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Introducing the Canadian Quality and Patient Safety Advisory Committee3138511/12/2018 10:41:55 PMPatient Safety News The Canadian Quality and Patient Safety Advisory Committee is an initiative of the Canadian Patient Safety Institute (CPSI) and Health Standards Organization (HSO), together with patients, providers, care organizations, quality and patient safety councils/organizations, researchers and policy makers. The goal of the committee is to establish consensus on quality and patient safety goals for health and social services, which will focus action and resources that improve patient experience, outcomes and reduce care variation. The advisory committee will work toward designing a national quality and patient safety framework, advising on required quality and patient safety practices as well as resources that support implementation and uptake at the system, organization and practice level. As a result, the committee intends to drive measurable improvements on patient experience, outcomes and unwarranted care variation across Canada. Despite efforts to date, Canada lags in quality and patient safety compared to developed countries. If no action is taken, roughly 400,000 patients every year will experience preventable harm – and this harm will result in an additional $2.75 billion (2017$) in annual health care treatment costs. According to the OECD, 70% of harm is preventable. Advancement in quality and patient safety requires a coordinated systems approach to safety. Based on a review of international and jurisdictional quality and patient safety priorities, the Canadian Quality and Patient Safety Advisory Committee agreed on six goal areas with identified objectives and outcomes People-Centred Care Appropriate Care Accessible Care Safe Care Efficient Care Integrated Care In the near term, the committee will focus on public engagement. Public consultation will include patients, the public (including Indigenous peoples), providers, healthcare delivery and social service organizations, federal, provincial and territorial governments, and other interested stakeholders. This outreach is intended to develop consensus on a Canadian Quality and Patient Safety Framework across key stakeholders that can influence and action improvements. For more information, please contact qualityservicesforall@healthstandards.org 11/12/2018 7:00:00 AMThe Canadian Quality and Patient Safety Advisory Committee is an initiative of the Canadian Patient Safety Institute (CPSI) and Health Standards11/12/2018 10:45:29 PM47http://www.patientsafetyinstitute.ca/en/NewsAlerts/News/Pages/Forms/AllItems.aspxhtmlFalseaspx
Patients At Parliament440911/5/2018 8:27:19 PMPatient Safety News ​On October 30th, 13 Patients from across Canada travelled to Ottawa to participate in Patients At Parliament, a unique campaign to raise awareness with Parliamentarians. We are grateful to the many staff and volunteers who made this fantastic event possible. Patients At Parliament highlight include Five teams of volunteers and staff met with 30 Members of Parliament and Senators in 10 buildings across the parliamentary precinct over the course of 8 hours. Participants spoke about their personal experience with harm and delivered key messages from the CPSW campaign. Guest speaker, Whitby Member of Parliament Celina Caesar-Chavannes provided unique advice to delegates over dinner. She offered strategies to promote our message and challenged the group to reach as many Members of Parliament as possible. Breakfast in the Parliamentary Restaurant in Center Block hosted by Mel Arnold MP for North Okanagan - Shuswap. All delegates attended Question Period and witnessed Canada's democratic system at its finest. Many MP's & Senators have committed to promoting our key messages at upcoming committee meetings and locally within their ridings. MP's and Senators also demonstrated support for CPSW by Tweeting key messages during the campaign. 11/5/2018 8:00:00 PMOn October 30th, 13 Patients from across Canada travelled to Ottawa to participate in Patients At Parliament, a unique campaign to raise awareness11/5/2018 8:41:13 PM130http://www.patientsafetyinstitute.ca/en/NewsAlerts/News/Pages/Forms/AllItems.aspxhtmlFalseaspx
Are you in danger? 5 Tips to Reduce Medication Risks2498010/29/2018 5:58:08 PMPatient Safety News Are you at risk of harm from your medications? Unsafe medication practices and medication errors are a leading cause of injury and avoidable harm in health care systems across the world. If you – or people you love – are over the age of 65, there is an increased risk of drug complications. Prescription, over-the-counter, naturopathic or recreational read on for 5 tips to reduce your medication risks! Approximately 6-7% of hospital admissions appear to be medication related, with over two-thirds of these considered avoidable. More than one in three Canadian seniors use at least one potentially inappropriate medication, which can lead to health risks, including falls, fractures, hospitalizations and death. In 2016, 1 out of 143 Canadian seniors were hospitalized due to harmful medication interactions. Two out of three Canadian seniors take at least five different prescribed medications; one out of four takes at least ten! Review medications with a doctor, nurse, or pharmacist if you or someone you love is over the age of 65, taking 5 or more medications, recently discharged from hospital, or concerned about side effects. "Each year, 50 per cent of medications are taken incorrectly, and an estimated 37 per cent of seniors in nine provinces receive a prescription for a drug that should not be taken by this population," says CEO Chris Power of the Canadian Patient Safety Institute (CPSI). "This year's Not All Meds Get Along campaign during Canadian Patient Safety Week encourages patients and healthcare providers to have an open conversation about medication risks." CPSI is promoting a list of top questions to help this conversation. Bring out the 5 Questions to Ask About Your Medications with your doctor, nurse, or pharmacist; when going home from hospital; or when visited by home care services. To reduce the risk of medication harm to you or your loved ones, consider these 5 tips KNOW Keep a list of all medications – prescription, over-the-counter, naturopathic, and recreational – and bring it in on your medical appointments to reduce the risk of harmful drug interactions. CHECK with your pharmacist, doctor, or nurse to confirm all medications are being taken properly. ASK to review ALL of your meds when your doctor or nurse starts, stops, or changes any of your medications. Ask your pharmacist to REVIEW YOUR MEDICATIONS when you are filling or refilling a prescription, or if you are adding, removing, or changing any non-prescription medications or supplements. DO NOT STOP OR CHANGE medications without first consulting a doctor or healthcare professional. We all have a role to play in reducing the risk of medication harm. Find resources and tools at asklistentalk.ca. 10/29/2018 6:00:00 AMAre you at risk of harm from your medications? Unsafe medication practices and medication errors are a leading cause of injury and avoidable harm in10/29/2018 6:07:58 PM199http://www.patientsafetyinstitute.ca/en/NewsAlerts/News/Pages/Forms/AllItems.aspxhtmlFalseaspx
#superSHIFTERS An evidence-based and multidisciplinary approach to improving surgical outcomes2576510/16/2018 7:14:42 PMSuper SHIFTERS SuperSHIFTER Dr. Claude Laflamme is the Medical Director of Quality and Patient Safety in the Department of Anesthesia at Sunnybrook Health Sciences Centre. He recently co-led a Canadian initiative aimed to improve safer surgical care across the country. Dr. Laflamme is currently involved in various aspects of quality and patient safety research. One of his interests is to spread best practices aimed at improving surgical outcomes from a multidisciplinary approach. What is Enhanced Recovery After Surgery? Enhanced Recovery After Surgery, or the acronym ERAS, is a program highlighting surgical best practices. It consists of evidence-based principles that support better outcomes for surgical patients. Implementing ERAS protocols result in an improved patient experience, reduced length of stay, decreased complication rates, and fewer hospital readmissions. ERAS is a comprehensive, multidisciplinary approach to the care of the surgical patient. The multi-modal approach to recovery was pioneered in 1995 by Danish surgeon Dr. Henrik Kehlet for colonic resections. The International ERAS® Society, based in Stockholm, Sweden, was officially registered in 2010 and since then, the ERAS principles have expanded around the world. They are now applied to nine different specialties. Is ERAS new to Canada? In 2013, I joined the Canadian Patient Safety Institute’s Safe Surgical Care Working Group to help develop the Integrated Patient Safety Action Plan and improve the quality of care in Canada. In looking at best practices in surgical care, it quickly became clear that ERAS was the path that we should take to improve surgical outcomes here in Canada. When the Safe Surgical Care Working Group met, we talked about how we could scale and spread ERAS in Canada. We invited representatives from McGill University, the University of Toronto, Alberta Health Services, and the British Columbia Patient Safety and Quality Council to join a group of CPSI partners we now call Enhanced Recovery Canada (ERC). Among ERC partners, we now have Health Quality Councils, the Royal College, healthcare providers such as nurses and doctors, and many other professional organizations. Today, Enhanced Recovery Canada is a group of clinical experts and leaders working together to improve surgical outcomes for all Canadians. In Canada, there are currently a few ERAS Clinical Centres of Excellence McGill University Health Centre, University of Toronto, Alberta Health Services, and the province of British Columbia. These healthcare organizations have gained significant knowledge and experience to support the implementation of ERAS program in other organizations. What is the role of Enhanced Recovery Canada? Enhanced Recovery Canada is a volunteer group of passionate physicians, nurses, and allied healthcare providers. The group first met in January 2017 and agreed to work together to spread ERAS across the country. Together, what they accomplished to date is very impressive. Everyone is very engaged. The first clinical pathway ERC has addressed is colorectal surgeries. Looking at the international ERAS principles, there are about 20 elements in colorectal. If we multiply this by the number of surgical specialties, it could be overwhelming. However, Enhanced Recovery Canada chose six pillars for colorectal surgeries patient and family engagement, nutrition, early mobilization, perioperative fluid management, multimodal pain management, and evidence-based surgical best practices. These core principles encompass the most important ERAS actions and are relevant for most surgeries. We started with colorectal, but want to touch areas such as urology, digestive, pancreatic procedures, as well as gynecology and obstetrics, which are in every operating room in the country. The next phase of the ERC initiative will address other evidence-based practices. Enhanced Recovery Canada has secured support from industry partners and over $500,000 has been committed over five years to fund this work. How is ERAS innovative? ERAS is evidence-based, it improves patient outcomes, and reduces both the length of hospitalization and cost. In addition, the fact that it is truly multidisciplinary shatters conventional siloed practice. It is a comprehensive approach, from the top down, that is multidisciplinary and includes both patients and healthcare providers. What major learning have you had that you can share about ERC? Most quality improvement projects are viewed as medical projects and not geared toward changing the culture of safety. They are not comprehensive and the work often vanishes after the project is completed. What we need to do is change care delivery that will create a ripple effect across services and throughout the country. I truly believe ERC can do that. What future possibilities do you see for ERAS? Because ERAS is truly multi-disciplinary, there are tremendous possibilities for the future. ERAS was originally developed for surgical procedures, but really it is a foundation that can be replicated for other things. If you want to speed up the process for quality improvement in Canada, ERC is the solution to make a patient safety culture happen. Collaboration between jurisdictions is also an ERC benefit. A few weeks ago, we had a discussion with the American College of Surgery (ACS), about their national quality surgical improvement program and they are very happy to work with us. In fact, two Canadian physicians are currently working with ACS to develop new material. The United States has protocols in place for colorectal surgeries and for hip and knee replacements; they will work on gynecology procedures next. ERC is convinced that once the multidisciplinary quality improvement structure is in place, it will be easier to spread new practices. Where can we go to learn more? For an international perspective, visit www.erassociety.org. There is valuable information on that website. The Canadian Patient Safety Institute provides the national perspective for Enhanced Recovery Canada. There is a lot of information out there and we have links on the website to McGill University Health Centre, who have excellent documentation on patient engagement, and Enhanced Recovery BC, who have good information to support the implementation of enhanced recovery programs. You can also learn from others and connect with an experienced ERAS coordinator. Questions about Enhanced Recovery Canada can be directed to info@cpsi-icsp.ca 10/16/2018 6:00:00 AMSuperSHIFTER Dr. Claude Laflamme is the Medical Director of Quality and Patient Safety in the Department of Anesthesia at Sunnybrook Health Sciences10/16/2018 7:55:46 PM311http://www.patientsafetyinstitute.ca/en/NewsAlerts/News/Pages/Forms/AllItems.aspxhtmlFalseaspx
#superSHIFTERS TeamSTEPPS Canada™: a powerful tool to improve patient safety and transform culture2568610/3/2018 7:50:40 PMSuper SHIFTERS ​SuperSHIFTERS Tricia Swartz, Jessica Kettles, Nada Strathearn and Gina De Souza are the Canadian Patient Safety Institute's team behind TeamSTEPPS Canada™. In this article they share their insights on this innovative SHIFT to Safety tool to improve teamwork and communications, and advance a patient safety culture. What is TeamSTEPPS? TeamSTEPPS® is an acronym for Team Strategies and Tools to Enhance Performance and Patient Safety. The program improves safety and transforms culture in healthcare through better teamwork, communication, leadership, situational awareness, and mutual support. TeamSTEPPS Canada™ is an evidence-based teamwork system that optimizes patient care by improving communication and teamwork skills among healthcare professionals at the point of care. It includes a comprehensive set of ready-to-use materials and a training curriculum to integrate teamwork principles into a variety of settings. TeamSTEPPS Canada training session held in Halifax, Nova Scotia. Left to right (left side) Nada Strathearn, Project Coordinator, CPSI; Monique Thibodeau, Project Coordinator, CPSI; Rhonda Pouliot, Lead Collaborative Learning and Education, Health Quality Council of Alberta; Maryanne D'Arpino, Senior Director Safety Improvement and Capability Building, CPSI; (right side) Gina Peck, Project Coordinator, CPSI; Denise Durfy Sheppard, Department of Health and Community Services Newfoundland Labrador; Gina De Souza, Patient Safety Improvement Lead, CPSI; and Tricia Swartz, Patient Safety Improvement Lead, CPSI. How did you land on TeamSTEPPS as a tool to address teamwork, communication and patient safety culture? When the SHIFT to Safety platform was launched by the Canadian Patient Safety Institute about two years ago, we wanted to move away from simply providing the healthcare field with evidence-based products on what to do, and take an approach that would help them to address problems around how to do it. When we looked at why teams were struggling with implementing evidence based practices, or accelerating their quality improvement efforts, we learned through the literature that the main issues were a breakdown in communications and teamwork, and a lack of a patient safety culture. From there, we looked at various curriculum and programs that existed nationally and internationally that specifically addressed these issues. We reviewed about 10 different pre-existing programs and what would work best for the Canadian landscape. We landed on TeamSTEPPS®, a program designed by the Agency for Research and Healthcare Quality (ARHQ), in conjunction with the United States Department of Defense. The ARHQ is the Federal agency charged with improving the safety of America's health care system and they have trained more than 1,500 individual organizations in the United States through this program. There were a number of the key features that stood out about TeamSTEPPS. It had over 30 years of research and evidence behind it that backed up the program. Teams across the United States and our partners in Europe had amazing improvements in patient safety using the curriculum. TeamSTEPPS encourages customization and we would be able to contextualize it to the Canadian healthcare context to make it really resonate with providers, leaders, and patients and families here in Canada – a lot of curricula are very stringent and subject to copyright and intellectual property laws that do not allow others to customize content. Finally, because TeamSTEPPS is adaptable to a variety of settings, we knew it was the right program to bring to Canada. Another benefit of TeamSTEPPS that we valued was that it came with a very strong measurement platform. Not a lot of other curriculums came with the need to measure what you were doing to see where you had been and to evaluate your gains. We were able to customize the measurement platform using Canadian data sources and measurement methodology. What makes TeamSTEPPS so successful? TeamSTEPPS is more of a shared mental model. Healthcare providers tell us that work keeps piling on that they have to do and they are getting bogged down. TeamSTEPPS is not an additional thing that they need to do on top of the thousands of things they are already doing. It is not an additional checklist or task. It is more of getting on the same page and adopting the same model or way of thinking that should streamline all of those other things that you are doing. We like to say it is not something else to do; rather it is foundational to what you do. Is TeamSTEPPS new to Canadian healthcare organizations? One of the first things we did was an environmental scan to determine who was using TeamSTEPPS in Canada, to identify partners and areas of excellence. We identified some pocket areas, where TeamSTEPPS was being implemented in a small unit of a department. We followed-up with these individuals and teams to get a better idea of what they were doing, how TeamSTEPPS was being applied, and what challenges they had experienced. We wanted to learn from their experiences and identify gaps that we could address in building the Canadian program. How have you customized the TeamSTEPPS Canada program? There are a number of differences in the Canadian program that are innovative. First, we are using videos of real harm that are incredibly well done. We've swapped videos with American content and replaced them with videos that were scripted to show a real life Canadian example of harm that happened in the Canadian system and use that as a specific teaching opportunity to educate around the TeamSTEPPS tools and resources. We have an agreement with the Price family and the Health Quality Council of Alberta to use the Greg's Wings video – Falling Through the Cracks. Second, the curriculum is open to providers from all areas of healthcare, not just acute care, which is so often the case. It is applicable to long term care, primary care, and all sorts of settings. Also, it is not strictly for clinical providers. It is also applicable to non-clinical providers and in fact, the program is far more successful when your team includes non-clinical providers. Third, we asked representatives from Patients for Patient Safety Canada (PFPSC) to vet all of the patient engagement content and they rewrote that content for us. We are now partnering with PFPSC to create some patient-facing content that will give us a unique perspective and a customized curriculum. Finally, the tools and information in the TeamSTEPPS program always talk about sustaining improvement. A lot of other programs deliver content where you create a one-page action plan and at the end of the day you should be able to do these things, however this isn't realistic. Throughout the TeamSTEPPS Canada program, there are tools that help you to sustain and keep the momentum going. What major learnings can you share about the TeamSTEPPS program thus far? The curriculum appeals to and can be used by various healthcare settings and we are seeing that diversity. Traditionally, acute care people dominate in programs like this because acute care has more staff and access to more resources. In the sessions we have done to date, we have had equal representation from private healthcare settings, quality improvement, Corrections Canada staff, regulatory colleges, and primary care providers. The group has been diverse and that is what we were hoping for. The flexibility and variety in which you can deliver the content is extensive and variable. We have seen it delivered in a five per cent didactic approach and the rest done in group work, and vice versa. The content is so flexible and malleable that you can deliver it in any way and the content still resonates. What challenges have healthcare teams experienced in implementing the TeamSTEPPS Canada program? Initially, the teams thought they had to adopt everything. TeamSTEPPS addresses specific problems and provides solutions to those problems. We encourage teams to scale back and only introduce the tools they need to address a specific issue. We recommend that if you start there and understand your issue and then map that to the tools and resources within the curriculum, you can specifically and tactfully choose the solutions to implement. You don't have to implement the entire program. Can others replicate the TeamSTEPPS program? TeamSTEPPS Canada is trademarked and licenced to the Canadian Patient Safety Institute, as the pan-Canadian overseer of the program. Master training sessions are delivered in partnership with the Health Quality Council of Alberta, in a one-year trial program. Once the trial program has been evaluated, other regional training centers across Canada will be added. The one thing we have heard loud and clear is that it confuses staff when you add another program and use the moniker for that program – you've heard the cries, "Oh no, it's another program we have to learn." With TeamSTEPPS, you are not required to use the terminology, or implement the whole program and call it TeamSTEPPS Canada. And, you don't have to call it a TeamSTEPPS solution, or label it a TeamSTEPPS tool. If your issue is communication and want to use a TeamSTEPPS Canada communication tool, you can brand it with your organizational branding, adopt it, adapt it and roll it out as your own. What can we expect from TeamSTEPPS Canada program in the future? Currently, the program is a mix of didactic, and experiential and simulation learning. We would like to scale back the didactic side and embed more simulation and play into the curriculum itself and offer the program in a more updated and innovative format to appeal to a wide range of audiences. As well, the curriculum is more about patient involvement than patient engagement. We are working with a Masters student at the Canadian Patient Safety Institute who had done environmental scans with patients with a healthcare history, patients who do not have a healthcare history, and other partners to find out how to better create patient-facing content. Out of that report we will be developing a module on Patients in TeamSTEPPS that will actually involve patients in using the TeamSTEPPS tools as part of a team. With a broader view, we would like to see the community and more patients involved with TeamSTEPPS Canada program delivery. Whether they are patient advisors, or people who work in less formal roles within healthcare, it would be great to have them at the table learning about these tools alongside the teams that are now attending. Ultimately, our vision is to have a large, pan-Canadian community of practice where all TeamSTEPPS clinicians can connect to learn from one another. How can you find out more about TeamSTEPPS Canada? We would encourage you to take a Master Trainer session. To learn more about TeamSTEPPS Canada, visit www.patientsafetyinstitute.ca. Contact info@cpsi-icsp.ca if you are interested in bringing the program to your organization. 10/3/2018 6:00:00 AM SuperSHIFTERS Tricia Swartz, Jessica Kettles, Nada Strathearn and Gina De Souza are the Canadian Patient Safety Institute's team behind TeamSTEPPS10/4/2018 2:16:12 PM471http://www.patientsafetyinstitute.ca/en/NewsAlerts/News/Pages/Forms/AllItems.aspxhtmlFalseaspx

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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 PM4http://www.patientsafetyinstitute.ca/en/NewsAlerts/Alerts/Lists/Alerts/AllItems.aspxFalse
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 PM6http://www.patientsafetyinstitute.ca/en/NewsAlerts/Alerts/Lists/Alerts/AllItems.aspxFalse
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 PM3http://www.patientsafetyinstitute.ca/en/NewsAlerts/Alerts/Lists/Alerts/AllItems.aspxFalse
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 PM5http://www.patientsafetyinstitute.ca/en/NewsAlerts/Alerts/Lists/Alerts/AllItems.aspxFalse
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 PM3http://www.patientsafetyinstitute.ca/en/NewsAlerts/Alerts/Lists/Alerts/AllItems.aspxFalse