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 CPSI News



We need more champions like Maryann Murray51221/15/2018 3:55:29 PMPatient 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 PM161
Patient Safety Power Play - Expanding our international reach51301/15/2018 4:48:54 PMPatient Safety Power Plays ​At the Canadian Patient Safety Institute, we work to improve the safety and quality of care for all Canadians. Over the years, however, our efforts have attracted the attention of those outside of our borders. In fact, 30 per cent of our website traffic comes from outside of Canada. Over at Global Patient Safety Alerts, 21 of our 26 contributors are from foreign countries. We're thrilled to represent Canada on the international stage, and thanks to our ever-growing relationship with the World Health Organizations, our role is only set to grow. In September 2017, the WHO officially designated CPSI as a WHO Collaborating Centre for Patient Safety and Patient Engagement, to carry out activities in support of WHO programs internationally. What this means, is that in the coming years, CPSI will lend policy, strategic and technical advice on various WHO initiatives, as well as support for the development, adaptation, spread, and evaluation of patient safety tools and resources at a global level. We will be applying Canadian expertise to a few specific initiativesProvide coordination support and advice to the global Patients for Patient Safety champion network Provide coordination and secretariat support to the Patients for Patient Safety Advisory GroupProvide expert advice and capacity building for patient/family champions and leaders of patients for patient safety networks around the world.Support global efforts and initiatives on patient safety incident 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 While we're tremendously excited and ready to embrace our growing role internationally, rest assured that our focus remains on providing the Canadian healthcare system with products to improve patient safety domestically. What our expanding global reach allows us to do is export much of that knowledge to those needing help in other countries, and at the same time keep an eye out for improvement ideas that we can import into Canada as well. It's a win-win for all involved and it's a very Canadian thing to do! As always, I'd like to hear from you, be it about our international work or anything else that is on your mind. You can reach me via email at or on Twitter @ChrisPowerCPSI. Yours in patient safety, Chris PowerCEO, Canadian Patient Safety Institute 1/15/2018 7:00:00 AMAt the Canadian Patient Safety Institute, we work to improve the safety and quality of care for all Canadians. Over the years, however, our efforts1/15/2018 4:52:56 PM93
#SuperSHIFTERS An Interview with Celia Laur - Improving nutritional care in Canadian hospitals3334512/14/2017 10:55:06 PMSuper SHIFTERS Celia Laur is a PhD candidate at the University of Waterloo, a member of the CPSI Knowledge Translation/Implementation Science Faculty, and core member of the More-2-Eat (M2E) implementation project that aimed to improve nutrition care in Canadian hospitals. Celia, can you tell us a bit about your project Nutrition is an important part of recovery in hospital, making it a patient safety issue. M2E was designed to work with hospitals to improve their nutrition care such as by adding a nutrition screening and assessment process so that those at risk are seen by a dietitian and receive appropriate nutrition care throughout their stay. In M2E, 5 Canadian hospitals worked with researchers at the University of Waterloo to improve the nutrition care provided on one unit for a year. All five sites are now conducting nutrition screening, and dietitians are using a standardized assessment that allows them to triage patients and focus in on those patients most in need of their time. Some hospitals also introduced ways to decrease barriers to food intake such as by introducing mealtime volunteers to make sure that patients could reach their meal and have what they need to eat. Other sites focused on monitoring how much a patient was eating, determining why intake was poor, and putting into place changes that would support food intake for the patient. Overall, the M2E project supported hospitals to meet the nutrition needs of their patients, and encourages other hospitals to do the same. M2E is led by Professor Heather Keller, who is based at the University of Waterloo, and is the Schlegel Research Chair in Nutrition and Aging. Professor Keller is co-chair of the Canadian Malnutrition Task Force, which conducted a large study outlining the prevalence of malnutrition and barriers to food intake in Canadian hospitals. Why did you choose to tackle the issue of Malnutrition? 45% of people who stay 2 or more days in hospital in Canada are malnourished, and two thirds of these individuals leave hospital still malnourished [1]. All patients, malnourished or not, should receive appropriate nutrition care to support their recovery, making nutrition an important patient safety issue. Malnutrition has been shown to independently increase mortality, length of stay, and risk of readmission, affecting patient flow and, ultimately, healthcare costs [1-3]. In Canada, a malnourished patient's cost of hospital care was approximately $2000 more than a well-nourished patient's care [2]. Food is an important part of our lives, and in hospital it can support recovery, making nutrition care a crucial part of the hospital stay. Why is this approach innovative? For many years, people have been discussing the issue of malnutrition in hospital, but few attempts have been made to fix the problem. Pilots have been conducted, but few projects aimed to address the overall issues, or to change the nutrition culture of a hospital. M2E took that research and expert opinion about what should happen, and then worked with the hospitals to make a difference, support the nutrition care needs of patients, working towards improving the nutrition culture in hospital. What was one major learning you had from working on this project? Improving nutrition care in hospital is possible. Because of More-2-Eat, all five sites are screening at least 70% of patients on admission, and 100% of patients identified as severely malnourished are receiving appropriate care [4]. Over the year, use of nutrition care strategies to support malnourished or at risk patients (providing nutrient dense diets, oral nutritional supplements, preferred foods, etc.) increased from 31% to 61% over the course of the year [4]. A staff survey showed that 70% of staff noticed a positive change in nutrition care on their unit [5]. Interviews with hospital staff and management show what staff think about how changes to nutrition care should be made [6]. Results are on their way regarding the impact on length of stay, barriers to food intake, ways to keep the change going, and more. Can others tap into this program, can they replicate your success? Yes, we strongly encourage others to learn from the M2E hospitals and become a champion in their own setting. Everyone can be involved. In M2E, the 5 sites started with the Integrated Nutrition Pathway for Acute Care (INPAC) and worked towards implementing the components of INPAC. INPAC outlines a pathway for the identification, prevention, treatment, and monitoring of malnutrition [7]. The INPAC is designed to be a flexible guide, aimed at meeting the needs of the hospital or unit to benefit the patients. What we learned in M2E about what and how to implement INPAC is available in an online toolkit that anyone can access and use. There is also an online e-mail group that anyone can join that has people from across Canada discussing what they are doing in their hospital, while seeking advice from others going through the same process. Change is possible and we encourage you to get involved. Where can people go to learn more? For more information, the toolkit is available here http// More information about the Canadian Malnutrition Task Force is available here http// More-2-Eat is funded by the Canadian Frailty Network. References (1) Allard JP, Keller H, Jeejeebhoy KN, Laporte M, Duerksen D, Gramlich L, Payette H, Bernier P, Vesnaver E, Davidson B, Terterina A, Lou W. Malnutrition at hospital admission contributors and effect on length of stay. A prospective cohort study from the Canadian Malnutrition Task Force. J Parenter Enteral Nutrition 2016;40(4)doi 10.1177/0148607114567902. (2) Curtis LJ, Bernier P, Jeejeebhoy K, Allard J, Duerksen D, Gramlich L, et al. Costs of hospital malnutrition. Clinical Nutrition 2016 Sep. (3) Pamela L Ramage-Morin, Heather Gilmour, Michelle Rotermann. Nutritional risk, hospitalization and mortality among community-dwelling Canadians aged 65 or older. Health Reports 2017 Sep 1,;28(9)17. (4) Keller H, Valaitis R, McNicholl T, Laur C, Xu Y, Dubin J, et al. Successful Multi-Site Implementation of Nutrition Risk Screening and Assessment Triage in Medical Inpatients The More-2-Eat Study. ESPEN Conference Abstract 2017. (5) Laur CV, Keller HH, Curtis L, Douglas P, Murphy J, Ray S. Comparing Hospital Staff Nutrition Knowledge, Attitudes, and Practices Before and 1 Year After Improving Nutrition Care Results From the More-2-Eat Implementation Project. JPEN J Parenter Enteral Nutr 2017. (6) Laur CV, Valaitis R, Bell J, Keller HH. Changing nutrition care practices in hospital a thematic analysis of hospital staff perspectives. BMC Health Services Research 2017;17(498). (7) Keller HH, McCullough J, Davidson B, Vesnaver E, Laporte M, Gramlich L, Allard J, Bernier P, Duerksen D, Jeejeebhoy K. The Integrated Nutrition Pathway for Acute Care (INPAC) Building consensus with a modified Delphi. . Nutr J 2015;19(14)63.12/15/2017 7:00:00 AMCelia Laur is a PhD candidate at the University of Waterloo, a member of the CPSI Knowledge Translation/Implementation Science Faculty, and core12/15/2017 6:34:11 PM699
Patient Safety Power Play – 2017 in review3331112/7/2017 10:36:52 PMPatient Safety Power Plays It's that time of year again . . . how 2017 has flown by.... but that tends to happen when you love what you do and the people with whom you get to do it. Given that the year is winding down, this is the perfect opportunity to revisit my Canadian Patient Safety Institute 2017 checklist. Continually raising the bar for quality improvement and advancing the patient safety agenda? Check!Unprecedented collaboration with patients and partners? Check!A brand new bold strategic plan and a bright future for patient safety in Canada? Check! Here's a quick look at what made 2017 another smashing success and why the CPSI is better positioned than ever to continue working with the healthcare system to make care saferRelease of "The Case for Investing in Patient Safety" report (Left to right) Robert Vandervelde, CPSI, Michael Higgins, Alberta Prime TimeThe most recent data available on harm in healthcare, this report details the threats as well as the significantly higher healthcare costs that result from patient safety incidents.Joint Position Statement on the use of a Safe Surgical Checklist With the support of Alberta Health Services (AHS), the Canadian Anesthesiologists' Society (CAS), and the Operating Room Nurses Association of Canada (ORNAC), CPSI released a joint position statement calling for the widespread use of a surgical safety checklist in operating rooms across Canada.A Consortium Celebration After years of collaboration, members of the National Patient Safety Consortium gathered one more time to celebrate the fruits of our labour. See for yourself what passion for patient safety means to this incredible group.Federal Health Ministers making patient safety a priority Both former Health Minister Jane Philpott, and current Health Minister Ginette Petitpas Taylor were involved in a pair of our biggest events of the year STOP! Clean Your Hands Day and Canadian Patient Safety Week. We thank the office of the Health Minister for the ongoing support of, and interest in patient safety.#SuperSHIFTERS and #SHIFTtalks seriesWhen we launched SHIFT to Safety, we made it a goal to profile the best and brightest people and organizations that embodied what SHIFT to Safety is all about understanding HOW to improve culture, teamwork and quality. Each month, read a brand-new installment of the #SuperSHIFTERS and #SHIFTtalks series.WHO Collaborating Centre (From left to right) Dr. Jonas Gonseth-Garcia, Advisor, Quality in Health Systems and Services, Pan-American Health Organization/World Health Organization, Helen Haskell, Co-chair, WHO Patients for Patient Safety Advisory Group, and Chris Power, CEO, Canadian Patient Safety Institute. The World Health Organization has officially designated CPSI as a WHO Collaborating Centre for Patient Safety and Patient Engagement to carry out activities in support of WHO programs internationally. We're thrilled with this designation and the WHO's belief in our abilities. We look forward to representing Canada on the global stage! Of course, this is but the tip of the iceberg. Our website is bursting at the seams with patient safety and quality improvement opportunities. What about you? What are your highlights of the year? What will you remember about 2017 and what has you excited for 2018? As always you can connect with me directly at or on Twitter @ChrisPowerCPSI. Yours in patient safety, Chris Power CEO, Canadian Patient Safety Institute12/7/2017 7:00:00 AMIt's that time of year again . . . how 2017 has flown by.... but that tends to happen when you love what you do and the people with whom you get to12/7/2017 11:08:21 PM452
#SHIFTTalks Teamwork is where it’s at3330012/5/2017 8:12:53 PMSHIFT Talks When I started at the Health Quality Council of Alberta (HQCA) in 2015, my director handed me a giant binder – 3 inches, D-ring – it was huge. I admit, I was somewhat overwhelmed. My first thought was, "do you want me to read that whole thing?" The binder held information about a project involving TeamSTEPPS – a healthcare teamwork training program that provides a standard team-based approach to patient care. TeamSTEPPS is delivered by the Agency for Healthcare Research and Quality (AHRQ) out of the United States. Despite the initially feeling overwhelmed, my second gut reaction was yes, I'm up for the challenge! I went through the binder and searched the AHRQ website to try and get my head around what this TeamSTEPPS stuff was all about. I quickly realized that despite not knowing the "TeamSTEPPS" brand, I had been using the tools taught in the TeamSTEPPS program for years. My first exposure to TeamSTEPPS was back when I took an Emergency Medical Responder course (about a million years ago), and they introduced us to SBAR (Situation Background Assessment Recommendation), a standardized, mnemonic, communication tool that allows a quick, concise transfer of information from one healthcare practitioner to another. At the time, I did not fully recognize how important this was. I was young, and quite frankly, very naïve. As my career progressed, I started to recognize the power of this fundamental gem that I was taught so long ago. I noticed the silos among healthcare professions. Nurses speak "nurse," lab techs speak "lab tech," doctors speak "doctor" . . . you get the idea. The problem is that communication between professions is hindered; we are not all speaking the same language. And the REAL problem is that this is dangerous for patients. Communication is only ONE of the teamwork skills that TeamSTEPPS addresses. Leadership, situational monitoring and mutual support are all equally important to successful teamwork and positive patient outcomes. Fast forward to 2016. I received an email from our executive director drawing our attention to the work that the Canadian Patient Safety Institute (CPSI) had begun in TeamSTEPPS. I was thrilled to know that someone else was undertaking the implementation of TeamSTEPPS training into Canada. We quickly connected with CPSI, and are moving along in our teamwork journey as we "Canadian-ize" TeamSTEPPS content, together, as a team (see what I did there?). There are numerous stories where if teamwork were improved, then the outcome for the patient may have been different. Of course there is no way to know what could have been, but there are pivotal moments in all tragic patient outcome stories where it is clear that working together as a team could have improved the situation. Yup. Teamwork is where it's at! By Rhonda Shea BSc MA MLT Lead, Collaborative Learning &EducationHealth Quality Council of Alberta 12/5/2017 7:00:00 AMWhen I started at the Health Quality Council of Alberta (HQCA) in 2015, my director handed me a giant binder – 3 inches, D-ring – it was huge. I12/5/2017 9:32:19 PM797

 Latest Alerts



Neonatal Death12946352910/1/2017 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 PM7
Express Levothyroxine Doses in Micrograms not Milligrams1295935183/8/2017 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 PM8
Deteriorating Patient Condition Associated with Medical Gas System Dysfunction 1294535303/1/2017 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 Death1296135172/28/2017 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 1296235162/8/2017 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 PM6