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#SuperSHIFTERS - An Interview with Jim Ruiter3320610/13/2017 8:30:52 PMPatient Safety News<img alt="" src="/en/NewsAlerts/News/PublishingImages/2017/Dr.%20James%20Ruiter.jpg?Width=140" width="140" style="BORDER&#58;0px solid;" /> How do you build insight with education innovation? Jim Ruiter has the answer a play in three acts Jim, can you tell us about your initiative? Early in 2017 Salus Global™ was asked by District II of the American College of Obstetricians and Gynecologists, as part of their Bundle Implementation workshop in Albany New York, to present to obstetrical and gynecological physician representatives from many of the New York state hospitals. This was a 90 minute session presenting to a group of well-tenured academic obstetricians and gynecologists on how to use simulation effectively. As I pondered this opportunity, I was nervous. I am not an expert in simulation, nor is the organization I work for. Salus Global™ prides itself on being experts in teamwork, communication and high-functioning teams. With that in mind, I wondered how I could keep such a group engaged for 90 minutes on a topic they were already experts in. I started to reflect on all the successes Salus Global and the MOREOB® program have seen, and began to create a list of pearls of wisdom to share. As I completed the list, I realized this could be another boring lecture. A boring lecture would leave no lasting impact from the presentation. The more I thought about the lecture format the more I realized that I needed to present in a way that allowed others in the room to build their own insights. I wondered if a demo would fit the bill, but I've never been totally impressed with demos. Demos often don't 'cut-it'. I needed a way to create scenarios, which allowed the audience to build their own insight. I found myself building a script. The script process resulted in the creation of a play. A play could highlight the benefits and challenges of simulation. A play could build the insight and impact I was looking for. How did you build the play? I built the play in three acts. It's meant to demonstrate potential uses of simulation beyond simply for education purposes. The three acts allow us to run the same clinical simulation scenario twice using two different simulation approaches. These two opposing approaches are what allow the audience to build their own insights. In act I, the narrator comes out and interacts with the audience, trying to pull out from the audience what it knows of simulation – essentially identifying where the audience is starting from. During that first act, the scene is also set for the ensuing two acts. In act II, we have the actors play out a simulation scenario in one way, what I call a run-through modality (no breaks in the scenario till the end where the team debriefs). In act III, the same actors play out the same scenario, but with a pause-scenario modality (where the objectives are stated out front, and where the participants are encouraged to pause the scenario to discuss what ever issue on their mind – and then debrief). Act III allows them to demonstrate simulation conducted within a continuous quality improvement framework, using a modality that builds psychological safety and organisational trust. In the denouement, we brought all the actors to the front of the stage and the audience interacted with them, and by a simple show of hands we could show an increase in the number of individuals wishing to develop their own simulation program. The first time we presented the play, I recruited four actors. I had wanted seven, but the four turned out to be a gift. I quickly re-wrote the script to present the scenario as if another emergency was going on. We could accurately portray the limited resources often available to staff in an emergency. We assigned a narrator, simulation facilitator and staff taking part in the simulation as the roles. I was careful to include the frame of mind the actor was coming from in the script, this was the key to why simulation can succeed or can only be of value. One of the keys to developing insight in our audience, was not just demonstrating or acting out the play but, it was also the ability to peer into the minds of the actors throughout the play through freezing of the action. How we made this work was by having the narrator, at predetermined times – in response to body language for example – freeze the action on stage. The narrator would then ask the audience what they thought the actors were thinking at that time. The actor would then reveal their state of mind in a soliloquy. Utilizing audience feedback and multifaceted scripts we could demonstrate how complex adaptive systems can adapt, through simulation conducted within a continuous quality improvement framework. What do you think contributed to the success of this learning approach with your audience? There were many aspects that made the play a success. Firstly, we utilized real life scenarios. We chose to use the scenario of a post-partum hemorrhage and the secondary emergency that limited our human resources was a cord prolapse "down the hall." The scenario had realistic aspects that created stress that the audience was readily able to identify with. One aspect of the scenario was the lack of easy access to a refrigerated drug. The need for this drug forced the nurse to leave the physician with the patient alone. As this occurred, we could create insight by freezing the action and teasing out from the audience their thoughts, and then the thoughts of the characters in the play. Freezing the action allowed us to create learning we would not have gotten otherwise. Lastly, creating the play in three acts to provide an opportunity to act out the same simulation scenario two ways, while allowing the audience time to interpret and pick apart each portrayal. This approach allowed the audience to build their own insights into simulation by providing them two examples to compare. This was integral to the result, which ideally was the audience leaving with new learning they could apply in their own practice. What would you tell others planning or delivering education on simulation? My first thought would be, conduct your education in any way you think fits your audience. This example is not a one-size-fits-all solution. Do what works for your audience and helps you meet your goals. I would remind people that you couldn't bridge process gaps through simulation alone. You can identify gaps through simulation and address them through a continuous quality improvement framework, which may lead to a variety of strategies to close the gap. You need to offer simulation in the context of a continuous quality improvement cycle. Lastly, I would stress that simulation is a powerful tool, far more powerful that just education. It can help create psychological safety, identify an organization's external safety boundaries (allowing you to then push them), provides opportunities to engage and address issues and builds a more robust care system. Most importantly, it can build the overall organizational safety culture and creates safer, sustainable systems. If a simulation is used in isolation, nothing will change! Where can people go to learn more? You can contact me through Salus Global™ at http//www.salusglobal.com/contact-us Thank you to Dr. James Ruiter for his time and insights. Join us next month when we sit down with SuperSHIFTer Patrick Nellis to learn more about the launch of his new patient safety book entitled Ready for My Surgery Be Informed, Stay Safe and Take Control During Your Journey Through Surgery.10/20/2017 2:30:00 PMHow do you build insight with education innovation? Jim Ruiter has the answer: a play in three acts Jim, can you tell us about your10/16/2017 2:53:03 PM188http://www.patientsafetyinstitute.ca/en/NewsAlerts/News/Pages/Forms/AllItems.aspxhtmlFalseaspx
Patient Safety Power Play: Making the Case for Investing in Patient Safety3316410/10/2017 5:11:54 PMPatient Safety Power Plays<img alt="" src="/en/NewsAlerts/News/PublishingImages/2016/Chris%20Power%202016.jpg?Width=140" width="140" style="BORDER&#58;0px solid;" /> Benjamin Franklin told us that, "an ounce of prevention is worth a pound of cure", and this often-repeated homily is particularly applicable to the Canadian healthcare system. Or, as our business manager might phrase it now, statistics show that investing in patient safety today brings cost-saving further down the road. That it why we have taken into consideration, and will act accordingly, on the findings made by the report created by RiskAnalytica known as The Case for Investing in Patient Safety in Canada. We have done so to make sure that our mandate of providing safe care for all Canadians continues to be met. The report, which was released this year, estimates that over the next 30 years, 12.1 million Canadians will be harmed by a patient safety incident within acute and home care settings. A shocking statistic to be sure, even more so when compounded by findings that there could be roughly 400,000 annual cases of patient safety incidents, costing $6,800 per patient, resulting in an additional $2.75 billion in healthcare costs per year. I have been in healthcare for a long time, and have seen preventable incidents, and it saddens me to see such issues still occurring in our healthcare system. However, to those concerned, let me offer the following The Canadian Patient Safety Institute has a proven track record of delivering evidence-based tools and resources to healthcare organizations and providers so that they can provide the safest care to their patients. We are committed to continuing this work, but governments must also invest to show patient safety as something that cannot, and must not, be swept under the rug. We at the Canadian Patient Safety Institute have recently rolled out our new 2018-2023 Strategic Plan, known as Patient Safety Right Now, calling for immediate placement of well-crafted mechanisms to make sure patient safety is at the forefront of the Canadian healthcare landscape. The statistics produced by RiskAnalytica drive our new strategic plan as we hope to curb the trend of patient safety incidents and educate the public, healthcare providers, and healthcare leaders on the universal importance of patient safety. By working together, I know we can achieve wonderful things in the Canadian healthcare system, both immediately and in the years to come. The report, The Case for Investing in Patient Safety in Canada, may be viewed by clicking HERE Please let me know your comments on this important report at cpower@cpsi-icsp.ca Yours in patient safety, Chris PowerCEO, Canadian Patient Safety Institute10/10/2017 6:00:00 AMBenjamin Franklin told us that, "an ounce of prevention is worth a pound of cure", and this often-repeated homily is particularly10/10/2017 5:32:05 PM160http://www.patientsafetyinstitute.ca/en/NewsAlerts/News/Pages/Forms/AllItems.aspxhtmlFalseaspx
#SHIFTtalks Supercharge your hand-hygiene education: Are you a Tough Scrubber?3310510/2/2017 4:38:32 PMPatient Safety News<img alt="" src="/en/NewsAlerts/News/PublishingImages/2017/Laura%20Shapiro%20and%20Rebecca%20Bunston%202017-10.jpg?Width=140" width="140" style="BORDER&#58;0px solid;" />​​​ Photo caption Occupational therapist Laura Shapiro (left) and physiotherapist Rebecca Bunston (right) helped develop Tough Scrubber at St. Michael’s Hospital. ​By the St. Michael’s Hospital Heart and Vascular Program’s Quality and Safety Leader Group ​​Fun, fast, challenging, hilarious. Is this how your staff would describe their hand-hygiene education? Try Tough Scrubber and they just might. In the Heart and Vascular Program at St. Michael's Hospital, our traditional hand hygiene interventions were feeling a bit stale. Engagement was low – and honestly, it showed in our compliance rates. We needed more than a poster. We needed a sensation! Enter Tough Scrubber, the brainchild of our program's Quality and Safety Leader Group. A play on the Tough Mudder concept, front-line staff go through a fast-paced, over-the-top simulation that's tailored for their clinical area. There's a quick quiz before they start and a quick debrief after they finish… and that's it. The whole process takes 10 minutes or less. We're happy to report, it was a huge hit! This five-minute video will tell you more about how Tough Scrubber works. We've also put together a toolkit to help hand-hygiene champions implement Tough Scrubber in their own hospitals and health-care organizations. For us at St. Michael's, Tough Scrubber opened the door to a new way of thinking about hand hygiene. It's OK to ask questions and to give your colleagues feedback – we're all learning. Doing hand hygiene correctly can be tough, but it's much easier when we help each other out. To date, 43 Heart and Vascular staff have completed Tough Scrubber, and our hope is that you will too. All it takes is our toolkit, 4-5 hand-hygiene leaders (to run the activity and pose as patients), an empty patient room with two beds, and the everyday equipment described in the scenarios (e.g. a wheelchair, a basin). In our Heart and Vascular Units, we've improved our compliance rate for Moment 1 by 27% in three years. This is certainly the result of a combination of years of education, hard work and many different kinds of interventions. However our Tough Scrubber sessions truly felt like the tipping point. For more information on Tough Scrubber and to download the toolkit, visit www.stmichaelshospital.com/toughscrubber. Try it, and let us know how it worked for you! If you have any questions or fe​edback, please contact us at BunstonR@smh.ca and ShapiroL@smh.ca.​​10/2/2017 6:00:00 AM Photo caption: Occupational therapist Laura Shapiro (left) and physiotherapist Rebecca Bunston (right)10/3/2017 2:55:35 PM781http://www.patientsafetyinstitute.ca/en/NewsAlerts/News/Pages/Forms/AllItems.aspxhtmlFalseaspx
#SuperSHIFTERS – Meet St. Boniface Hospital, TeamSTEPPS® enthusiasts!330619/25/2017 7:11:15 PMSuper SHIFTERS​​​ ​​​​ St. Boniface Hospital in Winnipeg, MB, is our SuperSHIFTER for September. They embody the spirit of Canadian Patient Safety Institute's SHIFT to Safety program, providing support and content that improves patient safety through an emphasis on teamwork, communication and positive safety culture. Members of the team at St. Boniface, including Michaele Rivet, Patient Safety Consultant; Jen Kostyshyn, ED nurse; Dr. Jeff Klassen, ED physician; and Cheryl Bilawka, Educational and Development Specialist, recently spoke with CPSI's Vanessa Walsh to explore their unique journey implementing the TeamSTEPPS program (click here to learn more about TeamSTEPPS). Here is that conversation Q How did St. Boniface Hospital get started with TeamSTEPPS? A We started implementing TeamSTEPPS in our ED and shortly after our cardiac care program in 2010-11. We really liked how simple it was, and how it provided the concepts, tools and training for free. We sent a contingent of staff, physicians and leaders to an Agency for Healthcare Research and Quality (AHRQ) regional training centre in the United States for master trainer training. We linked up with our physicians, allied health, and support staff to begin running a training plan for all staff in the ICU's and ED. Q How did you measure your improvement efforts? A We administered the AHRQ Hospital Survey on Patient Safety Culture (HSOPS) in the ED as a baseline, and again at three months, six months and one year after our initial staff trainings. Our department had a significant staff turnover, and the data reflected that change, showing we lost the initial improvements gained after a year. We gleaned two big lessons – first that we needed to build internal capacity and bring master training in-house to maintain momentum, and second, although we had a coaching model in place it seemed our biggest challenge was to keep people thinking about TeamSTEPPS after their training. Q How did you scale up and go hospital-wide with the training? A We trained 244 master trainers in 18 months! They took all the concepts and tools and spread them within their own programs and staff. We also added a TeamSTEPPS Fundamentals training to General Hospital Orientation. Q Did you modify the training at all? A We made it our own in a couple of ways. The message on the importance of patient safety can sometimes be uncomfortable, so we purposefully built in humour to help staff pay attention and get talking about it. We broke out key strategies and tools into videos, and engaged staff in whatever way they were comfortable in. The videos are educational, funny and incorporate input from staff. We knew that most staff were on some sort of social media, and leveraged these platforms to promote our focus on teamwork and communication. If we could just breakdown TeamSTEPPS messages into bite-sized, post-able pieces, so it was constantly showing up in people's news feeds, it would always be on their minds. We also started in-situ education around a huddle once or twice a week. We took people away from what they were doing for five minutes and talked about a very specific and focused safety idea. This was done in small enough groups so it was a discussion and not a didactic lecture. It was also done right where we want these behaviours to happen, right at the bedside, so they can turn around and immediately start using it. Q How are you planning to sustain the gains you've made in teamwork and communication for increased patient safety? ASTEPP UP for Patient Safety is St-Boniface's TeamSTEPPS sustainment plan. It is entering its third year this month. Driven by a representative group of staff, it is a tailored monthly refresher for everyone that includes a theme, activities for role playing, and discussion topics for huddles at all levels of the organization. Past themes have focused on communication tools and strategies for escalation, and this upcoming year will zero in on advocacy and assertion. In the ED, we're always gathering input from staff to make sure it's relevant and delivered in the best possible way. We have a core group to distribute the information and educate people. For example, we have a trivia group, a research group, an engagement group, a huddle group, etc. We are also working on a new simulation project, to develop a simulation curriculum that incorporates all the TeamSTEPPS tools and strategies. Q What would you recommend to someone wanting to adopt TeamSTEPPS strategies and tools within their organization? A Active leadership support has been crucial to our success. TeamSTEPPS is all about knocking down hierarchies and barriers to communication. Our leaders understand the tools and concepts, use them, and expect staff to do the same. Also, every department, even within one hospital, can be a different environment. Knowing the culture and people can make a huge difference. We really tried to understand the issues that we were facing as well as the personalities in our department to create something that would work for us. Q Where can people go if they're interested in learning more about your work? A Reach out to us at @sbh_winnipeg on Twitter or by email at mrivet@sbgh.mb.ca and cbilawka@sbgh.mb.ca.​​ Join us next month as SHIFT to Safety features #SuperSHIFTER Dr. James Ruiter from Salas Global Corporation, sharing an innovative insight into simulation methodology for patient safety. 9/25/2017 6:00:00 AM St. Boniface Hospital in Winnipeg, MB, is our SuperSHIFTER for September. They embody the spirit of Canadian Patient Safety10/19/2017 7:11:00 AM607http://www.patientsafetyinstitute.ca/en/NewsAlerts/News/Pages/Forms/AllItems.aspxhtmlFalseaspx
CPSI designated as WHO Collaborating Centre for Patient Safety and Patient Engagement329799/14/2017 8:47:00 PMPatient Safety News With the support of the Government of Canada, the World Health Organization (WHO) has officially designated the Canadian Patient Safety Institute as a WHO Collaborating Centre for Patient Safety and Patient Engagement to carry out activities in support of WHO programs internationally. Of the more than 800 WHO Collaborating Centres from 80 countries worldwide, 31 are from Canada. The Canadian Patient Safety Institute is the only WHO Collaborating Centre in Canada with a focus on both patient safety and patient engagement. The four-year agreement (2017-2021) will include activities targeted in four areasProvide coordination support and advice to the global Patients for Patient Safety (PFPS) advisory group Support global efforts and initiatives on patient safety reporting and learning systems Contribute to the planning and implementation of the 3rd Global Patient Safety Challenge on Medication Safety Support global patient safety initiatives in achieving safer care "The Canadian Patient Safety Institute has a long-standing collaborative relationship with the WHO Patient Safety Programme internationally, and has been a catalyst in developing collaborative partnerships across the country," says Chris Power, CEO, Canadian Patient Safety Institute. "We have benefited from the support of the WHO and their members in the development of Canadian products and services, and indirectly we have provided Canadian support to assist transitional and developing countries. We are excited about this opportunity to advance safer care through patient safety and patient engagement, both locally and globally." Building on the Canadian Patient Safety Institute's well established support to Patients for Patient Safety Canada over the past 10 years, the Canadian Patient Safety Institute will provide support to the global PFPS advisory group that will include coordination and secretariat support for the WHO PFPS Advisory Network and building capacity for patient/family champions and leaders of PFPS global networks. Each year of the agreement, the Canadian Patient Safety Institute will coordinate quarterly meetings of the PFPS advisory group and deliver three knowledge transfer webinars in English and French, to build capacity of the Network's patient safety champions and leaders. "The WHO's PFPS programme engages patients and families in improving the safety of health care, to enhance and build capacity, and to become informed and knowledgeable partners in their own care," says Helen Haskell, Co-chair, WHO Patients for Patient Safety Advisory Group. "PFPS workshops bring together PFPS advocates, health care professionals, local leaders, health care organizations and policy-makers to share knowledge about the national health system and to explore mechanisms to improve patient engagement for safety. Working with the Canadian Patient Safety Institute as a WHO Collaborating Centre provides the opportunity to share our experiences and knowledge on patient safety and patient engagement." To broaden reporting, learning and sharing from harm, the Canadian Patient Safety Institute hosts Global Patient Safety Alerts, a web-based resource featuring a comprehensive collection of patient safety alerts, advisories and recommendations from around the world. Work will continue to expand its use and contributions from international organizations. "Too much healthcare delivered around the world carries avoidable harm," says Sir Liam Donaldson, Patient Safety Envoy, WHO. "With tools like Global Patient Safety Alerts, we can effectively share information about patient safety risks and effective ways to manage those risks and prevent harm. Through initiatives like the WHO Collaborating Centers, the processes to collect, analyze, communicate and disseminate information and trends to users and potential contributors can be improved." As the Canadian coordinating body, the Canadian Patient Safety Institute is participating in the 3rd Global Patient Safety Challenge on Medication Safety. The Canadian Patient Safety Institute is a member of the WHO Patients and Public Working Group and provides expertise and support to the global medication safety challenge. Maryann Murray, a member of Patients for Patient Safety Canada, recently addressed the World Health Assembly's annual meeting to share her experiences leading to her daughter's death, and highlighted the Five Questions to Ask about Your Medications, a Canadian tool developed by patients and providers on how to have a conversation about safe medication use. The tool is available in 20 different languages. "The challenge of improving medication safety is now being embraced in Canada and around the world. By sharing knowledge and resources, we contribute to the development of universal products and tools that will assist in significantly reducing medication harm around the globe," says Maryann Murray. To support global patient safety initiatives, the Canadian Patient Safety Institute will provide policy, strategic and technical advice and consultation at various platforms including WHO global and regional consultations or events, working groups, and committees; and provide advice and support in the development, adaptation, spread, and/or evaluation of patient safety tools and resources at a global level. Patient engagement is a priority for many Canadian organizations. Led by the Canadian Patient Safety Institute, the National Patient Safety Consortium, a group of more than 50 organizations, established the Integrated Patient Safety Action Plan, a shared action plan for safer healthcare. One of the plan's guiding principles is patient engagement. "Patient engagement is a core strategy for advancing universal health coverage, safe and quality health care, service coordination and people-centredness," says Dr. Neelam Dhingra-Kumar, Coordinator, Patient Safety and Quality Improvement, WHO headquarters, Geneva. "Canada is recognized as a world leader in both patient safety and patient engagement so we believe that this collaboration will help improve lives around the world." For more information about the WHO Collaborating Centre designation, visit the WHO website. 9/17/2017 6:00:00 AMWith the support of the Government of Canada, the World Health Organization (WHO) has officially designated the Canadian Patient Safety Institute as9/17/2017 7:52:08 PM862http://www.patientsafetyinstitute.ca/en/NewsAlerts/News/Pages/Forms/AllItems.aspxhtmlFalseaspx
Change Day Ontario 2017328959/11/2017 7:23:21 PMPatient Safety News ​Change Day Ontario Make a Difference in Patient Care Associate Medical Services and Health Quality Ontario – with support from The Canadian Patient Safety Institute - invite you to support healthcare organizations from across Ontario for two months in the Fall as Change Day Ontario 2017 takes place. What is Change Day Ontario? It is a growing global movement that supports people with first hand experience in the Canadian healthcare system to create positive change. But how is this done you ask? By making pledges – large or small- to drive the change they want to see forward. This event is about people connecting through their ideas and stories and sharing them through social media. Its about engaging with one another and overcoming barriers. Ultimately, Change Day Ontario is about is about helping to improve care for patients and providers. With that in mind, join Change Day Ontario and make a pledge to improve compassionate quality care and inspire positive change within the health system. Visit changedayontario.ca to learn more and to sign up as an Ambassador. As a reminder, pledging begins September 12, 2017, and will culminate in a day of celebration which will take place on November 17, 2017. Change Day Alberta​​​​ http//www.changedayab.ca/ Change Day BC https//changedaybc.ca/9/12/2017 2:30:00 PM Change Day Ontario: Make a Difference in Patient Care Associate Medical Services and Health Quality Ontario – with support from The Canadian10/4/2017 3:25:25 PM221http://www.patientsafetyinstitute.ca/en/NewsAlerts/News/Pages/Forms/AllItems.aspxhtmlFalseaspx
Patient Safety Power Play: Partnering to prevent the Deteriorating Patient Condition328909/8/2017 5:32:03 PMPatient Safety Power Plays<img alt="" src="/en/NewsAlerts/News/PublishingImages/2016/Chris%20Power%202016.jpg?Width=140" width="140" style="BORDER&#58;0px solid;" /> Early warning signs of deteriorating condition are often unrecognized, leading to devastating results. Research shows that virtually all critical patient events are preceded by warning signs that occur several in advance. The Canadian Patient Safety Institute (CPSI) and the Healthcare Insurance Reciprocal of Canada (HIROC), continuously assert the importance of patient engagement in healthcare. We believe the patient and family have a voice at the bedside, and are vital to safe care outcomes. When it comes to the deteriorating patient condition, family members are a vital part of the healthcare team and are often best positioned to recognize the sometimes subtle, yet very important changes in their loved one's condition that may indicate deterioration. They may not know WHAT is wrong, but they're often the first to notice when something "just isn't right". Look no further than the story of Mataya Robin as an example of what we're talking about CPSI and HIROC, determined to be instrumental in ending preventable harm caused by the deteriorating patient condition, have partnered in an effort to curate the most comprehensive set of tools and resources related to the deteriorating patient condition in Canada, if not the world. You can access them all free of charge by searching "Deteriorating Patient Condition" or "DPC" at www.patientsafetyisntitute.ca. Deteriorating Patient Condition If you've got a family member currently in the healthcare system, learn to recognize the signs and symptoms of the deteriorating patient condition and how to effectively discuss your concerns with the healthcare provider. For providers and leaders, learn about the deteriorating patient condition in various care settings, and become a champion for patient engagement as you empower patients and family members to serve as your eyes and ears and monitor for early warning signs that something may be wrong. Together, we can reduce preventable harm. Yours in patient safety, Chris Power Catherine Gaulton CEO CEO Canadian Patient Safety Institute Healthcare Insurance Reciprocal of Canada 9/8/2017 6:00:00 AMEarly warning signs of deteriorating condition are often unrecognized, leading to devastating results. Research shows that virtually all critical9/8/2017 6:01:24 PM366http://www.patientsafetyinstitute.ca/en/NewsAlerts/News/Pages/Forms/AllItems.aspxhtmlFalseaspx
#SHIFTTalks Hear me out328919/8/2017 4:10:54 PMPatient Safety News<img alt="" src="/en/About/Programs/shift-to-safety/shift-faculty/PublishingImages/Joanna%20Noble.JPG?Width=140" width="140" style="BORDER&#58;0px solid;" /> The value of effective communication during patient handovers Just hours after being discharged from the emergency department, a five-week old infant sustained permanent brain damage due to a delayed diagnosis and treatment for meningitis. The cause – miscommunication and the absence of a reliable process to ensure pending tests following a patient discharge. Cases like these beg the question, are poor communication practices during shift changes and transfers between care providers so ubiquitous in healthcare that we have become numb to their chilling effects on patient safety? Sadly, we might think we’re communicating well but in the chaotic and stressful healthcare environment, the messages can easily start to look like a game of broken telephone. Communication handovers – be they between healthcare providers, facilities or sectors – can be complex. One article suggested that the average healthcare provider encounters 11 to 15 interruptions hourly. Other research tells us that only 42% of nurses can identify their patient’s primary care provider and 23% of physicians can identify their patient’s primary nurse. According to CRICO, healthcare miscommunication cost $1.7B and impacted nearly 2,000 lives in a study of claims filed between 2009 and 2013. A similar grim situation exists in Canada. The Canadian Adverse Events Study found miscommunication during care transitions were a key factor in medication adverse events. Based on claims data from HIROC (the Healthcare Insurance Reciprocal of Canada), communication failures contributed to an estimated $305 million in medical legal costs since 1987. Contrary to these findings, The 2015 Accreditation Canada Report on Required Organizational Practices (ROP) revealed an overall compliance score of 99% for the practice of ensuring effective information at transition points. However, this finding specified that tests for compliance did not assess the quality of information transferred. There are some promising signs that things are changing. We are seeing studies on standardized practices to bridge the gap between varying communication styles. There is also a focus on team-based safety practices such as routine huddles and debriefs to enhance communication. And finally, tools and resources like CPSI’s SHIFT to Safety platform help empower patients and families to start conversations during care transitions. For leadership, it comes down to prioritizing effective communication, making use of technology and building of a culture of safety. We must do it for our staff, our organizations and for our patients who leave their fate in our hands. ​ ​By Joanna Noble, Supervisor, Knowledge Transfer Healthcare Risk Management, HIROC 9/8/2017 6:00:00 AMThe value of effective communication during patient handovers Just hours after being discharged from the emergency department, a five-week old9/11/2017 4:40:02 PM809http://www.patientsafetyinstitute.ca/en/NewsAlerts/News/Pages/Forms/AllItems.aspxhtmlFalseaspx
Patient Safety Power Play: Meeting with the Council of Federation98978/3/2017 9:56:35 PMPatient Safety Power Plays<img alt="" src="/en/NewsAlerts/News/PublishingImages/2017/Council%20of%20Federations%20Event%20-%20Overhead%20Shot.JPG?Width=140" width="140" style="BORDER&#58;0px solid;" /> Today in Canada, every 17 minutes someone dies in a hospital from an adverse event. That's about 31,000 people a year. We also know 1 out of 18 hospital visits results in preventable harm or even death. It's no better in the community, where up to 13 per cent of people receiving home care experience a harmful adverse event like a fall or medication error. According to a June 2017 report from the Organization for Economic Co-operation and Development, the economic burden of adverse events in Canadian hospitals in 2009-2010, where the burden attributable to preventable adverse events was estimated at $ 397 million. This level of harm is simply unacceptable. The Canadian Patient Safety Institute (CPSI) hopes that the Council of the Federation, composed of Canada's premiers, will make patient safety promotion a priority. As policy makers and elected officials gathered in Edmonton during the Council of the Federation last month to make difficult decisions about where to invest money, I was fortunate to have the opportunity to stress the point to them that the work of the Canadian Patient Safety Institute is critically important for preventing harm from happening, responding to harm when it does happen and learning from harm so that it doesn't happen again. In the months ahead, as we near a decision from Health Canada regarding our future funding, we look forward to close collaboration with all levels of governments and the stakeholder community, so all Canadians can access safe healthcare. Since 2003, CPSI has been on the front lines, working with providers and healthcare organizations to improve patient safety through education, research, and evidenced-based clinical interventions. We've received excellent support from Health Canada and both federal and provincial governments over the years, but the reality is we need more to ensure Canada has the safest healthcare system in the world. CPSI is the only national organization solely dedicated to reducing preventable harm and improving the safety of healthcare. Established as the result of a rallying cry led by dedicated individuals working within the healthcare system that couldn't experience one more incident of a patient getting harmed CPSI has a mandate to provide national leadership by working with federal, provincial and territorial leaders on developing evidence based tools and resources to educate and inspire safer care. In order to continue our mandate, we're looking for support from throughout the healthcare system, if you'd like to lend a voice to our cause, please reach out to me via email at cpower@cpsi-icsp.ca to learn more about how you can help. Thank you. Yours in patient safety, Chris Power8/3/2017 6:00:00 AMToday in Canada, every 17 minutes someone dies in a hospital from an adverse event.  That's about 31,000 people a year. We also know 1 out of 188/3/2017 10:04:28 PM231http://www.patientsafetyinstitute.ca/en/NewsAlerts/News/Pages/Forms/AllItems.aspxhtmlFalseaspx
Patient Safety Power Play: Powering up for Canadian Patient Safety Week!99497/10/2017 7:08:20 PMPatient Safety Power Plays<img alt="" src="/en/NewsAlerts/News/PublishingImages/2016/Chris%20Power%202016.jpg?Width=140" width="140" style="BORDER&#58;0px solid;" /> As someone whose entire professional life has revolved around the healthcare system in one way or another, one of my favourite times of year will be upon us before you know it. Of course, I'm referring to Canadian Patient Safety Week . . . the marquee event of the Canadian Patient Safety Institute! For more than 10 years, Canadian Patient Safety Week has been our annual opportunity to reach out to thousands of healthcare providers. In that time, we've raised awareness on patient safety issues such as medication safety, infection prevention and control and good communication. We've celebrated with webinars, Twitter talks, social media campaigns, competitions, and who could forget our famous Canadian Patient Safety Week packages filled with everything you need to make your week a success and spread the message of patient safety in your organization. This year we're aiming to outdo ourselves yet again. In case you hadn't heard, the theme for Canadian Patient Safety Week 2017 is Take With Questions as we focus on medication safety and the 5 Questions to Ask About Your Medications. This year, we are making it our mission to encourage patients and remind healthcare professionals what lifesaving questions we should all ask about our medications. Over the course of the next couple of months, we'll slowly unveil different aspects of the Take With Questions theme, as we build towards our biggest Canadian Patient Safety Week yet, from October 30 to November 3. If you aren't subscribed to our mailouts, or following us on social media, now would be a great time to start so you don't miss a thing! We've also got limited quantities of the famous Canadian P​atient Safety Week packages so don't wait too long to order yours! If you've got any questions about Canadian Patient Safety Week, you can email our planning team at cpsw@cpsi-icsp.ca. How does your organization celebrate Canadian Patient Safety Week? Have you started planning yet? Do you have any questions? Connect with me anytime via email at cpower@cpsi-icsp.ca or follow me on Twitter @ChrisPowerCPSI. Yours in patient safety, Chris Power7/10/2017 6:00:00 AMAs someone whose entire professional life has revolved around the healthcare system in one way or another, one of my favourite times of year will be7/31/2017 3:16:00 PM618http://www.patientsafetyinstitute.ca/en/NewsAlerts/News/Pages/Forms/AllItems.aspxhtmlFalseaspx