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 CPSI News



Highlights of 2016 collaboration with Atlantic Health Quality Patient Safety Collaborative: First National Incident Management Skills Development Session!47321/6/2017 10:26:13 PMPatient Safety News The Canadian Patient Safety Institute (CPSI) is celebrating many successful collaborations in 2016 and wanted to share one of those highlights with you. The Atlantic Health Quality Patient Safety Collaborative (AHQPSC) prioritized incident management skills development as a key area of focus for the health professionals who serve as patient safety and quality and risk specialists across the four Atlantic Provinces. The two-day in-person training opportunity was designed to equip Health Professionals with core concepts in Patient Safety Incident Management with a focus on translating the knowledge, skills, and attitudes to effectively identify, report, and learn from patient safety incidents. On October 5 and 6, the AHQPSC and CPSI hosted the first National Patient Safety Incident Management Skills Development Session in Halifax. National partners, which included, Patients for Patient Safety Canada, Institute for Safe Medication Practices Canada, Accreditation Canada, Master Facilitators, and the Canadian Patient Safety Institute greatly contributed to the overall success of this initiative. The two-day session encompassed the fundamentals of the continuum of incident Participants were engaged in multiple activities that explored meaningful patient engagement, patient safety culture, physician engagement, various incident analysis methodologies, best practices and national accreditation standards. Final evaluation by participants revealed that 97.1% would recommend this session to others. "massive learning opportunity and sharing experience with provinces…I would recommend for more employees to attend" (session participant). As the initial pilot we are very pleased with the overall learning outcomes. As a result of this national learning opportunity Prince Edward Island has already garnered the learnings from this event and delivered a province specific skills development workshop October 27, 2016. They had over 100 participants in attendance. "Invaluable; Informative, Excellent workshop, were just some of the comments shared by attendees. The evaluation from this successful event will be integrated within a broader national needs assessment currently underway, which will aim to explore the current educational content, tools and resources for incident management across Canadian healthcare organizations and to assess the needs of Canadian organizations in relation to incident management, professional development, education and training. CPSI wishes to thank the Atlantic Health Quality Patient Safety Collaborative for their on-going commitment to patient safety and in providing this unique learning opportunity.1/6/2017 10:00:00 PMThe Canadian Patient Safety Institute (CPSI) is celebrating many successful collaborations in 2016 and wanted to share one of those highlights with1/6/2017 10:40:55 PM225
2017: The year of the possible47271/6/2017 6:01:53 PMPatient Safety Power Plays I'm always excited by possibility and really enjoy the challenge of taking something possible and making it into a reality. Never more so than when I think about patient safety for the people of Canada. We are a skilled and conscientious nation, so safety for all patients is most definitely possible. Here are some of the ways we at the Canadian Patient Safety Institute work with our partners to change possible to realShift to Safety After a huge launch in 2016, we know you expect big things from SHIFT to Safety moving forward. We have a lot planned for SHIFT to Safety this year and are excited to bring it to you. If you haven't discovered SHIFT to Safety yet, you can learn all about it here. With this program, the possibilities are endless!National Patient Safety Action Plan To date, we have nearly 70 per cent of objectives listed in the National Patient Safety Action Plan complete and with the outstanding organizations that have come to the table and taken the lead on some of this work, we're well on our way to 100 per cent. There's to much happening to list here but I encourage you to learn more.Atlantic Learning Exchange The Atlantic Provinces are small but mighty and when they come together they can accomplish great things. This will be on display this May as the 4th Atlantic Health Quality and Patient Safety Learning Exchange is held in Charlottetown, PEI. Held every two years, this event is a prime example of what makes the Atlantic Provinces special and why they lead by example when it comes to partnering for patient safety. Let's build on the successes of the past to truly make 2017 the year of the possible. I know that with the incredible support we receive from our partners, our leaders, and our fellow citizens, patient safety will be at the forefront of our Canadian healthcare system. We know it's possible, let's make it a reality together. As always, please send me your thoughts and join in the patient safety conversation Yours in patient safety, Chris Power1/6/2017 8:00:00 PMI'm always excited by possibility and really enjoy the challenge of taking something possible and making it into a reality. Never more so than when I1/6/2017 6:08:22 PM129
National Consortium Quarterly Update2462212/15/2016 4:40:18 PMPatient Safety News The National Patient Safety Consortium's fourth national gathering held on September 23, 2016 in Ottawa was the largest to date. It brought together a diverse group of 100 stakeholders, all committed to improving patient safety in Canada. Participants included representatives from nine provincial ministries and one territorial ministry of health; Health Canada, Canadian Institutes of Health Research, and the Public Health Agency of Canada for the federal health portfolio; professional associations, provincial quality and safety organizations, and many patient representatives. This year, the Consortium meeting was preceded by a full-day Leads Group meeting, the results of which helped shape the agenda and conversations at the Consortium. The two days were full of vibrant discussion and passionate engagement. Overall, meeting evaluations were positive, with 84% agreeing that that meeting objectives had been met. Highlights of the day included Patient partners celebrating patient engagement with the Consortium and urging action for safe care; Thought-provoking presentations by an esteemed International Expert Panel, bringing insights from Scotland, the United States, and Canada;Leads Groups' sharing on the progress of the Integrated Patient Safety Action Plan over the past year, with presentations and discussion on recommended priority actions to accelerate patient safety in their respective areas; andIdeas for ways to deepen collaboration and focus energies in the final 18 months of the Integrated Patient Safety Action Plan, including leveraging actions with health ministries across Canada. Throughout the two days, there was a persistent drum beat around the crucial importance of partnering with patients and families and acknowledgement of the leadership role played by Patients for Patient Safety Canada– to paraphrase international expert panelist Dr. Brian Robson, "Patients will define the future of patient safety in Canada." The Steering Committee will also be meeting in December to review the Consortium meeting and plan for 2017. As of Q2, 54% of Consortium actions are already complete, 17% are currently in progress, and 29% are scheduled to start later. 12/15/2016 4:00:00 PMThe National Patient Safety Consortium's fourth national gathering held on September 23, 2016 in Ottawa was the largest to date. It brought together12/21/2016 3:28:01 PM169
Improving Patient Safety Rounds at the IWK Health Centre2080612/14/2016 3:47:31 PMPatient Safety News ​After attending the Advancing Safety for Patients in Residency Education (ASPIRE) program at the Royal College two years ago, Dr. Sarah Stevens, a paediatric anaesthesiologist at the IWK Health Centre in Halifax, Nova Scotia got to thinking that although her perioperative group were functioning well as a team, the review of morbidity and mortality might be improved if the approach to case review was more educational. "What we did was look at a couple of topics that had raised a lot of discussion," says Dr. Stevens. "One of the early topics was a review on the effect of an upper respiratory tract infection on children and why anaesthetists don't like to put babies who have an acute respiratory infection to sleep. Patient Safety Rounds provided a setting for a joint case presentation between surgery and anesthesia, discussion of outcomes and review of the literature. Rounds included the entire perioperative team (pediatric anesthesiologists, pediatric surgical specialists, OR/ PACU nurses and anesthesia assistants). Input and questions from the audience were encouraged and the format was well received. The audience was provided with evidence-based literature about the decision making process and proceeding with a pediatric elective case, or not, when faced with an acute respiratory infection. It was very instructive for the post-anaesthesia care unit nurses and nurses in the operating room, who also felt much more educated about the topic." An interdisciplinary team has been formed to plan Patient Safety Rounds quarterly. The team includes a nurse educator, Kathy MacDonald a registered nurse from the Children's Operating Room who also oversees perioperative morbidity reviews; an anesthesiologist (Dr. Stevens); and a surgeon, Dr. R. Romao, Pediatric Surgeon and Urologist. So far, six rounds have taken place with 45 minutes allocated for presentation followed by 15 minutes of active discussion. Attendance at each of the rounds has drawn between 25 to 55 healthcare professionals. Patient Safety Rounds are also being utilized as a way of providing formal education on quality improvement and patient safety to clinical fellows and residents, who are encouraged to present cases they have experienced, in a safe learning environment. When a young patient had a pulmonary embolism after surgery, the team used that case and invited the nurses from the floor to attend the Perioperative Patient Safety Rounds and learn about the patient's risks. As a result of a case a screening protocol a decision tree has been developed by a multi- disciplinary team to decide what children should receive venous thromboembolism prophylaxis and determine the type of thromboprophylaxis that should be administered. "There has been a trickle-down effect in the sense that there is education, collaboration, the ability to ask questions about the management and care of children in a forum where everyone has the opportunity to provide input," says Dr. Stevens. "We are focusing less on the morbidity and mortality, and more on the event and what we can learn from it to improve our care. The formal morbidity and mortality process still occurs at another time." During another round, data from the surgical safety checklist, central line infections, wound infections, and septic infections was presented so that the staff could see the impact of how changes in the operating room over the last five years are having a positive effect. "Our goal this year is to get our colleagues in emergency medicine and paediatrics involved," says Dr. Stevens. "Getting information back to the primary care team is really valuable. Medicine has evolved in such a way that we tend to work in silos, and getting education from other team members will give you a much more complete picture."12/14/2016 4:00:00 PMAfter attending the Advancing Safety for Patients in Residency Education (ASPIRE) program at the Royal College two years ago, Dr. Sarah Stevens, a12/14/2016 4:00:18 PM764
Patient Safety Power Plays – Looking back on 20163083712/9/2016 6:41:30 PMPatient Safety Power Plays ​Time flies when you're having fun. That must explain why 2016 feels like its gone by in a flash! An eventful year is coming to a close, and I personally would like to thank everyone who touches the work we do and the broader patient safety and quality agenda for your ongoing commitment and contributions to our cause. Before we turn the page and welcome 2017, I'd like to reflect on a few milestones that made 2016 so memorable for me and many others. First and foremost is the tenth anniversary of Patients for Patient Safety Canada, whose members, driven by their own stories of loss and not wanting others to experience that grief, are giving a voice to patients and families. This amazing group continues to grow and inspire us every time we lean on them. We all benefit from the wisdom and experience they bring. Next up was the 2016 Great Canadian Healthcare Debate, held at the National Health Leadership Conference in Ottawa. CPSI's motion, "A Public Reporting of the 15 Never Events," was one of three selected for inclusion at the conference, and was expertly debated by our own Hina Laeeque. What a great opportunity to put patient safety forward for discussion on the national stage. This was followed by the hotly-anticipated launch of SHIFT to Safety – your source for everything patient safety. Whether you're a provider, leader, or a member of the public, provides you with access to tools and resources to make patient care safe, whatever your role. I'm truly excited to see where SHIFT to Safety goes next! Next was an event more than two years in the making, the launch of the Hospital Harm Measure, in partnership with the Canadian Institute for Health Information. Through this initiative, we now have a national picture of patient harm in acute care, coupled with evidenced-based improvement resources specific to the 31 types of harm captured in the measure. Finally, I'd be remiss if I didn't mention our most successful Canadian Patient Safety Week to date. From the Twitter Talk to the Questions Save Lives social media campaign, I loved seeing what felt like the entire country get involved and put patient safety in the spotlight. What was your highlight of the year? As always, my ear is yours to bend at On that note, I'd like to wish you and yours a bright and merry holiday season and all the best for a prosperous new year! Your in patient safety, Chris Power12/9/2016 5:00:00 PMTime flies when you're having fun. That must explain why 2016 feels like its gone by in a flash! An eventful year is coming to a close, and I12/9/2016 6:46:42 PM163

 Latest Alerts



DO NOT USE Endotracheal tubes with subglottic suction (EVAC-ETT) in pediatrics3052934903/28/2016 6:00:00 AMDeviceAlberta Health ServicesThis alert addresses the patient safety incidents which may occur when improperly sized endotracheal tubes (ETT) with subglottic suction (EVAC-ETT) are used in pediatric patients. The EVAC-ETT has a larger outer diameter as compared to the same size standard cuffed ETT. This has led to inappropriately large tubes being used in pediatrics resulting in post extubation complications and tracheal injury. Specific actions are recommended to prevent similar patient safety incidents.10/31/2016 10:21:27 PM
Choosing Correct Syringe Size- Medfusion Syringe Pump3063034911/6/2016 7:00:00 AMDeviceAlberta Health ServicesThis alert addresses the potential patient safety incidents of wrong dose of medication delivered via a syringe pump related to size of syringe used. The Medfusion syringe pump is able to automatically detect syringe size for all the syringes except for the 1 mL and 3 mL BD syringes because the barrel diameters are identical in size. This creates a risk of under or over infusion and relates to Smiths Medical Medfusion syringe pump (models 3500 & 4000). Recommendations to prevent incidents of wrong infusion are provided.11/7/2016 11:22:18 PM
Massive Transfusion Protocols24628348810/29/2015 6:00:00 AMBlood Products/TransfusionOregon Patient Safety Commission (USA)This alert discusses the patient safety incidents which occur as a result of delay in initiating massive transfusion protocols and communication breakdowns when acquiring blood products. The majority of these incidents involve postpartum hemorrhage. Postpartum hemorrhage is the leading cause of maternal mortality and morbidity worldwide and accounts for nearly a quarter of all pregnancy-related death . It can be exceptionally challenging to manage, as external signs and symptoms may not be apparent until a large volume of blood is lost, and approximately one third of women who experience postpartum hemorrhage have no risk factors upon admission. However, many studies suggest that postpartum hemorrhage can be prevented or well controlled with appropriate assessments and interventions. The National Partnership for Maternal Safety has developed a Consensus Bundle on Obstetric Hemorrhage to help facilities tackle this challenging issue. Their recommendations include four critical elements: readiness, recognition, response, and reporting/systems learning. The recommendations section of this alert provides details on each of these themes.12/19/2016 11:25:33 PM3
Adverse Events Related to Incorrect Route and Doses of EPINEPHrine24646348710/29/2015 6:00:00 AMMedicationOregon Patient Safety Commission (USA)This alert discusses the patient safety incidents of wrong route and/or wrong dose when topical EPINEPHrine is given by injection or injectable EPINEPHrine is given by intravenous (IV) injection for treatment of anaphylaxis or serious allergic reactions instead of intramuscular (IM) injection as required. The various strengths and types of EPINEPHrine have led to confusion and medication errors. Serious adverse reactions have occurred, including death. In the March 2009 issue of the Institute for Safe Medication Practices (ISMP) newsletter (, a fatal EPINEPHrine-related event is described in Canada in which topical EPINEPHrine 1:1,000 was inadvertently given for injection as a local anesthetic; the correct product was injectable EPINEPHrine 1:100,000 as a local anesthetic. The February 2015 issue of the ISMP newsletter ( shares errors occurring with the use of EPINEPHrine for the treatment of anaphylaxis and the risks associated with using 1 mg ampoules or vials. Specifically, an intramuscular dose of 0.3 to 0.5 mg of EPINEPHrine is recommended for anaphylaxis in adults. Autoinjectors of 0.3 mg are available for adult use. Deployment of EPINEPHrine autoinjectors is a way to avoid wrong dose and wrong route errors (intravenous instead of intramuscular) when ampoules or vials are used for severe allergic reactions or anaphylaxis. The concern with 1 mg ampoules or vials of EPINEPHrine is that the contents must be drawn into a syringe. During a stressful emergency situation, this has sometimes led to the erroneous administration of the full 1 mg dose IV, which could prove harmful to some patients. The alert provides recommendations for safe practices to mitigate the likelihood of medication errors involving topical and injectable EPINEPHrine.12/19/2016 11:25:40 PM3
Safe Placement / Inflation of the King LT Airway30533338310/19/2015 6:00:00 AMDeviceAlberta Health ServicesThis alert discusses the correct use of a supraglottic airway device to avoid patient safety incidents in patients requiring ventilatory assistance. The King LT is a supraglottic airway device used to secure and maintain the airway of patients requiring ventilatory assistance. If the King LT is incorrectly positioned and/or the cuffs are over inflated numerous complications may result (e.g. impaired cerebral blood flow (CBF), tracheal obstruction, or esophageal perforation). Recommendations for the appropriate use of this device are provided. 10/31/2016 10:21:29 PM