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Quarterly Update National Patient Safety Consortium294227/25/2016 8:21:02 PMPatient Safety News The 2014 – 2016 actions from the National Patient Safety Consortium are well underway. 60% of 2014-2016 Consortium actions are complete, as of March 31, 2016 (see figure below). The Evaluation Action Team continues to meet to develop the evaluation plan for the National Patient Safety Consortium and Integrated Patient Safety Action Plan. The meetings are held monthly and co-chaired by Dr. Lianne Jeffs and the Canadian Patient Safety Institute. The Steering Committee also meets regularly with the next meeting scheduled for August. The National Patient Safety Consortium will meet face to face for the fourth time in September in Ottawa. ​ The National Patient Safety Consortium is thrilled with this progress and highlights two events below during the National Healthcare Leadership Conference in Ottawa from June 6-7 The Canadian Patient Safety Institute hosted a 90-minute panel presentation sharing the work of the National Patient Safety Consortium and the Integrated Patient Safety Action Plan. The session showcased key contributions from partners such as Health Quality Ontario and Patients for Patient Safety Canada (a patient led program of the Canadian Patient Safety Institute). This was a chance for an in-depth dialogue with health care leaders about this large-scale, collective impact initiative. We were thrilled to have participants learn about this large scale change initiative. Helen Bevan also attended the session leading to fruitful discussions. The Canadian Patient Safety Institute, with support from Health Quality Ontario, sponsored motion "Public Reporting of the 15 Never Events" was selected as one of the top five motions of approximately 40 submissions for the Great Canadian Healthcare Debate by health leaders across Canada and was subsequently voted as one of the top three by the conference delegation. Never events are patient safety incidents that result in serious patient harm or death, and that can be prevented by using organizational checks and balances. The Never Events for Hospital Care in Canada report was prepared by the Canadian Patient Safety Institute and Health Quality Ontario along with the Atlantic Health Quality and Patient Safety Collaborative, British Columbia Patient Safety and Quality Council, Health Quality Council of Alberta, Manitoba Institute for Patient Safety, New Brunswick Health Council, Newfoundland and Labrador Provincial Safety and Quality Committee, and Patients for Patient Safety Canada (a patient led program of the Canadian Patient Safety Institute) for the National Patient Safety Consortium. 7/26/2016 4:00:00 PMThe 2014 – 2016 actions from the National Patient Safety Consortium are well underway. 60% of 2014-2016 Consortium actions are complete, as of March7/27/2016 9:54:51 PM70http://www.patientsafetyinstitute.ca/en/NewsAlerts/News/Pages/Forms/AllItems.aspxhtmlFalseaspx
Quarterly Update Home Care Safety294357/26/2016 3:46:45 PMPatient Safety News Coaching of Wave One teams from the Home Care Falls Prevention Improvement Collaborative is ongoing. Insights from this work will inform Wave two of the Collaborative. Evaluation of the Wave One Collaborative has started and is on track for a final report to be delivered in December 2016. The partner organizations (CHCA, CFHI and CPSI) met in April to debrief Wave One. Planning for Wave Two will include leveraging Team STEPPS® content where applicable to empower patients and families, as well as utilizing best practices in fall prevention as identified by ISMP Canada and RNAO. Members of the Home Care Safety Expert Faculty have expressed interest in supporting Wave Two and have identified areas of focus to build on. CPSI is working with the Canadian Home Care Association to find tools and resources to guide safety conversations between health care providers and patients when receiving home care services. The result of phase one of the work is the Am I Safe? report. Am I Safe? seeks to help healthcare providers, patients, and caregivers work together to evaluate and manage risk when receiving care at home. If you are aware of tools or resources that can help facilitate conversations about managing safety in the home please contact us at amIsafe@cpsi-icsp.ca 7/26/2016 4:00:00 PMCoaching of Wave One teams from the Home Care Falls Prevention Improvement Collaborative is ongoing.  Insights from this work will inform Wave7/27/2016 9:29:35 PM62http://www.patientsafetyinstitute.ca/en/NewsAlerts/News/Pages/Forms/AllItems.aspxhtmlFalseaspx
Quarterly Update Infection Prevention and Control294367/26/2016 4:18:37 PMPatient Safety News ​Over the past year the Infection Prevention and Control (IPAC) Action Teams have made progress on three actions from the IPAC Action Plan conducting an environmental scan, the creation of a pan-Canadian set of case definitions for surveillance of healthcare associated infections, as well as improving infection prevention and control through the use of strategies known to improve behaviour and culture. Since the last update, CPSI has engaged an expert Intervention Lead to provide strategic direction and guidance to CPSI regarding the integration of behaviour change to existing and potentially new campaigns. Over the next year, the Intervention Lead will be working with CPSI on the recruitment and selection of the behaviour change and implementation science volunteer faculty. This newly minted faculty will lead the behaviour change work associated with the IPAC integrated Action Plan. 7/26/2016 4:00:00 PMOver the past year the Infection Prevention and Control (IPAC) Action Teams have made progress on three actions from the IPAC Action Plan:7/26/2016 7:27:01 PM49http://www.patientsafetyinstitute.ca/en/NewsAlerts/News/Pages/Forms/AllItems.aspxhtmlFalseaspx
Quarterly Update Surgical Care Safety294377/26/2016 5:30:51 PMPatient Safety News ​Nine actions from the three-year Surgical Care Safety Action Plan have been started. As at the end of March 2016 three actions have been completed and six are continuing. Overall, at the end of the first year (2015-2016), the Surgical Care Safety Action Plan was 29% complete. Highlight The Canadian Medical Protective Association (CMPA), which provides medical liability protection for most Canadian physicians, and the Healthcare Insurance Reciprocal of Canada (HIROC), which provides liability insurance for healthcare organizations and their employees, collaborated to conduct a retrospective analysis of Canadian surgical safety incident data. This analysis of medico-legal data advances knowledge in patient safety concepts, and is intended to lead to system and practice improvements. The summary report and detailed analysis were released in April 2016. UpdatesAfter undertaking an environmental scan of existing surgical safety indicators, the Canadian Institute for Health Information struck a working group to identify a limited number of potential national surgical care safety indicators.The action seeking to identify new leading practices in surgical safety is moving steadily forward. The working group continues to gather information and has identified an advisory group.The action team working to identify patient engagement tools and resources for engagement of surgical patients and families is moving through the results of literature reviews.A survey of healthcare organizations will be issued to inform the work of two action teams patient and family engagement for surgical safety and prospective analysis for surgical safety.The forward momentum of the action team that will identify practices for communication and teamwork in surgical settings is underway with a white literature search.The surgical action that will identify and recommend evidence-based resources and toolkits for quality improvement education in surgical safety for policy makers, executives and clinical leaders is being combined with work being undertaken through the Patient Safety Education Action Plan The Surgical Care Safety Leads Group continues to support and contribute to the advancement of the Surgical Care Safety Action Plan. The members areArlene Kraft, Healthcare Insurance Reciprocal of CanadaBonnie McLeod, Operating Room Nurses Association of CanadaCarla Williams, Canadian Patient Safety InstituteCindy Hollister, Canada Health InfowayClaude Laflamme, Canadian Anesthesiologists SocietyDonna Davis, Patients for Patient Safety CanadaJennifer Rodgers, Canadian Patient Safety InstituteKapka Petrov, Patients for Patient Safety Canada Lorraine LeGrand Westfall, Canadian Medical Protective AssociationSandi Kossey, Canadian Patient Safety Institute 7/26/2016 4:00:00 PMNine actions from the three-year Surgical Care Safety Action Plan have been started. As at the end of March 2016 three actions have been completed7/27/2016 5:03:38 PM45http://www.patientsafetyinstitute.ca/en/NewsAlerts/News/Pages/Forms/AllItems.aspxhtmlFalseaspx
Medication Safety Quarterly Update294427/26/2016 5:10:19 PMPatient Safety News From the Medication Safety Action Plan, 58% of all actions in the plan have started with an average action completion of 44%. Progress continues to be steady with new actions set to begin this year. Since the last update, the white paper on medication incident reporting in Canada has been completed by co-leads ISMP Canada and CIHI. A summary of findings and recommendations from the white paper aimed to further advance sharing and learning from medication incidents will be posted soon. Following the launch of the 5 questions to ask about your medications list earlier this year, dissemination and communication of the tool has been ongoing and there has been significant interest and uptake of the tool across Canada. The list was translated into Polish, Portuguese, Spanish, Hungarian and Tibetan with translation into 11 other languages ongoing so that patients and families who speak these languages have a resource to help guide them to ensure they receive the information they need to take their medication safely. In addition, the list has been shared on Canada Health Infoway's Medication Management Community portal in response to a request for patient related medication safety materials from a colleague in France. An abstract on the list was submitted and has been accepted for presentation at the Canadian Home Care Association Homecare Summit in October. Over the next several months, action teams will continue to make progress on the completion of 2015/16 actions and starting new actions for 2016/17. 7/26/2016 4:00:00 PMFrom the Medication Safety Action Plan, 58% of all actions in the plan have started with an average action completion of 44%. Progress continues to7/27/2016 5:07:41 PM35http://www.patientsafetyinstitute.ca/en/NewsAlerts/News/Pages/Forms/AllItems.aspxhtmlFalseaspx

 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 PM9http://www.patientsafetyinstitute.ca/en/NewsAlerts/Alerts/Lists/Alerts/AllItems.aspxFalse
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 PM20http://www.patientsafetyinstitute.ca/en/NewsAlerts/Alerts/Lists/Alerts/AllItems.aspxFalse
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 PM9http://www.patientsafetyinstitute.ca/en/NewsAlerts/Alerts/Lists/Alerts/AllItems.aspxFalse
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 PM6http://www.patientsafetyinstitute.ca/en/NewsAlerts/Alerts/Lists/Alerts/AllItems.aspxFalse
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 PM10http://www.patientsafetyinstitute.ca/en/NewsAlerts/Alerts/Lists/Alerts/AllItems.aspxFalse