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 CPSI News



Niagara Health- Focused on Raising Awareness of Never Events 312873/17/2017 8:37:57 PMPatient Safety News It was all in the timing. Years before the pan-Canadian list of Never Events was released in September 2015, Niagara Health in Southern Ontario had already begun looking at ways to advance its safety culture. Never Events, named for being incidents that should never happen, can include instances of child abductions, suicides or patients receiving the wrong surgery. Niagara Health recognized that even one Never Event was one too many. With the hospital organization's new strategic plan containing a focus on ingraining a culture of safety and eliminating preventable harm in order to provide extraordinary care, this was seen as a perfect opportunity to embed Never Events within its strategic visioning to combat the challenges in different ways. A report, prepared by the Canadian Patient Safety Institute and Health Quality Ontario with many partners, specified 15 of the most serious known patient safety incidents and offered guidance on how hospitals might avert them. Those guidelines are not binding, so it remains up to healthcare organizations to decide if and how best to develop strategies that will help prevent such incidents. "It was actually the Never Events report itself that triggered the added patient safety attention because we saw it as an avenue to increase awareness, to focus on where we were with this set of 15 and did we need to do something about it," said Marilyn Kalmats, Director of Quality, Patient Safety and Risk Management at Niagara Health. As part of an organization that is focused on continuous learning and improvement, the report prompted the question "Were we missing something?" Niagara Health began reevaluating what it considered to be classified as a never event, prompting clinical staff and administration to take another look at prevention methods. Project teams with a clinical lead and physician lead as well as front-line staff were formed for each of the 15 event types, and were responsible for conducting a gap analysis for each one. A corporate gamification engagement strategy known as "Bridge to Extraordinary" was already in place at Niagara Health to help with education and information transfer about important topics. The organization – which services 430,000 patients from 12 municipalities across six sites was able to use this strategy to bring attention to Never Events in a fun and interactive way. Should a never event happen, they would apply the critical incident process which is already in place and involves a root cause analysis of the factors contributing to the incident, along with the development of recommendations to prevent future occurrences. Monthly reporting to the Executive Leadership Team and the Board Quality Committee are also a key part of this process. "We'd already done a lot of the leg work," said Zeau Ismail, Manager of Quality and Patient Safety at Niagara Health in speaking about the incident review process. "So when the report came out we tied it to the work we were already doing. If we hadn't had the foundation we built, this process wouldn't have been so easy to implement." Raising awareness of Never Events for all hospital staff was key, he said, adding creating a culture of safety, and responding to incidents in a non-punitive, transparent way helped build trust and put the emphasis on prevention. A successful tactic that was part of the Never Events campaign was to have all staff, not just clinical staff, participate in the learning and awareness of Never Events. As part of the corporate gamification strategy "Bridge to Extraordinary" for the month of June the Never Events were highlighted. Coffee cards were handed out as prizes for short quizzes in the monthly Never Events bulletins. Never Events were also discussed as learning opportunities at weekly huddle meetings – face-to-face gatherings of all staff at every site in public settings where anyone can listen in. "We talk about what we are focusing on and how we are going to improve in front of the general public," said Ismail. "It can be uncomfortable at times, but if we don't talk about this, we're not going to improve." If you would like to share your story on how your organization is focusing efforts to reduce never events, please contact the Canadian Patient Safety Institute at 3/17/2017 6:00:00 AMIt was all in the timing. Years before the pan-Canadian list of Never Events was released in September 2015, Niagara Health in Southern Ontario3/21/2017 6:56:46 PM217
Q3 National Patient Safety Consortium Update312733/15/2017 3:21:01 PMPatient Safety News The Steering Committee is pleased to report hat 68% of Consortium actions are complete, 21% of actions are started, 5% are scheduled to start later, and the remaining 5% is expected to start but delayed. A key action is the evaluation of the National Patient Safety Consortium and the Integrated Patient Safety Action Plan. The Evaluation Framework was presented at the Consortium meeting in September 2016. The Canadian Patient Safety Institute is pleased to announce that Vision & Results Inc., with the leadership of Dr. San Ng and Ms. Jean Trimnell will conduct the evaluation of the Consortium and the Integrated Patient Safety Action Plan. Dr. Ng is the founder of Vision & Results Inc. with a PhD from the University of Toronto. Ms. Trimnell has had an extensive career in Ontario's health sector including CEO and Vice President of several sites. Dr. Ng and Ms. Trimnell will be utilizing a collective impact model throughout the evaluation with preliminary findings anticipated for October 2017. 3/15/2017 6:00:00 AMThe Steering Committee is pleased to report hat 68% of Consortium actions are complete, 21% of actions are started, 5% are scheduled to start later,3/15/2017 3:37:58 PM96
Partnerships help pave the road in developing an Enhanced Recovery After Surgery strategy312513/9/2017 6:16:10 PMPatient Safety News This article is the first in a series on Enhanced Recovery After Surgery. As the national strategy evolves, information for the public, providers and leaders will be posted to Click on the link to learn more and watch for upcoming articles! Enhanced Recovery After Surgery (ERAS) consists of a number of evidence -based principles that support better outcomes for surgical patients including an improved patient experience, reduced length of stay, decreased complication rates and fewer hospital readmissions. "We want to take the ERAS learnings and evidence that has been acquired internationally and within Canada, and develop a strategy that can be moved across the country," says Carla Williams Patient Safety Improvement Lead, Canadian Patient Safety Institute. To start the ball rolling, a face-to-face meeting with key stakeholders was made possible through the generous support from 3M and Medatronics. "3M organizes its perioperative business around surgical best practices and has developed a number products and solutions for enhanced surgical care," says Lisa Mackie, Business Manager- Infection Prevention Division at 3M Health Care. "Developing an ERAS strategy involves many healthcare disciplines and collaboration across all the groups, and including industry is the key to success. This is a first step and it was a privilege to be involved." "The synergy and level of engagement of our partners at the meeting was amazing," says Carla Williams. "You could feel the passion, energy and commitment in the room. It would have been difficult to foster the rich conversations we had at the table and build the same momentum virtually. And, we could not have accomplished what we did without our industry sponsors." The inaugural S3A-Surgical Care Safety Best Practices Partners meeting, held in Calgary, Alberta, on January 29, 2016, has created a burning platform for the development of a dissemination and implementation strategy to advance the evidence-informed principles of ERAS in Canada. Some 24 organizations were invited to attend the face-to-face meeting, including representatives from Patients for Patient Safety Canada, the Royal College of Physician and Surgeons of Canada, Canada Health Infoway, various surgical specialties (Canadian Association of General Surgeons, Society of Obstetricians and Gynecologists Canada, Canadian Anesthesiologists' Society), provincial quality councils and allied health organizations (Dieticians of Canada, Canadian Physiotherapy Association, and Canadian Society of Hospital Pharmacists). Representatives from both 3M and Medatronics were also invited to attend the meeting and contribute to the discussions. "In addition to patient engagement, the ERAS principles also involve pain management, mobility and enhanced nutrition guidelines so we wanted to ensure the contribution of all relevant stakeholders," says Carla Williams. "The value of all of our partners working together is essential to achieving great outcomes with ERAS." A number of sites of excellence have already embraced ERAS principles, including Alberta Health Services (AHS), British Columbia Patient Safety & Quality Council and the Doctors of British Columbia, Eastern Health, McGill University Health Centre, and University of Toronto Best Practices in Surgery. During the meeting, AHS, McGill and the University of Toronto shared their learnings. Based on input from the meeting, a project charter has been developed to incorporate seven ERAS principles in all surgical carePatient engagement and awareness of the ERAS principles.Nutrition guidelines (pre and –post-op) that include no NPO (fasting at midnight), carb-loading pre-op, and feeding on post-op day zero.Intra-operative fluid management.Pain management and opioid sparing.Minimization of nausea and ileus.Minimization of tubes and drains.Early post-operative mobility. It was also agreed that data collection and measurement would be an integral part of this work. "The discussions during the meeting were very powerful," says Lisa Mackie. "Dr. Claude LaFlamme and Carla Williams did a fantastic job in setting up the day and leading the group discussions to scope out a plan to take this initiative forward." The identification of emerging best practices in surgical care safety along with a plan to spread and implement these best practices is one of the actions reflected in the Integrated Patient Safety Action Plan for Surgical Care Safety. Given the improved patient outcomes, ERAS principles emerged quickly as the logical choice. ERAS was originally developed exclusively for colorectal surgeries, however, the learning and evidence indicate that the same principles can be applied to any type of surgery. For more information on ERAS initiative, contact Carla Williams cwilliams@cpsi-icsp.ca3/9/2017 7:00:00 AMThis article is the first in a series on Enhanced Recovery After Surgery. As the national strategy evolves, information for the public, providers3/9/2017 6:46:35 PM317
Patient Safety Education Action Plan - Q3 Update312553/9/2017 8:24:17 PMPatient Safety News Over 25% of the Actions contained in the Patient Safety Education Action Plan have been started. Overall, at the end of December 2016, the Patient Safety Action Plan is close to 20% completed. Updates As part of discussions held on nature and scope of this work, the Patient Safety Action Plan team has leaned heavily on recommendations that came out of the Free from Harm Report (2015). Their main recommendation being, in order for patient safety culture to be influenced and have impact, senior leaders need to have specific knowledge and training. Based on this, an extensive e-scan is underway with significant leadership by HIROC. In addition, a straw dog for a patient safety culture bundle for senior leaders, has been developed. CPSI will coordinate an in-person working group meeting in the early spring to advance the progress on the bundle With the goal of advancing PSQI content into curriculum both within the academic setting and practice environment, the co-leads are developing a competency-based PSQI content framework (curriculum map). The content will be mapped to existing PS competency based frameworks such as CPSI SCF, CanMeds, HQCA, and others. This work is being lead by representatives from SIM-one, the Canadian Medical Protective Association, the University of Calgary, Queens University and Health Quality Council of Alberta. We will host a working group meeting March/April with the larger working group to ascertain expert feedback on the map to date.3/9/2017 7:00:00 AMOver 25% of the Actions contained in the Patient Safety Education Action Plan have been started.  Overall, at the end of December 2016,3/9/2017 8:37:10 PM164
Infection Prevention and Control – Q3 Update312633/9/2017 9:21:08 PMPatient Safety News Infection Prevention and Control (IPAC) Action Teams continue to make progress on three of the four goals IPAC Action Plan Improve infection prevention and control through a national campaign for public, patients and providers, focusing on raising awareness and promoting behaviour change; Improve infection prevention and control through the use of strategies known to improve behaviour and culture and Adopt a pan-Canadian set of common indicators for healthcare-associated infections. The fourth goal; Establish a national body to collect, analyze and report healthcare-associated infection data, is staged to begin once the work on the pan-Canadian set of indicator has been near completed. We are entering a very exciting time with respect to the first goal of improving infection prevention and control through a national campaign. As the lead for this goal, CPSI is pleased to announce that this campaign focused on raising awareness and promoting behaviour change, is coming alive this May 5th through the annual STOP! Clean Your Hands Day campaign. The Canadian Patient Safety Institute, along with our multiple supporters , are proud to be the Canadian hosts for STOP! Clean Your Hands Day 2017, which coincides with "Save Lives Clean Your Hands," a global initiative of the World Health Organization. The theme for STOP! Clean Your Hands Day 2017 is 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. Some of the activities planned for STOP! Clean Your Hands Day 2017 are a video competition and webinar.3/9/2017 7:00:00 AMInfection Prevention and Control (IPAC) Action Teams continue to make progress on three of the four goals IPAC Action Plan: Improve infection3/9/2017 9:31:09 PM157

 Latest Alerts



DO NOT USE Endotracheal tubes with subglottic suction (EVAC-ETT) in pediatrics1098434903/28/2016 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.10/31/2016 10:21:27 PM3
Choosing Correct Syringe Size- Medfusion Syringe Pump1098734911/6/2016 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 PM
Massive Transfusion Protocols10989348810/29/2015 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 PM3
Adverse Events Related to Incorrect Route and Doses of EPINEPHrine10990348710/29/2015 6:00:00 AMMedicationOregon Patient Safety Commission (USA)This alert discusses the patient safety incidents of wrong route and/or wrong dose when topical EPINEPHrine is given by injection or injectable EPINEPHrine is given by intravenous (IV) injection for treatment of anaphylaxis or serious allergic reactions instead of intramuscular (IM) injection as required. The various strengths and types of EPINEPHrine have led to confusion and medication errors. Serious adverse reactions have occurred, including death. In the March 2009 issue of the Institute for Safe Medication Practices (ISMP) newsletter (, a fatal EPINEPHrine-related event is described in Canada in which topical EPINEPHrine 1:1,000 was inadvertently given for injection as a local anesthetic; the correct product was injectable EPINEPHrine 1:100,000 as a local anesthetic. The February 2015 issue of the ISMP newsletter ( shares errors occurring with the use of EPINEPHrine for the treatment of anaphylaxis and the risks associated with using 1 mg ampoules or vials. Specifically, an intramuscular dose of 0.3 to 0.5 mg of EPINEPHrine is recommended for anaphylaxis in adults. Autoinjectors of 0.3 mg are available for adult use. Deployment of EPINEPHrine autoinjectors is a way to avoid wrong dose and wrong route errors (intravenous instead of intramuscular) when ampoules or vials are used for severe allergic reactions or anaphylaxis. The concern with 1 mg ampoules or vials of EPINEPHrine is that the contents must be drawn into a syringe. During a stressful emergency situation, this has sometimes led to the erroneous administration of the full 1 mg dose IV, which could prove harmful to some patients. The alert provides recommendations for safe practices to mitigate the likelihood of medication errors involving topical and injectable EPINEPHrine.12/19/2016 11:25:40 PM3
Safe Placement / Inflation of the King LT Airway10985338310/19/2015 6:00:00 AMDeviceAlberta Health ServicesThis alert discusses the correct use of a supraglottic airway device to avoid patient safety incidents in patients requiring ventilatory assistance. The King LT is a supraglottic airway device used to secure and maintain the airway of patients requiring ventilatory assistance. If the King LT is incorrectly positioned and/or the cuffs are over inflated numerous complications may result (e.g. impaired cerebral blood flow (CBF), tracheal obstruction, or esophageal perforation). Recommendations for the appropriate use of this device are provided. 10/31/2016 10:21:29 PM3