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 CPSI News



Love thy colleague101835/9/2016 5:52:29 PMPatient Safety Power Plays ​Healthcare can be an exciting, yet challenging profession. As providers, you're looked upon to be tough and resilient, always rising to the occasion during times of crisis. It's these moments that are likely the reason you got into healthcare in the first place. You're there for someone in their moment of need, and you're going to own it. These are the stories you'll recount long after you've worked your last shift. Exciting! You're also one of the first people to bear the brunt of someone's displeasure (to put it mildly) when you don't get the care outcome you were hoping for. With pressure and stressors coming at you from all sides, even internally, it's not always easy to keep your chin up. These are not moments you'll cherish, but the ones you'll learn from, and maybe the ones you'll need a little help to recover from. You're not alone, but sometimes it can feel that way. Healthcare settings are incredibly busy places, but you can still feel very isolated from everyone. Perhaps it is difficult to speak up when you're struggling. This is where a caring co-worker and the relationships you forge on the job can make all the difference. You might be more likely to take notice if a colleague is struggling if you know them better. You are definitely more likely to approach them to ask what's wrong. The same could be said about them, if you're the one who could benefit from the support of a co-worker when the going gets tough. It was John Lennon who penned the Beatles' 1967 single "All You Need Is Love," an appropriate theme for this month's Power Play. Coincidentally, the single's B-side was "Baby, You're A Rich Man." Quite appropriate considering we're all richer when we are open to love. If you're reading this, I want you to take the time to genuinely improve the relationships you have with the people you work closest with. Get to know each other, and you'll start to care for each other as people first, colleagues second. The impact that change in dynamic can have on the job will astound you. Looking back, the memories you treasure won't just be the ones where you saved a life, they'll be the ones about the special bonds you shared with those closest to you and how you had each other's backs. Please don't just take my word for it. I know there are countless examples out there illustrating exactly what I'm talking about. Share them with me at or @ChrisPowerCPSI and we can use those stories encourage others that when it comes right down to it, all you need is love. Yours in patient safety,Chris Power​5/9/2016 6:00:00 AMHealthcare can be an exciting, yet challenging profession. As providers, you're looked upon to be tough and resilient, always rising to the5/20/2016 8:51:34 PM145
10 years of partnering for patients – a message from the Patients for Patient Safety Canada Co-Chairs100114/7/2016 9:03:39 PMPatient Safety News​​​Sharon Nettleton​Denice Klavano Partnerships, at least the good ones, take time and energy to build. They are forged over time as trust and respect are earned. Many fail when the work is too difficult, when there isn't a shared vision or when success isn't realized quickly enough. Misunderstandings can create barriers large enough to derail efforts and change the course of action. Negativity can prevail. Systems remain unchanged. Unsafe care continues. This is unacceptable. Building strong partnerships is the hallmark of Patients for Patient Safety Canada. It is ingrained in our DNA. As members, we partner with each other to accomplish something greater than what we could alone. As patients and family members, many of whom have suffered grief and loss from healthcare errors, we partner with healthcare systems, in an effort to make improvements. We are volunteers. We choose this work and to be part of this incredible team; a team focused on doing some amazing things to make care safer for all. Not only are we committed to our cause, but we are also committed to each other. When it may have been easier to choose other pursuits, and where gratification may have been more instantaneous elsewhere, many of our initial members continued. Along the way, many others have joined our journey. Our supporters remind us that "changing a culture takes a decade". They encourage us to "stay the course." Volunteering to build a culture of safety in healthcare is an extraordinary thing. It is one of the most unique volunteer experiences that most of us have ever had. We've seen remarkable changes to the culture of patient safety over the last 10 years. Providers and leaders now invite us to be collaborators in communication, education, resource development, and safety design. These invitations extend beyond simply hearing our stories; the collaborators want us to be directly involved with shaping improvements. We took the time to build trust and earn respect, and now we have a partnership that is allowing us to make a real difference. For many of us, the phrase "Nothing about us without us," is starting to be realized. We are confident that the next 10 years will be very different – a faster pace of progression. With a shared vision, understanding of purpose, and strong partnerships, we believe something remarkable is on the horizon. In fact, we're already seeing a glimpse of this now shorter timelines, measurement of outcomes and experiences, transparency of results – good or bad – all so that swift actions can occur to keep things on track. We need to see what is working and what isn't. We need to know that resources aren't being wasted and that lives are not being needlessly harmed; that the healthcare system really 'cares' about its patients. Patient safety, patient experience, health outcomes and patient engagement are all connected. We may be patients, but 'patience' isn't our strong suit. As volunteers, we no longer hope to be involved in transforming healthcare, we expect it. Our destination is safe care. Our vision is 'Every Patient Safe'. Best regards, Denice Klavano and Sharon NettletonCo-Chairs, Patients for Patient Safety Canada 4/7/2016 6:00:00 AM Sharon Nettleton Denice Klavano Partnerships, at least the good ones, take time and energy to build. They are forged over time4/8/2016 2:26:24 PM366
Message from Martin Hatlie, CEO Project Patient Care101964/8/2016 2:12:13 AMPatient Safety News ​Congratulations to Patients for Patient Safety Canada on ten years of achievement since Vancouver 2006! Patients for Patient Safety Canada's rich history of dedication to the mission of harm prevention coupled with compassion for patients and families harmed in healthcare is a model for patient advocates in every nation. Your ability to engage with both head and heart, organize thoughtfully, collaborate authentically, and get things done is just terrific. It’s been an honor to work with Patients for Patient Safety Canada when that’s been possible, and astonishing to watch from across the border as you grow and collaborate so effectively with providers and health policy leaders. Onward Patients for Patient Safety Canada! 4/7/2016 6:00:00 AMCongratulations to Patients for Patient Safety Canada on ten years of achievement since Vancouver 2006! Patients for Patient Safety Canada's rich4/8/2016 2:29:28 PM297
Patients for Patient Safety Canada – 10 years strong102484/7/2016 8:51:52 PMPatient Safety Power Plays Firstly, please allow me to offer my sincere congratulations on the 10 year anniversary of Patients for Patient Safety Canada (PFPSC). I share your well-deserved pride as you celebrate the huge amount of work accomplished and the significant voice you have given to patients and their families. At CPSI, we begin each Board Meeting with a video of one of your powerful stories. The videos really remind us of the importance of carrying on your important work. You began by coming together as a few individuals, and now your work will be recognized around the world as you become World Health Organization Champions. Well done. Canadians agree that our healthcare system cannot continue to improve without the input of patients and their families. This message was already made clear to me throughout my career as a nurse and as I moved away from the front line and into leadership positions. It was further reinforced during my battle with cancer, where I found myself on the other side of the patient/provider relationship. Throughout that entire journey, there was nothing I wanted more than to be active and involved in my own care and to be seen as a partner to the amazing providers I had looking out for me. The focus of CPSI is collaboration – working with others to make positive change happen. I admire how PFPSC has illustrated the effectiveness of collaboration for over 10 years now. By sharing their individual stories, PFPSC members translate harm into healing and work with the healthcare system for nationwide improvement. Thank you for having the courage to make this possible. To the members of Patients for Patient Safety Canada, thank you again for your amazing work. While we look backward with pride over the past 10 years, it is now time to go forward into the future. Let's build on the past successes and really bring the patient voice clearly to the forefront of patient safety improvement. I look forward with excitement to our next 10 years together, and beyond. Please feel free to contact me personally at to discuss any patient safety issues that are on your mind. Yours in patient safety, Chris Power4/7/2016 6:00:00 AMFirstly, please allow me to offer my sincere congratulations on the 10 year anniversary of Patients for Patient Safety Canada (PFPSC). I share your4/8/2016 4:18:45 PM387
Patients for Patient Safety Canada celebrates 10 years of harm to healing102494/4/2016 2:56:44 PMPatient Safety News Donna Davis has been an outspoken advocate for the patient's voice for the past nine years, drawing on a deep well of heartache with an equally deep conviction that she's helping improve quality of care across this country. As a member of Patients for Patient Safety Canada since 2007, and a co-chair of that group for eight of those years, Davis has seen positive changes in the way health care providers collaborate with patients and their families. "When we first started we pretty much had to invite ourselves," Davis says of that initial founding group of patient safety champions. "We had to look for opportunities to say, hey, would you like us to come and talk to your group about patient safety? It has come a long way since then. Now we have so many requests coming our way that we can't fulfill them all." Davis remembers reaching out to the medical school at the University of Saskatchewan in those early days and asking if they'd ever had a guest speaker address the topic of patient safety. They had not. "And I said, well, I think I have a story your students need to hear." Fourteen years ago, Davis's 19-year-old son Vance died in a Saskatchewan hospital three days after he lost control of his truck on a rural road. Doctors had decided Vance's head injury was minor, only a concussion. Davis, a nurse by trade, felt otherwise but her growing concerns about his deteriorating health were dismissed and the family's ordeal was made even more tortuous by a series of miscommunications with health care workers. Five years of anger and frustration passed before Donna was contacted by the staff member who had conducted the hospital's review of Vance's case. "She phoned me and she said Donna, we failed Vance in our care of him, and we failed you as a family," Davis recalls. "So I finally had validation that what I knew in my heart to be true was in fact true. Then I had to do something to try and make it right so no other family would go through what we had gone through." Davis has been telling Vance's story ever since and believes it is that deeply personal perspective, just like those visceral experiences being shared by every one of the other patient safety volunteers now active with Patients for Patient Safety Canada, that is the prime motivator for improvements in the health care system. Davis says she's proud of PFPSC's role in recent years in contributing to a standardized method for investigating, disclosing and sharing information about accidental harm with medical professionals and the public. She's pleased that patient safety and interacting with patients and their families is now a common part of the curriculum for many health care providers. She's also proud of her group's standing as among the most active and credible patient safety advocates in the world. "I think every time we present to students, that's a huge milestone too. To have them hear our stories and hopefully influence and shape the kind of practitioners and providers they're going to be, and how they're going to listen to the patients and the families, before they get into the system and get jaded. "I know a number of times that I have presented to students, the way it's received and the emails and the cards I get back afterwards, is amazing. They just about all say I will take this with me throughout my career, and remember, so that's a huge thing." When she started advocating for patients, Davis had no idea of how healing that work would be. "But that's how I would describe it," she says. "It has healed a piece of my heart that was broken and I guess it's healed it because I know I'm honouring Vance's life and I'm making sense of his death." Davis thinks the old paternalistic attitudes in the health system, where the patient and family views were often dismissed as largely inconsequential, are slowly changing but there is still far to go. People's egos still get in the way. "Talk is cheap. It's easy to say 'yes, we're patient family centred, and yes, the patient family voice is important to us,' but when it comes right down to it, where they have to put it into practice, it's really easy to fall back into the old way, and that's what I still see quite a bit," says Davis, who works as a nurse manager of a long-term-care integrated facility in southern Saskatchewan. "We just need to just stay our course. We have to realize that culture can't be changed overnight. We have to celebrate the successes that we do have and we have to bring people on board, even if it is one at a time. We have to keep doing what we're doing and that's reaching out to partner positively with the health care community."4/4/2016 6:00:00 AMDonna Davis has been an outspoken advocate for the patient's voice for the past nine years, drawing on a deep well of heartache with an equally deep4/4/2016 4:03:55 PM465

 Latest Alerts



Atypical Presentation of Diabetic Ketoacidosis with Sodium Glucose Co-transporter 2 (SGLT2) Inhibitors9272338110/8/2015 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 Care927333808/13/2015 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 repositioning927433798/10/2015 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 Transport927533787/13/2015 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 Fentanyl927633775/14/2015 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