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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

 

 

Patient Safety Power Plays: Making patient safety a priority27076Patient Safety Power PlaysWhy does patient safety matter? For the answer to that question, I invite you to read about Emmy Gunther, a young girl who suffered a severe injury to her hand while in hospital. What happened to Emmy occurs every day in Canadian healthcare – one in every 18 hospital stays results in at least one harmful event. It's also worth noting that this statistic doesn't cover home care, long-term care, community care, or any other clinical settings. Even if you, or someone you know, has experienced harm in healthcare, you may not be aware of the magnitude of the problem. This is why stories like Emmy's are so important. They give the public greater awareness of how dangerous healthcare can be and how common harm in healthcare is. In this instance, CPSI was contacted by CBC News to provide our perspective. Opportunities like these are a great way for us to speak directly to the public. When awful events happen, it's our job to ensure that they don't happen in a vacuum, and that we take the opportunity to educate the public on how big a problem harm in healthcare is, and what needs to be done to make things better. Our bold new five-year strategy, Patient Safety Right Now is launching April 1, 2018 with a major focus on making patient safety a priority. We're committed to raising the public's consciousness around this issue and creating the political pressure required to improve patient safety and quality in Canada. I look forward to sharing more details about this exciting work, and all aspects of our new strategy, with you in the coming months. CPSI is always looking for opportunities to become part of the story. Questions? Comments? My inbox is open to you anytime at cpower@cpsi-icsp.ca Follow me on Twitter @ChrisPowerCPSI. Yours in patient safety, Chris Power 2/5/2018 7:00:00 AMWhy does patient safety matter? For the answer to that question, I invite you to read about Emmy Gunther , a young girl who suffered a severe2/5/2018 8:40:25 PM402http://www.patientsafetyinstitute.ca/en/NewsAlerts/News/Pages/Forms/AllItems.aspxhtmlFalseaspx
#SHIFTTalks Cross-Country Collaboration for Improved Patient Care27080SHIFT Talks In healthcare there is no shortage of improvement opportunities, but people are often working in isolation. There is often will to act and good ideas to improve, but teams often need support for implementation. One Sectors' Solution The Canadian ICU Collaborative was formed in 2003 to address this gap in critical care and since then, has designed and delivered many collaboratives* on over a dozen topics. Teams have been supported to improve sepsis care, transfusion practices, end-of-life care, delirium management and to reduce ventilator associated pneumonia (VAP) and central line associated bloodstream infections (CLA-BSI). Overall, results have been positive. For example, in one VAP and CLA-BSI Collaborative, one team reduced their VAP rate to zero for 14 consecutive months and another team went 13 months without a line infection. An Example The most recent initiative was named the "PAD Your ICU" virtual series and was completed in March 2017. It engaged 41 interdisciplinary improvement teams (10 paediatric and 31 adult acute care) to work together to improve the management of pain, agitation and delirium. In ten months, teams attended five webinars and 11 connection calls where participants were provided with clinical content and advice on improvement science. Teams set specific aims, shared ideas and knowledge, implemented iterative tests of change, measured progress and shared successful approaches for organizational change. Teams stayed connected via an online sharing system. You can read some of their stories here Scoring tools for delirium assessment helps to mobilize sedated pediatric patients Documenting delirium in the ICU a simple yet effective approach The collaborative approach has provided a platform to connect, learn from others and make substantive improvements in a variety of settings. You might consider joining a collaborative the next time the opportunity occurs!What You Can Do – Starting Today! "Participants told us that it was great to talk to their Canadian colleagues who have similar issues and want to make progress." In the absence of a formal collaborative, here are some ideas to better connect and support implementationLook for other organizations in your community to visit and learn from (including those who may be outside of healthcare),Join a list serve or social media platform with others working on the same problem, especially those who are actively working on improvement initiativesReview innovative practices from world class organizations,Rely on validated improvement approaches,Share your data, learning and challenges with those that matter In closing, we leave you with a final thought from Dr. W. Edwards Deming "When we cooperate, everybody wins." *Collaboratives (also known as Breakthrough Series Collaboratives) were designed by the Institute for Healthcare Improvement (IHI) in 1993 and have been successfully applied worldwide to significantly improve quality and safety in healthcare. Guided by a philosophy of "all teach, all learn", multiple organizations come together to make improvements on a specific healthcare challenge. The approach allows teams to address a common problem, to leverage ideas and to share what they learn along the way. The process is based on three to four learning sessions, team action periods and methods for support (coaching calls, measurement help, discussion forum, file sharing, Faculty feedback).Authors Bruce Harries co-founded Improvement Associates in 2000. He is Collaborative Director for the Canadian ICU Collaborative and has advised on several initiatives such as the National ICU Scorecard and Safer Healthcare Now! Bruce is on the board of the Health Quality Council of Alberta (HQCA) and on Faculty of the BCPSQC Quality Academy. He is a graduate of Trent University, the Banff School of Advanced Management and holds an MBA from IMD in Lausanne, Switzerland. Leanne Couves co-founded Improvement Associates in 2000. Leanne has designed and supported over 20 Breakthrough Series Collaboratives across Canada and has taught at over 70 Learning Sessions. She has led the writing of several improvement guides based on these approaches. Leanne is on Faculty of the BCPSQC Quality Academy. Leanne holds a Bachelor of Commerce degree and Certificate in Adult and Continuing Education from the University of Alberta.2/5/2018 7:00:00 AMIn healthcare there is no shortage of improvement opportunities, but people are often working in isolation. There is often will to act and good ideas2/5/2018 8:52:06 PM407http://www.patientsafetyinstitute.ca/en/NewsAlerts/News/Pages/Forms/AllItems.aspxhtmlFalseaspx
Surgical Safety Checklist: Smart for patients. Smart for providers.27014Patient Safety News A Surgical Safety Checklist plays an important role in reducing the likelihood of complications following surgery and is known to improve surgical outcomes. Implementing a Surgical Safety Checklist helps to initiate, guide and formalize communication among the team conducting a surgical procedure; and ensures that critical safety steps are integrated into the surgical workflow. The three phases of the checklist include Briefing (before the induction of anesthesia); Time-Out (before skin incision) and Debriefing (before the patient leaves the operating room). "Although healthcare professionals make every reasonable effort to provide safe care to their patients, harmful surgical incidents, including wrong site surgeries and retained surgical items continue to occur in operating rooms across the country," says Dr. Giuseppe Papia, Vascular and Endovascular Surgeon and Critical Care Medicine specialist at Sunnybrook Health Sciences Centre. "It is with standardized protocols like the Surgical Safety Checklist that can improve communication and collaboration across the surgical team and prevent patient safety incidents. Patient harm is reduced by fostering highly reliable surgical teams which work more effectively together to produce better patient outcomes. The Surgical Safety Checklist is an essential perioperative communications tool for surgical teams across Canada." A Joint Position Statement outlining the advocacy and support for use of a Surgical Safety Checklist has been adopted by the Canadian Patient Safety Institute, Alberta Health Services (AHS), Canadian Anesthesiologists' Society (CAS), and the Operating Room Nurses' Association of Canada (ORNAC). The purpose of the statement is to convey the commitment of these organizations to prioritize perioperative patient safety by creating an environment conducive to the effective adoption and use of a Surgical Safety Checklist. It is a call to action that supports a cultural shift from the front lines - to leadership - to patients and advocates for the widespread use of Surgical Safety Checklist. Support for the Joint Position Statement is widespread. A number of surgical groups have endorsed the Joint Position Statement, including the Canadian Orthopaedic Association; Canadian Neurosurgical Society; Canadian Society of Cardiac Surgeons; Canadian Society for Vascular Surgery; Canadian Society of Otolaryngology Head and Neck Surgery; Canadian Association of General Surgeons; Canadian Association of Paediatric Surgeons; Canadian Association of Thoracic Surgeons, ant the Society of Obstetricians and Gynaecologists of Canada. Supporters promoting the statement include the Canadian Ophthalmological Society and Canadian Thoracic Society. The Joint Position Statement also acknowledges "never events" – serious patient safety incidents that should not occur if healthcare systems support and empower providers in their use of available preventative measures. While "never events" damage patients' confidence in the healthcare system, the Surgical Safety Checklist can facilitate communication amongst teams and help to avoid "never events." A Safer Surgery Checklist was first developed by the World Health Organization in 2008. The Canadian Patient Safety Institute then adapted the checklist to include a Canadian context and the Surgical Safety Checklist was introduced in May 2009. For almost a decade, the Surgical Safety Checklist has been used by surgical teams across the country to support excellent patient care through good communication and teamwork. To learn more about the Surgical Safety Checklist and the Joint Position Statement advocating for and supporting the use of a Surgical Safety Checklist, visit www.patientsafetyinstitute.ca1/31/2018 7:00:00 AMA Surgical Safety Checklist plays an important role in reducing the likelihood of complications following surgery and is known to improve surgical1/30/2018 6:16:22 PM184http://www.patientsafetyinstitute.ca/en/NewsAlerts/News/Pages/Forms/AllItems.aspxhtmlFalseaspx
How Patients Experience Cancer Care In Canada: New Report27018Patient Safety News ​A new report published by the Canadian Partnership Against Cancer illustrates the experiences of patients from the time cancer is suspected through adjusting to a "new normal" after treatment ends. This is the first in a series presenting national survey data and insights from over 30,000 patients living with and beyond cancer. Living with Cancer A Report on the Patient Experience finds that while their cancer may be well treated, many Canadians experience significant physical and emotional side effects of cancer that are often not adequately addressed. The report calls for the increased adoption and use of tools to identify patient needs, in an effort to deliver better, more person-centred cancer care. Learn more 1/30/2018 7:00:00 AMA new report published by the Canadian Partnership Against Cancer illustrates the experiences of patients from the time cancer is suspected through1/29/2018 9:30:53 PM142http://www.patientsafetyinstitute.ca/en/NewsAlerts/News/Pages/Forms/AllItems.aspxhtmlFalseaspx
We need more champions like Maryann Murray5122Patient Safety News If you've ever wondered what kind of difference one person can make, look no further than the impact Ms. Maryann Murray has made on patient safety. Last July, Ms. Murray had the opportunity to meet with her local Member of Parliament, Mr. David Sweet, and share her concerns regarding harm in the Canadian healthcare system. She talked about her involvement in Patients for Patient Safety Canada, and the work the Canadian Patient Safety Institute and others are doing to improve patient safety in Canada. She also left him with a fact sheet on patient safety, which demonstrates the magnitude of the problem. Ms. Murray knows this first-hand. Her daughter Martha died in 2002, after a series of errors. She since joined Patients for Patient Safety Canada with a desire to ensure what happened to Martha doesn't happen to anyone else. The encounter obviously left a definite impression on Mr. Sweet, who shared the details of their meeting with Ms. Murray with the Hon. Ginette Petitpas Taylor, the federal Minister of Health. In turn, she responded with a letter back to Ms. Murray thanking her for her efforts to improve Canada's healthcare system (click the thumbnail above to see the letter). Since joining Patients for Patient Safety Canada, Ms. Murray has been a champion for patient safety in healthcare, both at home and abroad. Her dedication to the cause is remarkable and is noticed by everyone she meets. Her story was also featured in the debut episode of CPSI's PATIENT podcast. She is living proof of the difference one person can make.1/15/2018 7:00:00 AMIf you've ever wondered what kind of difference one person can make, look no further than the impact Ms. Maryann Murray has made on patient safety. 1/15/2018 4:43:43 PM494http://www.patientsafetyinstitute.ca/en/NewsAlerts/News/Pages/Forms/AllItems.aspxhtmlFalseaspx

 Upcoming Events

 

 

Communication During Transitions of Care: how well are they really working and what can you do to improve them?8472WebExhttp://www.patientsafetyinstitute.ca/en/Events/Pages/Communication-During-Transitions-of-Care-2018-02-21.aspx2/21/2018 5:00:00 PM2/21/2018 6:00:00 PMEvidence demonstrates that communication is one of the leading contributors to adverse events. Transitions of care epitomize this challenge. Recognizing that what we say is not what others hear, this call will address how to manage that challenge.1/22/2018 6:51:31 PM42http://www.patientsafetyinstitute.ca/en/Events/Lists/Events/calendar.aspxFalseWebcastFalse
Early Bird Deadline: Canadian Patient Safety Officer Course33318Ottawahttp://www.patientsafetyinstitute.ca/en/education/psoc/Pages/default.aspx2/23/2018 12:00:00 AM2/23/2018 11:59:00 PMThe Canadian Patient Safety Officer Course is jointly developed and delivered by the Canadian Patient Safety Institute and HealthCareCAN, supported by experts from across Canada and internationally.12/11/2017 9:00:55 PM183http://www.patientsafetyinstitute.ca/en/Events/Lists/Events/calendar.aspxFalseWorkshopTrue
Webinar 1: Introduction to Knowledge Translation and Implementation Science27010WebExhttp://www.patientsafetyinstitute.ca/en/Events/KTIS-Webcast-Series-2018/Pages/Introduction-to-Knowledge-Translation-and-Implementation-Science-2018-02-26.aspx2/26/2018 5:00:00 PM2/26/2018 6:00:00 PMThis is the first in a series of interactive webinars designed to build capacity in the basic principles of knowledge translation and implementation science.1/29/2018 6:41:48 PM42http://www.patientsafetyinstitute.ca/en/Events/Lists/Events/calendar.aspxFalseWebcast;Learning SeriesFalse
Innovations in Patient Safety Education Awards27382WebExhttp://www.patientsafetyinstitute.ca/en/Events/Pages/Webinar-Innovations-in-Patient-Safety-Education-Awards-2018-03-14.aspx3/14/2018 4:00:00 PM3/14/2018 5:00:00 PMJoin us for a webinar to learn how the 2017 Innovations in Patient Safety Education (IPSE) award winners, 2/7/2018 9:52:09 PM30http://www.patientsafetyinstitute.ca/en/Events/Lists/Events/calendar.aspxFalseWebcastFalse
Webinar 2: Knowledge creation & synthesis27062WebExhttp://www.patientsafetyinstitute.ca/en/Events/KTIS-Webcast-Series-2018/Pages/Webinar-2-Knowledge-creation-synthesis-2018-03-28.aspx3/28/2018 4:00:00 PM3/28/2018 5:00:00 PMThis second interactive webinar in the series will draw upon Dr. Ian Graham's Knowledge to Action cycle and focus specifically on the central role of developing and synthesising evidence of what to implement and which knowledge translation and implementation strategies are most effective for promoting implementation, and developing the knowledge infrastructure to make best use of evidence. 1/30/2018 9:31:27 PMhttp://www.patientsafetyinstitute.ca/en/Events/Lists/Events/calendar.aspxFalseWebcast;Learning SeriesFalse