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Everybodys got a story to tell200522/6/2017 4:12:00 PMPatient Safety Power Plays If there is one thing we’ve learned at the Canadian Patient Safety Institute, it’s to believe in the power of the story and the human experience. Look no further than our Patient and Provider Stories. These heart breaking tales have become a staple of Canadian Patient Safety Week and are so powerful that we call upon them at events throughout the year. For this, we are incredibly grateful to the brave members of Patients for Patient Safety Canada and the healthcare providers who have come forward to share their stories with us. These are stories on a small scale. They’re still very niche, but if you’ve heard or seen them for yourself, you know the impression they can make on a person. On a much larger scale, stories are what makes Bell’s Let’s Talk Day so successful. One day, each year, devoted to talking about mental health awareness. Not only is this event fueled by stories about struggles with mental health issues, but it encourages everyone to open up and share their own experiences. Bell has the kind of reach to ensure everyone knows about Let’s Talk Day, but it’s the stories that are the real stars of the show and that give the event its appeal. We’re doing a lot of work at the moment to define the CPSI story. What’s it all about? Where did we come from and where are we going? You’re going to be hearing a lot from us in the coming year about the CPSI story. I firmly believe it to be an important part of our way forward. We’ve been at this a long time, and we need to do a better job telling our story if we’re going to continue to have an impact on the healthcare system. How about you? What’s your story? As always, I’m available to you either by email at​ or on Twitter @ChrisPowerCPSI. Yours in patient safety, Chris Power 2/6/2017 7:00:00 AMIf there is one thing we’ve learned at the Canadian Patient Safety Institute, it’s to believe in the power of the story and the human2/6/2017 5:23:42 PM202
Pioneer in the patient movement still dedicated to the cause202191/31/2017 9:03:06 PMPatient & Family stories Anne Lyddiatt wears many hats in her volunteer efforts but the priority remains the same — getting out the message for patient safety across Canada. After her many long years and varied roles in the battle to improve patient safety in Canada, Anne Lyddiatt still somehow retains enough energy to sweat the details. Even minor problems can get her back up. She was waiting for a ride inside a back entrance of a sprawling hospital in Sherbrooke, Quebec, recently when she spotted some striking patient safety posters mounted on a nearby wall. Good, right? Wrong. The place where Lyddiatt was standing was neither a public entrance nor a high-traffic area for medical staff. "But there were those posters on a wall back in the corner, out of view, nowhere where visitors or patients and staff would normally be going," Lyddiatt says. "I felt like taking them down and walking them over to the other side of the hospital." The Ontario member of Patients for Patient Safety Canada became one of this country's first patient safety champions 10 years ago but her work for the cause stretches considerably farther, steeped in her background with VON Canada and as a longtime nurse educator. A diagnosis of inflammatory arthritis forced her to leave the nursing work force many years ago but once her disease was under control, Lyddiatt threw herself into volunteer activity and she's never slowed down since. For the past 20 years she's been the national trainer for the Patient Partners in Arthritis Program. She regularly offers the patient perspective in Strategy for Patient Oriented Research master classes, sponsored by the ON SPOR SUPPORT unit through the Canadian Institutes of Health Research. And she's just completed a three-year term on the board of the Cochrane Collaboration, which has been producing systematic reviews of primary research in human health care and health policy for the past 20 years. Lyddiatt continues to chair that organization's consumer group, where her dedication to the patient perspective remains undiminished. "It's one of those things you just keep working away at," Lyddiatt says of her patient advocacy. "If it's something that can help get out the message for patient safety, as far as I'm concerned if you're able to do it and have the time, then you just jump in and do it." Looking back, Lyddiatt says she can't point to a single dramatic safety incident that first drew her attention. "It was a series of small things that really shouldn't happen. Medication errors and things like that. To me it was, okay, this is an accident waiting to happen," she says. "By the time I got into patient safety and heard some of the stories I realized I was a little behind the times because some of those drastic things had already happened. So that made me even more convinced that this was really necessary, something that really needed feedback. Obviously we needed input from health providers but you also needed to have it patient driven as well." That conviction was only strengthened by a deeply troubling personal experience with the health care system a few years back. Lyddiatt's adult daughter, Jeri-Joann, suffered a series of adverse events in a number of health care facilities, including two debilitating bouts of C. difficile diarrhea, prior to her death in 2011. The lack of empathy and understanding that Lyddiatt and her daughter encountered at times over that period confirmed for her how crucial it is to have that perspective, whether you call them patients or clients or consumers, at the forefront of any health care strategy. "I think when you are navigating the health care system, whether it's for yourself or a family member or whomever, you need to be really clear and know what your goals are and what you want and need. You need to not be afraid to express that. And sometimes that will be different from the provider's goals and what they are aiming for but you need to somehow work out a system where you and the providers can work together." Lyddiatt says she generally keeps her nursing background under wraps on those frequent occasions when she finds herself on a site visit within a health care setting. She prefers to just stand back and observe. "If that sounds like spying on staff it's not because I realize they're fighting against obstacles too," Lyddiatt says. "Nursing has changed, there's a lot more paperwork, there are so many things that are different. But I still think that there's the element of safety in patient care that sometimes gets lost in the shuffle. There's a lack of listening to a patient and the family. Either it's 'we don't have time" or "you don't understand what we're doing,' which isn't always the case. "We know this happens in hospitals all the time. But I really am concerned and alarmed by what happens in nursing home and long term care facilities because many of those patients don't have a voice. They don't have a voice personally and many of them don't have someone to speak up for them. You know the horror stories that go on in some of these, and I'm not saying they're all bad because that's not the case, but I do think that's an area of patient safety that we haven't really tackled and we need to look at." For all the strides that have been made in patient engagement and patient safety, bringing change to medicine and health care "is really difficult and it's always slow," Lyddiatt says. "Why, I have no idea. But the standard response you get whenever you want to try something new is, well, we've always done it that way. And the other is well that's the way I was trained and it was good enough for me, so therefore it's good enough for the next guy," she says. "I can understand it, if you've been doing something for 20 or 30 years and it's always worked for you why would you want to change? But by the same token, the world has changed. I really fault the med schools. I think they do the best they can but I don't think they've changed as quickly as they could to keep up with the times." Lyddiatt takes the same measured view when assessing the general legacy of patient advocacy in Canada. One development she'd like to see is a greater emphasis on patient solutions rather than patient stories about adverse events. "I think we've come a long, long way since we first started. We've got a lot more patients involved and I they're a lot more engaged than they were originally. I don't think there's a shortage of volunteers anymore," Lyddiatt says, checking off the pluses. "The one thing we have to do is look at the issues that we regard as real patient safety problems and not only tell our stories but also come up with realistic solutions about how we can prevent this in the future."1/31/2017 7:00:00 AMAnne Lyddiatt wears many hats in her volunteer efforts but the priority remains the same — getting out the message for patient safety across Canada. 1/31/2017 9:12:24 PM312
Help us reduce falls and make care safer: join our expert faculty2007911/18/2016 4:39:46 PMPatient Safety News ​A unique opportunity is open to members of the Canadian healthcare community to contribute to the new way forward on protecting patients from falls. As part of the Canadian Patient Safety Institute's (CPSI) SHIFT to Safety initiative, CPSI and the Registered Nurses' Association of Ontario (RNAO) are putting together a team of experts in fall prevention and injury reduction to help craft the next version of the Falls Getting Started Kit. The Getting Started Kit is a free resource designed to help care providers successfully implement evidenced-based falls prevention and injury reduction strategies to keep their patients, clients or residents safe. Like all SHIFT to Safety tools, this kit empowers healthcare providers to prioritize safety when caring for their patients and to promote a safe healthcare experience for everyone. The primary role the faculty will be to assist in the revision and dissemination of the update of the Falls Getting Started Kit,contribute to knowledge transfer activities such as webinars; and offer expert knowledge to CPSI/RNAO and on occasion, to respond to inquiries from the field. If this sounds like an exciting opportunity, and you or someone you know, would like to get involved in improving safety by reducing falls, click the button below to learn more or email us at​. Learn more 1/25/2017 9:00:00 PM A unique opportunity is open to members of the Canadian healthcare community to contribute to the new way forward on protecting patients from falls.1/26/2017 10:34:42 PM864
Project Saving Legs: New hope for Diabetics facing amputation202261/23/2017 8:12:36 PMPatient Safety News Peripheral artery disease (PAD) is a build-up of plaque in the walls of the arteries, blocking the flow of blood to the limbs, most commonly the legs. This vascular disease affects as many as 800,000 Canadians and people with diabetes are two to four times more likely to be affected. Even with treatment, 40 per cent of people with severe PAD face major amputation. In Ontario alone, more than 2,000 leg amputations are performed each year. Project Saving Legs is a project, rather than a single procedure, to raise awareness and to invent and offer the most advanced treatments to eliminate amputations, and to educate and train a new generation in these advanced techniques. The project is an initiative led by Vascular Surgeons at Sunnybrook Health Sciences Centre, with an aim to open a clinic specializing in saving legs through treating diabetic foot ulcers. By promoting early detection and diagnosis of wounds, and aggressive treatments, Sunnybrook's mission is to reduce amputation rates from 40 to five per cent. In Canada, anyone with diabetes has a 15 to 25 per cent risk of developing a foot ulcer. When a patient with diabetes develops a foot ulcer, their chance of dying in the next two years is 50 per cent; and their chance of having an amputation in next two to five years is over 75 per cent. The day that a patient develops a foot ulcer is actually a worse outcome than a day when a patient is diagnosed with breast cancer, prostate cancer, or colon cancer combined. "If you are a diabetic and with a foot ulcer where the blood flow below the knee is affected, which is typically the case, you would inevitably need an amputation, but that has now changed," says Dr. Giuseppe Papia, Vascular & Endovascular Surgeon. Sunnybrook's vascular and wound care experts are working concurrently, using the toe and flow model to increase blood flow to the area, to benefit patients who develop a foot ulcer. By using the latest skills and equipment, patients can be treated quickly and in a multidisciplinary fashion. Dr. Papia, and his colleague Dr. Andrew Dueck, perform some 250 procedures annually using a minimally invasive angioplasty to clear blockages and restore blood flow to patients' legs. The procedure involves sending a balloon catheter through tiny arteries in the leg to open blood vessels leading to the foot. Patients often experience immediate relief from pain and typically return home the same day. "Sunnybrook is one of the first medical centers in Canada to treat vascular disease with angioplasty balloons that are covered in an anti-inflammatory drug," says Dr. Papia. "To angioplasty the artery open is not enough, it will scar back down. The drug minimizes scar tissue formation, which can lead to blockage of the artery. When you use an anti-inflammatory drug and deliver it to the actual spot that you need it, it will make a difference over the long-term." Sunnybrook is very unique in Canada, in that vascular surgery, cardiac surgery and cardiology are combined as one program. As a result, the procedure is done is a dedicated Cath Lab, rather than a radiology suite or an operating room with hybrid equipment. In 2008, Dr. Papia began looking at alternate treatments for vascular disease. While doing a fellowship in endovascular surgery at the Cleveland Clinic, he worked with a mentor to learn how to do the angioplasty procedure. At that time, coronary technologies and wires used in the heart were used; they did not have the right equipment and had to make the wires longer and put them together to perform the vascular procedure. Dr. Papia then learned that this type of procedure was being done in Europe and subsequently did site visits and worked with physicians there. During those site visits, he was inspired by the diabetic foot hospitals that are dedicated to aggressive and early treatment for patients with vascular problems. He found the centers in Europe incredibly organized. "They function much like a cancer center, but for diabetic foot problems," says Dr. Papia. "The patient shows up and has everything done from diagnostics to multidisciplinary visits -- medical, surgical, podiatry and wound care are all in one spot. Amputation rates are extremely low and the quality of life rates for these patients are extremely high; overall their outcomes are great." With increasing age and obesity, diabetic rates are exploding not only in the Western world, but globally. Dr. Papia says that not only is it an epidemic, but there is a tsunami coming to our health system because of this problem. Data from the Ontario government indicates that if you have a foot ulcer and are a diabetic, to treat that ulcer will cost about $6,000 to $9,000. If you have an infected foot ulcer, antibiotics and medical costs bring the cost closer to $12,000 to 13,000. If you end up having a leg amputation, the cost to the health system is closer to $65,000 to $70,000 for the same patient. "There is a tenfold increase in cost if we don't prevent these ulcers and treat them early," says Dr. Papia. "Looking forward, we have the potential to benefit patients and make a huge impact on their quality of life," says Dr. Papia. "If I had to pick an area in healthcare 2030 that would address this colossal problem, this would be one of them. It makes sense that if you have this problem that we know is very costly, and has an outcome or diagnosis that is worse than many cancers, without a dedicated center we are going to have a hard time making a difference." Dr. Papia says if you look at cancer centers for example, or trauma centers, you can't have just one. You need them everywhere if you are going to make a difference. His vision is to take this grassroots initiative provincially and nationally as a campaign for awareness, education, research and ultimately treatment. Project Saving Legs has a Twitter feed and Facebook page to help spread the word and build momentum. Tweet using #SavingLegs, or visit https// For more information, contact How the angioplasty procedure worksAfter undergoing ultrasound tests (that detail blood flow and reveal narrowed arteries or blockages), a physical exam and sometimes a CT scan in the clinic, patients head to the catheterization lab for an angioplasty procedure. If the patient requires it, some mild sedation may be offered. X-rays of the groin area are then taken to determine the safest point of entry to the patient's femoral artery.After administering a local anesthetic, a small needle puncture will be made in the groin on the side opposite the problem leg. (For a right foot ulcer, Dr. Papia prefers to access the femoral artery from the left side of a patient's groin, a technique that offers him the most manoeuvrability down the blood vessel and offers the best picture of what's happening from the aorta all the way down the leg.) The artery is then punctured with a needle, and a catheter is fed up and over the middle of the femoral artery, down into the opposite leg. (This is all visible on the X-ray monitor mounted next to the operating table.) A coronary wire is fed through the catheter. Dye is injected through the catheter, allowing the surgeon to see the blood flow and vessels via moving X-ray pictures (fluoroscopy). A blood thinner is administered (catheters can sometimes block blood flow and start clotting in the artery); then the wire of choice is fed through the catheter down to the target area. The wire is used to clear the blockage, and then a tiny balloon is slid down to the site of the angioplasty. Using a small hand pump, the surgeon inflates the balloon inside the artery, leaving it in place for three minutes or so, opening up blood flow through the vessel. The balloon, wire and catheter are removed from the patient, and the wound is closed with a closure device. Patients go home four hours post-procedure and return for a diagnostic checkup in a month's time. 1/23/2017 7:00:00 AMPeripheral artery disease (PAD) is a build-up of plaque in the walls of the arteries, blocking the flow of blood to the limbs, most commonly the1/23/2017 10:23:31 PM140
Highlights of 2016 collaboration with Atlantic Health Quality Patient Safety Collaborative: First National Incident Management Skills Development Session!200821/6/2017 10:26:13 PMPatient Safety News The Canadian Patient Safety Institute (CPSI) is celebrating many successful collaborations in 2016 and wanted to share one of those highlights with you. The Atlantic Health Quality Patient Safety Collaborative (AHQPSC) prioritized incident management skills development as a key area of focus for the health professionals who serve as patient safety and quality and risk specialists across the four Atlantic Provinces. The two-day in-person training opportunity was designed to equip Health Professionals with core concepts in Patient Safety Incident Management with a focus on translating the knowledge, skills, and attitudes to effectively identify, report, and learn from patient safety incidents. On October 5 and 6, the AHQPSC and CPSI hosted the first National Patient Safety Incident Management Skills Development Session in Halifax. National partners, which included, Patients for Patient Safety Canada, Institute for Safe Medication Practices Canada, Accreditation Canada, Master Facilitators, and the Canadian Patient Safety Institute greatly contributed to the overall success of this initiative. The two-day session encompassed the fundamentals of the continuum of incident Participants were engaged in multiple activities that explored meaningful patient engagement, patient safety culture, physician engagement, various incident analysis methodologies, best practices and national accreditation standards. Final evaluation by participants revealed that 97.1% would recommend this session to others. "massive learning opportunity and sharing experience with provinces…I would recommend for more employees to attend" (session participant). As the initial pilot we are very pleased with the overall learning outcomes. As a result of this national learning opportunity Prince Edward Island has already garnered the learnings from this event and delivered a province specific skills development workshop October 27, 2016. They had over 100 participants in attendance. "Invaluable; Informative, Excellent workshop, were just some of the comments shared by attendees. The evaluation from this successful event will be integrated within a broader national needs assessment currently underway, which will aim to explore the current educational content, tools and resources for incident management across Canadian healthcare organizations and to assess the needs of Canadian organizations in relation to incident management, professional development, education and training. CPSI wishes to thank the Atlantic Health Quality Patient Safety Collaborative for their on-going commitment to patient safety and in providing this unique learning opportunity.1/6/2017 10:00:00 PMThe Canadian Patient Safety Institute (CPSI) is celebrating many successful collaborations in 2016 and wanted to share one of those highlights with1/6/2017 10:40:55 PM598

 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 PM
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 PM