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Saint Elizabeth takes a practical approach to falls prevention37099/16/2016 2:11:21 PMPatient Safety News Saint Elizabeth Health Care has built a culture of falls prevention with their staff, in terms of the orientation they provide, assessments for identifying clients who are high risk, and processes for reporting and evaluating falls to proactively reduce falls and injuries from falls. With over 8,000 employees in 24 offices across the country Saint Elizabeth's Falls Prevention Committee works across the entire organization to look at trends and investigate higher risk falls to identify lessons learned and address what is happening across all areas. On the Rehabilitation side, exercise programs for community dwelling and long term care seniors is helping to improve balance and reduce the frequency of falls; and that is having a positive impact on their client's quality of life. Even with the comprehensive approach to falls prevention, Saint Elizabeth was seeing an increased level of frailty in seniors, and as a result an increase in falls. The not-for-profit organization joined the Home Care Safety Falls Collaborative to refocus their efforts with the support of a larger collaboration. They wanted to see what their peers were doing and learn from experts in falls prevention. "At the end of the day, we wanted to have a greater impact and we knew that a collaborative and partnership approach would help us to have the desired effect," says Rheta Fanizza, Chief Business Officer and Senior VP Innovation at Saint Elizabeth Health Care. "By working with the Falls Collaborative we learned that there are some practical things that you can do to really make a big difference." Saint Elizabeth's multi-pronged approach involved an Interprofessional group, including a patient representative, to put falls prevention strategies in place. The Collaborative team met with staff, introduced online education and did joint visits to ensure the education was brought into practice. The results were impressive! On average, over a six-month period, one group had recorded 7.6 falls and that metric was reduced to 1.6. Fanizza – who also serves as Chair of the Home Care Safety Leads Group for the Integrated Patient Safety Action Plan – says that the Collaborative team had varying levels of knowledge about quality improvement and part of their involvement was to develop foundational quality improvement processes. Through monthly teleconferencing the team discussed what are the quality improvement initiatives? How do you know if you have achieved success? What do you measure? How do you set targets? How do you set stretch goals? Each month, a team member would be accountable to report back to the Collaborative about the initiatives that had been put in place and the outcomes. "By engaging with the group, there was an inherent accountability and it had the desired effect for the clients that we care for," says Fanizza. Saint Elizabeth is looking to implement quality improvement initiatives across all business lines. One area they have been looking at is the juncture between falls and incontinence. They have had a consensus building day, and are in the process of developing a white paper on falls and incontinence. "Looking at the literature, there are a lot of reasons why seniors fall, but one of them is that they are rushing because they have incontinence issues," says Fanizza. "On the flip side, they have generalized weakness and they fall. With the leadership of our staff across all the disciplines, we are not only taking a look at what we can do to prevent falls, but to reduce the level of incontinence in the clients that we see. We are developing strategies to help staff identify those that are at risk for falls and those that are incontinent, and implementing best practice treatment recommendations." "The overall impact of participating in the Collaborative is that the clients we care for are falling less," says Fanizza. "By increasing the quality of care we provide, we have seen a correlation in fewer falls being reported and investigations being conducted, and a reduction in the number of follow-up visits by supervisors. As an organization, this is a great example of how investing in staff training and development, collaborating with others, and embracing continuous improvement can yield amazing results." The Canadian Patient Safety Institute, the Canadian Home Care Association and the Canadian Foundation for Healthcare Improvement launched the Home Care Safety Falls Collaborative in the fall of 2015. Organizations providing care in the home participated in a series of online virtual meetings and received individualized coaching and support to prevent falls in the home. Teams participating in the Collaborative included the Canadian Red Cross, Eastern Health, Saint Elizabeth Health Care, VHA Home HealthCare and the Winnipeg Regional Health Authority. 9/16/2016 2:00:00 PM  Saint Elizabeth Health Care has built a culture of falls prevention with their staff, in terms of the orientation they provide, assessments9/20/2016 4:53:55 PM242
Join CPSI’s new expert faculty289829/9/2016 8:46:29 PMPatient Safety News The Canadian Patient Safety Institute (CPSI) is assembling a new expert faculty and is looking for the best and brightest in the areas of knowledge translation and implementation science. As part of CPSI's new SHIFT to Safety initiative, this new faculty of experts will collaborate on developing ideas, solutions, and strategies to implement patient safety practices, strengthen teamwork, communications and leadership targeted at reducing patient harm. SHIFT to Safety was launched in July 2016 and is the new source for patient safety, bringing the public, providers, and healthcare leaders together like never before. Specifically, faculty members will be involved in shaping several key SHIFT to Safety resources, including Team STEPPS© and the Home Care Quality ​Improvement Collaborative​, byIdentifying and evaluating emerging Canadian and international evidenceProviding advice on the evaluation, sustainability and improvement of these resourcesAssisting with knowledge transfer activities including participation in webinars and learning programsProviding support by participating in online discussion forums, sharing information and resourcesResponding to queries from healthcare practitioners as opportunities arise Patients and family members of organized patient safety groups, healthcare providers, educators, administrators, and academic researchers with experience and expertise in the areas of practice change, patient safety and quality improvement, teamwork, communications and leadership are invited to apply.​ Click here to learn more. 9/9/2016 4:00:00 PMThe Canadian Patient Safety Institute (CPSI) is assembling a new expert faculty and is looking for the best and brightest in the areas of knowledge9/14/2016 7:48:47 PM593
Patient Safety Power Play: The National Patient Safety Consortium – bringing a shared vision for change alive295969/7/2016 7:23:54 PMPatient Safety Power Plays While there is a great deal of hype around New Year's Eve – I'm thinking of the enthusiasm for resolutions, new projects, etc. – for me, autumn is a more significant time for becoming re-energized. It might be a remembrance of all that back to school energy in my life and the lives of my children, or just the Canadian crispness in the air, but autumn is when I take stock of important projects. In line with this autumn energy, the National Patient Safety Consortium gathers this month for its fourth face-to-face meeting. In 2014, the Canadian Patient Safety Institute brought together key partners in Canadian healthcare and established the National Patient Safety Consortium to drive a shared action plan for safer healthcare. More than 50 participating organizations, including national organizations, provincial and territorial quality and patient safety councils, government representatives, professional associations and patient groups are working to bring a shared vision for change to life. Please have a look at some of the interesting achievements belowNever Events for Hospital Care in CanadaPatient Safety and Quality Priorities for Consortium Participants A Canadian Snapshot (Dec 2015)Patient Engagement Resources Overall, 60 per cent of all Consortium actions are complete, thanks entirely to the collaboration of the many groups involved. It really is incredible that such diverse groups can come together in such an effective way. In order to have a collective impact, five specific conditions must be met, and I'm proud to say that we are excelling in each Common Agenda – agreed upon very early in the process Shared Measurement – collected and shared quarterly with all of you Mutually Reinforcing Activities – each action contributes to the overarching goal Continuous Communication – face-to-face meetings scheduled and attended Backbone Support – dedicated staff are committed to our success Positive, long-term change is achievable only when people work together. Thanks to each member, and to everyone committed to positive nation-wide healthcare improvement, the shared vision is not only alive, but well. Please feel free to contact me personally at to discuss any patient safety issues that are on your mind. Yours in patient safety, Chris Power9/7/2016 4:00:00 PMWhile there is a great deal of hype around New Year's Eve – I'm thinking of the enthusiasm for resolutions, new projects, etc. – for me, autumn is a9/20/2016 4:52:23 PM264
Canadian Red Cross shares key learnings from the Home Care Safety Falls Collaborative236138/30/2016 3:14:18 PMPatient Safety News ​​In late 2015, the Canadian Patient Safety Institute, the Canadian Home Care Association and the Canadian Foundation for Healthcare Improvement launched the Home Care Safety Falls Collaborative. Organizations providing care in the home participated in a series of online virtual meetings and received individualized coaching and support to prevent falls in the home. Teams from the Canadian Red Cross, Eastern Health, Saint Elizabeth Health Care, VHA Home HealthCare and the Winnipeg Regional Health Authority participated in the six-month Collaborative. In this article, The Canadian Red Cross shares their key learnings from the Collaborative. The Canadian Red Cross (Ontario Community Health & Wellness programs) used a two-prong approach in setting the goals they wanted to achieve as it relates to the Home Care Safety Falls Collaborative. One of their measures focused on a specific targeted client population at high risk for falls and the other was to develop a service planning tool related to the outcome of the InterRAI Community Health Assessment (CHA), which is a standardized tool that is a mandated requirement of all Ontario community support service programs. "The Service Planning Tool helps frontline workers to identify action items that engage both the client and the caregiver in the care process, and promotes the understanding that clients and/or their caregivers have a responsibility to be actively involved in their care," says Jody Hales, Director of Quality Assurance & Risk, Canadian Red Cross Community Health & Wellness programs. "It is not just about providing a service; the client and/or their caregiver need to be engaged, and take on a role of responsibility as it relates to their own well-being." In developing and evaluating the Service Planning Tool, one of the key findings was that many caregivers are a family member or significant other of the client, who work outside of the home and therefore are most often not present for the client's assessment (assessments are done during the regular work day, most often when the caregiver is working). "That was quite a finding for us," says Hales. "Even though we are a 24/7 service, our supervisors work nine to five, Monday to Friday and are on-call for emergencies, we don't plan after-hour home visits and we may need to consider that. We need to understand our client population; you can't put everyone into one basket." This pilot project was affiliated with the Canadian Red Cross assisted living and attendant care programs in Cornwall, Ontario focusing on the use of the InterRAI Community Health Assessment (CHA) tool. This involved using the electronic validated assessment tool (as mandated in Ontario), where information is auto-populated into clinical assessment protocols (CAPs), which help identify specific risks to each individual client, which in turn, informs the care planning process. "One of our key findings was with connectivity issues at the point of care, being in the client's home – connectivity was very sporadic," says Hales. "This led to the completion of a provincial survey which identified that connectivity was a huge challenge across the province, not only in outlying areas, but in apartment buildings, basements suites and other geographic areas. Before you employ anything electronically, you really need to conduct foundational work to determine its feasibility and identify what effect it will have on both the provider and the end user." The connectivity issues resulted in the Canadian Red Cross supervisors and care coordinators having to print off the forms and manually completing them during the assessment at the point-of-care, then returning to the office and entering the data electronically (where there was good connectivity) which in turn would then auto-populate the risks for each specific client – clinical assessment protocols (CAPs). The supervisors and care coordinators would then travel back to the client's home to discuss the identified risks to inform the care planning process, in collaboration with the client. It is a huge, time-intensive process that requires duplicate effort resulting in additional workload. The Canadian Red Cross is now looking at options to address the identified connectivity challenges. Another key learning was related to client engagement. Understanding what is important to the client, rather than relying on worker perception. The Canadian Red Cross had a client representative join their Falls Collaborative team. "Our client representative was invaluable," says Hales. "She reviewed existing support documents and provided open and honest feedback. What was really interesting and important was to be cognizant of the level of information that we are providing. It is critical to understand our audience when delivering information. We must make it relevant and understandable for our clients and caregivers. We need to identify what is most important to our end user - our clients and focus on that." Jody Hales explains that they don't service just one client population. "As a service provider, it is vital that we understand the unique needs of all our client populations and although it is predominantly the senior, frail population that most often uses our services, we also have an attendant care population -servicing adults with physical disabilities." "Our quality improvement work is a continuous process," says Hales. "You can't just develop something and leave it. You need to engage clients, their caregivers and our frontline staff – those that are using the tools to ensure they continue to be relevant and responsive to the needs of our client population(s). We recognize that clients and their caregivers are critical partners in their plan of care. As we move forward with our client/caregiver engagement journey, our commitment is to creating the best possible client experience in partnership with our clients, families and the broader community." ​8/30/2016 4:00:00 PMIn late 2015, the Canadian Patient Safety Institute, the Canadian Home Care Association and the Canadian Foundation for Healthcare Improvement9/8/2016 4:02:16 PM284
PSEP – Canada to help St. Michael’s build patient safety capacity236188/30/2016 3:54:00 PMPatient Safety News St. Michael's Hospital in downtown Toronto has embarked upon a renewed patient safety program to embed safety into the forefront of everything they do. Policies have been revamped and new tools, roles and supports have been created around the elements of a strong safety culture. "St. Michael's has been committed to patient safety in a fulsome way since 2004," says Dr. Chris Hayes, Medical Director, Quality and Performance. "We have now reached a point where we want to take patient safety to the next level and we are investing more in it as the science improves. It is a corporate commitment to advance our approach to patient safety in our journey to being a highly safe organization." St. Michael's already has a program in place that trains people in quality improvement skills; and now they are embarking on the same capacity building for patient safety by using the Patient Safety Education Program – Canada (PSEP – Canada) as the catapult. As a trained Master Facilitator for PSEP – Canada, Dr. Hayes knows how the PSEP – Canada program can help St. Michael's build that capacity. Rather than using the traditional approach where a few individuals are selected to take the PSEP – Canada training and bring their new knowledge and skills back to their organization, St. Michael's is bringing a PSEP – Canada workshop to their home front, training 30 people from their organization at the same time. They have strategically partnered with their corporate education portfolio to train individuals as patient safety educators, providing patient safety knowledge and pedagogical approaches so that they can be patient safety champions at the unit level. "The difference with bringing the program in-house is that we can apply the PSEP – Canada training into our contextual framework and align it with our messaging and corporate priorities," says Dr. Hayes. "The role of our educators is to translate knowledge and skills to the clinical units. We are augmenting our clinical educators with patient safety content so that they can embed it into what they already do. They will now have the language, the nomenclature and the capabilities to more easily translate patient safety examples and science, and human factors with confidence." St. Michael's worked with the PSEP – Canada team to choose the modules that are aligned with the hospital's strategic plan and patient safety program. A two-day PSEP – Canada workshop will be delivered at the hospital on September 20 to 21, 2016. Master Facilitators have been secured, patient representatives have signed up, the room is booked and they are ready to learn. "At the conclusion of the PSEP – Canada "Become a Patient Safety Trainer" workshop, we will have immediately created a large network of patient safety educators in our own building that we can connect with, and we will work with them to share the PSEP – Canada content hospital-wide," adds Dr. Hayes. "We are really excited about this big step in capacity building all at once." ​8/30/2016 4:00:00 PMSt. Michael's Hospital in downtown Toronto has embarked upon a renewed patient safety program to embed safety into the forefront of everything they8/30/2016 4:01:50 PM934

 Latest Alerts



Atypical Presentation of Diabetic Ketoacidosis with Sodium Glucose Co-transporter 2 (SGLT2) Inhibitors11138338110/8/2015 6:00:00 AMMedicationAlberta Health ServicesThis alert discusses the patient safety incident of diabetic ketoacidosis in patients treated with a specific type of oral hypoglycemic which may be observed in the presence of only moderately increased blood glucose levels. Serious cases of diabetic ketoacidosis (DKA) have been reported in patients treated with sodium glucose co-transporter 2 (SGLT2) inhibitors which are oral hypoglycemic agents approved for type 2 diabetes. The onset of DKA symptoms can occur with only moderately increased blood glucose levels observed of less than 11 mmol/L. Such atypical presentation can delay diagnosis and treatment. The alert provides recommendations for preventing, assessing and treating DKA in patients taking SGLT2 type of oral hypoglycemics.3/17/2016 4:51:24 PM9
Safe Insulin Pump Therapy in Acute Care1113933808/13/2015 6:00:00 AMDeviceAlberta Health ServicesThis alert discusses the potential of significant patient safety incidents when an insulin pump is not used appropriately. Insulin pumps deliver continuous subcutaneous rapid acting insulin and are used in the care of patients with type 1 diabetes. Patients do not receive intermediate or long acting insulin. Severe hyperglycemia and/or diabetic ketoacidosis (DKA) can result when insulin pump therapy is stopped for as little as 2-4 hours and insulin is not replaced, even if glucose values are normal or low when the pump is stopped. The alert provides recommendations / actions to be taken to ensure safe use of an insulin pump in diabetic care in the acute care setting.3/17/2016 4:51:27 PM20
Prevention of upper extremity injuries to clients during assisted transfers and repositioning1114033798/10/2015 6:00:00 AMCare ManagementAlberta Health ServicesThis alert addresses the patient safety incidents of injuries to upper extremities which may occur during assisted transfers or repositioning of clients. Such incidents have occurred in a variety of care settings. Likelihood of injury may be increased with impairments in cognition, motor control and sensation. Hence functional assessments are necessary to mitigate risk. Actions to prevent injuries to upper extremities during client transfer or repositioning are provided.3/17/2016 4:51:29 PM9
Cerebrospinal Fluid (CSF) Sample Transport1114133787/13/2015 6:00:00 AMSpecimen/LaboratoryAlberta Health ServicesThis alert discusses the need to provide expedited transport and processing of a critical laboratory specimen to ensure an optimal patient outcome. The specimen discussed is a cerebrospinal fluid (CSF) sample. CSF is obtained from a lumbar puncture from a patient suspected of meningitis. Meningitis is a disease associated with a high morbidity and mortality. Rapid initiation of appropriate antimicrobial therapy is essential to improved clinical outcome. The factors that contribute to sub-optimal processing of the CSF sample include the following: - Transport of CSF samples from collection to receipt in the laboratory does not meet the turnaround time required to provide optimal results for patient care. - CSF samples must be sent to the laboratory immediately (within 15 minutes) after collection to ensure sample integrity and not delay efficient laboratory processing and rapid reporting of initial results (i.e. gram stain). Recommendations are provided to reduce the risk of sub-optimal processing of the CSF sample and a negative impact on patient care.3/17/2016 4:51:30 PM6
Identifying & Responding to Poisoning from illegally manufactured Non-Pharmaceutical Fentanyl1114233775/14/2015 6:00:00 AMMedicationAlberta Health ServicesThis alert addresses the patient safety incidents of poisoning and death due to street drug use of illegally manufactured non-pharmaceutical fentanyl. The Alberta Health Services have observed an increase in the incidence of this issue with an anticipated increase of patients presenting to EMS and/or Emergency Departments following ingestion of illegally manufactured non-pharmaceutical fentanyl. Early signs of illegally manufactured non-pharmaceutical fentanyl overdose include respiratory depression, cold, clammy skin, altered level of consciousness, constricted pupils, and unresponsiveness to pain. Illegally manufactured non-pharmaceutical fentanyl is considerably more toxic than other opioids and even in small quantities it can be particularly harmful to opioid-naïve users. Individuals may not know that they have consumed illegally manufactured non-pharmaceutical fentanyl when they have taken it along with oxycodone or heroin. Illegally manufactured non-pharmaceutical fentanyl products are often green in color contributing to the slang used to name these products; “greenies”, “green beans”, or “green apples” are common names. Another slang name is “oxy” although pharmaceutical oxycodone tablets are usually white. The alert provides several recommendations for treatment and response to illegally manufactured non-pharmaceutical fentanyl ingestion.3/17/2016 4:51:32 PM10