic anesthesia monitor data capture was also incorporated to produce an intra-operative record. 

“Safe drug administration and independent verification and appropriate labelling of high risk drugs are compromised every day because of the lack of available and cost-effective solutions,” says Dr. Fedorko.  “The barcode aided medication verification process is a safe and effective way to intercept and prevent potential medication errors during anesthesia. It can be easily and economically implemented in any size surgical facility, across a variety of surgical procedures and in a large volume of patients.”

The research report, A Point of Care Mediation Bar-Coding System in Operating Rooms for Drug Dispensing, Labeling, and Administration Verification during Anesthesia, is available on the Canadian Patient Safety Institute website. 

Canadian Medication Incident Reporting and Prevention System website launched 

A new website is now available with information on the Canadian Medication Incident Reporting and Prevention System (CMIRPS), a collaborative program to reduce and prevent harmful medication incidents in Canada.

Health Canada, the Canadian Institute for Health Information (CIHI), the Institute for Safe Medication Practices Canada (ISMP Canada) and the Canadian Patient Safety Institute (CPSI) are partnering to contribute information, tools and expertise in the prevention of harmful medication incidents.

The CMIRPS partner organizations support a safe medication use system for Canadians by:

• Providing defined channels for the reporting of medication incidents by healthcare facilities, individual practitioners and consumers.
• Analysing medication incident reports and making recommendations for risk mitigation activities.
• Developing and broadly disseminating information on preventative measures and best practices for safe medication use, including prescribing, order communication, product labelling, packaging and nomenclature, compounding, dispensing, distribution, administration, and monitoring.
• Working with stakeholders in the pharmaceutical manufacturing industry to address issues related to the naming, packaging and labelling of marketed products in Canada.

Visit the new CMIRPS website today for more information about the program and its partners.

In conjunction with CMIRPS, the Canadian Patient Safety Institute has developed an innovative information-sharing resource to help you prevent and mitigate patient safety incidents. Global Patient Safety Alerts contains more than 700 patient safety incident advisories, alerts, and recommendations. Learn what works and share your own insights and solutions with healthcare providers, healthcare organizations, patients, and the public. For more information about Global Patient Safety Alerts visit www.globalpatientsafetyalerts.com

The Canadian Patient Safety Institute is undertaking a consultation process to solicit feedback from healthcare professionals and leaders across Canada on the revised Canadian Disclosure Guidelines, first published in 2008.  The document was updated in consultation with a small group of members from the original Disclosure Working Group, and is titled Canadian Disclosure Guidelines: Being Open with Patients and Families. 

Two national webinars have been scheduled to outline the changes to the document and provide more insight into the consultation process. An English session will take place on Tuesday, June 21st and a French session on Monday, June 27, 2011 from 12:30 to 2:00 pm EST.  Click here to register.

We invite your feedback

In mid-July, a survey will be sent to those that participated in the national webinars and other stakeholders to gather input and feedback on the draft publication. A survey report will be compiled by the end of the summer and this information will be used to finalize content for the Guidelines.  The new Canadian Disclosure Guidelines: Being Open with Patients and Families will be released this Fall.

This is your opportunity to get involved!  We value your input and look forward to hearing your thoughts on the new Guidelines through the survey. 

Click here to access the DRAFT Canadian Disclosure Guidelines document.

For more information on the webinars and the survey, contact Diane Aubin, daubin@cpsi-icsp.ca

For the Chatham Kent Health Alliance (CKHA), the hospital’s team of Patient and Family Advisors were major contributors to a successful Canadian Patient Safety Week by interacting with members of the public about patient safety and spreading the message that, “good healthcare starts with good communication.”

The Patient and Family Advisors at CKHA are a group of 13 volunteers who have past experiences at the hospital as either a patient or family member of a patient. Their primary function is to provide the perspective of the patient or family member which helps CKHA ensure their services are responsive to the needs of the people they treat.

During Canadian Patient Safety Week, the Patient and family Advisors were busy interacting with people at CKHA’s Wallaceburg and Chatham campuses and distributing information on the importance of the patient’s role in patient safety, good communication and the role of the identification band.

Brenda Foster, Program Director of Women and Children’s Health at CKHA, says using the Patient and Family Advisors to spread patient safety messages during Canadian Patient Safety Week was a positive experience that resonated strongly with people.

“Engaging the Patient and Family Advisors reaffirms that we’re on the right track and highlights the importance of involving them as patient safety advisors,” Foster says. “We would like to see the role of the Patient and Family Advisors continue to expand over the course of the next year.”

Shane Helgerman, the Director of Mission, Quality Improvements, and Learning Services at CKHA, agrees, saying the Patient and Safety Advisors are helping create more awareness around patient safety because of the perspective they bring to the issue.

“It was a huge success. We’ve had a lot of positive feedback,” Helgerman says.

As one of only 21 organizations in Ontario that has been recognized by the Registered Nurses Association of Ontario (RNAO) as a Best Practice Spotlight Organization, an honour bestowed upon organizations committed to implementing the RNAO’s best practice guidelines, CKHA also used Canadian Patient Safety Week as an opportunity to celebrate the “Beat Practice Champions” who have been instrumental in implementing the best practice guidelines.

During the week, CKHA’s 2010 Patient Safety Award, sponsored by the CKHA’s Quality/Risk & Patient Safety Council, was presented to the hospital’s Infection Prevention and Control (IPAC) Team for their efforts during the H1N1 outbreak. The winning team is comprised of Erika Vitale, Sheila Campbell-Vanboxtel, Glenda McFadden, Dr. Pierre Letarte and was nominated by Carol Turner, IPAC Coordinator.

The week also featured a number of poster display throughout the organizations highlighting various aspects of patient safety such as medication reconciliation, pressure ulcer prevention, Safer Healthcare Now! initiatives and infection prevention, to name a few.

Whether you are a seasoned pro or just getting started at dabbling in social media, the Canadian Patient Safety Institute (CPSI) strives to be interactive, providing you with an opportunity to customize your online experience. 

“Social media is much more than Twitter and Facebook,” says Abisaac Saraga, Web & Social Media Manager at CPSI. “It is about accessibility of information, allowing user input, interaction and dialogue; and allowing the user to customize their experience.”

CPSI has a number of opportunities available to help you get engaged in social media:

Patient Safety Crosswalk was designed for information sharing.  Organizations share links to patient safety information on their website including news, events, programs and more

Improving Care Search Centre – Users can customize the news and information they want to see from several websites together in one place. Users will also be able to search all of the CPSI websites, including Global Patient Safety Alerts, Safer Healthcare Now! and Stop! Clean Your Hands, as well as websites from organizations across Canada and around the world. 

Twitter @Patient_Safety –CPSI shares updates on programs, news, and events with followers and people following twitter topics such as #ptsafety #cdnhealth #hcsmca.

Twitter @SafeCareLibrary – Updates on patient safety research shared by its followers, as well as twitter topics such as #ptsafety and #healthlit.

StopSuperbugs.com – A magazine website built by the New Approach to Controlling Superbugs team to help “spread the word” about the new approach to controlling superbugs and Positive Deviance. This is a useful resource for users engaged in the infection control community.

Want to learn more about how to get engaged?   The Healthcare Social Media Canada network meets every Wednesday for an online discussion on the best ways to use the Social Media to get accurate information to those who want it. Join the conversation on Twitter at #hcsmca, or email asaraga@cpsi-icsp.ca for more information. 

​In 2010, the Canadian Patient Safety Institute embarked on an exciting partnership with Northwestern University, Chicago, USA to adapt a patient safety curriculum for practicing, frontline healthcare professionals in Canada. The PSEP program is built on a train the training team model which provides a peer to peer framework to guide patient safety education for all healthcare professionals.

Despite the recent gains in healthcare professional knowledge of patient safety issues, large numbers of healthcare teams have not had access to training in the basics of patient safety knowledge and competencies. The Become a Patient Safety Trainer conference is a perfect opportunity for the teams to gain access to a comprehensive set of materials, methodologies, and tools that will enable them to transfer this invaluable knowledge in their respective organizations.

Teams who attend the PSEP-Canada program Become a Patient Safety Trainer conference  have the opportunity to practice improving patient safety skills and actively plan next steps for patient safety education in their home organization. The PSEP-Canada conference is built with an interprofessional approach. For optimal learning outcomes, participating teams are comprised of at least one physician, one other clinical professional such as a nurse, pharmacist or other provider, and one healthcare administrator with responsibility for patient safety and quality, as well as a senior executive from the organization.

Currently, over 60 healthcare professionals from varied healthcare organizations across Canada have obtained certification as PSEP Canada trainers over the past year. Through the PSEP Canada Community of Practice, these Certified Patient Safety trainers will have access to updated curriculum materials, video vignettes, ongoing WebEx learning events as well as a virtual forum to continue the conversations.

If your organization would like to become a partner and to bring PSEP – Canada to your area, please contact: psepcanada@cpsi-icsp.ca or you may also contact Abigail Hain at 613-738-4779 with any questions you might have about the upcoming Become a Patient Safety Trainer conference.

It has been six months since the Patient Safety Crosswalk was launched, and the response from the patient safety community has been remarkable. Thanks to the contributions of several organizations across the country and beyond, the Crosswalk has established itself as a go-to resource for sharing and learning in the patient safety community. Since its launch, Crosswalk has attained some significant milestones:

• 16,000 page views
• 240 articles posted
• More than 75 organizations currently contributing to Crosswalk
• Contributions from international organizations, including one in Sao Paulo, Brazil – a distance of 10,685 km  from our location in Canada!

“The uptake has been tremendous and we are pleased to see the number of organizations participating,” says Ali Alidina, Information Manager at the Canadian Patient Safety Institute.  “Crosswalk was launched to track what was happening across the country during Canadian Patient Safety Week last fall and the participants have been very supportive and continue to use this tool as a valuable source of patient safety and quality improvement information.”

We invite you to read some of the user feedback from Crosswalk contributors below.  To provide us with your feedback, please take a few minutes to complete our online survey so that we can make Crosswalk your go-to resource for the latest information on patient safety.  The survey is available in both English and French – click on the links and complete the survey today!

Coming soon – the Improving Care Search Centre!

Information on the Patient Safety Crosswalk will become even more accessible in May when the Canadian Patient Safety Institute launches the Improving Care Search Centre – a Google-like search centre which will bring patient safety and quality improvement information from across Canada and around the world together in one place.  Website visitors will be able to view Crosswalk news feeds on a customized dashboard within the Improving Care Search Centre alongside other great patient safety feeds like a calendar of events or a @SafeCareLibrary Twitter feed. CPSI is inviting organizations to register for the Improving Care Search Centre launch, which will take place on May 3rd.

As part of the Improving Care Search Centre, you can also register your organization to become part of CPSI’s Improving Care Alliance, which will allow your organization’s information to be searched and appear on our site; your organization will receive its own profile page featuring your logo, organization description and website link. For further information, please email Cecilia Bloxom, Director of Communications at cbloxom@cpsi-icsp.ca.

Patient Safety Crosswalk Feedback:

Camilla Covello, director of the International Services at IQG, lead organization for the Brazilian National Accreditation Program:

IQG has partnered with Accreditation Canada to provide quality and patient safety accreditation in Brazil. IQG is using the information posted to Crosswalk to help mitigate risk and spread national and international concepts of best practice care. Camilla Covello says that Crosswalk helps to promote and strengthen local initiatives in quality and patient safety:

"The information on Crosswalk is an invaluable tool in incorporating patient safety polices into Brazilian and Latin American healthcare organizational strategies. Positioning quality and patient safety is a top priority for IQG in Brazilian healthcare and the information on Crosswalk is a useful tool in helping to achieve our objectives and safety results."

Bernadette MacDonald, Vice-President, Programs and Services, Accreditation Canada:

“Accreditation Canada is pleased to participate in the Patient Safety Crosswalk,” says Bernadette MacDonald.  “It offers a convenient, central place for participating organizations to share resources and highlight particular activities they are pursuing to enhance patient safety at a system level.”  

Tim Closson, President and CEO of the Ontario Hospital Association (OHA):

"Patient Safety Crosswalk is an excellent opportunity for the OHA to help raise awareness about our patient safety initiatives on a national scale,” says Tom Closson. “This includes educational events, such as the Patient Safety certificate course; valuable resources like the 2010 Guidebook to Patient Safety Leading Practices and Patient Safety Award; and our recent achievements, available online through the Quality and Patient Safety Plan 2010-2013 - Year 1 Status Update. Since its launch, the OHA has supported the Crosswalk initiative because we believe it is important to share information that can help improve patient safety and quality of care with a large network of people and organizations - patients and those working in the field.”

The Ontario Hospital Association (OHA) and the Ontario Ministry of Health and Long-Term Care have teamed up with the Canadian Health Services Research Foundation (CHSRF) and the Canadian Patient Safety Institute (CPSI) to offer a unique and comprehensive education curriculum to support Ontario hospital boards in their ongoing efforts to improve governance for quality and patient safety. This program is geared toward hospital board chairs, CEOs and members of healthcare board quality committees.

The one and a half -day session builds on the Effective Governance for Quality and Patient Safety program, developed by CHSRF and CPSI, and has been tailored to address Ontario-focused issues and legislation.

During the sessions, participants will explore evidence-informed approaches to governance and leadership and share innovative health governance practices, resources and tools:

• Learn how to apply the principles of the Excellent Care for All Act (ECFAA)
• Understand a Board’s core functions related to quality and patient safety
• Identify approaches to measuring the quality of care
• Recognize how an organizational culture of quality and patient safety can be led, supported and sustained by the Board
• Develop tools, structures and processes that will assist participants in improving their organizations’ governance practices related to quality and patient safety
• Access the CPSI/CHRSF and OHA quality and patient safety toolkits

Education sessions have been scheduled throughout Ontario. To register for the following sessions, click on the applicable link:

• April 6-7 – North Bay (Best Western)
  https://regportal.oha.com/April6
• April 13-14 – Thunder Bay (Victoria Inn)
  https://regportal.oha.com/April13
• May 5-6 – Toronto (Estates of Sunnybrook)
  https://regportal.oha.com/may5

This program is supported by the Government of Ontario and space is limited; there is no registration fee.  For additional registration and program details email gceinfo@oha.com, or call (416) 205-1362.

The Patient Safety Education Project (PSEP) Canada recently completed a second pilot session and certified an additional 10 interprofessional teams as PSEP-Canada Patient Safety Trainers to support patient safety and quality improvement work.  The two-and-a-half day conference focuses on core patient safety content and effective teaching approaches to effectively drive patient safety improvements in healthcare organizations.

Executive leaders from all participating organizations joined their teams for the last half-day of the program to build-on the session learning’s and gain momentum for implementing Action Plans developed by each team on a quality improvement or patient safety issue in their organization.

 “The program stimulated a lot of thought and provided the support we need to customize patient safety education tailored to our needs,” says John McKeekin, Project Manager from Correctional Services Canada (CSC).  The CSC team included seven participants who will now develop a project plan and ‘train the trainers’ across five regions to sustain the program and roll out the patient safety training modules to the 57 federal penitentiaries across the country.  “The facilitation techniques and the Canadian-focused curriculum will be invaluable as we move forward,” says John.

“We now have a huge repository of information that will be our go-to resource, and methodologies and tools for training on patient safety topics,” says Eileen Chang, Patient Safety and Risk Management Specialist, Baycrest Geriatric Health Care System in Toronto, ON.  Baycrest is developing a patient safety plan aligned with the organization’s strategic plan and will use the learnings to develop an education program for health professionals that is aligned with day-to-day practice. “This program pulls it all together into a formalized framework with bite-size pieces that can be utilized across health disciplines,” says Eileen. 

“This program fills a gap and provides a solid foundation to help take patient safety education to the front-line,” says Kristi Chorney, Manager of Quality, Patient Safety and Risk, Brandon Regional Health Authority, one of the 12 Master Facilitators completing certification as a PSEP-Canada Master Facilitator; 24 Master Facilitators have now been certified to lead the program. “This group was very energetic.  There was excellent discussion about methods to advance from attitudes about patient safety into cultural change or the normal way of performing our work. We went away with a feeling that something good was going to happen in terms of being proactive rather than reactive in our approach to patient safety education.”

Some 41 participants from across Canada completed the Become a PSEP-Canada Patient Safety Trainer program in Ottawa, February 8 to 10, 2011. The first pilot session, held in November 2010, also certified eight interprofessional teams as PSEP Canada trainers..

PSEP-Canada is a partnership between the Canadian Patient Safety Institute and Northwestern University, with content adapted for Canadian healthcare settings.  Learnings from the two pilot sessions will be considered in finalizing the PSEP-Canada Patient Safety Trainer program, to be officially launched in the Fall of 2011.  For more information, visit www.patientsafetyinstitute.ca or contact Abigail Hain 613-738-4779 or email psepcanada@cpsi-icsp.ca.

Celebrating Canadian Patient Safety Week Series

The Quality and Patient Safety Team at St. John’s Rehab in Toronto say staff and patients have a greater understanding of their role in patient safety following Canadian Patient Safety Week.

Comprised of Sonia Jacobs, Director of Quality and Patient Safety and Decision Support and Privacy Officer; Wendy Hooper, Manager of Quality and Patient Safety; and Shadan Fallahi, Patient and Staff Safety Advisor, the Quality and Patient Safety Team worked hard to ensure the week was a success and that message behind Canadian Patient Safety Week – Good Healthcare Starts with Good Communication - was delivered.

For all three members of the Quality and Patient Safety Team, the highlight of the week was seeing patients engaged in their own safety and the impact it had on some during their stay in hospital, especially for one patient who was admitted during the week. The patient and her family were encouraged by the focus the staff at St. John’s Rehab placed on patient safety.

“It made her feel more at home, especially on her first night in hospital. That was a really positive experience for all of us,” Jacobs says.

Hooper says taking part in CPSW was very energizing for the entire staff, giving everyone a chance to reflect on patient safety, see where things are working as well as what is needed to improve patient safety. Effort was made to ensure that all staff could get involved, regardless of their role or shift schedule.

To accomplish this, a Mobile Patient Safety Information Cart was taken to all the inpatient units throughout the course of all three shifts – something Hooper says the staff appreciated. In addition to educating people, staff and patients were encouraged to get in on the fun by testing their knowledge of patient safety in exchange for a treat and a chance to win a prize at the end of the week.

Hooper says one patient in particular has been actively taking part in the week’s activities and even visited the Canadian Patient Safety Institute’s website to learn more about patient safety. He also accompanied the Mobile Patient Safety Information Cart as it travelled throughout the hospital, encouraging staff and his fellow patients to participate and providing his personal insights and perspective on patient safety.

Canadian Patient Safety Week also provided St. John’s Rehab with the perfect opportunity to launch their Quality and Patient Safety Dashboards – a paper-based quality improvement strategy that Jacobs says will, “make the data come alive.”

The Dashboard shows trends in data and will be used to engage front-line staff members by demonstrating the progress their efforts to improve patient safety are having on patient care.

The Canadian Patient Safety Institute (CPSI) and the Canadian Nurses Association (CNA) have signed a partnership agreement to jointly support a range of patient safety initiatives by contributing resources to reach common outcomes.  The partnership agreement formalizes the relationship and recognizes the need for leadership and a coordinated voice at the pan-Canadian level.  It also acknowledges the mutual interest in promoting patient safety in the Canadian healthcare delivery system in both official languages and will facilitate achieving common goals.

“Relationships are at the core of CPSI’s new way of doing business,” says Hugh MacLeod, CEO of the Canadian Patient Safety Institute.  “We are committed to working in collaboration with other health organizations such as the CNA to make healthcare safer —this new partnership agreement demonstrates our commitment to transform and jointly realize a new patient safety vision for the Canadian health system.” 

“This partnership agreement reinforces the vision and mission of the Canadian Nurses Association and enhances the registered nurses role in patient safety,” says Judith Shamian, President of the Canadian Nurses Association. “Promoting quality practice environments is a priority for the CNA and this partnership will help to reinforce the nursing perspective related to patient safety issues.”

Under the agreement, CPSI and the CNA will promote each other’s patient safety work such as Safer Healthcare Now! and the CNA’s Patient Safety Resource Guide.  They have also agreed to continue to collaborate on: medication reconciliation initiatives; research (and sources of funding) involving leading practices in nursing that have demonstrated a positive impact on patient safety;  national issues that have an impact on patient safety with other national organizations (such as national disclosure guidelines, quality work life and quality healthcare); and meet regularly to discuss national issues and opportunities for potential collaboration on health policy initiatives.

The two-year agreement will be reviewed in 2013.

Safe care…accepting no less.

www.globalpatientsafetyalerts.com

Click here to read the News Release.

Join us on February 15th, 2011 at 10:30am ET to start the conversation with the launch of Global Patient Safety Alerts.  Global Patient Safety Alerts is an innovative information-sharing resource to help you prevent and mitigate patient safety incidents in your organization and help others succeed.

Frontline healthcare providers and healthcare organizations around the world that are looking for and developing solutions to patient safety incidents and challenges should join this launch. With access to global patient safety incident advisories, alerts, and recommendations, you can learn what works and share your own insights and solutions with healthcare providers, healthcare organizations, patients, and the public.

By asking, listening, and talking to one another, we can grow our own patient safety and quality initiatives and help others grow theirs.

Click here for the Global Patient Safety Alerts Launch.  Note, you can test the broadcast on your computer before hand in Flash or Windows Media.  The broadcast will be on February 15, 2011 at 8:30am MT / 10:30am ET / 11:30am AT / 4:30pm CET

The Global Patient Safety Alerts launch will be available in English only

The Canadian Patient Safety Institute Strategic Plan, “Safe Care ... Accepting No Less”, was unveiled in early December 2010. Since its release we’ve heard from a number of organizations and individuals from across the countries who have told us that the messaging is clear and concise, with broad appeal to engage multiple stakeholders. With a new vision: ‘Safe healthcare for all Canadians,’ and a mission: ‘To inspire extraordinary improvement in patient safety and quality,’ this document sets out our roles, priorities and goals for the next five years.  It reinforces who we are, and describes what success and sustainability looks like going forward. It positions Safer Healthcare Now! as a flagship program for the organization and promotes governance and patient safety education to sustain patient safety and quality efforts.

We invite you to explore our new Strategic Plan and we are eager to hear what you think!  Click here to access a copy of the new CPSI Strategic Plan and send your comments to: info@cpsi-icsp.ca

Celebrating Canadian Patient Safety Week Series

For Sean Bisschop, the Quality and Patient Safety Coordinator at Orillia Soldiers’ Memorial Hospital, Canadian Patient Safety Week 2010 was a fantastic opportunity to engage patients and staff and to shine a spotlight on patient safety and quality improvement.

“Canadian Patient Safety Week really put the spotlight on patient safety – allowing staff and patients to talk openly and freely about it. Momentum built as people caught on to the idea,” Bisschop says. “One of our goals was pure participation. There was growing interest (as the week went on and as) word spread with staff calling to see what’s next on the schedule.”

One of the highlights from Canadian Patient Safety Week was Patient Safety Stories, a noon-hour catered lunch with a number of topics revolving around patient safety culture. Co-hosted by Bisschop and the Chair of the Board, the session featured a viewing of a video produced by the Josie King Foundation which tells the story of 18-month-old Josie King, who died from medical error in 2001, as well as a video titled ‘Beyond Blame,’ which addresses healthcare providers and their reactions to the errors in which they were involved.

“This session stimulated a lot of conversation about the culture of blame, asking questions and owning up to mistakes. It created a safe place for folks to think and talk about errors. It was very compelling and word spread quickly,” Bisschop says, adding that several of the units and staff who couldn’t attend were asking if additional sessions could be organized so they could also watch the videos. A member of the Senior Leadership Team also asked to show the video at their team’s next meeting.

Another highlight from the Canadian Patient Safety Week celebrations was the “Walk in a Patient’s Shoes – Live with Staff” event hosted in the cafeteria by the hospital’s Regional Falls Program staff. As part of the event, staff members were fitted with various pieces of equipment designed to simulate seniors’ health issues and asked to navigate hospital spaces.

For instance, weight bags were strapped to one leg to simulate mobility barriers, oven mitts were adorned to mimic reduced sensation when using a cane or walker, and ear plugs and special glasses were used to replicate hearing and vision problems.

Regardless of the impairment, Bisschop says the experience was an eye-opener for staff and that even hospital president and CEO Elisabeth Riley got involved by strapping herself into a ceiling lift used to transport patients with reduced mobility around a room via tracks on the ceiling.

The entire event was captured on video, featuring comments from staff reflecting on their experiences and shown to staff.

“Our leadership was great,” Bisschop says. “Patients and staff really enjoyed seeing staff, Board members and members of the senior team step into their shoes.”

Paper highlights patient safety risks in primary care settings

Johanna Trimble and her family are all too familiar with the patient safety risks that exist in primary care.

In 2006, Trimble’s mother-in-law Fervid, was diagnosed with MRSA stemming from a persistent infection in one eye and subsequently contracted another superbug, C. difficile, from an outbreak in her nursing home. After six rounds of powerful antibiotics to combat the infection, Fervid’s health deteriorated and she died in October 2008, at 92 years of age.

Trimble, a member of the BC Patient Voices Network and a member of Patients for Patient Safety Canada, is applauding the recent release of the ‘Patient Safety in Primary Care’ Background Research Paper. Commissioned by the Canadian Patient Safety Institute (CPSI) and the BC Patient Safety & Quality Council, the paper explores the current state of knowledge, as well as the key issues, priorities, opportunities and strategies for advancing patient safety in primary care in Canada.

“Because our system is so fragmented, there has been little ability to report safety issues in primary care. It is difficult to change something you can’t measure,” Trimble says. “Our family has experienced this directly.”

She says the paper brings the extent of the issue to awareness and proposes ways to address it — an important first step.

“I hope that the paper will inspire Canadians to pay attention to how safety programs in other places, for example the U.K., have been developed and have made a real impact. We can learn from these experiences and see that it can be done.”

Dr. John Maxted, Assistant Professor in the Department of Family & Community Medicine at University of Toronto and the chair of the pan-Canadian Advisory Group that guided the research process, says the goal of the paper is to give momentum to the safety issues and ultimately compel leaders and providers towards system improvements.

“It’s an issue that needs attention – this kind of research has to move people to take action,” Maxted says. “If the paper is reviewed and causes people to pay attention and it stimulates people to take action to improve patient safety in primary care, then we will have accomplished what we wanted to.”

In the meantime, patient safety advocates such as Trimble will continue to rally people around the cause in an effort to ensure what happened to Fervid doesn’t happen to anyone else.

“Let’s drop the negative and passive attitudes of ‘it’s so big we can’t do anything about it’, or ‘it’s not so bad’ or ‘we keep trying but it doesn’t work’. There’s a saying – ‘make it easier to do the right thing and harder to do the wrong thing,’” she says. “Let’s give this priority and resources and change it!”

The report, ‘Patient Safety in Primary Care,’ is available on the BC Patient Safety & Quality Council’s website at www.bcpsqc.ca and the Canadian Patient Safety Institute website at www.patientsafetyinstitute.ca.

The Canadian Healthcare Association (CHA) and the Canadian Patient Safety Institute (CPSI) are partnering to deliver an updated Canadian Patient Safety Officer Course in 2011. The course is scheduled from April 12-15 inclusive, at the Chateau Laurier in Ottawa, Ontario.

This comprehensive patient safety course is designed for healthcare professionals and leaders who understand the fundamentals of patient safety and have the formal responsibility for disseminating patient safety principles and programs throughout their organizations. Drawing on the experience of patient safety experts, the program will be delivered using lectures, interactive workshops, case studies, teambuilding activities, networking and communication, and physician engagement strategies.

Register prior to January 31, 2011 to take advantage of the early-bird fee of $3,500.  The registration fee for applications received after January 31st is $3,900 for the four-day course. 

Don’t miss out on this exciting learning opportunity!  For more information, visit the CHA website www.cha.ca, or send an email to safety@cha.ca

The Patient Safety Education Project (PSEP)-Canada held a pilot session in Toronto (ON), from November 15 to 17, where some 40 participants and seven interprofessional teams were trained in the program, Become a PSEP-Canada Patient Safety Trainer. This two-and-a-half day conference focused on core patient safety content and effective teaching approaches to effectively drive patient safety improvements in healthcare organizations.

The Patient Safety Education Project was developed by Dr. Linda Emanuel and her team from Northwestern University and in partnership with the Canadian Patient Safety Institute (CPSI), content has been adapted for Canadian healthcare settings.  The sessions were led by Dr. Emanuel, faculty from Northwestern, and representatives from CPSI; together with a group of PSEP-Canada Master Facilitators from various Canadian healthcare institutions that have been trained to guide patient safety education in this peer-to-peer framework.

Teams attending the conference were challenged to consider innovative ways to deliver an education program that influences the growth and dissemination of practice improvement ideas in their home organization. Participation in the Become a PSEP-Canada Patient Safety Trainer conference allowed teams to tackle the very real challenge of influencing change, while at the same time emphasizing innovation, true engagement of peer professionals as well as capacity building to improve patient safety. The Canadian master facilitators hosting the conference modeled the use of role play, trigger tape clinical vignette discussions as well as case-based reviews. At the end of the Conference, participants were certified as PSEP Canada Patient Safety Trainers and are now equipped with a core curriculum with supporting materials such as video clips, to teach their colleagues core skills in patient safety.

Participants in the Become a PSEP-Canada Patient Safety Trainer conference must have commitment and support from an executive leader in their organization. The Executive sponsors attended a half-day executive track session on the final day of the conference to learn how to support implementation, and together with the participating teams developed next steps.

Teams participating in this pilot session included representatives from Brant Community Healthcare System (ON); Bridgepoint Health (ON);  Grand River and St. Mary’s General Hospitals (ON); Royal Victoria Hospital (ON), Safer Healthcare Now! (Atlantic Node); St. Michael’s Hospital (ON); and Trillium Health (ON).

The next pilot session of the Become a PSEP-Canada Patient Safety Trainer will take place from February 8 to 10, 2011 in Ottawa, Ontario.  For further details, contact Abigail Hain, ahain@cpsi-icsp.ca

Social media is fast becoming one of the most effective ways to monitor recent developments in patient safety and provide real time commentary.  Movement toward these networks is evident as the healthcare industry recognizes the importance and benefits of spread using social media.  Many healthcare organizations are using Twitter to announce educational programs and Facebook to build communities of people with shared interests. You can watch videos uploaded to You Tube channels and read commentary shared on blogs. The evolution of the e-patient, those who are equipped, enabled, empowered and engaged in their health and healthcare decisions, is generating a two-way conversation to improve quality within the health system.

The Canadian Patient Safety Institute (CPSI) is using social media to create awareness, social consciousness and knowledge spread. We know that you are the experts in the field, and that you have opinions and resources to share. We want all patient safety professionals to be part of the ongoing discussions on patient safety (#ptsafety) and share their voice as individuals, rather than that of their organization.

The first step is to create your own Twitter account to tweet patient safety information.  Twitter really is easy and you don’t have to be technologically savvy to participate.   Tweet to let people know about an article or speaking engagement.  Tweet to ask questions on burning patient safety issues. Re-tweet interesting links to friends and coworkers. Tweet to get immediate feedback on something you want to know.  Jumpstart your research and find out what people are saying about a topic. Once you get started, you’ll learn quickly - just join in on the conversations and share your thoughts on patient safety. And, if you want to tweet about things, that’s fine too!

At CPSI, interest on Twitter peaked recently when activities were highlighted during Canadian Patient Safety Week (hashtag #CPSW) and Halifax 10, the Canadian Healthcare Symposium (hashtag #Halifax10). We thank our followers on both Twitter and Facebook who participated in the discussions and shared information on these topics. CPSI will continue to use these networks as a catalyst in patient safety conversations and to communicate information on some of the great tools and resources available.

Tweet about patient safety today using the hashtag #PtSafety, and follow CPSI, @Patient_Safety.

If you have questions on how CPSI is using social media to promote patient safety, contact Abisaac Saraga at asaraga@cpsi-icsp.ca

Evidence-based information to inform decisions and barcode scanning for bedside medication delivery

North York General Hospital (North York) in Toronto, ON is implementing new technology that will reduce medication errors and provide clinical staff with the latest evidence-based information to inform their decisions. The Canadian Patient Safety Institute (CPSI) congratulates North York on this initiative to improve patient safety and enhance the quality of patient care.

“North York is an example of one of the pockets of excellence we are seeing in improving patient safety across the country,” says Hugh MacLeod, CEO of CPSI.  “Using evidence based information to inform decisions and barcode scanning for medication delivery at bedside will help reduce medication errors. CPSI would like to recognize North York for their leadership in integrating this technology into their hospital electronic health record system.”

The ‘eCare’ initiative moves beyond manual systems that are vulnerable to errors and summarizes mountains of medical literature for healthcare providers, all to benefit patients. The new system includes barcode scanning to uniquely identify each medication and each patient. This will reduce the risk for medication errors by alerting healthcare providers if they are about to make an error when administering a medication. 

“A significant proportion of preventable errors involve medications prescribed and administered using traditional, manual systems,” says Dr. Jeremy Theal, Director of Medical Informatics and a gastroenterologist at North York.  “By integrating the latest medical literature and implementing barcode scanning with electronic orders, we are raising the bar on patient care and preventing errors to significantly improve patient safety.  Ultimately, we have new tools that research shows will help people get better faster, and save lives.”

A key feature of ‘eCare’ is the computerized provider order entry (CPOE) which allows physicians to enter their orders electronically instead of on paper, reducing the possibility for misinterpretation and increasing information-sharing among healthcare providers.  The CPOE solution incorporates the latest medical knowledge into the clinicians' workflow, including clinical decision support and a library of over 300 evidence-based order sets. North York is the first hospital in Canada to implement an electronic order entry system that integrates regularly-updated evidence from the medical literature into the doctor's decision-making process.

“This hospital-driven initiative is the result of outstanding teamwork involving informatics personnel, nurses, pharmacists, physicians, dieticians, physiotherapists and more,” says Dr. Tim Rutledge, Interim President and CEO at North York.  “The tremendous efforts of all involved will ultimately benefit our patients.  ‘eCare’ is a significant step forward in patient safety, quality of care and achieving a paperless medical record.”

The Canadian Patient Safety Institute commends the Province of Manitoba on its first annual patient safety report, Patient Safety in Manitoba 2007 to 2010. Manitoba Health Minister Theresa Oswald released the report on November 1, 2010 in conjunction with Canadian Patient Safety Week, as one of the next steps in Manitoba’s strategy to reduce errors in the healthcare system and foster a culture of openness and transparency among health professionals. 

The report demonstrates that Manitoba’s mandatory, no-blame critical incident reporting legislation has increased the number of incidents being reported and the opportunity to learn and prevent the recurrence of errors that do take place. Reporting of critical incidents has been mandatory in Manitoba since 2006.

“Manitoba’s steps in patient safety show a commitment to transparency, humility of leaders and the acknowledgement the system is imperfect,” said Hugh MacLeod, CEO of the Canadian Patient Safety Institute. “This honesty positions Manitoba as a leader in Canada and will set the stage for transformation in patient safety.”

To increase public transparency, a summary of critical incidents reported to Manitoba Health will be issued on a quarterly basis, starting in 2011.  In addition, starting next year, Manitoba Health and the Manitoba Institute for Patient Safety will co-host a patient safety learning day to bring together patient safety investigators from the Regional Health Authorities, quality improvement staff, doctors, nurses and pharmacists to review trends in critical incidents and other quality issues with a goal to identify actions to address these issues.

The province has also launched a new website that includes information for the public on what to do if someone has a patient safety concern and how the province is improving patient safety.

“Patients and families expect the healthcare system to investigate when errors happen and make changes to prevent them from happening again,” said Oswald.  “Patient safety is a priority for Manitoba’s healthcare system. The new steps introduced not only support making the system safer, but also improve transparency so that Manitobans can see how acknowledging errors that occur in healthcare improves patient safety.”

The new annual report and other patient safety information are now available on the website: www.gov.mb.ca/health/patientsafety.