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 CPSI News



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." "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" Ioana Popescu "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 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 involved in,4/17/2018 6:52:41 PM
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 PM
National Patient Safety Consortium Quarterly Update341364/11/2018 4:52:50 PMPatient Safety News The National Patient Safety Consortium is very pleased with progress of actions. As of December 2017 (Q3), 91% of actions are complete or underway. The one remaining action on implementing the Never Events report across jurisdictions will be carried over to next fiscal year. The National Patient Safety Consortium Action and the Integrated Patient Safety Action Plan are currently being evaluated by Vision & Results Inc. Thus far, CPSI staff, Steering Committee members, Leads Groups, patients, and Action Teams have been interviewed as well as an online survey. Currently, a second phase of focus groups is being conducted with the Steering Committee and Leads Groups. Interim results found that "the Consortium is an exemplar of a strong collective impact model there is a shared vision and agenda, concrete plan and activities, an effective coordination body, and ongoing monitoring and reporting." The results will be shared in May 2018. The key learnings of this large-scale collaboration, including the evidence-based outputs from the Integrated Patient Safety Action Plan and recommendations from the independent evaluation, will inform the next steps of this work. 4/11/2018 6:00:00 AMThe National Patient Safety Consortium is very pleased with progress of actions.  As of December 2017 (Q3), 91% of actions are complete or4/11/2018 4:58:04 PM
Surgical Care Safety Quarterly Update340784/10/2018 8:48:51 PMPatient Safety News The Surgical Care Safety Leads team and action partners have continued to make steady progress since our face to face meeting in October. Highlights includes completion of a report which synthesizes all the current literature related to teamwork and communication in the surgical setting. Additionally, in response to actions targeted at the identification of a national set of surgical indicators, through a collaboration led by CIHI, a working group reviewed existing surgical indicators and identified a set of 8 indicators that would have broad applicability in Canada. These indicators are currently being reviewed by the provincial and territorial health ministries to determine alignment of these indicators with those being collected currently. Through a partnership with Patients for Patient Safety Canada, the Canadian Anesthesiologists' Society and the OR Nurses Association of Canada, several surgery related patient engagement tools were complied, reviewed and curated and have been posted for reference on the Patient Engagement Hub of the Canadian Foundation for Healthcare Improvement's website. Efforts have focused on brining to conclusion as many of the surgical care safety actions as is possible; the majority of when will be successfully completed by March 31, 2018. It has been determined that due to scope and complexity the action relating to the dissemination and implementation of best practices (Enhanced Recovery After Surgery – ERAS) will be integrated into CPSI's new strategic planning process. Six working groups have been developed to adapt and adopt existing evidence-based guidelines which will support an implementation strategy being planned for 2019-2020.4/10/2018 6:00:00 AMThe Surgical Care Safety Leads team and action partners have continued to make steady progress since our face to face meeting in October. 4/10/2018 8:54:05 PM
Update: Infection Prevention and Control340814/10/2018 9:00:41 PM Over the past year the Infection Prevention and Control (IPAC) Action Teams have made progress on many actions from the IPAC Action Plan including developing and launching programs aimed at preventing and controlling infections through behavioural change strategies and development of a pan-Canadian set of case definitions for surveillance of healthcare associated infections. Since the last update, CPSI, using its international Knowledge Translation and Implementation Science Faculty has developed a knowledge translation and implementation science education webinar series. This is an exciting 6-part series of interactive webinars designed to build capacity in the basic principles of knowledge translation and implementation science. The webinar series is designed as a suite, with each session building on the last and thus is ideally suited to those who can participate in all six. The series is intended to create awareness of barriers knowledge translation principles and assist in identifying barriers to uptake of knowledge. With respect to the development of pan-Canadian set of case definitions for surveillance of healthcare associated infections, collectively we have identified the set of case definitions for both acute and long-term care. With the ultimate goal being widespread adoption and application of these definitions across the country, work is underway to disseminate the new long-term care definitions and implement strategies to promote pan-Canadian adoption of both the long-term care and acute care definitions. 4/10/2018 6:00:00 AMOver the past year the Infection Prevention and Control (IPAC) Action Teams have made progress on many actions from the IPAC Action Plan4/10/2018 9:04:10 PM

 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 PM
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 PM
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 PM
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 PM
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 PM