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North York General Hospital receives 2017 Patient Safety Champion Award recognizing its innovative approach to Never Events324146/12/2017 4:03:58 PMPatient Safety News Jennifer Quaglietta (Director, Patient Experience) and Quality and Renee Blomme (Manager Patient Experience & Corporate Risk) North York General Hospital is the 2017 recipient of the Patient Safety Champion Award for organizations. Presented annually by the Canadian Patient Safety Institute, HealthCareCAN, and Patients for Patient Safety Canada, the Patient Safety Champion Award recognizes volunteers and organizations that are taking a leadership role in ensuring that patients and families are at the centre of patient safety initiatives. The prominent Award was presented at the National Health Leadership Conference in Vancouver, on June 12, 2017. In September 2015, an Action Team from the National Patient Safety Consortium released the 15 "Never Events" for Hospital Care in Canada, based on adverse events that have been demonstrated to be reliably preventable. A never event is best described as patient safety incidents that result in serious patient harm or death, and can be prevented using organizational checks and balances. North York General Hospital (NYGH) was quick to align its efforts to support the elimination or reduction of organizational never events, creating 15 Never Event Action Teams (NEATs) to lead the identification, measurement and documentation of strategies to mitigate and decrease the likelihood and severity of all 15 never events. In a phased roll-out strategy, beginning during Canadian Patient Safety Week in October 2016, and continuing until April 2018, each NEAT team is working on an action plan to identify, develop and implement innovative prevention and mitigation strategies for a prescribed never event. The progressive rollout strategy provides an opportunity to learn from each launch and make adjustments along the way. One of the first initiatives out of the gate was an action plan for pressure injury prevention strategies. Consolidating work that had been underway since April 2015, this was an opportunity to implement a new approach to pressure injury prevention and care. Comprehensive in nature, the new care model was accompanied by the introduction of inter-professional staff education initiatives, targeted engagement of the patient and family in pressure injury prevention strategies, the adaptation of previously established risk assessment measures and processes, and the creation of an evidence-based, holistic pressure injury prevention plan. This work has been led by Anna Tupis, Director, Cancer Care and Ambulatory Care. Quality Improvement initiatives associated with the new model of care delivery for pressure injury prevention includeA monthly Dashboard Report to facilitate the tracking of identified wounds. An education program, where 200 frontline nurses and 40 wound care champions have received in depth training in pressure injury prevention and care. A comprehensive bed surface survey facilitated the purchase of 286 new specialty bed surfaces.The launch of a health teaching pamphlet on pressure injuries for patients and families was developed in conjunction with the Patient & Family Advisory Council (PFAC).Corporate streamlining of wound care products to better facilitate the standardization of clinical wound care management. "This pressure injury NEAT demonstrates how NYGH, through a quality lens, endeavours to keep our patients safe through an interdisciplinary approach to care," says Anna Tupis. In addition, work is now underway to pursue the development of a mattress selection algorithm, as well as engaging in a review of clinical electronic documentation forms. For more seamless transitions of care, the revised electronic documentation forms would allow for wound care summaries and care plans to be easily shared with community partners upon discharge. "For our first never event, we wanted to choose one that was having the most impact on the patient experience," says Jennifer Quaglietta, Director, Patient Experience and Quality. "Looking at our incident reporting system and in collaboration with the PFAC, we had noted that hospital-acquired pressure injuries were a challenge that we were facing." Stage III and IV pressure ulcers, or bed sores, can lead to serious complications, such as infections of the bone or blood (sepsis). NYGH has mandated the reporting of all incidents at stage III or IV pressure ulcers acquired after admission to hospital. Last year, double-digit incidents were recorded for pressure ulcers; however as the injury prevention strategies were implemented, no critical pressure ulcers have been reported since the first quarter of 2017. "We wanted to handle this project in a way that would be sustainable. If we would have gone with all 15 NEAT projects in one go, I don't think we would have been able to manage it in a manner that would have been supportive to everyone involved," says Renee Blomme, Manager Patient Experience & Corporate Risk. "This is not a new process, it is something that our people are familiar with and builds on the work that teams have already done for our Enterprise Risk Management Program, where you look at a risk and identify strategies for prevention and mitigation." A comprehensive governance structure has also been implemented. Each of the 15 NEATs is led by a program manager and a physician co-chairs the team. In addition, each NEAT is supported by a dedicated Patient and Family Advisor. The mandate of each team is to drive project completion, assess mitigation and prevention strategies, identify gaps and develop action plans to ensure that a protocol or standard of care is in place to prevent injuries or decrease the risk to patients. Jennifer Quaglietta, Renee Blomme and Katie Anawati act as the Secretariat for the project teams, to ensure the proper structure is in place and help the project teams to prepare reports that flow to the Steering Committee and Quality Committee of the Board. As quality and safety is a strategic priority of the organization, the program is managed under the leadership of Karyn Popovich, Vice President of Clinical Programs, Quality and Safety, and Chief Nursing Executive. Karyn acts as the key link between the work of the Steering Committee and the Senior Leadership Team (SLT) and Quality Committee of the Board. "We are committed to providing safe, quality care to our patients, and implementing NEATs builds a structure of accountability and proactive approach to patient safety," says Karyn Popovich. All 15 NEAT leads sit on a NEAT Steering Committee that meets quarterly to discuss rollout plans, best practices and lessons learned. The NEAT Steering Committee provides updates to the NYGH Quality of Care Committee, who provides operational oversight for the quality, safety and risk of the organization. The Quality of Care Committee meets monthly to review progress, provide recommendations on issues and support various resolutions. The Quality of Care Committee, through Karyn Popovich, report up to the SLT, comprised of the CEO, all Vice-Presidents and the chair of the Medical Advisory Committee. A Never Event dashboard tracks how many never events are occurring at NYGH on a quarterly basis. Once or twice a year, a report on never events is presented to the Quality Committee of the Board, which provides governing oversight of the quality, safety and risk of the organization. "Patients come first in everything we do," says Jennifer Quaglietta. "To ensure the initiative remains grounded in patient experience, we have integrated Patient and Family Advisors at each level -- on each of the project teams, on the main Steering Committee and the Quality of Care Committee." NYGH has shared their work with the Joint Centre for Transformative Healthcare Innovation, a consortium of six hospitals in the Greater Toronto area that provides an opportunity to learn from others, share best practices and spread a project's scale. They also hope to spread their work provincially, nationally and internationally by the end of the year. "We are excited to receive this Award and the opportunity to really showcase the great work being done by the staff at North York General Hospital on a daily basis," says Katie Anawati, Patient Safety and Risk Specialist. "We have a wonderful inter-professional team and as a community hospital, we have taken a bottom-up, team approach to this initiative." Congratulations, North York General Hospital! Your innovative approach to Never Events is truly inspiring.6/13/2017 6:00:00 AMJennifer Quaglietta (Director, Patient Experience) and Quality and Renee Blomme (Manager Patient Experience & Corporate Risk) North York6/19/2017 6:00:12 PM677
Holland Bloorview’s Quality, Safety and Performance team recognized for advancing effective partnerships between clients and families, and clinicians324156/12/2017 3:55:33 PMPatient Safety News (Left to right) Sonia Pagura – Sr. Director Quality, Safety and Performance; Adrienne Zarem – Family Leader; Nicholas Joachimides – Manager of Patient Safety; Elena Garisto – Quality Coordinator; Laura Oxenham-Murphy – Manager of Quality; Julia Hanigsberg – President & CEO; Diane Savage – VP, Programs & Services; and Alifa Khan – Family Leader Holland Bloorview Kids Rehabilitation Hospital received honourable mention for the 2017 Patient Safety Champion Award for organizations. Presented annually by the Canadian Patient Safety Institute, HealthCareCAN, and Patients for Patient Safety Canada, the Patient Safety Champion Award recognizes volunteers and organizations that are taking a leadership role in ensuring that clients and families are at the centre of patient safety initiatives. At Holland Bloorview Kids Rehabilitation Hospital, it goes without saying that clients and families are partners in care and decision-making. The hospital's Quality, Safety and Performance (QSP) team is no exception, partnering deeply with clients and families to advance quality and safety. Their resolve was twofold. Firstly, to exceed compliance with Accreditation Canada's client and family centred care (CFCC) standards, an integral component of the Qmentum accreditation program. CFCC is an approach that fosters respectful, compassionate, culturally appropriate, and competent care that responds to the needs, values, beliefs, and preferences of clients and their family members. Secondly, to partner with the Canadian Patient Safety Institute to update and contribute to existing learning modules in the Patient Safety Education Program (PSEP – Canada). This partnership was anchored in the belief that providing knowledge and skills would ensure that clients and families felt better prepared to contribute to patient safety initiatives. Holland Bloorview has developed an innovative and original framework that fully integrates 17 family and youth leaders into its Accreditation Steering Committees and working groups across the hospital to drive improvement. The Family Leader Accreditation Group (FLAG) is a formalized committee where staff and family leaders are partnered as equal members on six accreditation teams who meet, update and share quality and safety initiatives. The FLAG model provides the opportunity for patients and families to share their insights, expertise and lived experiences in patient safety. This perspective allows for healthcare providers to recognize and identify safety improvement standards and services that can be made in alignment with clients and families. To ensure FLAG members and staff were prepared and successful in the accreditation partnership, the QSP team provided both groups with tools and training. Toolkits were developed outlining the purpose of the partnership and highlighting everyone's roles and responsibilities to ensure staff and families worked together cohesively. In addition, Holland Bloorview provided multiple orientation and training sessions to staff and family leaders on how to effectively engage and partner within their accreditation teams. This included supporting the staff leads in providing the right type of background information about quality and safety processes, tips on hosting meetings with families, and opportunities for ideas to be generated. Both the toolkit and orientation prepared families so that they could meaningfully participate and engage when it came time for accreditation team discussions and decision-making. The QSP team also worked with its family leaders and the Canadian Patient Safety Institute to update and contribute to existing PSEP – Canada learning modules to integrate client and family centred care into its framework. A new module was collaboratively developed to reflect the client and family perspective and teach clients and families how to partner effectively with clinicians. Holland Bloorview then trained its 17 family and youth leaders in a modified PSEP – Canada certification program, who in turn have trained some 15 staff members who lead the accreditation teams. Over the next two years, plans are in place for FLAG to train more than 200 parents, youth and children who volunteer to advance quality and safety in pediatric rehabilitation at Holland Bloorview. Holland Bloorview is now working with the Canadian Patient Safety Institute and Patients for Patients Safety Canada to together deliver the first-ever family, patient and youth leadership training across Canada. The PSEP – Canada Become a Patient and Family Leader Patient Safety Trainer Course will be held November 17 and 18, in Toronto. Sonia Pagura, Senior Director of Quality, Safety and Performance, was the visionary leader behind both initiatives. "Having a dyad approach of both parties in it together in ways of mutual and equal understanding in this language of quality and safety is the richness and what allows for those meaningful outputs and outcomes," says Sonia Pagura. "Our family leaders have experienced a change in their own conversations and the ways that they emerge, and recognize that this is an incredible model that should continue on. It is so amazing for us as an organization, knowing that this initiative was meaningful and certainly impactful." Holland Bloorview's leadership and partnerships, in combination with its dedication to client and family centred care is building capacity amongst clients and families and provides a foundation that other organizations, sectors and health systems can model in their approach to improve, transform and provide quality and safe care. Their work has informed the hospital's strategic plan that includes a commitment to evolving and growing client-centred quality and safety, which supports and augments the organization's vision of patient safety going forward. "We have made a great impact on the system in terms of conversations of what this partnership looks like from a client and family leader perspective and how you can harness that energy and desire of people wanting to contribute, to building a system that provides for high outcomes," says Sonia Pagura. "Our President and CEO, Julia Hanigsberg, has a blog that talks about accreditation not being an event, but a journey; it speaks to the strength of leadership. None of this could have occurred without the senior leadership of the organization being innovative and courageous, believing in it, supporting it financially, providing resources and education, walking the talk and speaking the language of why this was so important." The Patient Safety Champion Awards is pleased to recognize the Quality, Safety and Performance team at Holland Bloorview for its unwavering commitment to client and family centred care.6/13/2017 6:00:00 AM (Left to right): Sonia Pagura – Sr. Director Quality, Safety and Performance; Adrienne Zarem – Family Leader; Nicholas Joachimides –6/12/2017 8:22:40 PM163
Peterborough Regional Health Centre applauded for strategies that enhance communication and cultural awareness324186/12/2017 5:37:53 PMPatient Safety NewsScott Wight (Safe Handover Project Manager)and Sonya Kemp (Patient & Family Representative) Peterborough Regional Health Centre received honourable mention for the 2017 Patient Safety Champion Award for organizations. Presented annually by the Canadian Patient Safety Institute, HealthCareCAN, and Patients for Patient Safety Canada, the Patient Safety Champion Award recognizes volunteers and organizations that are taking a leadership role in ensuring that clients and families are at the centre of patient safety initiatives. The Joint Commission (2010) estimated that 80 per cent of sentinel harm events are the result of miscommunication between caregivers and between caregivers and patients. In 2016, two key projects were implemented at Peterborough Regional Health Centre (PRHC) with the aim of improving safety through enhanced patient partnership and communication. The Safe Handover project involved the redesign of nursing transfer of accountability to a bedside model that integrates patient and family input and applies a standardized approach to safety checks. To enhance staff awareness and skills working across cultures, the Clinical Cultural Competence project included the development and implementation of mandatory training on health disparities, and approaches to assessment and communication that would support patient safety and health equity. The core aim of both projects was to foster a culture that values and seeks to understand what matters most to patients and families. Focusing on relationships and communication in a more meaningful way was the key to improve patient safety in every interaction. Patients and families were engaged throughout the Safe Handover project. In the planning phase, patient advisors provided input on the standardized approach, design of patient communication boards, and content of associated policies and processes. During the implementation phase, every patient and nurse on the inpatient units was surveyed over a two-week period. Now in the sustainability phase, patients and nurses continue to provide feedback through post-discharge phone calls and surveys conducted on a bi-weekly and monthly basis. The input received is provided to the staff on the unit and discussed at the Nursing Professional Practice Council.Safe Handover Leadership Team (left to right) Sean Martin, Director Collaborative Practice, Quality & Ethics; Barb Huggins, Manager, Collaborative Practice; and Scott Wight, Clinical Technology Project Manager Patient communication boards were introduced to facilitate two-way communication from the team to the patient and family, and also for the patient and family to communicate back to staff. On each shift change, nurses introduce themselves, complete a standardized safety check, ask the patients and families if they have any questions, and update the care board with the nurse's name and any other pertinent information. PRHC staff are now directly engaging patients and families in two-way communication at every transfer in nursing care. The transition to include patients and families in nursing transfer of accountability, at shift change and when being transferred between units, has resulted in improvements in patient safety, and nurse and patient satisfaction. Safe Handover has reduced medication errors, averted falls, and provided early identification of changes in clinical status. Patient surveys and post-discharge phone calls indicate that patients feel more informed, involved, safer and valued. Nurses say that they feel more prepared for their shift, have an increased awareness of safety-related priorities for their patients and that patient needs are being met in a timelier manner. Currently, at the one-year mark, 80 per cent of inpatient units have adopted the standardized approach and by the fall of 2017, work will begin to transition outpatient units to the new model for safe handovers to ensure consistency across the hospital. The model is also being considered to enhance the physician handover process. A need to focus on cultural competence within PRHC was identified through community input, post-discharge phone calls, feedback through Patient Relations and other means. Input was sought from local community groups in order to improve the quality of care provided to populations at-risk of experiencing health disparities, including the elderly, impoverished, mental health and addictions and First Nations. In the first step of a phased approach, initial awareness training was provided by nurse educators and social workers; the second phase will see a partnership with patients, families and community groups to facilitate more targeted content.Lori Darrington, RN and Brianne Callaghan, RN performing bedside handover with a patient PRHC has helped its staff to understand and integrate what patients value and why. More than 1,000 clinical staff have been trained in a two-hour Clinical Cultural Competence workshop to increase awareness of their own biases and stereotypes, and how those factors can influence the provision of care in a manner that decreases safety and leads to health disparities. The focus was not to teach about specific cultures, but rather to take an approach that helps staff understand that everyone is unique and that to understand their values and beliefs, you need to ask specific questions in a respectful way. The Cultural Competence training program is being integrated as a core component for all new hires. An e-learning module is now being developed for non-clinical staff. The Clinical Cultural Competence project also included the implementation of a new interpreter service that provides 24/7 access to qualified medical interpreters in over 200 languages. This has been of particular benefit to refugee patients and families and their community support groups. PRHC is a member of a recently formed Peterborough Community Cultural Competence Working Group and will be hosting a Cultural Competence Train-the-Trainer workshop for its community partners. The group has collectively identified culture-related training resources available locally and uploaded them to a public website to help build capacity through education across all sectors within the community. "Ultimately, what is important is how we engage patients and families in their care on a daily basis," says Sean Martin, Director, Collaborative Practice, Quality & Ethics and Chair of the Nursing Professional Practice Council. "Our commitment to partner with patients and families in all respects will build stronger relationships, improve communication and will result in more patient-centred and effective care plans." The Patient Safety Champion Awards recognize Peterborough Regional Health Centre for its meaningful integration of patients and family as members of the care team, and for opening a dialogue internally and externally that will continue to drive patient safety through engagement. Congratulations! 6/13/2017 6:00:00 AMScott Wight (Safe Handover Project Manager)and Sonya Kemp (Patient & Family Representative) Peterborough Regional Health Centre received6/13/2017 5:11:04 PM243
Scoring tools for delirium assessment helps to mobilize sedated pediatric patients324066/9/2017 9:34:22 PMPatient Safety News The rate of delirium for pediatric patients mirrors that of adult patients, with about 25 per cent of pediatric patients experiencing delirium at some point during their ICU stay. As pediatric patients are often much more heavily sedated, the actual rate of delirium could be higher. Last year, 10 paediatric teams and 31 adult acute care teams from ICUs across the country participated in a national initiative to learn more about pain, agitation and delirium. PAD Your ICU was designed and delivered by the Faculty of the Canadian ICU Collaborative and supported by the Canadian Patient Safety Institute. The initiative helped participants to improve care of the critically ill patient through implementation of standardized screening, and prevention and management strategies. When Dr. Paul Doughty took a staff position at the Alberta Children's Hospital in Calgary, he found that many times patients were delirious and on multiple medications to achieve adequate degrees of sedation. He was very keen to use his physiotherapy background to get pediatric patients in the ICU mobilized. However, he quickly learned that there was no way that some of his patients could participate in meaningful rehabilitation, as they were overly sedated and could not be aroused to participate. Generally, patients were spending a longer time on ventilators and were not engaged in rehabilitation to the extent that they could be. Wendy Bissett and Dr. Paul Doughty "At that time, there were no pediatric-specific tools in place to actually measure for the presence or absence or delirium," says Dr. Doughty. "We had a few champions on the unit who recognized there was a problem, and when we heard about the pain, agitation and delirium (PAD) Your ICU National initiative, the timing was perfect as we were at the beginning stages of trying to promote change," says Dr. Doughty. "If we wanted to achieve more engagement in rehabilitation on the unit, we first had to improve the patient's level of wakefulness." The PAD team from the Alberta Children's Hospital included Dr. Doughty; Laurie Lee, nurse practitioner; and Wendy Bissett, nurse educator. The team has since expanded to a larger group that includes a speech language pathologist to help with communication tools that enable intubated pediatric patients to better communicate with caregivers; respiratory therapists (RTs); representatives from pharmacy and rehabilitation; and a larger number of nursing staff who are all act as champions within the unit. The team is really proud of what they have been able to accomplish so far and a number of initiatives are yet to be introduced into what they have built as a three-stage implementation plan. First, was to introduce an objective scoring tool to better identify if the patient had pain or agitation, or if they were delirious. Previously, if the patient seemed unsettled, they would get a multitude of medications, including analgesic agents, sedative agents, and at times muscle relaxants to keep them calm while on a ventilator. "It was more of a shotgun, rather than a targeted approach," says Dr. Doughty. "By implementing a scoring tool, we are now better able to target what our patients need, rather than using a high dose or costly medications to address a patient's pain and agitation issues." Second, was to introduce the scoring tool to bedside nurses who did the brunt of the work in terms of engagement and scoring. "Our program would not have been successful if it were not for the willingness of the bedside nurses to actually get involved with the program, score the patients and buy-in to our attempt to minimize PAD," says Dr. Doughty. "Our nurses recognized that this is an opportunity to take a leadership role. It has really been a team effort that has built a stronger, more successful program." Third, was to incorporate the scoring tool into the patient's electronic medical record (EMR) so that everything can be entered at the bedside. The data drawn from the EMR provides a prospective data analysis to see how the unit is doing in terms of the optimization of pain, agitation and delirium. The team is now looking at an early rehabilitation plan and linking that to an extubation readiness testing plan. "With further involvement of the RTs, we will be able to keep our patients more awake, assess them for earlier extubation in an objective way, and involve our patients with early rehabilitation strategies, which have shown to significantly decrease the rates of delirium in the adult world and we would expect the same outcome amongst our pediatric patients," says Dr. Doughty. Alberta Children's Hospital involves both families and caregivers in the patient's care plan. A novel sleep hygiene program for pediatric ICU patients has been implemented as lack of sleep is a large contributor to the onset of delirium. "We have created a new program where patients map out day-to-day journal of what their child's activities would typically be and we try to replicate that to the best we can in the confines of the ICU," says Dr. Doughty. We are trying to promote a better regimen of sleep hygiene to decrease the rate of delirium amongst our patients." The management of PAD has also been included in the hospital's family pamphlet that provides information on admission to the ICU. A large family communication board is placed in the patient's room and every day PAD goals are recorded on the board so that families are aware of them. "Family members have a lot of questions, especially when a small patient on a ventilator wakes up and appears unsettled," says Dr. Doughty. "The first question they ask, is my child comfortable? Our goal is to keep pediatric patients comfortable and safe, while minimizing the risk of delirium and maximizing the family's involvement in the prevention of delirium." During the PAD Your ICU National initiative, participants learned ways to engage families in the management of the patient's delirium. "A primary driver in reducing pain, agitation and delirium in the ICU is recognizing that patients and their families are an integral and important part of the care team," says Leanne Couves, Improvement Associates. "Developing mechanisms for effective two-way communication, such as discussions of PAD in family meetings and inclusion of family members in multi-disciplinary rounds, can help family members recognize PAD in their loved ones and assist in their care."6/12/2017 6:00:00 AMThe rate of delirium for pediatric patients mirrors that of adult patients, with about 25 per cent of pediatric patients experiencing delirium at6/9/2017 9:48:51 PM128
Patient Safety Power Play: Giving patient engagement a helping hand324026/9/2017 5:22:59 PMPatient Safety Power Plays When patients and healthcare providers partner effectively, the results are powerful. The notion of patient engagement is gaining a greater foothold in the Canadian healthcare system everyday. This shouldn't be news to anyone. What IS news, however, is that there is a brand-new resource available to help patients, families, patient partners, providers and leaders to work together to effectively improve patient safety. Introducing Engaging Patients in Patient Safety a Canadian Guide. This is the first patient engagement guide of its kind in Canada that is specifically targeted toward, and written by, patients, providers and leaders. The Guide was developed in collaboration with patients and patient engagement experts spanning the country and is designed to be used in all healthcare settings. My ask of you, whether you`re a provider or a patient, is to share this far and wide. Please help us get this important information into the hands of people who can do some good with it. The Guide lives online and will be updated periodically as new evidence and best practices in patient engagement emerge. In other news, the Canadian Patient Safety Institute has been recognized with a number of awards recently, and I'd like to take a moment to congratulate everyone involved in this work. A win for us, is a win for patient safety.Hands in Healthcare Magazine and Canadian Patient Safety Week won International Association of Business Communicator (IABC) Gold Quill AwardsSHIFT to Safety, Hands in Healthcare, and the Questions Save Lives Social Media Campaign from Canadian Patient Safety Week won Awards of Excellence at the Edmonton IABC Capital Awards.Provider and patient video series won a national Gold Award of Excellence by the Canadian Public Relations Society As always, I want to engage with you! If there is anything you`d like to ask, or share with me, feel free to email me at or follow me on Twitter @ChrisPowerCPSI. Yours in patient safety, Chris Power6/9/2017 6:00:00 AMWhen patients and healthcare providers partner effectively, the results are powerful. The notion of patient engagement is gaining a greater foothold6/20/2017 2:02:20 PM151

 Latest Alerts



DO NOT USE Endotracheal tubes with subglottic suction (EVAC-ETT) in pediatrics1227834903/28/2016 6:00:00 AMDeviceAlberta Health ServicesThis alert addresses the patient safety incidents which may occur when improperly sized endotracheal tubes (ETT) with subglottic suction (EVAC-ETT) are used in pediatric patients. The EVAC-ETT has a larger outer diameter as compared to the same size standard cuffed ETT. This has led to inappropriately large tubes being used in pediatrics resulting in post extubation complications and tracheal injury. Specific actions are recommended to prevent similar patient safety incidents.5/31/2017 7:20:44 PM9
Choosing Correct Syringe Size- Medfusion Syringe Pump1228134911/6/2016 7:00:00 AMDeviceAlberta Health ServicesThis alert addresses the potential patient safety incidents of wrong dose of medication delivered via a syringe pump related to size of syringe used. The Medfusion syringe pump is able to automatically detect syringe size for all the syringes except for the 1 mL and 3 mL BD syringes because the barrel diameters are identical in size. This creates a risk of under or over infusion and relates to Smiths Medical Medfusion syringe pump (models 3500 & 4000). Recommendations to prevent incidents of wrong infusion are provided.11/7/2016 11:22:18 PM3
Incident Reported with Cold and Flu Product32142339911/4/2015 7:00:00 AMMedicationInstitute for Safe Medication Practices CanadaThis newsletter discusses the patient safety incidents that can occur with non-prescription medications that are available as combination packs. These products contain more than one ingredient, and some products even contain more than one type of tablet within the same package. For example, some cold and flu products contain different tablets for daytime and nighttime use. Each type of tablet contains ingredients that will help relieve cold and flu symptoms, but the ingredients in the nighttime medicine can help with sleep, while the ingredients in the daytime medicine do not cause drowsiness. Mixing up the two products could cause problems; for example if the nighttime product was taken during the day it could cause drowsiness and impair the ability to drive. A specific incident is described where a consumer purchased a cold and flu product that was sold as a combination package, with separate blister packs of medicine intended for daytime or nighttime use. One blister pack contained green tablets (intended for daytime) and the other blister pack contained white tablets (intended for nighttime). At bedtime, the consumer took what was believed to be the nighttime tablet to help with sleep, but had difficulty sleeping. This affected the consumer’s work productivity the following day. The consumer realized later that the tablet taken the previous evening had been one of the daytime tablets. The consumer also assumed that the green pills were for nighttime use and the bright white ones were for daytime. Suggestions are provided for consumers to help prevent patient safety incidents with combination packaged medications. As well recommendations for practitioners to assist consumers in avoiding medication mix-ups are provided. 5/31/2017 7:22:56 PM
Application of TALLman Lettering for Selected High-Alert Drugs in Canada32221339210/30/2015 6:00:00 AMMedicationInstitute for Safe Medication Practices CanadaThis Safety Bulletin describes the development and application of TALLman lettering as a strategy to reduce medication errors. TALLman lettering is a method of applying uppercase lettering to sections of look-alike, sound-alike (LASA) drug names to bring attention to their points of dissimilarity. By accentuating the points of difference, the application of TALLman lettering to a drug name may alert healthcare providers that the drug name in question can be confused with another drug name. However, overuse of the technique may reduce its effectiveness, as names may cease to appear novel. Therefore, the use of TALLman lettering should be limited to drug name pairs associated with significant risk to patient safety. TALLman lettering will have the greatest impact on the differentiation of LASA drug names if the approach to capitalization is applied consistently. Key milestone projects of the Institute of Safe Medication Practices (ISMP) Canada and other collaborative partners are described. The bulletin contains a list of TALLman lettering for look-alike, sound-alike drug names in Canada as well as the source for this list. 5/31/2017 7:28:14 PM
Massive Transfusion Protocols12283348810/29/2015 6:00:00 AMBlood Products/TransfusionOregon Patient Safety Commission (USA)This alert discusses the patient safety incidents which occur as a result of delay in initiating massive transfusion protocols and communication breakdowns when acquiring blood products. The majority of these incidents involve postpartum hemorrhage. Postpartum hemorrhage is the leading cause of maternal mortality and morbidity worldwide and accounts for nearly a quarter of all pregnancy-related death . It can be exceptionally challenging to manage, as external signs and symptoms may not be apparent until a large volume of blood is lost, and approximately one third of women who experience postpartum hemorrhage have no risk factors upon admission. However, many studies suggest that postpartum hemorrhage can be prevented or well controlled with appropriate assessments and interventions. The National Partnership for Maternal Safety has developed a Consensus Bundle on Obstetric Hemorrhage to help facilities tackle this challenging issue. Their recommendations include four critical elements: readiness, recognition, response, and reporting/systems learning. The recommendations section of this alert provides details on each of these themes.12/19/2016 11:25:33 PM6