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 CPSI News



Patient Safety Power Play: Make this a summer to remember312447/30/2018 6:54:07 PMPatient Safety News Canada has some of the shortest summer months, full of the longest summer days. As I look forward to enjoying the beautiful weather with my friends and family, I can't help thinking of the progress we've made this year. It's as if, by marking our successes, I can make the days a little longer and the weather a little warmer! First of all, I would like to offer my thanks to all our hard-working members of the Canadian healthcare community. I wish to thank you, as always, for your amazing efforts on behalf of the thousands of people you care for every day. Whether you serve in the front lines, behind the scenes, at the policy-making table, in homes or in researching the future of care, a career in healthcare is one of the most challenging – and rewarding. By definition, you think of others before you think of yourselves. I urge each and every one of you to take time this summer with family and friends to care for yourselves so you can continue to care for the rest of us. Next, I would like to thank each one of you who have helped us in our mission to make healthcare safer for patients. Our tireless volunteers in Patients for Patient Safety Canada share their stories and dedicate their efforts to holding the healthcare system accountable. Those of you who participate in our annual STOP! Clean Your Hands Day and Canadian Patient Safety Week campaigns help improve patient safety for everyone. The healthcare workers, educators and administrators who participate in CPSI programs are each doing their part to help us achieve our vision to ensure Canada has the safest healthcare in the world. Finally, I want to recognize our partner organizations, without whom we would have a much harder task than the momentous one that lies before us. Our Voting Members consist of national organizations, federal departments, and local government agencies who all work together to guarantee patient safety across Canada. Representing these groups, our devoted Board Members champion our efforts. Thanks to the partnerships and support we enjoy, this year CPSI developed Patient Safety Right Now, a bold new direction with an urgent call to action. Together with the exceptional efforts of the staff and supporters of the Canadian Patient Safety Institute, we will demonstrate what works and strengthen commitment to patient safety in Canada… right now! Our precious Canadian summer months are often a time many choose to take some well-earned vacation. The successes we've seen in the past year will help make those long summer evenings just that much better. I invite you to celebrate those successes with me – and tell me how we can work together in the next year to deliver on this promise of patient safety we have made together. Until then, enjoy your time in the summer sun, and think about how you and your organization will help address the concerns of multiple medications during Canadian Patient Safety Week at the end of October. Please have a look at the amazing resources and dedicated speakers available during October 29 to November 2nd visit Questions? Comments? My inbox is open to you anytime at Follow me on Twitter @ChrisPowerCPSI. Yours in patient safety, Chris Power7/30/2018 6:00:00 AMCanada has some of the shortest summer months, full of the longest summer days. As I look forward to enjoying the beautiful weather with my friends7/30/2018 7:02:25 PM222
Update: National Patient Safety Consortium299507/26/2018 2:53:30 PMPatient Safety News The National Patient Safety Consortium is pleased to present that 94% of Consortium actions are complete as of March 31, 2018. The Steering Committee met on May 2018 and has fulfilled its mandate to provide overall leadership and direction to the Consortium and Integrated Patient Safety Action Plan. The final Consortium meeting was also held in October 2017. Actions that will continue over the next fiscal year in collaboration with partners are Provide implementation guidance to facilities on Never Events Maintenance of the "Engaging Patients in Patient Safety a Canadian Guide" and help support implementation and use of the principles and tools through CPSI's Safety Improvement Projects A key focus of CPSI's future strategy is strengthened alliances with patients, governments, and other partners to influence levers for change in the system such as policy, standards and regulations. The interim evaluation findings also recommended evolving the structure of the Consortium to consider specific roles of Federal/Provincial/Territorial (FPT) partners and translating the evidence from the Action Plan outputs as they relate to the need for strengthened policy, measurement and standards. As key mechanisms to strengthen commitment for patient safety, CPSI with Health Standards Organization (HSO) has convened a new Canadian Quality and Patient Safety Advisory Committee. CPSI will also convene a new FPT Government Network. The purpose of the FPT Government Network is to promote national alignment on patient safety priorities. This will be done through strategic interactions with FPT policy makers as well as broadly disseminating the key learnings from the Integrated Patient Safety Action Plan. 7/26/2018 6:00:00 AMThe National Patient Safety Consortium is pleased to present that 94% of Consortium actions are complete as of March 31, 2018.  The Steering7/26/2018 2:57:19 PM75
Update: Home Care Safety299527/26/2018 4:33:23 PMPatient Safety News As of March 31, 2018, for the home care safety action plan, 57% of actions are complete, 24% of actions are in progress, and 19% of actions are yet to start. Some of these actions will be transitioned over the current fiscal year as further described below. The Canadian Home Care Association has been a significant partner in the Leads Group work for the Home Care Safety Action Plan. It is hoped that past highly successful work with the Wave One and Wave Two Home Care Improvement Collaboratives will lead to ongoing involvement of home care organizations with CPSI's upcoming Safety Improvement Project in Team STEPPS and medication safety at transitions of care (aligns with World Health Organization 3rd Global Patient Safety Challenge Medication without harm. CPSI and CHCA will explore opportunities to utilize communications tools that were developed during the Home Care Safety Action Plan into the work of Safety Improvement Projects. Work continues, lead by St. Elizabeth Home Care agency focused on a tool to support systems to systems communications. Once the final product is finalized it will be shared with the field. The tool will assist organizations in looking at the information exchange that occurs between organizations. Improving information exchange is seen as one way to assist in the area of transition in care which is a major safety focus. 7/26/2018 6:00:00 AMAs of March 31, 2018, for the home care safety action plan, 57% of actions are complete, 24% of actions are in progress, and 19% of actions are yet7/26/2018 5:13:21 PM56
Update: Medication Safety299547/26/2018 5:17:04 PMPatient Safety News Four years after the Medication Safety Summit, the Medication Safety Action Plan is 100% complete. All partners, stakeholders, teams, and patient volunteers made immense contributions to achieving the collective goal of accelerating improvements in medication safety in the theme areas of reporting/learning/sharing, evidence informed practices, partnering with patients and technology. The Leads Group provided steady guidance, leadership and determination as the action plan was implemented with purpose. Given our collective success and the need to maintain momentum in advancing medication safety, the following initiatives will continue over the next year Increasing spread and uptake of the 5 Questions to Ask About Your Medications tool to further integrate into medication safety practice and education in the health system Continue integrating opioid safety tools and resources into practice to empower patients to increase their knowledge about the use of opioids and prevention of harm Continuing the bi-monthly Med Safety Exchange Webinar Series that focuses on sharing and learning from recommendations from medication incident reporting systems These initiatives in addition to new projects including an upcoming CPSI Safety Improvement Project on medication safety at transitions of care will align and support the World Health Organization's 3rd Global Patient Safety Challenge Medication Without Harm. The Canadian Patient Safety Institute would like to sincerely thank the Leads Group, all partners, stakeholders, patient volunteers and action teams for their excellent work and support through the progress of the Action Plan. Medication safety will continue to be a priority in patient safety and Canadian healthcare and partnerships will continue to be necessary advance this important work.7/26/2018 6:00:00 AMFour years after the Medication Safety Summit, the Medication Safety Action Plan is 100% complete. All partners, stakeholders, teams, and patient7/26/2018 5:21:52 PM45
Update: Infection Prevention and Control (IPAC)299567/26/2018 5:29:24 PMPatient Safety News Great progress has been made on the IPAC action plan, with all but 3 actions completed as of March 31, 2018. CPSI is committed to continue to work with our partners on the remaining actions. With respect to the 2 actions focused on measurement and surveillance, CPSI has embedded this work into our new strategic direction, Patient Safety Right Now. More specifically, the actions that will be carried on into the 2018/2019 fiscal year are Work with partners to promote the pan-Canadian adoption of IPAC surveillance definitions Contribute to the development of a solution for pan-Canadian collection, analysis and reporting of Healthcare Associated Infection surveillance data Knowledge translation and implementation science activities aimed at healthcare providers and leaders who are looking for behaviour change strategies to accelerate their quality improvement efforts. In 2018/19, CPSI is committed to the completion of the knowledge translation and implementation science national webinar series, aimed at healthcare providers and leaders, as a central focus of CPSI's new strategic plan.7/26/2018 6:00:00 AMGreat progress has been made on the IPAC action plan , with all but 3 actions completed as of March 31, 2018. CPSI is committed to continue to work7/26/2018 5:32:29 PM29

 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 PM4
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 PM6
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 PM3
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 PM5
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 PM3