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Canadian Patient Safety Institute

Safe care....accepting no less​

The Canadian Patient Safety Institute (CPSI) has over 10-years of experience in safety leadership and implementing programs to enhance safety in every part of the healthcare continuum.​

SHIFT to Safety


Improving patient care safety and quality in Canada requires everyone’s involvement—SHIFT to Safety gives you the tools and resources you need to keep patients safe, whether you are a member of the public, a provider, or a leader.


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Our Programs​

 CPSI Latest News



Learning online with the Canadian Patient Safety Officer Course30473Patient Safety News ​Since the Canadian Patient Safety Officer Course online program was introduced two years ago, more than 60 learners have enrolled and 31 have graduated from the program. To be certified as a Canadian Patient Safety Officer, learners complete eight modules in 100 hours of study, delivered entirely online using readings, videos, webinars, discussion forums, and hands-on project work, with expert faculty to provide support and feedback. Learners have 12 months to complete the program. The learners represent a broad mix of those novice to the fields of patient safety and quality improvement, and those with considerable experience in both healthcare and in patient safety/improvement. Some have had ongoing formal roles and others are newly assuming those roles. Three Faculty members, Kristi Chorney, Pauline MacDonald and Barb Saunders, support the learners along their journey. The Faculty act as facilitators and mentors to the learners, grading and providing feedback on their assignments. They also monitor the discussion board and will comment on the student's posts. "The passion we see in our learners in trying to make a difference and increase patient safety in Canadian healthcare is clearly evident," says Kristi Chorney, CPSOC Facilitator. "Typically, this is something that they take on above and beyond their full-time work and the time and energy put into their assignments demonstrates that they are increasing their patient safety knowledge." The Project Plans for final projects being submitted by the learners focus on a variety of clinical improvements (venous thromboembolism prophylaxis, falls prevention, sepsis), communication and teamwork improvements (safety briefings), and patient partnership initiatives (patient and family involvement in hazard identification). Some Project Plans correlate with Accreditation Canada required organizational practices (medication safety and handovers). The topics are well aligned with the current priorities in patient safety. "It is encouraging to see the Project Plans and how the learners are planning to apply new skills at the end of the program, says Kristi Chorney. "It is one thing to gain the knowledge, but it is another thing to translate that knowledge into action. That is what appears to be happening. " The Discussion Forum has generated 19 pages of dialogue with interactions on everything from how to engage people to new approaches like positive deviance and how to use those types of tools. "The interactions on the Discussion Forum have been excellent," says Pauline MacDonald. "Some learners dive right into the discussion forum and contribute new ideas. Their thoughtful questions and posts on the discussion forum reflect their commitment, journal their learnings and foster practical, collegial discussions." Learners are saying that the course is very valuable and they are going to take what they learned back to their work environment in an effort to make change. They are giving the online program high marks for its content, resources and webinars. One participant says, "The course has provided me with the skills and tools to continue my work in the quality field. It is very well designed and relevant to today's healthcare practice and the assignments are great learning opportunities." "Our learners are highly motivated and committed," says Barb Saunders. "They are genuinely concerned about the state of patient safety in healthcare generally and specifically within their organization. They seek opportunities to learn the theoretical concepts to increase their knowledge, as well as to acquire skills to strengthen the culture of patient safety, improve healthcare reliability, and lead sustainable improvements. They have a strong moral compass and strongly believe in, and advocate for, true patient and family partnerships." The Canadian Patient Safety Officer Course is jointly developed and delivered by the Canadian Patient Safety Institute and HealthCareCAN. For more information or to apply for the Canadian Patient Safety Officer Course online program, visit www.patientsafetyinstitute.ca10/20/2016 4:00:00 PM Since the Canadian Patient Safety Officer Course online program was introduced two years ago, more than 60 learners have enrolled and 31 have10/20/2016 4:55:24 PM134
Sharing ideas to improve medication safety globally30418Patient Safety NewsWhen the International Medication Safety Network (IMSN) meets in Toronto on October 24, 2016, for the 2016 IMSN Global Regulatory Meeting, delegates from 27 member countries, the World Health Organization (WHO) and invited regulators will share their views and concerns on labelling, packaging and nomenclature issues prone to medication errors at a global level. Mr. Wu Tuck Seng, Chairperson of the National Medication Safety Committee, Ministry of Health, and Deputy Director and Head of the Pharmacy Department, National University Hospital in Singapore will be closely following discussions on how to use technology and automation to improve medication safety, specifically bar-coding. Currently, bar-coding of medications is not mandatory in Singapore. They are working towards establishing national compliance, if possible, similar to that in the United States."I want to find out more about bar-coding; the strategies we can employ, what are the challenges, and how we can implement bar-coding at a national level for all drugs," says Mr. Wu. "I want to know how others have worked with the pharmaceutical manufacturers to address bar-coding and medication safety."When it comes to medication safety and medication errors, Singapore uses the root cause analysis methodology to look at what happened, why it happened and what they can do to prevent similar medication errors in the future from a people, process and system perspective. "The majority of medication errors occur at the prescribing and drug administration stage rather than at dispensing," says Mr. Wu. "We need to better understand the opportunities for errors, and learn from our near misses and mistakes and how we can improve our systems, process and people holistically. Healthcare providers can provide insight about where things go wrong before they go wrong. The drugs we use now are more potent and sophisticated. Hence, we need to exercise vigilance even more and involve and work with the staff that are storing, preparing, and administering the drug."Mr. Wu says that the medication errors they commonly see are a combination of the wrong dilution, wrong concentration or the wrong dose being administered. To mitigate this, Singapore hospitals have been using premixes where available. They have been trying to get heparin in pre-mixed doses, but to date, have not been successful.Medication errors involving opioid drugs directly relates to how they are drawn into the syringe and then administered. An ampoule of morphine injection typically contains 10mg. Often times, the prescribed dose is less. For example, if 5mg is needed, only half the volume should be drawn up into the syringe. However, the usual practice is such that the nurse/doctor will draw up the entire 10mg dose into the syringe, and before drug administration the volume not required would be squirted out before the injection. Unfortunately, invariably another staff that is told to administer the medication fails to check the dose or expects the dose to be correct and mistakenly administers 10 mg instead of 5 mg. "This is a practice and process problem, not a drug concentration problem. The objective is to ensure they only administer what is prescribed," says Mr. Wu. For insulin safety, one hospital in Singapore has developed an insulin vial cap device that fits over the insulin vial. Once attached, it cannot be removed. This cap only allows you to use insulin syringes to draw out the insulin from the vial. It will not allow the use of non insulin syringes. This is a forcing function. The device costs approximately $20 per unit in Singapore currency ($20 CDN).The IMSN Global Regulatory Meeting agenda will address manufacturer labelling and look-alike/sound-alike drugs. The IMSN is working with the WHO to develop an international naming nomenclature to address this. "These are important issues pertaining to medication safety that continue to confront us," says Mr. Wu. "We can mitigate medication errors by introducing specific nomenclature for look-alike/sound-alike drugs besides labelling and packaging that can better differentiate them."10/19/2016 6:00:00 AMWhen the International Medication Safety Network (IMSN) meets in Toronto on October 24, 2016, for the 2016 IMSN Global Regulatory Meeting, delegates10/19/2016 5:23:32 PM236
Technology helps to reduce medication errors across the United States30419Patient Safety News In the United States, great advances have been made in medication safety where strategies have been put in place for preventing errors, like not using dangerous abbreviations and identifying high alert drugs that are most likely to injure someone when they are used in error. More than 90 per cent of hospitals are barcoded and are using computerized prescribing and bedside barcode scanning, where the doctor's orders are computerized. When the pharmacy dispenses the drug, it is labelled with a barcode. If the incorrect drug is scanned, there is an alert. The nurse or pharmacist on dispensing, and the nurse when administering get notified that there is something wrong, specifically, it is the wrong drug or dose for that patient. The use of bedside barcode scanning ensures that the right drug is being given to the right patient, at the right time. "We have had very positive outcomes with manufacturers and regulators in terms of understanding that drug naming, labelling, and packaging is important," says Michael Cohen, President, Institute for Safe Medication Practices (ISMP). "Going forward we need to improve upon the availability of ready-to-use pharmaceuticals, like syringes or pre-mixed IV solutions, for institutional use in acute care hospitals. That in itself would address a lot of the errors we are seeing in our reporting programs in the United States, Canada and other places as well." Technology is at the forefront across the United States, where infusion pumps are smart pumps used by and large in almost all hospitals. The smart pumps contain a library of drugs and the concentrations that are available for use in the hospital. When a patient needs an infusion, the nurse will look at the label to confirm it is the right drug, then put the IV tubing into it, hang it on an IV pole, attach the IV to a pump and push a button to start the infusion; the rate of the infusion is selected. Based on the concentration of the solution, the library knows how much drug is in each ml of solution. If a tenfold increase or decrease is accidentally ordered as an example, an alert is generated. In some cases it is a hard stop and you can't undo, or infuse anything without checking it out. ISMP has been funded by the US Food Drug Administration (FDA) to develop a self-assessment tool for high alert drugs. The tool includes prevention strategies for each pharmaceutical that will allow hospitals to assess where they are in implementing each of the strategies. They will be able to compare themselves to each of the participating hospitals in a variety of demographic categories across the country. "There are a lot of different things that can go wrong with medications, but we have done a good job with identifying them and applying prevention strategies," says Michael Cohen. "We are not perfect. Sometimes the system fails and they get through." Michael Cohen, along with David U and Dr. Michael Hamilton from ISMP Canada, are members of the World Health Organization (WHO) Global Patient Safety Challenge on Medication Safety, Medicines Working Group. They are proposing solutions that address many of the obstacles the world faces today to ensure the safety of medication practices. The work will be launched in the first quarter of 2017.10/19/2016 6:00:00 AMIn the United States, great advances have been made in medication safety where strategies have been put in place for preventing errors, like not10/19/2016 5:25:25 PM71
Prescrire addresses medication safety in France30422Patient Safety News Prescrire, a non-profit medication safety organization in France, is committed to better patient care. Prescrire provides clear, comprehensive and reliable information on drugs, therapeutic and diagnostic strategies to enable fully-informed decision-making. The organization also provides continuing education to healthcare professionals, mainly physicians, nurses and pharmacists in the primary care sector. The independent organization is non-partisan and fully funded by its subscribers. "Our aim is to help healthcare providers by providing evidence-based information on products and strategies," says Etienne Schmitt, Head of the Prescrire Programme in France, Éviter l'Évitable ("Preventing the Preventable"), a voluntary medical error reporting programme (including medication errors). "We have created an evidence scale using a risk and benefit approach that advises healthcare professionals on products to avoid where there is not enough assessment. We provide information every time there is a change to products, including the labelling and design of new products." Prescrire's assessment of the harm-benefit balance of new drugs and indications are based on a rigorous procedure that includes a systematic and reproducible literature search, identification of patient-relevant outcomes, prioritisation of the supporting data based on the strength of evidence, comparison with standard treatments, analysis of both known and potential adverse effects, and a systematic assessment of the packaging and the labelling. Prescrire publishes a monthly journal in French and an international edition in English 11 times a year, plus a yearly supplement in French devoted to drug interactions. Prescrire also provides an annual list of drugs to avoid, to help healthcare professionals and patients choose high-quality treatments that minimize the risk of adverse effects. The 2016 review examined medications over a six-year period (from 2010 to 2015) and identifies 74 drugs that are more harmful than beneficial in all the indications for which they have been authorised. In most cases, when drug therapy is necessary, other drugs with a better harm-benefit balance are available. Medication safety issues that are currently top-of-mind in France include over-the-counter (OTC) products, and the confusion between injectables, particularly concentrates and diluted products. "OTC products are gaining in popularity because they are less expensive," says Etienne Schmitt. "There is a lot of confusion with packaging and product names due to umbrella brands, and people don't understand how to use the products appropriately. Health agencies should advocate for a better design of product labels and more clarity in product names. The current consultation launched by the French Drug agency (ANSM) gives Prescrire an opportunity to speak-up on patient safety." Working with regulators on how to prevent medication errors, Prescrire is advocating for better drug formulation and increased transparency from drug agencies, to promote safe labelling and international naming of drugs. Etienne Schmitt says the International Medication Safety Network (IMSN) is a good opportunity to share information amongst members and to get input on their programs. "Working together the IMSN are developing actionable items, providing recommendations and preparing position statements to improve medication safety world-wide. One example is improving the packaging and labelling of vaccines, because vials can be easily confused with other products. Ready to use products, such as prefilled syringes, offer more rigour around the preparation and labelling of vaccines and will contribute to safer care, but are costly and increase the volume storage."10/19/2016 6:00:00 AMPrescrire, a non-profit medication safety organization in France, is committed to better patient care. Prescrire provides clear, comprehensive and10/19/2016 5:28:14 PM44
September has been a busy month for all of us!9224Patient Safety Power Plays ​For everyone at the Canadian Patient Safety Institute, this flurry of activity culminated in Ottawa with a pair of important events all driving the patient safety agenda forward. On September 22, representatives of the Leads Groups for the Integrated Patient Safety Action Plan met face to face for the first time. The Leads Groups are made up of the key individuals and organizations that are taking a leadership role in the areas of focus of the Integrated Patient Safety Action Plan. At the conclusion of the meeting, each of the Leads Groups had a recommended action that they brought to the attention of the National Patient Safety Consortium the next day. With the Leads Groups representatives joining the Consortium meeting, almost 100 organizations participated, including national organizations, provincial and territorial quality and patient safety councils, government representatives, professional associations and patient groups. This group has done so much since its launch in 2014 and it's always great when we have a chance to come together again. I invite you to keep tabs on their progress here. We are thrilled that many participants were re-energized by the meeting and the impact we are making for safer healthcare in Canada. This video highlights some of the key work, all achieved in the spirit of collaboration and system improvement. On top of that, we are happy to see that our collective efforts are being noticed at the highest levels of government and are excited about what this could mean for future patient safety improvement. Thank you to all attendees for your passion for patient safety. None of this would be possible without you. Finally, our 2015-16 Annual Report, titled "Making the Shift," is hot off the presses and it captures, not just a busy, but an incredibly busy year at the Canadian Patient Safety Institute. You can read all about it here. Chris Power CEO, Canadian Patient Safety Institute10/4/2016 4:00:00 PMFor everyone at the Canadian Patient Safety Institute, this flurry of activity culminated in Ottawa with a pair of important events all driving the10/4/2016 6:04:08 PM103

 Upcoming Events



2016 Home Care Summit5097Vancuver, BC 12:00:00 AM10/27/2016 11:59:00 PMThe Canadian Patient Safety Institute is proud to support this event.This event is hosted by Canadian Home Care Associaton5/27/2016 9:00:27 PM10
Measuring Patient Harm in Canadian Hospitals Virtual Announcement5126WebEx 5:00:00 PM10/26/2016 6:00:00 PMJoin the expert panel to hear an announcement​ on Measuring Patient Harm in Canadian Hospitals and available Hospital Harm Improvement Resources to make care safer. 9/30/2016 6:02:18 PM14
HF101: Human Factors for Safer Healthcare5108Toronto 12:30:00 PM10/27/2016 8:30:00 PMThe Canadian Patient Safety Institute is proud to support this event.This event is hosted by Healthcare Human Factors7/5/2016 7:29:32 PM10
Twitter Talk Event #AskListenTalk30410Twitter 4:00:00 PM10/28/2016 5:00:00 PMThe one-hour Twitter Talk will explore two discussi​on topics moderated by a special guest. Participating in Twitter chats can help you gain followers and influence others by sharing great insights.10/18/2016 8:35:51 PM11 Event
Horizon Health Network’s inaugural Patient and Family Centred Care Experience Conference5091Moncton, New Brunswick 12:00:00 AM11/8/2016 11:59:00 PMThe Canadian Patient Safety Institute is proud to support this event.This event is hosted by Horizon Health4/28/2016 7:09:23 PM3