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#SHIFTtalks: Measurement and Monitoring – It’s more than just a number38575/9/2018 8:35:34 PMSHIFT Talks With the launch of Safer Healthcare Now! in 2005, the Canadian Patient Safety Institute introduced the importance of measurement to the science of patient safety based on Peter Drucker's often quoted statement"If you can't measure it, you can't manage it" Over the ensuing years, Safer Healthcare Now!, came to recognize that although our ultimate goal may be to achieve specific improvement targets defined by outcome measures, it was necessary to identify the steps in a process that lead to the desired outcome. These process measures form the foundation of the improvement journey, particularly, as a practice guide for those at the frontline of healthcare. While monitoring the process improvement and outcomes, balancing measures, that is, ensuring that improvement in one area is not causing new problems in other parts of the system, must also be concurrently monitored. Among the measurement issues that became evident during the evolution of Safer Healthcare Now! and are still true today include frontline staff may collect and submit improvement data yet they rarely receive feedback on their progress; healthcare providers don't always use their performance results to guide their improvement efforts; one data point at goal does not equate with sustained improvement; and if you stop monitoring when you reach your goal, your improvement gains are frequently lost. In Canada, as in the UK and US, the focus of governments on assessing both quality and safety has increased over the past 10 years. Although a large number of quality outcomes have been specified, the approach to safety has been much narrower, leaving many aspects of safety unexplored. The measurement of harm, so important in the evolution of patient safety, has been largely neglected and there have been prominent calls for improved measures. There is a critical need for patient safety measurement at the frontlines, so that clinical teams can focus on key problems. Dr. Don Berwick stated in his review of the Mid Staffordshire NHS Foundation Trust, that 'most health care organizations at present have very little capacity to analyse, monitor, or learn from safety and quality information. This gap is costly and should be closed'. There is no one authoritative source of data on patient safety and no single measure. In 2013, Professors Charles Vincent, Susan Burnett and Jane Carthey published their report, The Measurement and Monitoring of Safety, which describes their framework designed to close the gap identified by Berwick. The conceptual model provides a broader view of the information needed to create and sustain safer care and recognizes there is no single measure of safety. Vincent et al. identified five areas of measurement that are informed by five key questions Past harm (Has patient care been safe in the past?); Reliability (Are our clinical systems and processes reliable?); Sensitivity to operations (Is care safe today?); Anticipation and preparedness (Will care be safe in the future?); and, Integration and learning (Are we responding and improving?). The 'Measurement and Monitoring of Safety' model has been introduced in a demonstration project to eight teams from seven organizations, representing five provinces in Canada. These teams have reported that it has moved them away from "…meaningless measurement and data collection to a more fluid and dynamic approach to safety." Working with coaches, they have learned to change their focus from the absence of harm, to the presence of safety, that is, just because a patient has not experienced harm does not mean their care delivery has been safe – it may simply mean they have been lucky. Applying both quantitative measures and qualitative data helps healthcare providers move from assurance to inquiry. Using the Measurement and Monitoring of Safety conceptual model to guide your safety conversations and observations is as important as the measures you use. Ultimately, this approach will move healthcare beyond simply measuring the number of harms incurred because safe healthcare is more than just a number. This blog post was compiled by Anne MacLaurin, Patient Safety Improvement Lead and Virginia Flintoft, Manager, Central Measurement Team.​​​Anne Maclaurin ​Virginia Flintoft​5/9/2018 6:00:00 AMWith the launch of Safer Healthcare Now! in 2005, the Canadian Patient Safety Institute introduced the importance of measurement to the science of5/9/2018 8:56:57 PM110http://www.patientsafetyinstitute.ca/en/NewsAlerts/News/Pages/Forms/AllItems.aspxhtmlFalseaspx
The Bug Stops Here31545/3/2018 4:13:04 PMPatient Safety NewsCanadian Patient Safety Institute brings the global STOP! Clean Your Hands Day to Canada Thousands of healthcare providers in hundreds of healthcare sites across Canada and around the world will participate in today's STOP! Clean Your Hands Day. It is led by the Canadian Patient Safety Institute (CPSI), in conjunction with the World Health Organization's SAVE LIVES Clean Your Hands campaign. The Canadian program is a partnership with Infection Prevention and Control Canada, Patients for Patient Safety Canada, Public Health Ontario, and the Public Health Agency of Canada. Thanks to GOJO Canada for their sponsorship of STOP! Clean Your Hands Day. The theme for this year's campaign is "Clean your hands The bug stops here!" Each year in Canada, 8,000 to 12,000 patients die from complications of healthcare-associated infections. Through the simple act of promoting optimal hand hygiene, people across the country will help to reduce that number. "Hand hygiene is the simplest and most effective way to reduce and prevent infections," says The Honourable Ginette Petitpas Taylor, Federal Minister of Health. "We should all be working together to encourage and promote hand hygiene, including patients, caregivers and health care providers. Washing your hands not only prevents you from getting sick, but also reduces the risk of infecting others." CPSI Chair Dr. Brian Wheelock helps Federal Health Minister Ginette Petitpas Taylor clean her hands, preventing infections and saving lives, on STOP! Clean Your Hands Day. This important message will be reinforced in three major ways today Healthcare providers, administrators and patients will take pictures of themselves cleaning their hands. They will share these images on social media using the hashtags #STOPCleanYourHandsDay and #thebugstopshere. Their pictures not only enter them to win prizes but also pledge a commitment to hand hygiene today and every day of the year! Hundreds of healthcare providers and advocates will tune in to a webinar, hosted by CPSI, that begins at 12 noon ET/10 am MT. The webinar will feature Lori Moore, a Healthcare Clinical Educator with GOJO, addressing hand hygiene uptake in healthcare settings. She will join Dr. Benedetta Allegranzi of the World Health Organization's Infection Prevention and Control Global Unit, who will share her experience with preventing sepsis in healthcare settings. Finally, at healthcare sites across the country, STOP! Clean Your Hands Day activities, stickers and messaging will be shared with visitors. "By taking part in STOP! Clean Your Hands Day, we are joining thousands of healthcare providers, leaders, and patients around the world," says CPSI Chair Dr. Brian Wheelock. "We all share the belief that every patient experience should be safe, and that preventing harm is worth the effort. Even an action as simple as cleaning your hands can save a life. Today, we say #thebugstopshere." #thebugstopshere with Dr. Theresa Tam, Chief Public Health Officer of Canada, CPSI Chair Dr. Brian Wheelock and Federal Health Minister Ginette Petitpas Taylor. Important facts on hand hygiene Every year 220,000 Canadian patients (approximately one in nine) will develop a hospital-associated infection during their stay in hospital, and an estimated 8,000 of those patients will lose their lives. Furthermore, the cost to treat hospital-acquired infection is estimated to be more than $100 million annually. In the acute care setting, infections will be the biggest driver of patient safety incidents, accounting for roughly 70,000 patient safety incidents per year on average – generating an additional $480 million per year on average in healthcare costs. Hand hygiene is important all year round, not just on STOP! Clean Your Hands Day. Canada's Hand Hygiene Challenge supports organizations in their efforts to improve hand hygiene www.handhygiene.ca, is packed with tools, information, and resources to reduce the occurrence of healthcare-associated infections. "During my work in managing infectious disease outbreaks internationally, ensuring good hospital infection control practices is a critical component of the response" says Dr. Theresa Tam, Canada's Chief Public Health Officer. "The simple step of regular, thorough hand washing by health and other care providers can have a powerful impact on limiting the spread of infections and on the recovery of patients. This lesson is equally important in Canada's health care facilities." About Canadian Patient Safety Institute The Canadian Patient Safety Institute is a not-for-profit organization that exists to raise awareness and facilitate implementation of ideas and best practices to achieve a transformation in patient safety. CPSI reflects the desire to close the gap between the healthcare we have and the healthcare we deserve. CPSI would like to acknowledge funding support from Health Canada. The views expressed here do not necessarily represent the views of Health Canada. www.patientsafetyinstitute.ca For inquiries, please contact info@patientsafetyinstitute.ca 5/4/2018 2:00:00 PMCanadian Patient Safety Institute brings the global STOP! Clean Your Hands Day to Canada Thousands of healthcare providers in hundreds of healthcare5/4/2018 2:44:09 PM286http://www.patientsafetyinstitute.ca/en/NewsAlerts/News/Pages/Forms/AllItems.aspxhtmlFalseaspx
#SuperSHIFTER Stuff Patients Want . . . From Patients Who Know: A Hospital Handbook263564/24/2018 8:25:13 PMSuper SHIFTERS #SuperSHIFTERS Lora Appel The ability to create initiatives and share them is the nucleus of OpenLab. Located at the University Health Network in Toronto, Ontario, OpenLab is a design and innovation shop dedicated to finding creative solutions that transform the way healthcare is delivered and experienced. Lora Appel, PhD is a Project Lead for From Patients Who Know A Hospital Handbook. What can you tell us about the Hospital Handbook? Our research shows that patients who leave the hospital do not retain a lot of the information they have been given. They can't remember the names of the healthcare providers who treated them. They are given important information and if it is not written down, it is not passed on to their caregivers and they can end up being re-admitted to the hospital. Basically, the Hospital Handbook addresses a problem in communication and how to navigate your hospital stay. We came up with the idea of working with real users of the health system, which is a focus of OpenLab. For our research, we wanted to include people living in what we call a "Naturally Occurring Retirement Community (NORC)". These tend to be apartment buildings where 30 per cent of residents are seniors, but this occurred naturally, unlike in long-term-care homes where you need to meet certain criteria to be accepted. We went to Kingston, Ontario where one of these buildings exists and worked with over 40 seniors to gather their experiences of living through the hospital system, whether going for an appointment or through emergency services, and seeing what they had learned from the system and what they wished they would have known. With that input we compiled the From Patients Who Know A Hospital Handbook. Unlike other resources that are top-down where the medical system is telling patients what they need to know, this Handbook is a patient-to-patient explanation of 'here is what I learned and here are the things that I didn't know that would have helped me'. For example, when you get to the emergency department, we talk about how you are triaged. Some patients think that if they come to the hospital by ambulance, they will get some kind of priority when being admitted, and that is not true. And worse, they then need to incur the cost of the ambulance trip. Any patient that comes across the Handbook can use it. The concept behind having end users design tools like this is that it can be applied to many sectors. We provide the Hospital Handbook for free, online. All we ask is that anyone who shares it provides the appropriate credit to the seniors who helped us to create it, and that no one is charged to receive it. If another institution or hospital wants to use it for their patients, they have to provide it free of charge. What patient safety issues has the Hospital Handbook addressed and why? Clearly, there are a number of things. Often, patients are unable to recall verbal information given to them during admission and on discharge. This is the most important information they are getting about their care and they are not retaining it. It is a time where there is a lot of anxiousness and stress involved, compounded by the fact that you are not feeling well. There is an expectation that the patient will go home with some sort of written information that they can look at later, and can ask their family or caregiver for help interpreting it. The Hospital Handbook has sections where you can write down notes and it prompts you to be both an advocate for yourself, but also to think about questions you should ask the doctor or healthcare team. It is both an empowering tool and a communication tool. It is also a basic directory of where to find what in the hospital. Where are the elevators? Where are the bank machines? The guide includes practical things that aren't easily, or often, communicated. A side project included in the Handbook is called the Patient-Orientated Discharge Summary (PODS). When you leave the hospital, you are given a piece of paper with clinical information that is meant to be shared between your hospital clinician and primary care provider, yet it includes pertinent things like how often you should take your medication, medications started and stopped, and symptoms you should watch out for. Often, it is written in such a way that it is incomprehensible, and there is no motivation whatsoever to make you want to read it. What we have created is something that is highly visual; it takes all the essentials and provides it in a way that the patient is prompted to ask, okay did I understand that? It is results in a teach-back moment. That is our goal for the PODS project; to have healthcare providers provide the discharge summary, explain it and have the patient repeat back what they understood. This process allows for better understanding of what to expect once they leave the hospital. There are a lot of interactive tools throughout the Handbook. There are so many healthcare providers coming and going during your stay—occupational therapists, doctors, nurses, pharmacists and others. You don't really know who is who. We have a section 'Face2Name' where you can write down what you can best remember about someone. Perhaps, it is their hair colour, their accent, or the type of clothing that they wear. You record who they are, what they told you and there is room to draw an illustration of the person as a visual representation. Then, when they enter your room, you recognize them and know what to expect. What is innovative about the Hospital Handbook? The Handbook is co-designed with users, real patients and caregivers, people like you and me who have years of lived experience. The fact that it is paper-based is not innovative, but the way it is designed involving the user from the start to the finish is. We went to Kingston a couple of times to work with this group of seniors to discuss what topics they wanted to include. In most hospital directories, the first page is a welcome message from the CEO. From a patient perspective, they don't really need that. What they want are instructions on free parking around the hospital so their families don't have to pay twenty dollars a day when they come to visit. Working with patients is an innovative aspect of the Handbook, from the topics, to how to solve problems. There are also elements of humour, so rather than everything being about illness, it is more about how you can manage the system. We have jokes, interesting quotes and tidbits of good information, like 'don't bring your walker because it will go missing". Then there is the basic design of the book, which focuses on known principles, like having white space to break up the copy. What major learnings helped you to create the Handbook? From our evaluations, we learned that the existing resources provided in hospitals are unattractive, unengaging, and even if they have the content users don't want to interact with it. There was a strong design focus in making the information humorous, playful and wanting to look at elements where you could learn. However, what we found was that the content still trumps the look and feel, and we need to find a way to satisfy both of these essential aspects. Can it be replicated? Are there other opportunities you can see with this Handbook? Our goal is to make the Handbook replicable and scalable. We will do this either by creating an online version that people can customize; or an app for next generations that want an interactive digital copy. We are also looking at redesigning the Handbook for specific groups, like indigenous and first nations people. Moving forward, what is unique about our initiative is that we don't want to necessarily own this; we want to share it so that other institutions can customize it to their needs. We will include a set of principles, such as how to involve patients when developing a section. Down the line we could create a digital library where institutions could drag and drop sections, or "chapters" that are relevant in a more scalable manner. The initial Handbook is quite broad in scope and talks about a couple of the areas that we know would be important regardless of what institution you are going to. Navigation around a hospital is notoriously bad. In our Handbook we have explanations on how room numbers work. We also talk about the language and jargon used by the medical team; what does it mean? There are a couple of broad topics, but the idea now is to take this book and customize it to a hospital so that the patient is not getting a generic version, but a map of their hospital specifically. We are also working with the Canadian Patient Safety Institute to evaluate the Handbook. It is very difficult to evaluate a paper resource like this and see that it has a direct impact on the quality of care, or metrics like readmission rates, and length of stay. My background is based in design science and how to creatively, but rigorously evaluate an intervention that is not through traditional means like randomized control trials. To evaluate the Handbook we are moving away from standardized surveys, to conducting more qualitative interviews, and undertaking usability studies where we provide our Handbook and a standardized hospital directory and ask patients to find relevant information, like where they can find parking, or where they can get their hospital card. We will let them think-out-loud through the process of finding this information and see if it took less time, was less frustrating, or clearer and more enjoyable to use one resource over the other. How can I get a copy of the Hospital Handbook and who can I contact for more information? Click here to download a copy of the Hospital Handbook. To learn more, visit http//uhnopenlab.ca/project/stuffpatientswant, or contact Lora Appel at lora.appel@uhn.ca @UHNOpenLab #SuperSHIFTer4/25/2018 6:00:00 AM#SuperSHIFTERS Lora Appel The ability to create initiatives and share them is the nucleus of OpenLab. Located at the University Health Network4/24/2018 9:19:15 PM262http://www.patientsafetyinstitute.ca/en/NewsAlerts/News/Pages/Forms/AllItems.aspxhtmlFalseaspx
A milestone for the Canadian Incident Analysis Framework263394/17/2018 6:38:20 PMPatient Safety News It has been five years since the Canadian Incident Analysis Framework was introduced as a resource to support those responsible for, or involved in, managing, analyzing and/or learning from patient safety incidents. Based on the 2006 Canadian Root Cause Analysis Framework, it is designed for any healthcare setting with the goal of increasing the effectiveness of analysis in enhancing the safety and quality of patient care. The authors of the Framework set out to develop a resource that would stand the test of time. And they have truly done just that! The Working Group that created the Framework included representatives from Canadian Patient Safety Institute and partner organizations, Patients for Patient Safety Canada, the Institute for Safe Medication Practices Canada, and the Saskatchewan Ministry of Health. "Everyone, in all areas of healthcare, including patients and families, can and should be engaged in using a systematic approach to reporting and learning," says Carolyn Hoffman, Executive Director (Saskatchewan Registered Nurses' Association). "The Framework supports this and is an effective tool for healthcare organizations, no matter where they are on their patient safety journey. I was proud to collaborate on the development of the framework and continue to promote and support its use. What we developed five years ago is still very relevant today, and a needed tool to build strong patient safety cultures." Ioana Popescu "The development of the Framework was truly a collaborative effort among the Working Group members and many stakeholders we consulted with, and because of that we were able to generate lots of innovative content," says Ioana Popescu, Patient Safety Improvement Lead (Canadian Patient Safety Institute). "Examples include positioning patients/ families as partners, resources to engage patients as partners, three methods for analysis (concise, comprehensive and multi-incident), and an innovative diagramming method to better identify contributing factors and their interconnections (constellation diagram)". Sharon Nettleton, a member and former Co-Chair of Patients for Patient Safety Canada, says that, "the Framework is a critical building block in making care safer for patients. It attempts to tie together essential parts of the safety cycle, from preparation and education to reporting, learning, disclosing, informing and implementing changes for improvement. It gets to the heart of what a culture of safety is all about" "The Framework highlights how important and connected each of the components are in making patient care safer," says Sharon Nettleton. "We had many heartfelt discussions five years ago about what this document should be and why it was needed. In the end we agreed that it was important to outline the whole process. Each component mattered. The key for me - for patients and families - was to highlight the importance of our involvement at every stage and especially in analysis and learning. Our insight, experiences and involvement is critical when the safety of our care is at hand. We are an essential part of the team. We see this as a challenge to all leaders, healthcare providers, organizations and patient safety experts moving forward, to keep patients and families front and centre and involved in every step and every stage, making the safety of our care a priority." Julie Grenall Over the past five years, ISMP Canada has provided incident analysis training to more than 600 healthcare providers across the country, through workshops and to individual organizations upon request. "ISMP Canada sees the Canadian Incident Analysis Framework as a crucial foundation document to support healthcare providers in all settings with analysis of patient safety incidents," says Julie Greenall, Director of Projects and Education (ISMP Canada). "We use the framework ourselves when undertaking analyses and, as evidence, I keep a sample constellation diagram on the wall of my office as a teaching tool for students." In a 2017 evaluation, users of the Incident Analysis Framework reported that they have made changes in investigating patient incidents (83 per cent); they are now developing actions in response to incident (69 per cent); they are reporting patient safety incidents (69 per cent); they are sharing what was learned within their organization (55 per cent); and they do ongoing monitoring of patient safety risks, and communicating with patients about safety events (both 49 per cent). The Framework has been referenced and incorporated in many patient safety programs and resources like the Canadian Patient Safety Officer Course, Hospital Harm Improvement Resource, Patient Safety and Incident Management Toolkit and the Engaging Patients in Patient Safety – a Canadian Guide. It had also informed policies and practices especially through the Accreditation Canada's Required Organizational Practices. "I started specializing in patient safety in 2000 and have been fortunate enough to have contributed to the design of methods and tools to support learning and improving on patient safety at the international, national, provincial level and local settings since that time," says Paula Beard, Executive Director, Patient Safety (Alberta Health Services)."Contributing to the Canadian Incident Analysis Framework allowed me to provide insights collected over time and to work with other key leaders to do so. After reviewing the content again and considering the guidance provided, the Canadian Incident Analysis Framework continues to reflect leading practice today. This document has stood the test of time and is as important in 2018 as it was in 2012 when we released it." The Canadian Incident Analysis Framework provides methods and tools to assist in answering the following questions What happened? How and why it happened? What can be done to reduce the likelihood of recurrence and make care safer? What was learned? The Framework walks you through elements of conducting an analysis, using a concise, comprehensive or multi-incident approach. The methods and resources included in the framework are designed to support organizational learning, quality improvement, a safe and just culture and improve the success of analysis in enhancing the safety of patient care. Learn more about the Framework and complementary resources here. We would be happy to learn about how the Framework impacted you and/or your organization and to answer your questions at info@cpsi-icsp.ca. 4/17/2018 6:00:00 AMIt has been five years since the Canadian Incident Analysis Framework was introduced as a resource to support those responsible for, or involved4/23/2018 7:51:03 PM613http://www.patientsafetyinstitute.ca/en/NewsAlerts/News/Pages/Forms/AllItems.aspxhtmlFalseaspx
Patient Safety Education Quarterly Update341344/11/2018 2:56:42 PMPatient Safety News The National Patient Safety Consortium Education Working Group is very pleased to launch the Patient Safety Culture Bundle for CEOs and Senior Leaders on CPSI's SHIFT to SAFETY webpage. A Working group of partners, co-led by the Canadian College of Health Leaders (CCHL) and HealthCareCAN, were brought together to establish this framework. Through a literature review of more than 60 resources, a Patient Safety Culture Bundle has been created and validated through interviews with Canadian thought leaders. The Bundle is based on a set of evidence-based practices that must all be applied to reliably deliver good care. The key components required for a Patient Safety Culture are identified under three pillarsENABLING - ENACTING - LEARNING Within each pillar are links to valuable tools and resources to help healthcare leaders establish and sustain a patient safety culture. Our intent is to establish links to helpful resources for each practice listed within the bundle. We are asking for your help in contributing any resources that can be linked to the elements within the Bundle. These resources can be in any form video, tool, policy, procedure, program description, framework, etc. We are committed to providing a robust framework to advance a safety culture. The Bundle is a dynamic tool that will be continually updated. We invite you to the check back often for more links and resources.4/11/2018 6:00:00 AMThe National Patient Safety Consortium Education Working Group is very pleased to launch the Patient Safety Culture Bundle for CEOs and Senior4/11/2018 3:06:01 PM88http://www.patientsafetyinstitute.ca/en/NewsAlerts/News/Pages/Forms/AllItems.aspxhtmlFalseaspx

 Latest Alerts

 

 

Neonatal Death11218352910/1/2017 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 PMhttp://www.patientsafetyinstitute.ca/en/NewsAlerts/Alerts/Lists/Alerts/AllItems.aspxFalse
Express Levothyroxine Doses in Micrograms not Milligrams1123135183/8/2017 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 PM3http://www.patientsafetyinstitute.ca/en/NewsAlerts/Alerts/Lists/Alerts/AllItems.aspxFalse
Deteriorating Patient Condition Associated with Medical Gas System Dysfunction 1121735303/1/2017 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 PMhttp://www.patientsafetyinstitute.ca/en/NewsAlerts/Alerts/Lists/Alerts/AllItems.aspxFalse
Gaps in Medication Monitoring May Contribute to Death1123335172/28/2017 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 PMhttp://www.patientsafetyinstitute.ca/en/NewsAlerts/Alerts/Lists/Alerts/AllItems.aspxFalse
Some Medications Don’t Mix 1123435162/8/2017 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 PMhttp://www.patientsafetyinstitute.ca/en/NewsAlerts/Alerts/Lists/Alerts/AllItems.aspxFalse