Sign In

 CPSI News



#SuperSHIFTERS Q and A with Patrick Nellis3320911/14/2017 10:59:18 PMSuper SHIFTERS Are you prepared for surgery? Learn how to be informed, stay safe and take control of your health journey! Patrick Nellis is the creator of a new, innovative surgical patient engagement program called Ready for My Surgery. His book, Ready for My Surgery Be Informed, Stay Safe and Take Control During Your Journey Through Surgery, is being released November 2017. Why did you write this book? It was a bit of a journey for me to come to the place where I realized there was a real need for this type of resource. For most of my clinical career, I worked as an anesthesia assistant at two large teaching hospitals in downtown Toronto. I was a member of a team providing anesthesia care to patients undergoing a wide variety of surgeries. During that time, I was also an educator, teaching healthcare professionals at the bedside and in the classroom. I've also had the opportunity to travel extensively to hospitals across Canada. I had the privilege of spending weeks at a time in the operating rooms of these different hospitals and this gave me a wonderful opportunity to observe patient care across the country. These experiences allowed me to recognize that patients undergoing surgery remain largely unaware of what is happening to and around them and what their role is in their care. Having recognized this, I felt quite driven to share what I know with patients in an attempt to help them have a better experience. I wanted to provide a resource for people from every walk of life that would reduce the common feelings of fear and anxiety that often go along with having surgery. There is no shortage of unknowns—from the operating room to the surgery itself, managing pain, and managing at home after the surgery. The goal with my book, Ready For My Surgery Be Informed, Stay Safe and Take Control During Your Journey Through Surgery is to not only reduce anxiety, but to give patients the knowledge and tools to take control of their health and be better prepared to actively participate in their healthcare. The great thing is that there is mounting research to show that this has the potential to improve outcomes and significantly improve the patient experience. Who will benefit from reading your book? I wrote this book for patients and their families. It isn't simply about the surgery, which is just one part of their journey. It attempts to address all aspects of care including recovery, discharge, and home preparation. Patients often have anxiety about the surgery itself, but sometimes it's their recovery that can be the biggest challenge. There are three core sections of the book—before surgery, the day of surgery, and recovery. Inside each chapter, there are insider tips, calls to action and patient stories. What ties it together is a comprehensive checklist, a practical tool to carry and use throughout the entire process. I think the importance of families and caregivers deserves equal attention—healthcare can be overwhelming and their roles should not be underestimated. I believe the book can also help healthcare practitioners and students build empathy for patients by better understanding the patient journey. There are tools that they can share with patients. In fact, some of the tools are already in use by healthcare professionals that worked with me to review the book. How did you develop this book? One of the things I realized early on when writing the book is that I needed to connect with the reader. I wanted to share a little bit of my story and give people the inside scoop on what to expect. My goal was for the book to feel like a personal conversation, rather than a clinical brochure. I ended up writing the book twice—it turns out that writing a book isn't easy! The first round was really about getting my thoughts on paper. I then worked hard to find my voice as a writer and connect with the reader. The more I wrote, the more I realized how much there was to write about, and how much I needed to research. I wanted this to be an engaging and useful book that would empower patients and help them take action. I included some of the important work being done across the country, such as the "5 Questions to Ask About Your Medications" infographic produced by CPSI and others, infection control tips, and smoking cessation tools. Overall, the book is meant to be a tool to help build engagement and provide patients a greater sense of control. What was your greatest learning when writing the book? There came a point in time when I realised that while the book may be a good resource, it wasn't good enough on its own. I wanted to engage people much earlier in the process and explain why they needed to be involved in their healthcare. I wanted to walk them through all of the steps of their care, from the day their surgery is booked through their period of recovery. We know that teaching patients to be actively involved in their healthcare makes a difference; it can improve their outcome post-surgery and reduces their risk of re-admission. I've heard from many patients that it's also important not to inundate people with tons of information at one time, but instead share small bits of relevant information throughout their journey. With this in mind, I expanded the scope of my project. I have a good understanding of the modern, digital tools available to support communication and content delivery so I used this to build what has become a surgical patient engagement program. The book is a major pillar of this program but it is just one part. It's personal, digital, accessible and inexpensive to deliver—I want to impact as many patients as possible so I worked hard to reduce barriers for people to access this information. The hub for this program is my new website For the most part people don't want to have surgery, but they want a good outcome. I found that I was not alone in feeling like we could take the patient experience and patient engagement to another level. Meaningful patient engagement is not a one-way street. What is important to patients should be important to their healthcare team, and vice versa. I see it as a step beyond patient-centred care. It isn't simply focusing on the patient, but instead involving the patient as a partner in their care. The best analogy I've come up with is to consider the patient as a core member of their healthcare team. For example, it's not until the patient walks into the operating room on the day of surgery that the OR team is complete. In a team, when everyone understands and fulfills their role, the team will function at its best. Looking at it this way, it becomes clear just how important the role of the patient really is. What is the best advice you received when writing the book? Don't try to build something in isolation. With this in mind, I made a point of sharing the book early in the process even though it wasn't perfect. I found that the more people you reach out to and the more feedback you get early on, the better. I connected with anesthesiologists, respiratory therapists and nurses, the Canadian Patient Safety Institute, and a number of patients, including some from Patients for Patient Safety Canada to read drafts of the book. I took all of that feedback to edit and refine the content. This was actually one of the most fun and validating aspects of this project, building new relationships with others that are also working hard to make the patient experience better. There is an important movement happening here. Being patient and persistent is the other valuable piece of advice I received. It takes a lot of time to introduce a new idea and bring people to the place where its value is seen. The book alone took eight or nine drafts. It exciting to now have a beta version to share. The Ready for My Surgery program is now ready for a pilot run. Once I've received further feedback from patients, healthcare providers and organizations such as CPSI and PFPSC, I'll move the book and program through final production. This has been fascinating journey for me and I'm looking forward to seeing the impact this program has on patients, their families and those that care for them. Where can we learn more? I'd be thrilled to chat with anyone interested in patient engagement or with those that think this program may be a fit for their patients or their institution. Feel free to visit my website at or email me at Our thanks to Patrick Nellis for sharing a profile of his new book, Ready for my Surgery Be Informed, Stay Safe and Take Control During Your Journey Through Surgery, which is currently in production. Join us next month to meet our next #SuperSHIFTer …11/16/2017 7:00:00 AMAre you prepared for surgery? Learn how to be informed, stay safe and take control of your health journey! Patrick Nellis is the creator of a new,11/14/2017 11:08:16 PM47
Enhanced Recovery Canada: a collaboration to improve surgical safety3321011/14/2017 10:42:16 PMPatient Safety News Enhanced Recovery Canada (ERC) is well-positioned to improve surgical safety across the country. Since the group was formed earlier this year, a project charter, governance structure and position statement have been developed and stable funding has been secured. Enhanced Recovery Canada recently reached out to a number of industry partners and over $500,000 has been committed over five years to fund the work of the project. An Enhanced Recovery After Surgery (ERAS) project plan has been finalized. Membership supporting the six guideline working groups is being determined. These guideline working groups will develop clinical pathways based on six core ERAS evidence informed principles patient engagement, nutrition, mobility, perioperative fluid management, multimodal pain management and evidence-based surgical best practices. The first clinical pathway being developed will support colorectal surgery. A knowledge management specialist from Alberta Health Services' Guideline Resource Unit (GURU) has been hired to support the guideline working groups gather existing evidence and defining any gaps that may need to be addressed. Colorectal pathways will be launched during the Canadian Anesthesiologists' Society Conference in June 2018. The work will then spread to other surgical types, incorporating the colorectal pathways that can be more broadly applied. Enhanced Recovery Canada members are looking to raise the visibility of the project. Presentations have been made at a number of conferences and members will highlight their activities at a number of events to be held in 2018. In addition, a six-part Enhanced Recovery After Surgery video interview with Dr. Henrik Kehlet is now available on the Canadian Patient Safety Institute's ERC webpage. Click here to view the video series. "I am very pleased with the momentum that has been maintained by our partners group. The passion and interest of our industry partners is very evident," says Carla Williams, Patient Safety Improvement Lead, Canadian Patient Safety Institute. We have a lot of irons in the fire to ensure the long term sustainability of Enhanced Recovery Canada." Visit to learn more about Enhanced Recover After Surgery and Enhanced Recovery Canada.11/15/2017 7:00:00 AMEnhanced Recovery Canada   (ERC) is well-positioned to improve surgical safety across the country.  Since the group was formed earlier11/14/2017 11:11:43 PM37
Patient Safety Power Play: Your Words Guide our Future980511/9/2017 11:00:25 PMPatient Safety Power Plays Healthcare is a big deal in Canada. Not only is it one of the biggest expenditures for governments, both provincially and federally, but it has a tremendous personal impact on the life of every Canadian. With those kinds of stakes, it's important to ask some pretty serious questions about the future of our healthcare system, and CPSI's role within it. Are we equipped to continue improving patient safety in the future? As patients or providers, what do you need from us, to continue accelerating change in healthcare? How can we at CPSI build on the momentum we've created since 2003 to make Canada's healthcare system the safest in the world? As it happens, Health Canada is asking those very same questions. Making sure that Canadians are getting the best from the healthcare system is top priority for Health Canada. To that end, Health Canada is conducting a review of all government funded, pan-Canadian healthcare organizations, including CPSI. The objective of the review is to advise the Minister of Health on the future of healthcare policy, and deliver to Canadians the care they need. This is a unique opportunity to share your thoughts on our healthcare system, and where it's going, with Health Canada. We ask that you set aside some time to share a few words about your involvement with CPSI and the importance of keeping patient safety on the national agenda. What you share can aid us in showing just how strong and impactful our mandate is. You can click here to share your thoughts directly with the reviewers. Speaking of sharing, we have just come off our annual Canadian Patient Safety Week, a time where we shine a spotlight on patient safety. The momentum generated during this week across the country is incredible, and I'd like to thank everyone who took part. Here is a brief glimpse of the week and the reach it hadOur PATIENT podcast reached number two for the week in the medical category on iTunes The Take With Questions Quiz had 4911 participantsOur Question Your Meds Contest received 125 entries#asklistentalk received 3.744 million impressions, 1469 tweets, and had 700 participants using it, with an average of 15 tweets per hour From all of us at the CPSI, we thank you! As always, I'm open to your questions and comments. Do you have any Canadian Patient Safety Week memories to share? Do you have any questions about Health Canada's pan-Canadian Healthcare Organization Review? Feel free to contact me at Yours in patient safety Chris PowerCEO, Canadian Patient Safety Institute11/10/2017 7:00:00 AMHealthcare is a big deal in Canada. Not only is it one of the biggest expenditures for governments, both provincially and federally, but it has a11/9/2017 11:06:51 PM258
Federal minister of health endorses Canadian Patient Safety Week 20171006311/2/2017 4:05:47 PMPatient Safety News We are proud to share with you the official comments of Federal minister of health, The Honourable Ginette Petitpas Taylor, posted today on the Government of Canada's website. The minister commends our work, reminds Canadians to participate in the many activities, and most of all, she encourages all to, "learn more about the importance of patient safety and the role they can play in making care safer for their loved ones". Read the official announcement here.11/3/2017 6:00:00 AMWe are proud to share with you the official comments of Federal minister of health, The Honourable Ginette Petitpas Taylor, posted today on the 11/2/2017 4:15:51 PM73
#SHIFTtalks Keepers and sharers of information; who is truly in charge of the patient health record?970410/27/2017 9:11:36 PMSHIFT Talks By Teri Price Teri Price is a Patient Safety Champion Award winner and member of Patients for Patients Safety Canada. She also volunteers with the IMAGINE Citizens Collaborating for Health organization, to find out more about their work go to Greg's family has established a not-for-profit organization in his honour called Greg's Wings. To learn more about Greg's story go to "Some men see things as they are and say why. I dream things that never were and say why not." – George Bernard Shaw My brother Greg loved to challenge the status quo. He believed that thinking outside the box and from different perspectives can lead to positive change and innovation. Greg was an engineer and entrepreneur. He was an intelligent and driven person who was healthy and active. My brother Greg died on May 19, 2012. He had testicular cancer. A cancer that has a 96-99 per cent survival rate. For Greg, the mass in the back of his abdomen put pressure on his Inferior Vena Cava (IVC). Greg died of a blood clot. Our health system failed Greg in many ways. Too much time passed where he was left uninformed, and unaware of what was happening and in several instances, nothing was happening. Recently I had the opportunity to hear Zayna Khayat, (Senior Advisor, Health System Innovation and Director, MaRS EXCITE) present on the "Future of Health" and she described how patients in the future would have all their health information in their own hands and predicted that doctors of the future would be the ones subscribing to their patient's information. This would be a powerful shift. Patients deserve to be partners in their care in whatever way works for them. They are the only one consistently present when they are required to move though the health system. Wouldn't it make sense to enable them to be keepers and sharers of their own health information? I believe digital health is going to change how we track our own information, how we interact with our care providers, how we share information and it will enable us to contribute to our own health records. Movements like OpenNotes have demonstrated the benefits that result from giving patients access to their doctor's notes and has been successful at shifting the mindset of participating physicians. This is beneficial because Patients remember less than half of what they discuss with their healthcare provider. Having access to notes provides the opportunity for patients to review important information at any time. Information is power. Reading notes can enable a patient to feel more confident, prepared and in control. Having access to health information can lead to better questions, more confident decisions, and builds trust. Patients can choose to share information with family members or health professionals beyond their regular care team on their own terms. Having access to notes can make healthcare safer. When patients can review information, they identify mistakes and ensure accuracy. So what is stopping us from getting to the place Zayna described, where the patient has all of their health information in their hands? Paternalistic culture? Misconceptions of the risks and benefits? Canada Health Infoway has recently released a valuable series of Digital Health Myths that debunk the reasons that are often used to limit digital health implementation. Technology isn't the barrier. The digital health industry is exploding and I am excited and optimistic about what ideas and innovations are happening. It's time to say 'why not', it's time to admit there are no more excuses, it's time to make the change and enable patients to access and contribute to their health information.11/1/2017 6:30:00 PMBy Teri Price Teri Price is a Patient Safety Champion Award winner and member of Patients for Patients Safety Canada. She also volunteers with11/2/2017 4:03:44 PM451

 Latest Alerts



Neonatal Death12946352910/1/2017 6:00:00 AMObstetrics/ Labour and DeliveryManitoba HealthThis alert describes a fatal patient safety incident of a neonatal death. The incident is described. A gravida 2 Para 1 (giving birth for the second time) patient was admitted to an acute care centre at 0448h. Due to fetal bradycardia (low heart rate) and breech presentation (buttocks first), the patient underwent an emergency Cesarean Section (C-section). Following the C-Section (birth time noted as 0841h), the neonate had depressed apgar scores. The neonate was transferred to a tertiary care facility and passed away. Contributing factors to the incident included the following: - differing definitions of the urgency of the C-section - lack of expressive/receptive communication regarding the urgency of the event - lack of fetal heart rate monitoring during OR prep and during transfer to the OR. System learnings are provided in the alert9/1/2017 8:54:10 PM4
Express Levothyroxine Doses in Micrograms not Milligrams1295935183/8/2017 7:00:00 AMMedicationInstitute for Safe Medication Practices CanadaThis alert discusses the patient safety incidents that can occur when converting units of measure of medication. Specifically, the errors in dosage of levothyroxine are discussed when milligrams of strength are converted to micrograms and vice versa. Canadian manufacturer labels express levothyroxine doses in micrograms (mcg) only. However, throughout the medication-use process (e.g., prescribing, dispensing, and administration), levothyroxine doses may be expressed in micrograms (mcg) or in milligrams (mg). As a result, patients and healthcare providers may need to convert doses from milligrams (mg) to micrograms (mcg), or vice versa to match the prescribed dose to a particular product. Errors in the calculations required to convert between units are contributing to these errors and near misses. A common calculation error occurs when converting between 0.025 mg and 25 mcg, causing in a 10-fold error in dosing. The resultant dose, sometimes 250 mcg rather than 25 mcg, is considered a reasonable dose for some patients and, as such, does not raise a red flag for most practitioners. The authors of the alert recommend that It is strongly recommended that levothyroxine doses be expressed consistently in micrograms (mcg), not milligrams (mg). Using microgram units reduces the need for decimals (which can lead to errors), allows the dose to correspond directly to the manufacturer’s label (avoiding the need for conversion), and will standardize how levothyroxine information is communicated.9/1/2017 8:54:18 PM5
Deteriorating Patient Condition Associated with Medical Gas System Dysfunction 1294535303/1/2017 7:00:00 AMMedical GasManitoba HealthThis alert describes a fatal patient safety incident related to dysfunction of a medical gas (oxygen) system. The incident is described. An elderly patient with few medical conditions or health issues presented to an Emergency Department with a three day history of nausea, vomiting and upper abdominal pain. The patient did not have any signs or symptoms of an acute condition except for an elevated white blood count. Vital signs were recorded within normal limits for their age. The patient was admitted to hospital where he/she received therapy to correct dehydration. It was noted that the patient had previously indicated in an advance care plan the desire to not be resuscitated. Approximately 32 hours later, the patient began to exhibit behaviour that was described as “strange” by their family. On assessment, the patient’s oxygen levels were found to be low, the patient was short of breath and was confused about their whereabouts. Following the administration of high concentration oxygen, diagnostic tests showed right lower lobe pneumonia, possibly related to aspiration. Challenges were noted during attempts to provide high concentration oxygen with the medical gas equipment; there were difficulties with getting adequate pressure from the medical gas system despite attempts using a number of different oxygen regulators. During this time, the patient did not receive supplemental oxygen to treat his/her oxygen deficiency. Despite aggressive treatment, the patient’s condition continued to decline. The patient died approximately seven hours later. Contributing factors included the following: • The wall oxygen outlet near the bed was damaged. • The condition of the medical gas system located behind the wall may have been disturbed by the bed frame with a monkey bar apparatus attachment. • No standardized regional process for medical gas system functioning checks was in place. • The patient may not have been receiving adequate oxygen flow potentially further compromising his/her respiratory status. • Documentation regarding the clinical condition of the patient receiving oxygen therapy and their response to therapy was inconsistent. System learnings are provided in the alert.9/1/2017 8:54:09 PM
Gaps in Medication Monitoring May Contribute to Death1296135172/28/2017 7:00:00 AMMedicationInstitute for Safe Medication Practices CanadaThis alert discusses the harmful patient safety incidents that can occur when patients with chronic medical conditions taking prescription medication over the long term are not adequately monitored. Barriers to the care of such patients are highlighted and a specific case to illustrate these issues is presented. Levothyroxine was prescribed for a young adult with hypothyroidism. She took this medication once daily for at least 4 years before her death. Abnormal results on laboratory tests conducted 3 years before her death suggested that the levothyroxine dose was too high. However, there was no documentation of any follow-up related to these results and no indication that any additional investigations had been ordered. According to available records, it appears that the prescriber authorized refills of the levothyroxine prescription multiple times without seeing the patient and without ordering repeat thyroid function tests. About 1 month before her death, the patient went to the hospital because of palpitations and shortness of breath. Thyroid function tests at that time yielded results indicative of hyperthyroidism, probably due to an excessive replacement dose of levothyroxine. Additional investigations revealed evidence of heart damage. The patient later experienced cardiac arrest and could not be resuscitated. Post-mortem investigations suggested that excessive levothyroxine therapy over a prolonged period may have contributed to the development of cardiomyopathy, which in turn led to her death. Risk factors are provided for harm related to long-term medications; they are categorized according to patient-related, practitioner-related and communication failure issues. Recommendations are provided for both the healthcare system and individual practitioners’ practices to improve the monitoring of, and communication with, patients who are taking medications for chronic conditions.9/1/2017 8:54:19 PM
Some Medications Don’t Mix 1296235162/8/2017 7:00:00 AMMedicationInstitute for Safe Medication Practices CanadaThis alert discusses the patient safety incidents that can occur when certain medications, not intended to be taken concurrently, are taken together. Side effects from that action may result in serious adverse events and even death. A patient safety incident is described. An elderly consumer had noticed some changes in her mental and physical health. A medication review showed that the consumer was taking 2 medications that may cause side effects when used together: citalopram (an antidepressant) and tramadol (a pain reliever). Her doctor stopped both medications safely, and the consumer recovered her mental abilities. Physically, her health did not recover and after this incident, she was no longer able to take care of herself. Recommendations for the consumer to prevent similar patient safety incidents are provided.9/1/2017 8:54:21 PM6