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Ten years of putting patients first235294/24/2017 9:50:35 PMPatient Safety News<img alt="" src="/en/NewsAlerts/News/PublishingImages/2017/Theresa%20Malloy-Miller.jpg?Width=140" width="140" style="BORDER&#58;0px solid;" /> From the depths of a parent's worst nightmare, Theresa Malloy-Miller has emerged as a tireless advocate for the patient's voice in Canadian health care. As one of Canada's original patient safety champions, Theresa Malloy-Miller is also a full-fledged member of a club that no-one wants to belong to. It's a sad fact that most of this country's strongest voices for improved patient care draw strength for their advocacy from a frequently tragic personal experience with the health delivery system. Theresa is no different. She and her husband Tim took their 17-year-old son Daniel to a London, Ontario hospital in January 2003 with what they suspected was a severe case of the flu. Four days later their boy was dead. An autopsy confirmed myocarditis, a heart infection that can cause rapid onset of heart failure. That hospital experience left the Millers reeling with shock and grief, but also confounded by a succession of missed signals, poor communication and medical mistakes they fervently believe reduced their son's chances of survival. The hospital stonewalled at first, but the couple's ongoing search for answers eventually culminated in the first patient safety conference ever held in London. It also opened the doors for Theresa to become one of the two patient advisors on the Quality and Patient Safety Committee and the Co-chair of the Patient Experience Committee. After numerous internal and external reviews of Daniel's death, hospital procedures were modified and communication guidelines strengthened. It took four years and a change in hospital administration, but the Millers finally received an apology. Daniel's story is still used at London Health Sciences Centre in staff education sessions. Theresa was still burdened with a mother's grief in 2006 when she first heard, almost by accident, about a conference being held in Vancouver later that year to create Patients for Patient Safety Canada, a group of committed individuals charged with promoting the patient and family voice in the health care system. "Daniel had passed away in 2003; it was three years later," Theresa recalls over the phone from her home in Delaware, Ontario. "You know, your life stops, you search, and I was at that point of needing to do something." She contacted one of the conference organizers, Ryan Sidorchuk, then Canada's first global patient safety champion who was selected for a multi-national summit with the World Health Organization's World Alliance for Patient Safety in London, England, in 2005. He invited her to attend the inaugural Vancouver meeting. Theresa did and she's been an active member of Patients for Patient Safety Canada ever since, working on quality control and the patient experience at her local level while spearheading research and knowledge transfer initiatives nationally. "I was really reaching for something," she says of those early days. "I think when you lose a child it just turns your life upside down. So my life was nothing like what it was before anyway. It was in disarray. "I think Patients for Patient Safety brought me back to a more similar style of how I approach things. Always if I set a goal and I have a plan I'm comfortable in that space. It brought me probably to a more familiar place at a time when nothing was familiar." Working alongside other volunteers, many of whom had suffered similar adverse experiences, was a healing experience for her. "You can't move forward in patient safety by yourself. The task is too large. So being part of a group is just more effective. You get inspired by what other people are doing and the group opens up opportunities." The patient safety work also gave her a way to channel some of the anger she was still carrying, Theresa adds, "absolutely. The anger is indescribable. Anger that I never envisioned could be possible. Certainly it gave Daniel a voice which was really important to me." Ask her what the most encouraging development she's seen in health care over the last 10 years is and Theresa is quick to answer. "The central thing I see is the acceptance and the need for a patient family voice in health care. It is so central now in how health care is going to progress." Allowing that the person who has the health needs to be at the centre of the health care equation is just a dramatically different approach from the way it used to be", Theresa says. At the time of Dan's ER visits Theresa felt that their views and information were not considered. "We knew a lot about Daniel and all of the people who interacted with us never wanted to hear our view. And it was the crux of why it didn't work out. The only way forward in health care is for the person who has the health need to be at the centre of that circle." If she had but one message to pass on to health care providers, it would be, "as people we all have health needs and we're all on the same team. There's only one team when it comes to health." Unlike many of her patient safety counterparts who regularly weave their personal loss into their public advocacy work, Theresa stopped telling Daniel's story at patient forums a few years ago. It was just too difficult for her. Every time she revisited the story she'd need weeks to recover. But she has no doubt that Daniel, who was always a peacemaker among his friends, would be proud of the positive force for change that his mom has become. Theresa has recorded Dan's story in video form, a long version with her husband Tim and a shorter version with the help of CPSI. Both of these videos continue to be viewed. Theresa has put her focus into contributing to patient safety issues. She is the chair of the Knowledge Transfer Working Group of PFPSC. This group of PFPSC members, with the help of CPSI staff and in partnership with the WHO, has been able to bring many topics related to patient safety to an international audience. At a local level, she brings a patient voice to hospital safety and quality projects and measures. As part of the hospital-based Patient Experience Committee, she is able to add input into hospital policies like disclosure and family visiting, as well as contribute to local patient safety education sessions. There are many ways to contribute to patient safety. When Theresa reflects on what pushes her to continue to be involved in patient safety, Dan's voice comes to her quickly. "His favourite thing that he'd always say to me was, 'you are so annoying,' Theresa says, with a little laugh. "It's something that's stuck in my head. As much as I was devastated, at those really low points I would hear him say that. 'You are so annoying.' I think he would expect me to do something positive and not just sort of wallow in the pit." Being part of PFSC has provided Theresa with a positive meaningful and way to contribute to patient safety.4/24/2017 6:00:00 AMFrom the depths of a parent's worst nightmare, Theresa Malloy-Miller has emerged as a tireless advocate for the patient's voice in Canadian health4/24/2017 9:58:56 PM6
Joint Centres InnovationEX 201734784/19/2017 4:39:23 PMPatient Safety NewsInvitational Forum on Reducing Harm - April 5, 2017 Transparency and culture change key to patient safety See the patient in front of you as an individual, care for them to the best of your abilities and apologize to them directly in a timely manner if you make a mistake. That is a distillation of some of the patient-centred advice provided at a comprehensive review of patient safety and reducing harm in hospitals provided by a range of participants at the forum held in conjunction with the 4th annual InnovationEX of the Joint Centres for Transformative Health Care Innovation held at Markham-Stouffville Hospital. Markham-Stouffville is a member of the Joint Centres along with Mackenzie Health, Michael Garron Hospital, North York General Hospital, Southlake Regional Health Centre and St. Joseph's Health Centre. In addition to this year's focus on patient safety, the event also showcased innovative work at the six hospitals aimed at improving quality, safety and bringing more value to the health care system. "You're doing innovation in the best way. You're doing innovation as it's touching patients," said Dr. Bob Bell, Deputy Minister of Health and Long-term Care in his introductory remarks. In his presentation, Bell focused on how the revised Quality of Care Information Protection Act, to be proclaimed this summer, will increase transparency in dealing with preventable errors in hospitals. As keynote speaker at the forum, Chris Power, CEO of the Canadian Patient Safety Institute (CPSI) provided a comprehensive overview of the status of patient safety in Canada today. "We know that in health care things go wrong despite our best efforts. But most times we get it right," she said. However, Power said someone in a Canadian acute care hospital dies from a preventable event every 17 minutes and this statistic has not changed much in recent years. Whether it is possible to totally eliminate such errors depends on your perspective, she said, with other speakers in the meeting opining that while total elimination of error was not possible much more could be done to reduce the impact to patients of such incidents. With communication breakdown identified as the main cause of preventable errors, Power said, the key to changing the situation lies in creating a safety culture, and improving teamwork and communications. Power then talked about work being done at CPSI to identify the "winning conditions" for improving patient safety. These conditions includeImproving the reliability of human decision-making – currently seriously underdeveloped in Canada because of a very strong tradition of clinical autonomy and suspicion of standardized work.Developing a sense of urgency about the issue – a sense that Power says that "appears to have waned" in recent years.A commitment to good governance and management commitment. Power and others talked about "pockets of excellence" in Canada while the governance capacity overall for system performance has not improved greatly.Access to reliable data of a granular nature that will be useful for individual clinician. Power said with the increased cadre of sophisticated patient-advocates "patients and the public are going to be the ones that transform health care. Not us." This was a theme that continued through the panel discussion that followed which included input from panel member, Diane McKenzie, patient and family advisor at St. Joseph's. The other major focus of the panel discussion was the comparison between managing patient safety in hospitals with how safety is dealt with in the aviation and space industries. Insights were provided by former astronaut and emergency room physician and now CEO of Southlake, Dr. Dave Williams, and Samuel Elfassy, managing director, corporate safety, environment and quality for Air Canada. The panel discussion was moderated by Dr. Joshua Tepper, president and CEO of Health Quality Ontario. Safety is one of the six dimensions of quality that defines a high quality health care system and drives the work of Health Quality Ontario. Comparing and contrasting safety in the hospital sector with that of the aviation industry is a long-standing fixture in patient safety debates and from the panel discussion it was clear clinicians still need to do more to embrace the culture ingrained in pilots and astronauts. Elfassy said changing the culture in hospitals will require a lot of transparency, data and personal story telling. Williams evoked the power of story-telling and shared the impact that unexpected outcomes let alone medical errors can have on clinical staff when he spoke of becoming tearful recently while giving rounds at Southlake discussing an incident from 30 years ago where no errors were made but there was a very tragic outcome. Williams noted those in the aviation industry have an extensive exposure to a terminology and culture of safety that is only just starting to be embraced by medicine. While Williams and Power focused on the need for more standardization in health care, McKenzie added that providers need to account for the individual needs of patients at the same time. The discussion briefly touched on whether fiscal restraints on hospitals had an impact on patient safety. Power and others noted all variables impacting patient care in hospital such as bed shortages should be viewed through a safety lens. Hospitals will continue to need to provide the highest quality and safest care within the constraints of their funding envelopes. The discussion concluded by returning to the focus on individual patient care to improve patient safety and reduce medical error. McKenzie noted that while developing standards of care are very important there must also be recognition that some patients will not fit the care models that are developed and there must be a process to ensure they also receive optimal care. "We promise patients the highest quality of care and we will build their trust when we fulfill that promise," said Tepper. Dr. Tim Rutledge, Chair of the Joint Centres, wrapped up the forum and set the tone for continued work on the issue of reducing harm by reiterating "we need a culture of trust, a culture of learning and a culture of collaboration". He noted there was a palpable sense this existed in the organizations who participated in the forum.4/19/2017 6:00:00 AMInvitational Forum on Reducing Harm - April 5, 2017 Transparency and culture change key to patient safety See the patient in front of you as an4/19/2017 4:42:41 PM29
Patient Safety Power Play: Let’s celebrate!260764/11/2017 3:59:32 PMPatient Safety Power Plays I have a favour to ask. Please take a few moments out of your day to celebrate someone important to you who is making a difference. Whatever the reason, large or small, take the time and make the effort to celebrate one another. In the workplace, especially one as frantic as healthcare, these can be moments that bring colleagues together and build a stronger culture. In the realm of patient safety, for instance, time is running out to submit your nominations for the Patient Safety Champion Awards. Presented in partnership with our good friends at HealthCareCAN, these awards are your opportunity to recognize both volunteers, and entire organizations, for the work they do to engage with patients and families and ensure they're at the centre of all patient safety initiatives. Not only that, but winners will be flown to the National Health Leaders Conference to accept their award. After the awards ceremony, we're going to host a webinar with the winners and runners-up, where we can share the work they've done with the country and encourage others to follow their example. The deadline to submit your nominations has just been extended to April to give everyone one last chance to submit their nomination. Win or lose, a nomination itself is a tremendous gesture that will leave a lasting impression on someone very deserving. For some inspiration, you can learn all about Johanna Trimble and Michael Garron Hospital, who were the winners of the Patient Safety Champion Awards last year. I for one am looking forward to celebrating our Patient Safety Champions this June at the National Health Leaders Conference. How about you? Any celebrations to share, or people to recognize? I invite you to connect with me at or follow me on Twitter @ChrisPowerCPSI. Yours in patient safety, Chris Power4/11/2017 6:00:00 AMI have a favour to ask. Please take a few moments out of your day to celebrate someone important to you who is making a difference. Whatever the4/11/2017 7:31:19 PM148
Niagara Health- Focused on Raising Awareness of Never Events 312873/17/2017 8:37:57 PMPatient Safety News<img alt="" src="/en/NewsAlerts/News/PublishingImages/2017/Never%20Events%20News%202017-03.jpg?Width=140" width="140" style="BORDER&#58;0px solid;" /> It was all in the timing. Years before the pan-Canadian list of Never Events was released in September 2015, Niagara Health in Southern Ontario had already begun looking at ways to advance its safety culture. Never Events, named for being incidents that should never happen, can include instances of child abductions, suicides or patients receiving the wrong surgery. Niagara Health recognized that even one Never Event was one too many. With the hospital organization's new strategic plan containing a focus on ingraining a culture of safety and eliminating preventable harm in order to provide extraordinary care, this was seen as a perfect opportunity to embed Never Events within its strategic visioning to combat the challenges in different ways. A report, prepared by the Canadian Patient Safety Institute and Health Quality Ontario with many partners, specified 15 of the most serious known patient safety incidents and offered guidance on how hospitals might avert them. Those guidelines are not binding, so it remains up to healthcare organizations to decide if and how best to develop strategies that will help prevent such incidents. "It was actually the Never Events report itself that triggered the added patient safety attention because we saw it as an avenue to increase awareness, to focus on where we were with this set of 15 and did we need to do something about it," said Marilyn Kalmats, Director of Quality, Patient Safety and Risk Management at Niagara Health. As part of an organization that is focused on continuous learning and improvement, the report prompted the question "Were we missing something?" Niagara Health began reevaluating what it considered to be classified as a never event, prompting clinical staff and administration to take another look at prevention methods. Project teams with a clinical lead and physician lead as well as front-line staff were formed for each of the 15 event types, and were responsible for conducting a gap analysis for each one. A corporate gamification engagement strategy known as "Bridge to Extraordinary" was already in place at Niagara Health to help with education and information transfer about important topics. The organization – which services 430,000 patients from 12 municipalities across six sites was able to use this strategy to bring attention to Never Events in a fun and interactive way. Should a never event happen, they would apply the critical incident process which is already in place and involves a root cause analysis of the factors contributing to the incident, along with the development of recommendations to prevent future occurrences. Monthly reporting to the Executive Leadership Team and the Board Quality Committee are also a key part of this process. "We'd already done a lot of the leg work," said Zeau Ismail, Manager of Quality and Patient Safety at Niagara Health in speaking about the incident review process. "So when the report came out we tied it to the work we were already doing. If we hadn't had the foundation we built, this process wouldn't have been so easy to implement." Raising awareness of Never Events for all hospital staff was key, he said, adding creating a culture of safety, and responding to incidents in a non-punitive, transparent way helped build trust and put the emphasis on prevention. A successful tactic that was part of the Never Events campaign was to have all staff, not just clinical staff, participate in the learning and awareness of Never Events. As part of the corporate gamification strategy "Bridge to Extraordinary" for the month of June the Never Events were highlighted. Coffee cards were handed out as prizes for short quizzes in the monthly Never Events bulletins. Never Events were also discussed as learning opportunities at weekly huddle meetings – face-to-face gatherings of all staff at every site in public settings where anyone can listen in. "We talk about what we are focusing on and how we are going to improve in front of the general public," said Ismail. "It can be uncomfortable at times, but if we don't talk about this, we're not going to improve." If you would like to share your story on how your organization is focusing efforts to reduce never events, please contact the Canadian Patient Safety Institute at 3/17/2017 6:00:00 AMIt was all in the timing. Years before the pan-Canadian list of Never Events was released in September 2015, Niagara Health in Southern Ontario3/21/2017 6:56:46 PM485
Q3 National Patient Safety Consortium Update312733/15/2017 3:21:01 PMPatient Safety News<img alt="" src="/en/NewsAlerts/News/PublishingImages/2016/Consortium%20Thumbnail.jpg" style="BORDER&#58;0px solid;" /> The Steering Committee is pleased to report that 68% of Consortium actions are complete, 21% of actions are started, 5% are scheduled to start later, and the remaining 5% is expected to start but delayed. A key action is the evaluation of the National Patient Safety Consortium and the Integrated Patient Safety Action Plan. The Evaluation Framework was presented at the Consortium meeting in September 2016. The Canadian Patient Safety Institute is pleased to announce that Vision & Results Inc., with the leadership of Dr. San Ng and Ms. Jean Trimnell will conduct the evaluation of the Consortium and the Integrated Patient Safety Action Plan. Dr. Ng is the founder of Vision & Results Inc. with a PhD from the University of Toronto. Ms. Trimnell has had an extensive career in Ontario's health sector including CEO and Vice President of several sites. Dr. Ng and Ms. Trimnell will be utilizing a collective impact model throughout the evaluation with preliminary findings anticipated for October 2017. 3/15/2017 6:00:00 AMThe Steering Committee is pleased to report that 68% of Consortium actions are complete, 21% of actions are started, 5% are scheduled to start later,4/3/2017 9:00:57 PM211
Partnerships help pave the road in developing an Enhanced Recovery After Surgery strategy312513/9/2017 6:16:10 PMPatient Safety News<img alt="" src="/en/NewsAlerts/News/PublishingImages/2017/Shift%20Logo%20for%20News.png?Width=140" width="140" style="BORDER&#58;0px solid;" /> This article is the first in a series on Enhanced Recovery After Surgery. As the national strategy evolves, information for the public, providers and leaders will be posted to Click on the link to learn more and watch for upcoming articles! Enhanced Recovery After Surgery (ERAS) consists of a number of evidence -based principles that support better outcomes for surgical patients including an improved patient experience, reduced length of stay, decreased complication rates and fewer hospital readmissions. "We want to take the ERAS learnings and evidence that has been acquired internationally and within Canada, and develop a strategy that can be moved across the country," says Carla Williams Patient Safety Improvement Lead, Canadian Patient Safety Institute. To start the ball rolling, a face-to-face meeting with key stakeholders was made possible through the generous support from 3M and Medatronics. "3M organizes its perioperative business around surgical best practices and has developed a number products and solutions for enhanced surgical care," says Lisa Mackie, Business Manager- Infection Prevention Division at 3M Health Care. "Developing an ERAS strategy involves many healthcare disciplines and collaboration across all the groups, and including industry is the key to success. This is a first step and it was a privilege to be involved." "The synergy and level of engagement of our partners at the meeting was amazing," says Carla Williams. "You could feel the passion, energy and commitment in the room. It would have been difficult to foster the rich conversations we had at the table and build the same momentum virtually. And, we could not have accomplished what we did without our industry sponsors." The inaugural S3A-Surgical Care Safety Best Practices Partners meeting, held in Calgary, Alberta, on January 29, 2016, has created a burning platform for the development of a dissemination and implementation strategy to advance the evidence-informed principles of ERAS in Canada. Some 24 organizations were invited to attend the face-to-face meeting, including representatives from Patients for Patient Safety Canada, the Royal College of Physician and Surgeons of Canada, Canada Health Infoway, various surgical specialties (Canadian Association of General Surgeons, Society of Obstetricians and Gynecologists Canada, Canadian Anesthesiologists' Society), provincial quality councils and allied health organizations (Dieticians of Canada, Canadian Physiotherapy Association, and Canadian Society of Hospital Pharmacists). Representatives from both 3M and Medatronics were also invited to attend the meeting and contribute to the discussions. "In addition to patient engagement, the ERAS principles also involve pain management, mobility and enhanced nutrition guidelines so we wanted to ensure the contribution of all relevant stakeholders," says Carla Williams. "The value of all of our partners working together is essential to achieving great outcomes with ERAS." A number of sites of excellence have already embraced ERAS principles, including Alberta Health Services (AHS), British Columbia Patient Safety & Quality Council and the Doctors of British Columbia, Eastern Health, McGill University Health Centre, and University of Toronto Best Practices in Surgery. During the meeting, AHS, McGill and the University of Toronto shared their learnings. Based on input from the meeting, a project charter has been developed to incorporate seven ERAS principles in all surgical carePatient engagement and awareness of the ERAS principles.Nutrition guidelines (pre and –post-op) that include no NPO (fasting at midnight), carb-loading pre-op, and feeding on post-op day zero.Intra-operative fluid management.Pain management and opioid sparing.Minimization of nausea and ileus.Minimization of tubes and drains.Early post-operative mobility. It was also agreed that data collection and measurement would be an integral part of this work. "The discussions during the meeting were very powerful," says Lisa Mackie. "Dr. Claude LaFlamme and Carla Williams did a fantastic job in setting up the day and leading the group discussions to scope out a plan to take this initiative forward." The identification of emerging best practices in surgical care safety along with a plan to spread and implement these best practices is one of the actions reflected in the Integrated Patient Safety Action Plan for Surgical Care Safety. Given the improved patient outcomes, ERAS principles emerged quickly as the logical choice. ERAS was originally developed exclusively for colorectal surgeries, however, the learning and evidence indicate that the same principles can be applied to any type of surgery. For more information on ERAS initiative, contact Carla Williams cwilliams@cpsi-icsp.ca3/9/2017 7:00:00 AMThis article is the first in a series on Enhanced Recovery After Surgery. As the national strategy evolves, information for the public, providers3/9/2017 6:46:35 PM422
Patient Safety Education Action Plan - Q3 Update312553/9/2017 8:24:17 PMPatient Safety News<img alt="" src="/en/NewsAlerts/News/PublishingImages/2016/Education%20Thumbnail.jpg" style="BORDER&#58;0px solid;" /> Over 25% of the Actions contained in the Patient Safety Education Action Plan have been started. Overall, at the end of December 2016, the Patient Safety Action Plan is close to 20% completed. Updates As part of discussions held on nature and scope of this work, the Patient Safety Action Plan team has leaned heavily on recommendations that came out of the Free from Harm Report (2015). Their main recommendation being, in order for patient safety culture to be influenced and have impact, senior leaders need to have specific knowledge and training. Based on this, an extensive e-scan is underway with significant leadership by HIROC. In addition, a straw dog for a patient safety culture bundle for senior leaders, has been developed. CPSI will coordinate an in-person working group meeting in the early spring to advance the progress on the bundle With the goal of advancing PSQI content into curriculum both within the academic setting and practice environment, the co-leads are developing a competency-based PSQI content framework (curriculum map). The content will be mapped to existing PS competency based frameworks such as CPSI SCF, CanMeds, HQCA, and others. This work is being lead by representatives from SIM-one, the Canadian Medical Protective Association, the University of Calgary, Queens University and Health Quality Council of Alberta. We will host a working group meeting March/April with the larger working group to ascertain expert feedback on the map to date.3/9/2017 7:00:00 AMOver 25% of the Actions contained in the Patient Safety Education Action Plan have been started.  Overall, at the end of December 2016,3/9/2017 8:37:10 PM217
Infection Prevention and Control – Q3 Update312633/9/2017 9:21:08 PMPatient Safety News<img alt="" src="/en/NewsAlerts/News/PublishingImages/2016/Medical%20Kit.jpg" style="BORDER&#58;0px solid;" /> Infection Prevention and Control (IPAC) Action Teams continue to make progress on three of the four goals IPAC Action Plan Improve infection prevention and control through a national campaign for public, patients and providers, focusing on raising awareness and promoting behaviour change; Improve infection prevention and control through the use of strategies known to improve behaviour and culture and Adopt a pan-Canadian set of common indicators for healthcare-associated infections. The fourth goal; Establish a national body to collect, analyze and report healthcare-associated infection data, is staged to begin once the work on the pan-Canadian set of indicator has been near completed. We are entering a very exciting time with respect to the first goal of improving infection prevention and control through a national campaign. As the lead for this goal, CPSI is pleased to announce that this campaign focused on raising awareness and promoting behaviour change, is coming alive this May 5th through the annual STOP! Clean Your Hands Day campaign. The Canadian Patient Safety Institute, along with our multiple supporters , are proud to be the Canadian hosts for STOP! Clean Your Hands Day 2017, which coincides with "Save Lives Clean Your Hands," a global initiative of the World Health Organization. The theme for STOP! Clean Your Hands Day 2017 is Ask Yourself…Making a change to your behaviour can be as simple as asking yourself a question and understanding that change doesn't need to be a burden. Small, incremental changes can lead to big things. Not only can you improve your own practices, you're setting a great, easy to follow example for everyone around you! Whether you're a patient, provider, or work in a healthcare setting – if you're involved in the healthcare system, take the time to have a conversation with yourself and ask what you can change today to improve for tomorrow. Some of the activities planned for STOP! Clean Your Hands Day 2017 are a video competition and webinar.3/9/2017 7:00:00 AMInfection Prevention and Control (IPAC) Action Teams continue to make progress on three of the four goals IPAC Action Plan: Improve infection3/9/2017 9:31:09 PM217
Quarterly Update Surgical Care Safety312453/7/2017 8:58:44 PMPatient Safety News<img alt="" src="/en/NewsAlerts/News/PublishingImages/2016/Hospital%20Thumbnail.jpg" style="BORDER&#58;0px solid;" /> Nine actions from the three-year Surgical Care Safety Action Plan have been started - four have been completed and five are currently in progress. A further five will follow in the third year of the plan. Overall, at the end December 2016, the Surgical Care Safety Action Plan had achieved 46% progress. Updates The Canadian Institute for Health Information and their action team have completed their work identifying surgical care safety indicators that potentially could be used broadly across Canada. The report can be downloaded from the Surgical Care Safety Action Plan webpage.After thoughtful preparation by a small leadership group who are seeking to identify new leading practices in surgical safety, a broader partners' group will convene in January 2017 to discuss next steps. Watch for an update on this key meeting in the next quarterly update.The action team working to identify patient engagement tools and resources for engagement of surgical patients and families is moving through the results of literature reviews.Under the leadership of the Operating Room Nurses Association of Canada and the Canadian Anesthesiologists' Society, the action team continues to move forward on identifying practices for communication and teamwork in surgical settings. A white literature search has been completed and further environmental scanning is underway.The surgical action that will identify and recommend evidence-based resources and toolkits for quality improvement education in surgical safety for policy makers, executives and clinical leaders is being aligned with work being undertaken through the Patient Safety Education Action Plan.The action team seeking to identify prospective analysis tools and frameworks helpful to advance surgical safety is developing a report based on the findings from a white literature analysis. The Surgical Care Safety Leads Group continues to support and contribute to the advancement of the Surgical Care Safety Action Plan. The members areArlene Kraft, Healthcare Insurance Reciprocal of CanadaBonnie McLeod, Operating Room Nurses Association of CanadaBrian Penner, Patients for Patient Safety CanadaCarla Williams, Canadian Patient Safety InstituteCindy Hollister, Canada Health InfowayClaude Laflamme, Canadian Anesthesiologists SocietyDonna Davis, Patients for Patient Safety CanadaDonna Penner, Patients for Patient Safety CanadaJennifer Rodgers, Canadian Patient Safety InstituteKapka Petrov, Patients for Patient Safety Canada Lorraine LeGrand Westfall, Canadian Medical Protective AssociationSandi Kossey, Canadian Patient Safety Institute3/7/2017 7:00:00 AMNine actions from the three-year Surgical Care Safety Action Plan have been started - four have been completed and five are currently in progress. A3/9/2017 8:35:39 PM230
Medication Safety Q3 Update312343/6/2017 6:01:09 PMPatient Safety News<img alt="" src="/en/NewsAlerts/News/PublishingImages/2016/Medical%20Kit.jpg" style="BORDER&#58;0px solid;" /> Throughout the last quarter, progress on the Medication Safety Action Plan took significant steps forward with the completion of several actions due to the hard work and dedication from lead organizations and partners. Actions started jumped from 70% to 80% and actions completed jumped from 47% to 75% creating strong momentum for the remainder of this year and beyond into 2017/18. Highlights from this quarter include taking sustained action to address the current widespread issue of opioid safety with the goal to make opioid use safer for Canadians. In response to the growing crisis, on November 18, 2016, the Institute for Safe Medication Practices Canada, the Canadian Patient Safety Institute and Patients for Patient Safety Canada committed to the following in Health Canada's Joint Statement of Action to Address the Opioid Crisis By August 2017 Empowering patients to improve knowledge about the use of opioids, the options for non-medication treatment of pain, and the prevention of harm from medications by developing tools for patients and their healthcare providers.Tools will include the questions to ask; the information that helps answer the questions; and a template for non-pharmacological options that can be used during hospital discharge or in primary care.Selected hospitals and community pharmacies will provide this information to every patient with an opioid prescription.By November 2017 Providing resources for dealing with left-over end-of-life opioid supplies in the home. These resources will include information and procedures addressing improved in-house storage to reduce the risk of accidental harm, information about the safe storage and disposal of medicines, and procedures for the safe disposal of medicines and equipment. Actions that were previously underway to address opioid safety (90% complete) will be expanded and built upon throughout 2017/18 to meet the above commitments. Merging this work to align with commitments from other organizations will contribute to addressing this serious issue. In addition, Canada Health Infoway led the successful completion of the action to advocate for patient involvement in the development and use of digital health technology to improve medication safety. From November 16-22 during digital health week, the Canadian Society of Hospital Pharmacists, Neighbourhood Pharmacy Association of Canada and other medication safety partners joined the campaign as part of the action. Canada Health Infoway helped Canadians think digital health 23 million times over social media with patient engagement and education activities and events that occurred throughout the week.3/6/2017 7:00:00 AMThroughout the last quarter, progress on the Medication Safety Action Plan took significant steps forward with the completion of several actions3/6/2017 6:09:16 PM203