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Patient Safety Power Play: Our healthcare system needs each of us256249/21/2018 6:54:11 PMPatient Safety Power Plays I’m sure I’m not the only one who finds myself suddenly so much busier, come September. Children and grandchildren return to school; work colleagues are back from vacation. After the warm summer months, the cooler fall air finds me bristling with energy and excitement. I’m ready to start making changes. In response to the Pan-Canadian Health Organization review, and with guidance from our Board of Directors, we have met with the other organizations to discuss how we could best enhance our impact within the health care system, better responding to current and emerging priorities. Throughout this process, Health Canada has encouraged us to continue with business as usual, but we have done some thinking about future possibilities. As the review continues this fall, I will keep my team and our partners updated. I am confident that this next stage in the evolution of our healthcare system – whatever it will look like in the end – will mean a greater emphasis on patient safety. By the end of the month, I will be in Kuala Lumpur for the International Society for Quality in Health Care’s annual meeting. With over 180 invited speakers, 1,500 expected delegates and 400 posters, this year's conference will be ISQua's biggest to date. As we meet to discuss “Weaving the fabric of quality and safety”, I plan to present our patient safety culture “Bundle” for healthcare leaders. Through a literature review of more than 60 resources, the Bundle is based on a set of evidence-based practices that must all be applied in order to deliver good care. I believe that it will receive a warm welcome from representatives in health care around the world. However, the time I anticipated most this month was our own Canadian Patient Safety Institute Annual General Meeting. I spent time with Board Members, my CPSI colleagues, Health Canada representatives, and members of the public to celebrate another spectacular year of achievements in patient safety. You will see many of the highlights in our Annual Report, or by reaching out to one of the many individuals and organizations involved in our efforts this year. In fact, you would be best served by reaching out to one of my CPSI colleagues after you have read the Annual Report. For while I serve a role in forwarding patient safety in our healthcare system, I am proud to say that I am part of an amazing team. Each one of us pulls together to deliver the programs and campaigns that advance our cause. In this issue of the Digital Magazine alone, you will read about a partnership with the Canadian Association of Schools of Nursing to develop learning outcomes for patient safety in undergraduate nursing curricula. We are part of the World Health Organization’s Medication Without Harm campaign and have joined with McGill University Health Centre to deliver a November forum on Enhanced Recovery After Surgery. While I will spend several days this month focused on what we have achieved, our team is already moving forward with new patient safety campaigns sign up to stay informed. I serve as Chief Executive Officer of CPSI because I believe that no patient should suffer avoidable harm when seeking medical care. I am so proud of the team around me, and our partner organizations, for helping to advance this cause. Our healthcare system needs efforts from all of us, across the country and around the world, to make it the safest it can be. What are you doing to make health care safer? I would love to hear from you, and to thank you again for being a passionate advocate for patient safety in Canada. Questions? Comments? My inbox is open to you anytime at Follow me on Twitter @ChrisPowerCPSI. Yours in patient safety, Chris Power 9/21/2018 6:00:00 AMI’m sure I’m not the only one who finds myself suddenly so much busier, come September. Children and grandchildren return to school; work colleagues9/21/2018 7:04:52 PM77
Medication Without Harm – Canada’s contribution to a global effort to reduce medication errors55239/14/2018 4:14:12 PMPatient Safety News Unsafe medication is a leading cause of harm, most of it preventable, in healthcare systems around the world. The World Health Organization (WHO) has initiated the third Global Patient Safety Challenge on Medication Safety to focus on improving medication safety by strengthening the systems for reducing medication errors and avoidable medication-related harm. The overarching goal is to reduce the level of severe, avoidable harm related to medications by 50 per cent, over five years, globally. Medication safety issues can impact health outcomes, length of stay in a healthcare facility, readmission rates, and overall costs to Canada's healthcare system. Preventable medication hospitalizations cost over $140 million CAD in direct and indirect healthcare expenditures, with lost productivity, including time off work, adding $12 million in costs. Globally, the cost associated with medication errors has been estimated at over $55 billion. The Challenge aims to make improvements at each stage of the medication process, including prescribing, dispensing, administering, monitoring and use. The Canadian Patient Safety Institute is leading the Medication Without Harm campaign in Canada. Over the course of the next five years, together with patients and partners, the Canadian Patient Safety institute will develop and execute an implementation plan, monitor and evaluate progress made and work closely with the WHO to ensure the long-term sustainability of strategies implemented over the course of the campaign. The Canadian Patient Safety Institute strategic plan, PATIENT SAFETY RIGHT NOW, calls for medication errors to be reduced by 50 per cent within five years. Canadian Patient Safety Week, to be held October 29 to November 2, 2018, will focus on the medication safety to reduce medication errors across Canada. The theme, Not All Meds Get Along, prompts patients and healthcare practitioners to seek medication reviews for at-risk populations. Patients over the age of 65 are at a higher risk of experiencing medication complications. Two out of three Canadians over the age of 65 take at least five different prescription medications, while 27 per cent take at least 10 different prescription medications. An estimated 37 per cent of seniors in nine provinces have received a prescription for a drug that should not be taken by this population. In 2016, one in 143 Canadians were hospitalized due to harmful effects from the medications they were taking. Medication reviews are recommended for anyone taking five or more medications; patients who have been recently discharged from hospital; and anyone who is concerned about the side effects they, or their loved ones are experiencing. Medication reviews can be completed by your healthcare provider, or pharmacist. In collaboration with the Institute for Safe Medication Practices Canada (ISMP Canada), the Canadian Patient Safety Institute, Patients for Patient Safety Canada, the Canadian Pharmacists Association and the Canadian Society for Hospital Pharmacists a set of five questions has been developed to help patients and caregivers start a conversation about medications to improve communications with their healthcare provider. To increase spread and uptake, 5 Questions to Ask About Your Medications has been formally endorsed by over 70 organizations and regional health authorities for use within their organizations and the tool has been translated into 22 languages. In another partnership with ISMP Canada, a national interactive webinar series has been developed to facilitate shared learning from medication incident analyses and safety initiatives. The Med Safety Exchange is a series of one-hour webinars where frontline practitioners from Canadian healthcare organizations share key learnings to encourage participants to identify similar vulnerabilities and safety opportunities in their own systems and contribute their own strategies for dealing with identified medication safety issues. The bi-monthly webinar series will continue into 2019. In December 2017, Patients for Patient Safety Canada hosted a webinar on patient engagement in medication safety. This global webinar series was designed and facilitated by patient partners. To address opioid safety and stewardship, the Canadian Patient Safety Institute, ISMP Canada and Patients for Patient Safety Canada are working to empower patients and improve their knowledge about the use of opioids and options for non-medication treatment of pain. Two new tools are now available, including an information card that provides guidance on the safe storage and disposal of opioids in the home. The second is a handout to assist patients who have recently been prescribed an opioid following surgery. Common questions are addressed to ensure that patients, families and caregivers have a thorough understanding of how to take these medications properly and safely. Work will continue to integrate opioid safety tools and resources to further empower patients to be aware and increase their knowledge about the use of opioids, including implementing dissemination strategies and tactics to address left-over and end-of life opioid supplies in the home. A number of other initiatives are underway to support the challenge. These include the development of a Medication Safety Self-Assessment for High Alert Medications to help Canadian health organizations assess their safeguards and processes in managing high alert medications; and a safety improvement project, Medication Safety at Transitions of Care. In addition, ongoing work relating to the challenge includes supporting the outreach, education and feedback related to the implementation of the Protecting Canadians From Unsafe Drugs Act (Vanessa’s Law); supporting Health Canada’s ongoing work on a Drug Facts Table for Non-Prescription Drugs; and providing ongoing strategic guidance and support for the Canadian Mediation Incident Reporting and Prevention System (CMIRPS,) and to our partners - ISMP Canada, the Canadian Institute for Health Information (CIHI) and Health Canada. For more information, please contact or medrec@ismp-canada.org9/14/2018 6:00:00 AMUnsafe medication is a leading cause of harm, most of it preventable, in healthcare systems around the world. The World Health Organization (WHO) has9/14/2018 4:29:47 PM433
#SHIFTTalks Cancer survivor creates support network57019/14/2018 4:36:19 PMSHIFT Talks By Chelsea Campbell Chelsea Campbell is the Founder of a health care start-up known as Take Care which was launched in the Fall of 2017. Chelsea has been recognized for her work and has received funding through the GreenHouse, a social impact incubator, and The Spark Initiative. Chelsea is studying Social Development Studies at the University of Waterloo and aspires to be a Child Life Specialist in the near future. To find out more about Take Care go to In 2016, I was starting my second semester at the University of Waterloo when I was suddenly diagnosed with Thyroid Cancer. I was nineteen years old. I had just gained independence by moving away from home, I was just beginning to get into the rhythms of university life and now I found myself facing a serious health issue. I decided to stay in school throughout my cancer experience, and the medical care I received was incredible, but any social care was severely lacking. It was challenging to find the support I needed or even be able to recognize that I needed support at all. Almost a year later, I was introduced to another young adult with Thyroid Cancer and the instant connection we had was incredible. I felt understood and supported in a way I hadn’t up to that point. Months later, I was informed about a cancer support center right in my own city that I could have accessed. These encounters really got me thinking. Why wasn’t I connected with others? Why didn’t I know about the programs running in my own city? In a world so technologically advanced- why aren’t these things happening? My curiosity lead to conducting interviews as I connected with 72 individuals who had cancer as young adults and the results were significant. 92% of these individuals experienced loneliness during their cancer experience, while 64% experienced isolation. Only 8% knew more than 3 individuals around their age with cancer, this statistic alone is lonely and isolating. When I asked what is one thing that these individuals wished they had during their cancer experience, 97% of the answers I received had to do with connection. People want that connection and support, they just don’t know where to find it. Through these interviews, research and many conversations, I was able to recognize three distinct problems that were negatively impacting my cancer experience as a young adult and the experiences of those around me. The first problem is that there is a lack of meaningful connection and support for the young adult cancer community. You can find support and programming for children and for adults fairly easily but there is a distinct gap where young adult support should be. The second problem is that programs that do exist have low interaction because people who need them don’t know about them or they are not accessible due to factors such as location. The third problem is that mental health struggles are very prevalent amongst this specific community of young adults with cancer. Though these are big problems, it seemed as though they could be addressed, to some extent, in a simple way. In September of 2017 I entered into a social entrepreneurship program called GreenHouse, which is run through the University of Waterloo. It was there where I made it my mission to change the way young adults experience cancer and tackle these problems. I wanted to use technology in the young adult cancer community to create meaningful connection through suitable methods, to empower young adults through personal and adaptable connection, to bridge the gaps between what already exists and the individuals who could benefit from it and to allow for easier navigation of programs and resources for young adults in the cancer community. Which is when the concept of Take Care was created! Take Care is an app-based platform for young adults with cancer and young adult cancer survivors to find meaningful connection and support. Take Care focuses on connection to peers who understand, connection to programs the young adult can access in their own community, connection to helpful and applicable resources and connection to creative outlet space for young adults who may want to express themselves in different ways through our online platform. This simple solution has the ability to create a large impact. The Take Care app will be available for download on Apple and Android phones this Fall. Right now, Take Care is focused in Ontario, but it is our goal that Take Care would reach across Canada in the near future, to ensure every young adult touched by cancer is receiving the help and care that they deserve! In my opinion, the coolest thing about Take Care is that it was created due to a problem that I experienced as a patient in the health care system. Our experiences as patients allow us to understand challenges more deeply and create change so others don’t have to face these challenges in the same way. It is my hope that through Take Care, a stronger, more connected and supported young adult cancer community will be established so the only problem to be faced is the cancer itself! 9/14/2018 6:00:00 AMBy: Chelsea Campbell Chelsea Campbell is the Founder of a health care start-up known as Take Care which was launched in the Fall of 2017.9/14/2018 4:47:43 PM377
Patient Safety Power Play: New Safety Improvement Projects from CPSI297848/28/2018 8:03:54 PMPatient Safety Power Plays As the summer winds down and we all start planning for the next few months, I am excited to share that Canadian Patient Safety Institute will be launching new Safety Improvement Projects designed with a Quality Improvement/Knowledge Translation integrated learning design for accelerating Patient Safety in Canada. Sign up for more information, or send this note to the right person in your organization. CPSI wants to work with you, our committed partner, to implement and evaluate measurable and sustainable Safety Improvement Projects that align with pan-Canadian priorities. We hope that you will sign up to learn more about each of these projects, and consider introducing them in your organization with a goal of supporting higher patient safety standards within your organization and across the country. The new Safety Improvement Projects are as follows Measurement and Monitoring of Safety will create a culture of safety and reduce harm in your organization. An information webinar will be held on September 5 for your team members to learn more about the learning collaborative and get answers to their questions. Register here. Teamwork and Communication will lead to improved patient safety culture and positive patient outcomes. Medication Safety at Care Transitions will improve medication safety at discharge for frail elderly patients with poly-morbidity in your organization. Enhanced Recovery Canada will lead to improved outcomes and system efficiencies for colorectal surgery patients. Each Safety Improvement Project lasts 18 months and uses principles from the Institute for Healthcare Improvement Breakthrough Series and the Knowledge to Action Framework. By adopting these projects, you and your organization will step in to a leading role in healthcare delivery. Benefits to participating organizations Support of expert faculty and coaches who are knowledgeable about the best-known evidence as well as practical ideas, tips and tools for application. Use of a collaborative virtual space for networking with other participating teams and faculty, and continual and ongoing support provided through in-person and virtual contact opportunities with coaches. Opportunity to demonstrate, showcase and share the practices that support meeting strategic and operational objectives at a congress event. I encourage you to sign up for further information, or send this note to the right person in your organization. If you have any immediate questions, please email Thank you again for being a passionate advocate for patient safety in Canada. Questions? Comments? My inbox is open to you anytime at Follow me on Twitter @ChrisPowerCPSI. Yours in patient safety, Chris Power 8/28/2018 6:00:00 AMAs the summer winds down and we all start planning for the next few months, I am excited to share that Canadian Patient Safety Institute will be8/28/2018 8:11:08 PM459
Patient Safety Power Play: Make this a summer to remember312447/30/2018 6:54:07 PMPatient Safety News Canada has some of the shortest summer months, full of the longest summer days. As I look forward to enjoying the beautiful weather with my friends and family, I can't help thinking of the progress we've made this year. It's as if, by marking our successes, I can make the days a little longer and the weather a little warmer! First of all, I would like to offer my thanks to all our hard-working members of the Canadian healthcare community. I wish to thank you, as always, for your amazing efforts on behalf of the thousands of people you care for every day. Whether you serve in the front lines, behind the scenes, at the policy-making table, in homes or in researching the future of care, a career in healthcare is one of the most challenging – and rewarding. By definition, you think of others before you think of yourselves. I urge each and every one of you to take time this summer with family and friends to care for yourselves so you can continue to care for the rest of us. Next, I would like to thank each one of you who have helped us in our mission to make healthcare safer for patients. Our tireless volunteers in Patients for Patient Safety Canada share their stories and dedicate their efforts to holding the healthcare system accountable. Those of you who participate in our annual STOP! Clean Your Hands Day and Canadian Patient Safety Week campaigns help improve patient safety for everyone. The healthcare workers, educators and administrators who participate in CPSI programs are each doing their part to help us achieve our vision to ensure Canada has the safest healthcare in the world. Finally, I want to recognize our partner organizations, without whom we would have a much harder task than the momentous one that lies before us. Our Voting Members consist of national organizations, federal departments, and local government agencies who all work together to guarantee patient safety across Canada. Representing these groups, our devoted Board Members champion our efforts. Thanks to the partnerships and support we enjoy, this year CPSI developed Patient Safety Right Now, a bold new direction with an urgent call to action. Together with the exceptional efforts of the staff and supporters of the Canadian Patient Safety Institute, we will demonstrate what works and strengthen commitment to patient safety in Canada… right now! Our precious Canadian summer months are often a time many choose to take some well-earned vacation. The successes we've seen in the past year will help make those long summer evenings just that much better. I invite you to celebrate those successes with me – and tell me how we can work together in the next year to deliver on this promise of patient safety we have made together. Until then, enjoy your time in the summer sun, and think about how you and your organization will help address the concerns of multiple medications during Canadian Patient Safety Week at the end of October. Please have a look at the amazing resources and dedicated speakers available during October 29 to November 2nd visit Questions? Comments? My inbox is open to you anytime at Follow me on Twitter @ChrisPowerCPSI. Yours in patient safety, Chris Power7/30/2018 6:00:00 AMCanada has some of the shortest summer months, full of the longest summer days. As I look forward to enjoying the beautiful weather with my friends7/30/2018 7:02:25 PM288

 Latest Alerts



Neonatal Death11218352910/1/2017 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 PM4
Express Levothyroxine Doses in Micrograms not Milligrams1123135183/8/2017 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 PM6
Deteriorating Patient Condition Associated with Medical Gas System Dysfunction 1121735303/1/2017 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 PM3
Gaps in Medication Monitoring May Contribute to Death1123335172/28/2017 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 PM5
Some Medications Don’t Mix 1123435162/8/2017 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 PM3