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 CPSI News



Patient Safety Power Plays: Making patient safety a priority270762/5/2018 8:34:02 PMPatient Safety Power PlaysWhy does patient safety matter? For the answer to that question, I invite you to read about Emmy Gunther, a young girl who suffered a severe injury to her hand while in hospital. What happened to Emmy occurs every day in Canadian healthcare – one in every 18 hospital stays results in at least one harmful event. It's also worth noting that this statistic doesn't cover home care, long-term care, community care, or any other clinical settings. Even if you, or someone you know, has experienced harm in healthcare, you may not be aware of the magnitude of the problem. This is why stories like Emmy's are so important. They give the public greater awareness of how dangerous healthcare can be and how common harm in healthcare is. In this instance, CPSI was contacted by CBC News to provide our perspective. Opportunities like these are a great way for us to speak directly to the public. When awful events happen, it's our job to ensure that they don't happen in a vacuum, and that we take the opportunity to educate the public on how big a problem harm in healthcare is, and what needs to be done to make things better. Our bold new five-year strategy, Patient Safety Right Now is launching April 1, 2018 with a major focus on making patient safety a priority. We're committed to raising the public's consciousness around this issue and creating the political pressure required to improve patient safety and quality in Canada. I look forward to sharing more details about this exciting work, and all aspects of our new strategy, with you in the coming months. CPSI is always looking for opportunities to become part of the story. Questions? Comments? My inbox is open to you anytime at Follow me on Twitter @ChrisPowerCPSI. Yours in patient safety, Chris Power 2/5/2018 7:00:00 AMWhy does patient safety matter? For the answer to that question, I invite you to read about Emmy Gunther , a young girl who suffered a severe2/5/2018 8:40:25 PM402
#SHIFTTalks Cross-Country Collaboration for Improved Patient Care270802/5/2018 5:52:41 PMSHIFT Talks In healthcare there is no shortage of improvement opportunities, but people are often working in isolation. There is often will to act and good ideas to improve, but teams often need support for implementation. One Sectors' Solution The Canadian ICU Collaborative was formed in 2003 to address this gap in critical care and since then, has designed and delivered many collaboratives* on over a dozen topics. Teams have been supported to improve sepsis care, transfusion practices, end-of-life care, delirium management and to reduce ventilator associated pneumonia (VAP) and central line associated bloodstream infections (CLA-BSI). Overall, results have been positive. For example, in one VAP and CLA-BSI Collaborative, one team reduced their VAP rate to zero for 14 consecutive months and another team went 13 months without a line infection. An Example The most recent initiative was named the "PAD Your ICU" virtual series and was completed in March 2017. It engaged 41 interdisciplinary improvement teams (10 paediatric and 31 adult acute care) to work together to improve the management of pain, agitation and delirium. In ten months, teams attended five webinars and 11 connection calls where participants were provided with clinical content and advice on improvement science. Teams set specific aims, shared ideas and knowledge, implemented iterative tests of change, measured progress and shared successful approaches for organizational change. Teams stayed connected via an online sharing system. You can read some of their stories here Scoring tools for delirium assessment helps to mobilize sedated pediatric patients Documenting delirium in the ICU a simple yet effective approach The collaborative approach has provided a platform to connect, learn from others and make substantive improvements in a variety of settings. You might consider joining a collaborative the next time the opportunity occurs!What You Can Do – Starting Today! "Participants told us that it was great to talk to their Canadian colleagues who have similar issues and want to make progress." In the absence of a formal collaborative, here are some ideas to better connect and support implementationLook for other organizations in your community to visit and learn from (including those who may be outside of healthcare),Join a list serve or social media platform with others working on the same problem, especially those who are actively working on improvement initiativesReview innovative practices from world class organizations,Rely on validated improvement approaches,Share your data, learning and challenges with those that matter In closing, we leave you with a final thought from Dr. W. Edwards Deming "When we cooperate, everybody wins." *Collaboratives (also known as Breakthrough Series Collaboratives) were designed by the Institute for Healthcare Improvement (IHI) in 1993 and have been successfully applied worldwide to significantly improve quality and safety in healthcare. Guided by a philosophy of "all teach, all learn", multiple organizations come together to make improvements on a specific healthcare challenge. The approach allows teams to address a common problem, to leverage ideas and to share what they learn along the way. The process is based on three to four learning sessions, team action periods and methods for support (coaching calls, measurement help, discussion forum, file sharing, Faculty feedback).Authors Bruce Harries co-founded Improvement Associates in 2000. He is Collaborative Director for the Canadian ICU Collaborative and has advised on several initiatives such as the National ICU Scorecard and Safer Healthcare Now! Bruce is on the board of the Health Quality Council of Alberta (HQCA) and on Faculty of the BCPSQC Quality Academy. He is a graduate of Trent University, the Banff School of Advanced Management and holds an MBA from IMD in Lausanne, Switzerland. Leanne Couves co-founded Improvement Associates in 2000. Leanne has designed and supported over 20 Breakthrough Series Collaboratives across Canada and has taught at over 70 Learning Sessions. She has led the writing of several improvement guides based on these approaches. Leanne is on Faculty of the BCPSQC Quality Academy. Leanne holds a Bachelor of Commerce degree and Certificate in Adult and Continuing Education from the University of Alberta.2/5/2018 7:00:00 AMIn healthcare there is no shortage of improvement opportunities, but people are often working in isolation. There is often will to act and good ideas2/5/2018 8:52:06 PM407
Surgical Safety Checklist: Smart for patients. Smart for providers.270141/29/2018 8:57:34 PMPatient Safety News A Surgical Safety Checklist plays an important role in reducing the likelihood of complications following surgery and is known to improve surgical outcomes. Implementing a Surgical Safety Checklist helps to initiate, guide and formalize communication among the team conducting a surgical procedure; and ensures that critical safety steps are integrated into the surgical workflow. The three phases of the checklist include Briefing (before the induction of anesthesia); Time-Out (before skin incision) and Debriefing (before the patient leaves the operating room). "Although healthcare professionals make every reasonable effort to provide safe care to their patients, harmful surgical incidents, including wrong site surgeries and retained surgical items continue to occur in operating rooms across the country," says Dr. Giuseppe Papia, Vascular and Endovascular Surgeon and Critical Care Medicine specialist at Sunnybrook Health Sciences Centre. "It is with standardized protocols like the Surgical Safety Checklist that can improve communication and collaboration across the surgical team and prevent patient safety incidents. Patient harm is reduced by fostering highly reliable surgical teams which work more effectively together to produce better patient outcomes. The Surgical Safety Checklist is an essential perioperative communications tool for surgical teams across Canada." A Joint Position Statement outlining the advocacy and support for use of a Surgical Safety Checklist has been adopted by the Canadian Patient Safety Institute, Alberta Health Services (AHS), Canadian Anesthesiologists' Society (CAS), and the Operating Room Nurses' Association of Canada (ORNAC). The purpose of the statement is to convey the commitment of these organizations to prioritize perioperative patient safety by creating an environment conducive to the effective adoption and use of a Surgical Safety Checklist. It is a call to action that supports a cultural shift from the front lines - to leadership - to patients and advocates for the widespread use of Surgical Safety Checklist. Support for the Joint Position Statement is widespread. A number of surgical groups have endorsed the Joint Position Statement, including the Canadian Orthopaedic Association; Canadian Neurosurgical Society; Canadian Society of Cardiac Surgeons; Canadian Society for Vascular Surgery; Canadian Society of Otolaryngology Head and Neck Surgery; Canadian Association of General Surgeons; Canadian Association of Paediatric Surgeons; Canadian Association of Thoracic Surgeons, ant the Society of Obstetricians and Gynaecologists of Canada. Supporters promoting the statement include the Canadian Ophthalmological Society and Canadian Thoracic Society. The Joint Position Statement also acknowledges "never events" – serious patient safety incidents that should not occur if healthcare systems support and empower providers in their use of available preventative measures. While "never events" damage patients' confidence in the healthcare system, the Surgical Safety Checklist can facilitate communication amongst teams and help to avoid "never events." A Safer Surgery Checklist was first developed by the World Health Organization in 2008. The Canadian Patient Safety Institute then adapted the checklist to include a Canadian context and the Surgical Safety Checklist was introduced in May 2009. For almost a decade, the Surgical Safety Checklist has been used by surgical teams across the country to support excellent patient care through good communication and teamwork. To learn more about the Surgical Safety Checklist and the Joint Position Statement advocating for and supporting the use of a Surgical Safety Checklist, visit www.patientsafetyinstitute.ca1/31/2018 7:00:00 AMA Surgical Safety Checklist plays an important role in reducing the likelihood of complications following surgery and is known to improve surgical1/30/2018 6:16:22 PM184
How Patients Experience Cancer Care In Canada: New Report270181/29/2018 9:24:38 PMPatient Safety News ​A new report published by the Canadian Partnership Against Cancer illustrates the experiences of patients from the time cancer is suspected through adjusting to a "new normal" after treatment ends. This is the first in a series presenting national survey data and insights from over 30,000 patients living with and beyond cancer. Living with Cancer A Report on the Patient Experience finds that while their cancer may be well treated, many Canadians experience significant physical and emotional side effects of cancer that are often not adequately addressed. The report calls for the increased adoption and use of tools to identify patient needs, in an effort to deliver better, more person-centred cancer care. Learn more 1/30/2018 7:00:00 AMA new report published by the Canadian Partnership Against Cancer illustrates the experiences of patients from the time cancer is suspected through1/29/2018 9:30:53 PM142
We need more champions like Maryann Murray51221/15/2018 3:55:29 PMPatient Safety News If you've ever wondered what kind of difference one person can make, look no further than the impact Ms. Maryann Murray has made on patient safety. Last July, Ms. Murray had the opportunity to meet with her local Member of Parliament, Mr. David Sweet, and share her concerns regarding harm in the Canadian healthcare system. She talked about her involvement in Patients for Patient Safety Canada, and the work the Canadian Patient Safety Institute and others are doing to improve patient safety in Canada. She also left him with a fact sheet on patient safety, which demonstrates the magnitude of the problem. Ms. Murray knows this first-hand. Her daughter Martha died in 2002, after a series of errors. She since joined Patients for Patient Safety Canada with a desire to ensure what happened to Martha doesn't happen to anyone else. The encounter obviously left a definite impression on Mr. Sweet, who shared the details of their meeting with Ms. Murray with the Hon. Ginette Petitpas Taylor, the federal Minister of Health. In turn, she responded with a letter back to Ms. Murray thanking her for her efforts to improve Canada's healthcare system (click the thumbnail above to see the letter). Since joining Patients for Patient Safety Canada, Ms. Murray has been a champion for patient safety in healthcare, both at home and abroad. Her dedication to the cause is remarkable and is noticed by everyone she meets. Her story was also featured in the debut episode of CPSI's PATIENT podcast. She is living proof of the difference one person can make.1/15/2018 7:00:00 AMIf you've ever wondered what kind of difference one person can make, look no further than the impact Ms. Maryann Murray has made on patient safety. 1/15/2018 4:43:43 PM494

 Latest Alerts



Neonatal Death12946352910/1/2017 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 PM22
Express Levothyroxine Doses in Micrograms not Milligrams1295935183/8/2017 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 PM27
Deteriorating Patient Condition Associated with Medical Gas System Dysfunction 1294535303/1/2017 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 PM11
Gaps in Medication Monitoring May Contribute to Death1296135172/28/2017 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 PM9
Some Medications Don’t Mix 1296235162/8/2017 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 PM28