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 CPSI News



Patient Safety Power Play: Powering up for Canadian Patient Safety Week!98597/10/2017 7:08:20 PMPatient Safety Power Plays As someone whose entire professional life has revolved around the healthcare system in one way or another, one of my favourite times of year will be upon us before you know it. Of course, I'm referring to Canadian Patient Safety Week . . . the marquee event of the Canadian Patient Safety Institute! For more than 10 years, Canadian Patient Safety Week has been our annual opportunity to reach out to thousands of healthcare providers. In that time, we've raised awareness on patient safety issues such as medication safety, infection prevention and control and good communication. We've celebrated with webinars, Twitter talks, social media campaigns, competitions, and who could forget our famous Canadian Patient Safety Week packages filled with everything you need to make your week a success and spread the message of patient safety in your organization. This year we're aiming to outdo ourselves yet again. In case you hadn't heard, the theme for Canadian Patient Safety Week 2017 is Take With Questions as we focus on medication safety and the 5 Questions to Ask About Your Medications. This year, we are making it our mission to encourage patients and remind healthcare professionals what lifesaving questions we should all ask about our medications. Over the course of the next couple of months, we'll slowly unveil different aspects of the Take With Questions theme, as we build towards our biggest Canadian Patient Safety Week yet, from October 30 to November 3. If you aren't subscribed to our mailouts, or following us on social media, now would be a great time to start so you don't miss a thing! We've also got limited quantities of the famous Canadian P​atient Safety Week packages so don't wait too long to order yours! If you've got any questions about Canadian Patient Safety Week, you can email our planning team at How does your organization celebrate Canadian Patient Safety Week? Have you started planning yet? Do you have any questions? Connect with me anytime via email at or follow me on Twitter @ChrisPowerCPSI. Yours in patient safety, Chris Power7/10/2017 6:00:00 AMAs someone whose entire professional life has revolved around the healthcare system in one way or another, one of my favourite times of year will be7/10/2017 8:15:12 PM328
Consortium Update – The Home Stretch!325226/14/2017 4:22:45 PMPatient Safety News Consortium actions are well underway. As of March 31, 2017, almost all actions are completed (88%) and two actions remain but are in progress (13%). The Consortium is proud to have championed the development of the Patient Engagement Guide. This is an action that came out of the National Consortium's action plan and the guide will be valuable to the ongoing work that organizations across the country are doing in the advancement of patient engagement. The Steering Committee of the National Patient Safety Consortium would also like to thank two patient representatives who have contributed immensely to their work. Denise Klavano and Sharon Nettleton were instrumental members of this group. As the co-chairs for Patients for Patient Safety Canada they brought a unique and crucial perspective to the committee. As Sharon and Denise move on from their roles as the co-chairs for Patients for Patient Safety Canada the Steering Committee will be pleased to welcome their successors as new participants in the group. A key element of the National Patient Safety Consortium Action plan is an evaluation of their work, and that the work contained in the Integrated Patient Safety Action Plan. This evaluation is well underway. Through the leadership of Dr. San Ng and Jean Trimnell, Vision & Results Inc is conducting a thorough evaluation. Thus far, CPSI staff, Steering Committee members, Leads Groups, patients, and Action Teams have been interviewed. An online survey is also currently seeking feedback from partners and participants. Preliminary results will be shared in October 2017.6/28/2017 6:00:00 AMConsortium actions are well underway.  As of March 31, 2017, almost all actions are completed (88%) and two actions remain but are in progress6/28/2017 2:33:35 PM110
Medication Safety Update – Patient engagement key to medication safety success325246/14/2017 5:21:17 PMPatient Safety News Patient engagement has been and will continue to be crucially important to the progression and success of the Medication Safety Action Plan. Over the past quarter, two notable examples of progress stand out Through the Joint Statement of Action to Address the Opioid Crisis, the Institute for Safe Medication Practices Canada, Canadian Patient Safety Institute and Patients for Patient Safety Canada are working to empower patients to improve their knowledge about the use of opioids and options for non-medication treatment of pain. Recently, an information handout was developed and released that should be provided for patients with every opioid prescription. Click here to access this tool! The handout has already been endorsed for use by the Neighbourhood Pharmacy Association of Canada and Pharmasave. The Canadian Centre for Substance Abuse is coordinating progress reporting for all of the commitments made at the Opioid Summit. Click here to read the first progress report. Promotion, endorsement, dissemination and support for the 5 Questions to Ask About your Medications tool continues to expand across Canada and internationally. Over 70 organizations and regional health authorities have formally endorsed for use within their organizations (primary, community, acute and long-term care facilities) and the tool has been translated into over 15 languages. It continues to get international interest and the action team is committed to making the tool available at all points of in the health system where medications are prescribed and administered. Heading into 2017/18, the plan is well positioned for success by continuing to focus on our goals and sustaining impact and momentum of completed actions.6/28/2017 6:00:00 AMPatient engagement has been and will continue to be crucially important to the progression and success of the Medication Safety Action Plan. Over the6/28/2017 2:42:35 PM149
Home Care Safety Update – Collaborative hitting their stride325266/14/2017 4:52:30 PMPatient Safety News ​Wave Two of the Home Care Safety Improvement Collaborative is well under way. Teams have begun refining Aims and identifying measures to guide their work. Individual coaching sessions with each team are being facilitated by CPSI staff in collaboration with CHCA. These sessions help teams identify plan and test change ideas designed to make care safer. Collaboration between teams is starting to develop and teams that are working on similar concepts have recently been paired up to evaluate and provide feedback on each other's work. Future sessions will be more interactive and leverage the connections already made. 6/28/2017 6:00:00 AMWave Two of the Home Care Safety Improvement Collaborative is well under way.  Teams have begun refining Aims and identifying measures to guide7/10/2017 2:43:38 PM151
IPAC Update – STOP! Clean Your Hands Day raises IPAC to new heights325286/14/2017 4:59:02 PMPatient Safety News As part of the IPAC IAP, CPSI is actively addressing the goal of improving infection prevention and control using strategies known to improve behaviour and culture. This has been accomplished through a national campaign aimed at public, patients and providers, focusing on raising awareness and promoting behaviour change. As part of this work, CPSI has hosted with our partners, the annual Stop! Clean Your Hands Day campaign for Canada. The theme for STOP! Clean Your Hands Day, May 2017, was Ask Yourself… Making a change to your behaviour can be as simple as asking yourself a question and understanding that change doesn't need to be a burden. Small, incremental changes can lead to big things. Not only can you improve your own practices, you're setting a great, easy to follow example for everyone around you! Whether you're a patient, provider, or work in a healthcare setting – if you're involved in the healthcare system, take the time to have a conversation with yourself and ask what you can change today to improve for tomorrow. The campaign boasted a multifaceted engagement platform including a national webinar "Making it stick when asking, telling and begging just isn't enough", sold out with 383 attendees, a social media tending quiz entitled "How Clean are Your Hands", aimed at raising hand hygiene awareness for providers and the public, and a video competition focused on the theme of Ask Yourself. Of the 18 videos submitted from across Canada, we are pleased to report submissions from patients and families.6/28/2017 6:00:00 AMAs part of the IPAC IAP, CPSI is actively addressing the goal of improving infection prevention and control using strategies known to improve6/28/2017 2:47:46 PM78

 Latest Alerts



DO NOT USE Endotracheal tubes with subglottic suction (EVAC-ETT) in pediatrics1227834903/28/2016 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.5/31/2017 7:20:44 PM9
Choosing Correct Syringe Size- Medfusion Syringe Pump1228134911/6/2016 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 PM3
Incident Reported with Cold and Flu Product32142339911/4/2015 7:00:00 AMMedicationInstitute for Safe Medication Practices CanadaThis newsletter discusses the patient safety incidents that can occur with non-prescription medications that are available as combination packs. These products contain more than one ingredient, and some products even contain more than one type of tablet within the same package. For example, some cold and flu products contain different tablets for daytime and nighttime use. Each type of tablet contains ingredients that will help relieve cold and flu symptoms, but the ingredients in the nighttime medicine can help with sleep, while the ingredients in the daytime medicine do not cause drowsiness. Mixing up the two products could cause problems; for example if the nighttime product was taken during the day it could cause drowsiness and impair the ability to drive. A specific incident is described where a consumer purchased a cold and flu product that was sold as a combination package, with separate blister packs of medicine intended for daytime or nighttime use. One blister pack contained green tablets (intended for daytime) and the other blister pack contained white tablets (intended for nighttime). At bedtime, the consumer took what was believed to be the nighttime tablet to help with sleep, but had difficulty sleeping. This affected the consumer’s work productivity the following day. The consumer realized later that the tablet taken the previous evening had been one of the daytime tablets. The consumer also assumed that the green pills were for nighttime use and the bright white ones were for daytime. Suggestions are provided for consumers to help prevent patient safety incidents with combination packaged medications. As well recommendations for practitioners to assist consumers in avoiding medication mix-ups are provided. 5/31/2017 7:22:56 PM3
Application of TALLman Lettering for Selected High-Alert Drugs in Canada32221339210/30/2015 6:00:00 AMMedicationInstitute for Safe Medication Practices CanadaThis Safety Bulletin describes the development and application of TALLman lettering as a strategy to reduce medication errors. TALLman lettering is a method of applying uppercase lettering to sections of look-alike, sound-alike (LASA) drug names to bring attention to their points of dissimilarity. By accentuating the points of difference, the application of TALLman lettering to a drug name may alert healthcare providers that the drug name in question can be confused with another drug name. However, overuse of the technique may reduce its effectiveness, as names may cease to appear novel. Therefore, the use of TALLman lettering should be limited to drug name pairs associated with significant risk to patient safety. TALLman lettering will have the greatest impact on the differentiation of LASA drug names if the approach to capitalization is applied consistently. Key milestone projects of the Institute of Safe Medication Practices (ISMP) Canada and other collaborative partners are described. The bulletin contains a list of TALLman lettering for look-alike, sound-alike drug names in Canada as well as the source for this list. 5/31/2017 7:28:14 PM3
Massive Transfusion Protocols12283348810/29/2015 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 PM9