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Quarterly Update Infection Prevention and Control3082112/7/2016 5:17:26 PMPatient Safety News Infection Prevention and Control (IPAC) Action Teams continue to make 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. To advance the IPAC action plan goal of "Improving infection prevention and control through a national campaign for public, patients and providers, focusing on raising awareness and promoting behaviour change", CPSI conducted an environmental scan. The purpose of the environmental scan was to examine the complexities of changing healthcare workers' behaviour and to better understand how the use theories, models and strategies can be used to bring about behavioural change. The learnings and recommendations arising from this scan will be used to help inform future STOP! Clean Your Hands Day Campaigns. The executive summary of the Environmental Scan of Behaviour Change Campaigns Recommendations for the Canadian Patient Safety Institute is available for download from the CPSI website. IPAC Canada has completed on a review of the current CNISP case definitions and determining the challenges and barriers to use of these case definitions in smaller hospitals and community hospitals. The review has been sent to CNISP for consideration. At the same time, a sub-committee of the Surveillance and Applied Epidemiology Interest Group of IPAC Canada is reviewing the long term care definitions from McGeer et all (2008) and SHEA (2012). A report will be prepared for the action team early in 2017. Next steps are engage provincial health authorities to adopt the acute care and long term care definitions, and to prepare a business case to influence the establishment of a national repository. Work is moving forward to Improve infection prevention and control (IPAC) through the use of strategies known to improve behaviour and culture. In July 2016, Canadian Patient Safety Institute (CPSI) launched a new initiative called SHIFT to Safety. SHIFT to Safety promotes a positive, safe healthcare experience and an approach to safety that encompasses the importance of public, providers and leader's roles in patient safety. One of the new areas of focus for SHIFT to Safety is strengthening teamwork, communication, leadership and patient safety culture with the goal to reduce harm and strengthen patient safety. October 6th, was the first National Webinar for the new SHIFT to Safety Platform. The session objective was to introduce participants to new SHIFT to Safety content in behaviour change, knowledge translation, and implementation science. Dr. Jeremy Grimshaw and Dr. Kathy Suh presented to a 'sold-out' crowd of 237. Feedback has been positive, with respondents asking for more calls, webinars and resources in knowledge translation and implementation science. Based on the positive response a second call with SHN interventional leads and Dr. Grimshaw has been planned for Nov. 22nd, 2016. 12/7/2016 5:00:00 PMInfection Prevention and Control (IPAC) Action Teams continue to make progress on three actions from the IPAC Action Plan: conducting an12/7/2016 5:29:13 PM12http://www.patientsafetyinstitute.ca/en/NewsAlerts/News/Pages/Forms/AllItems.aspxhtmlFalseaspx
Medication Safety Quarterly Update3081112/7/2016 4:00:35 PMPatient Safety News ​Second quarter progress continues to be steady for actions addressing the key themes of evidence-informed practices aimed to make opioid use safer for Canadians and in reporting, learning and sharing with the completion and release of the white paper, Medication Incident Reporting in Canada. Led by partners ISMP Canada and CIHI, the paper sought to identify and define the current landscape of reporting and learning in Canada with the aim to utilize these findings to establish a strategy by which medication information from different data sources can be shared for learning purposes more effectively. The action team completed an extensive literature scan, survey and conducted multiple stakeholder interviews to inform the recommendations and conclusions in the report. Findings includeReporting systems in Canada are collectively broad in scope but are rarely interconnectedAlthough reporting systems are broadly available, there are gaps in what is reportedRecommendations are proposed to improve the quantity and quality of incident reporting, and to improve linkages across reporting systems. Key messages and the executive summary can be found here, with the full paper available upon request. ISMP Canada is already leading the follow up action by creating an advisory group to review the paper findings and develop a potential model that would optimize collecting and sharing of medication incident learnings from different sources more effectively. On September 27, 2016 A National call was held entitled Rebranding MedRec – How organizations are using '5 Questions to Ask about your Medications'. Attendees heard about the new MedRec rebranding strategy and how organizations are using '5 Questions to Ask About Your Medications' to engage patients and consumers. This call was very well received with over four hundred attendees. Other work supporting the uptake and dissemination of this tool includesCreating a YouTube video to increase public awareness and use of the tool Developing a version of the tool that patients can use to document the answers to the questions as they have the conversation with their healthcare providers ISMP Canada staff delivered a presentation on '5 Questions to Ask About Your Medications' and the concept of MedRec as a component of safe medication management on October 27, 2016 at the Canadian Homecare Association Summit in Vancouver. 12/7/2016 4:00:00 PMSecond quarter progress continues to be steady for actions addressing the key themes of evidence-informed practices aimed to make opioid use safer12/7/2016 4:14:56 PM9http://www.patientsafetyinstitute.ca/en/NewsAlerts/News/Pages/Forms/AllItems.aspxhtmlFalseaspx
Quarterly Update Home Care Safety3081512/7/2016 4:46:56 PMPatient Safety News ​Wave One of the Home Care Falls Prevention Collaborative officially finished with a recognition event at the Canadian Home Care Association Summit in Vancouver in October 2016. All five teams presented on their progress and were recognized for their commitment to patient safety. Planning for the Home Care Safety Improvement Collaborative, Wave Two is underway with a final face to face partner meeting scheduled for December 14, 2016. The focus of Wave Two will be on measurement for quality improvement and teams will be coached to work on an area of focus based on their own data. This second wave will run for approximately fourteen months and will give teams more time to understand their own challenges and build capacity to implement change. Members of the home care faculty, along with representatives from CIHI and CPSI measurement experts will be engaged to support knowledge translation related to understanding and using data in homecare. St. Elizabeth has conducted an environmental scan of communication tools and resources to improve system level communication in home care and will be focusing on identifying and evaluating the best tools and resources to assist in reducing harm associated with communication breakdowns at transition in and out of home care. The Canadian Home Care Association is currently assessing a series of tools for information and style which could be used in the creation of a tools and resources for the "Am I Safe project". The Canadian Institute for Health Information and CPSI are developing a learning pathway to assist individuals in the home care sector with advancing knowledge about measuring for improvement. 12/7/2016 4:00:00 PMWave One of the Home Care Falls Prevention Collaborative officially finished with a recognition event at the Canadian Home Care Association Summit in12/7/2016 4:55:21 PM12http://www.patientsafetyinstitute.ca/en/NewsAlerts/News/Pages/Forms/AllItems.aspxhtmlFalseaspx
Patient Safety Education Action Plan2637912/6/2016 10:17:31 PMPatient Safety News ​The Patient Safety Education Action Plan Co-leads (Canadian Medical Protective Association, Health Quality Council of Alberta, Queens University, University of Calgary, SIM-one, Patients for Patient Safety Canada, Canadian College of Health Leads, HealthcareCAN, and the Canadian Patient Safety Institute) believe that our work in providing the right evidence, resources, and tools will accelerate a forward movement in the field of health profession education. A movement that will equip all educators at every level of the system with the right tools and resources to ensure that ALL health professionals who enter into practice have the necessary knowledge, skills, and attitudes to impact a positive patient safety culture wherever they may be caring for patients. Patient Safety and Quality Improvement Education being the fundamental underpinnings for a new generation of healthcare leaders. Our focus this last quarter has been primarily on advancing the work around "Capability Building for Healthcare Senior Leaders". The co-leads and working group members contributing to this action are the Canadian College of Health Leaders, HealthcareCAN, Canadian Patient Safety Institute, and the Health Insurance Reciprocal of Canada. Underlying is the need to better understand what education/training/tools/resources senior health leaders in Canada require in order to influence and impact a positive patient safety culture. The approach the team is undergoing is in conducting an environmental scan to identify potential gaps and validate existing resources and programs that may prove to be of added value for this group. "Even though tools for developing a safety culture are available, a common set of best practices is needed. One can envision the development of a "culture bundle," analogous to the bundle of interventions that drastically reduced ventilator-associated pneumonia." (Free From Harm, 2015). "Patient safety culture is a complex phenomenon that is not clearly understood by hospital leaders, thus making it difficult to operationalize." (Sammer, 2010). The results we aim to achieve are to clarify what is meant by patient safety culture and the senior leader's role in shaping it. 12/6/2016 10:00:00 PMThe Patient Safety Education Action Plan Co-leads (Canadian Medical Protective Association, Health Quality Council of Alberta, Queens University,12/6/2016 10:40:37 PM39http://www.patientsafetyinstitute.ca/en/NewsAlerts/News/Pages/Forms/AllItems.aspxhtmlFalseaspx
Holland Bloorview driving the client and family voice338711/29/2016 3:16:50 PMPatient Safety News Holland Bloorview Kids Rehabilitation Hospital recently offered families and youth an education conference to provide key elements of understanding system issues that contribute to patient safety, as well as how to partner effectively with clinicians to co-create safe systems within healthcare. The Become a Family/Youth Leader Patient Safety Trainer conference was delivered in partnership with the Canadian Patient Safety Institute, to members of the hospital's Family Leader Accreditation Group and Youth Advisory Council on September 30 and October 1, 2016. In total, 14 family leaders, three youth and one child leader were trained during the conference. Holland Bloorview's Family Leader PSEP – Canada Planning Team (left to right) Nicholas Joachimides (Manager, Patient Safety), Elena Garisto (Quality Coordinator), Louise Kublick (Interim Director of Client and Family Integrated Care), Alifa Khan (Family Leader), Sonia Pagura (Senior Director, Quality, Safety and Performance), and Laura Oxenham-Murphy (Manager of Quality) "As we were thinking about meaningful engagement and partnership to drive the client and family voice, the thought was if we could train our family leaders in understanding what patient safety meant from the lens of families, then they would be on an equal playing field with our staff that has always been a part of accreditation," says Sonia Pagura, Senior Director, Quality, Safety and Performance. "We know what happens from the professional health discipline and the organizational perspective, but that is only one part. We also need the understanding that the family also have an active role in patient safety. They have an active role in all of the dimensions of quality and how they might be able to shift this paradigm." Holland Bloorview reached out to the Patient Safety Education Program – Canada (PSEP – Canada), to adapt the modules and program to a patient and family perspective. Their vision was twofold. First was the immediacy to scale up understanding for family leaders as they were embarking on the accreditation journey. The family leaders had committed to participate for 18 months to drive changes through excellence in accreditation. Second was within a three-year timeframe, to train just over 200 family, youth and children leaders participating in Holland Bloorview's Family, Youth and Children Programs to create capacity within the system. "We are already training staff and by building this critical mass within the organization on understanding what are the issues, what are some of the system drivers and human factor drivers, and our family, youth and children will eventually be the drivers of change for safety and quality," says Sonia Pagura. A team was formed and a Family Leader enlisted to adapt the PSEP – Canada p​rogram. When they looked at the curriculum, they found it to be provider-centric and profession centric and needed to make it family- and client-centric. For example, one of the modules says patients as partners, and that content was flipped to clinicians as partners, as it is not only providers partnering with families, it is families partnering with providers in that same knowledge and construct. Instead of just leadership, which would be leadership for providers, content was changed to leadership for families. "How does one take that leadership role through solution-focused leadership, through generative leadership and really look at tangible ways that we could bring some real live cases in building those skills that speak to families and partner effectively so that we have an actual dyad of having providers, families, and clients working together toward something that is meaningful, effective, efficient, safe, that has quality," says Sonia Pagura. Holland Bloorview is now developing their micro, meso and macro plans to ensure that staff and family leaders are all trained with the same information. Two of the family leaders, one youth leader and one child leader trained during the educational conference will be facilitating upcoming sessions for staff at Holland Bloorview. The 17-year-old youth leader, who is fully care-dependent, provided recently a session on communication with patients so that staff can actually see what that means. "This PSEP –​​ Canada program will have a system impact on a national and international scale," says Sonia Pagura. "If you look at legislation in Ontario, the Patient's First Act, it talks about coordination, transition, and about safety. This program lends itself very well to building that capacity. We have untapped potential and untapped capacity in the people we serve. It is our hope, that this will be the impetus for other organizations and that together we can continually build this critical mass that pushes change. We can't do this without partnering with our families. They are the ones that can see meaningfulness and the authenticity of how we want to change care to make it better for everyone. I get really excited and get goose bumps when I think about this opportunity." For more information on the Patient Safety Education Program – Canada, ​contact the PSEP – Canada team at psepcanada@cpsi-icsp.ca or call 1-866-421-6933. The Family Leader Accreditation Group at Holland Bloorview Kids Rehabilitation Hospital was recently recognized with honourable mention for the 2016 Volunteer Patient Safety Champion Award, for exemplifying the spirit of collaboration and engaging patients and families in patient safety. Click here to learn more.11/29/2016 3:00:00 PMHolland Bloorview Kids Rehabilitation Hospital recently offered families and youth an education conference to provide key elements of understanding12/1/2016 5:14:28 PM232http://www.patientsafetyinstitute.ca/en/NewsAlerts/News/Pages/Forms/AllItems.aspxhtmlFalseaspx

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DO NOT USE Endotracheal tubes with subglottic suction (EVAC-ETT) in pediatrics3052934903/28/2016 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 PMhttp://www.patientsafetyinstitute.ca/en/NewsAlerts/Alerts/Lists/Alerts/AllItems.aspxFalse
Choosing Correct Syringe Size- Medfusion Syringe Pump3063034911/6/2016 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 PMhttp://www.patientsafetyinstitute.ca/en/NewsAlerts/Alerts/Lists/Alerts/AllItems.aspxFalse
Safe Placement / Inflation of the King LT Airway30533338310/19/2015 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 PMhttp://www.patientsafetyinstitute.ca/en/NewsAlerts/Alerts/Lists/Alerts/AllItems.aspxFalse
Atypical Presentation of Diabetic Ketoacidosis with Sodium Glucose Co-transporter 2 (SGLT2) Inhibitors11473338110/8/2015 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 Care1147433808/13/2015 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 PM23http://www.patientsafetyinstitute.ca/en/NewsAlerts/Alerts/Lists/Alerts/AllItems.aspxFalse