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 CPSI News



CPSI designated as WHO Collaborating Centre for Patient Safety and Patient Engagement329799/14/2017 8:47:00 PMPatient Safety News With the support of the Government of Canada, the World Health Organization (WHO) has officially designated the Canadian Patient Safety Institute as a WHO Collaborating Centre for Patient Safety and Patient Engagement to carry out activities in support of WHO programs internationally. Of the more than 800 WHO Collaborating Centres from 80 countries worldwide, 31 are from Canada. The Canadian Patient Safety Institute is the only WHO Collaborating Centre in Canada with a focus on both patient safety and patient engagement. The four-year agreement (2017-2021) will include activities targeted in four areasProvide coordination support and advice to the global Patients for Patient Safety (PFPS) advisory group Support global efforts and initiatives on patient safety reporting and learning systems Contribute to the planning and implementation of the 3rd Global Patient Safety Challenge on Medication Safety Support global patient safety initiatives in achieving safer care "The Canadian Patient Safety Institute has a long-standing collaborative relationship with the WHO Patient Safety Programme internationally, and has been a catalyst in developing collaborative partnerships across the country," says Chris Power, CEO, Canadian Patient Safety Institute. "We have benefited from the support of the WHO and their members in the development of Canadian products and services, and indirectly we have provided Canadian support to assist transitional and developing countries. We are excited about this opportunity to advance safer care through patient safety and patient engagement, both locally and globally." Building on the Canadian Patient Safety Institute's well established support to Patients for Patient Safety Canada over the past 10 years, the Canadian Patient Safety Institute will provide support to the global PFPS advisory group that will include coordination and secretariat support for the WHO PFPS Advisory Network and building capacity for patient/family champions and leaders of PFPS global networks. Each year of the agreement, the Canadian Patient Safety Institute will coordinate quarterly meetings of the PFPS advisory group and deliver three knowledge transfer webinars in English and French, to build capacity of the Network's patient safety champions and leaders. "The WHO's PFPS programme engages patients and families in improving the safety of health care, to enhance and build capacity, and to become informed and knowledgeable partners in their own care," says Helen Haskell, Co-chair, WHO Patients for Patient Safety Advisory Group. "PFPS workshops bring together PFPS advocates, health care professionals, local leaders, health care organizations and policy-makers to share knowledge about the national health system and to explore mechanisms to improve patient engagement for safety. Working with the Canadian Patient Safety Institute as a WHO Collaborating Centre provides the opportunity to share our experiences and knowledge on patient safety and patient engagement." To broaden reporting, learning and sharing from harm, the Canadian Patient Safety Institute hosts Global Patient Safety Alerts, a web-based resource featuring a comprehensive collection of patient safety alerts, advisories and recommendations from around the world. Work will continue to expand its use and contributions from international organizations. "Too much healthcare delivered around the world carries avoidable harm," says Sir Liam Donaldson, Patient Safety Envoy, WHO. "With tools like Global Patient Safety Alerts, we can effectively share information about patient safety risks and effective ways to manage those risks and prevent harm. Through initiatives like the WHO Collaborating Centers, the processes to collect, analyze, communicate and disseminate information and trends to users and potential contributors can be improved." As the Canadian coordinating body, the Canadian Patient Safety Institute is participating in the 3rd Global Patient Safety Challenge on Medication Safety. The Canadian Patient Safety Institute is a member of the WHO Patients and Public Working Group and provides expertise and support to the global medication safety challenge. Maryann Murray, a member of Patients for Patient Safety Canada, recently addressed the World Health Assembly's annual meeting to share her experiences leading to her daughter's death, and highlighted the Five Questions to Ask about Your Medications, a Canadian tool developed by patients and providers on how to have a conversation about safe medication use. The tool is available in 20 different languages. "The challenge of improving medication safety is now being embraced in Canada and around the world. By sharing knowledge and resources, we contribute to the development of universal products and tools that will assist in significantly reducing medication harm around the globe," says Maryann Murray. To support global patient safety initiatives, the Canadian Patient Safety Institute will provide policy, strategic and technical advice and consultation at various platforms including WHO global and regional consultations or events, working groups, and committees; and provide advice and support in the development, adaptation, spread, and/or evaluation of patient safety tools and resources at a global level. Patient engagement is a priority for many Canadian organizations. Led by the Canadian Patient Safety Institute, the National Patient Safety Consortium, a group of more than 50 organizations, established the Integrated Patient Safety Action Plan, a shared action plan for safer healthcare. One of the plan's guiding principles is patient engagement. "Patient engagement is a core strategy for advancing universal health coverage, safe and quality health care, service coordination and people-centredness," says Dr. Neelam Dhingra-Kumar, Coordinator, Patient Safety and Quality Improvement, WHO headquarters, Geneva. "Canada is recognized as a world leader in both patient safety and patient engagement so we believe that this collaboration will help improve lives around the world." For more information about the WHO Collaborating Centre designation, visit the WHO website. 9/17/2017 6:00:00 AMWith the support of the Government of Canada, the World Health Organization (WHO) has officially designated the Canadian Patient Safety Institute as9/17/2017 7:52:08 PM176
Change Day Ontario 2017328959/11/2017 7:23:21 PMPatient Safety News ​Change Day Ontario Make a Difference in Patient Care Associate Medical Services and Health Quality Ontario – with support from The Canadian Patient Safety Institute - invite you to support healthcare organizations from across Ontario for two months in the Fall as Change Day Ontario 2017 takes place. What is Change Day Ontario? It is a growing global movement that supports people with first hand experience in the Canadian healthcare system to create positive change. But how is this done you ask? By making pledges – large or small- to drive the change they want to see forward. This event is about people connecting through their ideas and stories and sharing them through social media. Its about engaging with one another and overcoming barriers. Ultimately, Change Day Ontario is about is about helping to improve care for patients and providers. With that in mind, join Change Day Ontario and make a pledge to improve compassionate quality care and inspire positive change within the health system. Visit to learn more and to sign up as an Ambassador. As a reminder, pledging begins September 12, 2017, and will culminate in a day of celebration which will take place on November 17, 2017. Change Day Alberta​​​​ http// Change Day BC https// Butterworth9/12/2017 2:30:00 PM Change Day Ontario: Make a Difference in Patient Care Associate Medical Services and Health Quality Ontario – with support from The Canadian9/15/2017 7:19:44 PM89
Patient Safety Power Play: Partnering to prevent the Deteriorating Patient Condition328909/8/2017 5:32:03 PMPatient Safety Power Plays Early warning signs of deteriorating condition are often unrecognized, leading to devastating results. Research shows that virtually all critical patient events are preceded by warning signs that occur several in advance. The Canadian Patient Safety Institute (CPSI) and the Healthcare Insurance Reciprocal of Canada (HIROC), continuously assert the importance of patient engagement in healthcare. We believe the patient and family have a voice at the bedside, and are vital to safe care outcomes. When it comes to the deteriorating patient condition, family members are a vital part of the healthcare team and are often best positioned to recognize the sometimes subtle, yet very important changes in their loved one's condition that may indicate deterioration. They may not know WHAT is wrong, but they're often the first to notice when something "just isn't right". Look no further than the story of Mataya Robin as an example of what we're talking about CPSI and HIROC, determined to be instrumental in ending preventable harm caused by the deteriorating patient condition, have partnered in an effort to curate the most comprehensive set of tools and resources related to the deteriorating patient condition in Canada, if not the world. You can access them all free of charge by searching "Deteriorating Patient Condition" or "DPC" at Deteriorating Patient Condition If you've got a family member currently in the healthcare system, learn to recognize the signs and symptoms of the deteriorating patient condition and how to effectively discuss your concerns with the healthcare provider. For providers and leaders, learn about the deteriorating patient condition in various care settings, and become a champion for patient engagement as you empower patients and family members to serve as your eyes and ears and monitor for early warning signs that something may be wrong. Together, we can reduce preventable harm. Yours in patient safety, Chris Power Catherine Gaulton CEO CEO Canadian Patient Safety Institute Healthcare Insurance Reciprocal of Canada 9/8/2017 6:00:00 AMEarly warning signs of deteriorating condition are often unrecognized, leading to devastating results. Research shows that virtually all critical9/8/2017 6:01:24 PM249
#SHIFTTalks Hear me out328919/8/2017 4:10:54 PMPatient Safety News The value of effective communication during patient handovers Just hours after being discharged from the emergency department, a five-week old infant sustained permanent brain damage due to a delayed diagnosis and treatment for meningitis. The cause – miscommunication and the absence of a reliable process to ensure pending tests following a patient discharge. Cases like these beg the question, are poor communication practices during shift changes and transfers between care providers so ubiquitous in healthcare that we have become numb to their chilling effects on patient safety? Sadly, we might think we’re communicating well but in the chaotic and stressful healthcare environment, the messages can easily start to look like a game of broken telephone. Communication handovers – be they between healthcare providers, facilities or sectors – can be complex. One article suggested that the average healthcare provider encounters 11 to 15 interruptions hourly. Other research tells us that only 42% of nurses can identify their patient’s primary care provider and 23% of physicians can identify their patient’s primary nurse. According to CRICO, healthcare miscommunication cost $1.7B and impacted nearly 2,000 lives in a study of claims filed between 2009 and 2013. A similar grim situation exists in Canada. The Canadian Adverse Events Study found miscommunication during care transitions were a key factor in medication adverse events. Based on claims data from HIROC (the Healthcare Insurance Reciprocal of Canada), communication failures contributed to an estimated $305 million in medical legal costs since 1987. Contrary to these findings, The 2015 Accreditation Canada Report on Required Organizational Practices (ROP) revealed an overall compliance score of 99% for the practice of ensuring effective information at transition points. However, this finding specified that tests for compliance did not assess the quality of information transferred. There are some promising signs that things are changing. We are seeing studies on standardized practices to bridge the gap between varying communication styles. There is also a focus on team-based safety practices such as routine huddles and debriefs to enhance communication. And finally, tools and resources like CPSI’s SHIFT to Safety platform help empower patients and families to start conversations during care transitions. For leadership, it comes down to prioritizing effective communication, making use of technology and building of a culture of safety. We must do it for our staff, our organizations and for our patients who leave their fate in our hands. ​ ​By Joanna Noble, Supervisor, Knowledge Transfer Healthcare Risk Management, HIROC 9/8/2017 6:00:00 AMThe value of effective communication during patient handovers Just hours after being discharged from the emergency department, a five-week old9/11/2017 4:40:02 PM531
Patient Safety Power Play: Meeting with the Council of Federation98978/3/2017 9:56:35 PMPatient Safety Power Plays Today in Canada, every 17 minutes someone dies in a hospital from an adverse event. That's about 31,000 people a year. We also know 1 out of 18 hospital visits results in preventable harm or even death. It's no better in the community, where up to 13 per cent of people receiving home care experience a harmful adverse event like a fall or medication error. According to a June 2017 report from the Organization for Economic Co-operation and Development, the economic burden of adverse events in Canadian hospitals in 2009-2010, where the burden attributable to preventable adverse events was estimated at $ 397 million. This level of harm is simply unacceptable. The Canadian Patient Safety Institute (CPSI) hopes that the Council of the Federation, composed of Canada's premiers, will make patient safety promotion a priority. As policy makers and elected officials gathered in Edmonton during the Council of the Federation last month to make difficult decisions about where to invest money, I was fortunate to have the opportunity to stress the point to them that the work of the Canadian Patient Safety Institute is critically important for preventing harm from happening, responding to harm when it does happen and learning from harm so that it doesn't happen again. In the months ahead, as we near a decision from Health Canada regarding our future funding, we look forward to close collaboration with all levels of governments and the stakeholder community, so all Canadians can access safe healthcare. Since 2003, CPSI has been on the front lines, working with providers and healthcare organizations to improve patient safety through education, research, and evidenced-based clinical interventions. We've received excellent support from Health Canada and both federal and provincial governments over the years, but the reality is we need more to ensure Canada has the safest healthcare system in the world. CPSI is the only national organization solely dedicated to reducing preventable harm and improving the safety of healthcare. Established as the result of a rallying cry led by dedicated individuals working within the healthcare system that couldn't experience one more incident of a patient getting harmed CPSI has a mandate to provide national leadership by working with federal, provincial and territorial leaders on developing evidence based tools and resources to educate and inspire safer care. In order to continue our mandate, we're looking for support from throughout the healthcare system, if you'd like to lend a voice to our cause, please reach out to me via email at to learn more about how you can help. Thank you. Yours in patient safety, Chris Power8/3/2017 6:00:00 AMToday in Canada, every 17 minutes someone dies in a hospital from an adverse event.  That's about 31,000 people a year. We also know 1 out of 188/3/2017 10:04:28 PM208

 Latest Alerts



Neonatal Death13000352910/1/2017 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 PM
Express Levothyroxine Doses in Micrograms not Milligrams1301335183/8/2017 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 PM
Deteriorating Patient Condition Associated with Medical Gas System Dysfunction 1299935303/1/2017 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 PM
Gaps in Medication Monitoring May Contribute to Death1301535172/28/2017 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 PM
Some Medications Don’t Mix 1301635162/8/2017 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 PM