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Canadian Patient Safety Institute

Safe care....accepting no less​

The Canadian Patient Safety Institute (CPSI) has over 10-years of experience in safety leadership and implementing programs to enhance safety in every part of the healthcare continuum.​

SHIFT to Safety

 

Improving patient care safety and quality in Canada requires everyone’s involvement—SHIFT to Safety gives you the tools and resources you need to keep patients safe, whether you are a member of the public, a provider, or a leader.


 

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Our Programs​

 CPSI Latest News

 

 

Optimize your Team's performance and outcomes with Teamwork and Communication29715Patient Safety News ​The Teamwork and Communication Safety Improvement Project will empower participating teams to actively solve local level teamwork and communication issues that are impacting patient safety outcomes. Teamwork and Communication can mean different things to different people. Effective teamwork and communication are critical for ensuring high reliability and the safe delivery of care. Teamwork and communication can improve quality and safety, decrease patient harm, promote cross-professional collaboration and the development of common goals, decrease workload issues, and improve staff satisfaction and patient engagement. A new Safety Improvement Project focused on teamwork and communication is set to launch in January 2019. This collaborative learning approach will be delivered by expert faculty and coaches, and mentoring with be provided over 18 months. Participating teams will be provided TeamSTEPPS Canada Master Training, enabling them to roll-out TeamSTEPPS tools and resources at their local healthcare organization.“Communication is only ONE of the teamwork skills that TeamSTEPPS addresses,” says Rhonda Shea, Collaborative Learning and Education Lead, Health Quality Council of Alberta. “Leadership, situational monitoring and mutual support are all equally important to successful teamwork and positive patient outcomes. There are pivotal moments in all tragic patient outcome stories where it is clear that working together as a team could have improved the situation.” “This Safety Improvement Project will significantly improve teamwork and communication skills within the healthcare team,” says Tricia Swartz, Senior Program Manager, Canadian Patient Safety Institute. “Effective teamwork skills are essential for safe, quality healthcare that prevents and mitigates harm. By focusing on teamwork, communication and on a patient safety culture, you can truly raise the patient safety bar at your organization.” Core teams, each of four-members, will attend two in-person learning sessions and seven virtual learning sessions. Teams will receive key content on implementation and knowledge translation that will assist in their implementation efforts to ensure success and sustainability of project gains. This learning collaborative is sure to attract a lot of interest! Only eight teams from across the country will be selected to participate. Join an information webinar at 1200 Noon ET on Tuesday, February 5th or Tuesday, February 12th to learn more! Click here to register. Register Now (Tuesday, February 5th) Register Now (Tuesday, February 12th) The deadline for applications is March 1, 2019. For more information, email teamworkandcommunication@cpsi-icsp.ca The Teamwork and Communication is one of three Safety Improvement Projects being launched in January 2019 to support healthcare organizations in advancing patient safety. 1/10/2019 5:00:00 PM The Teamwork and Communication Safety Improvement Project will empower participating teams to actively solve local level teamwork and communication1/14/2019 8:54:22 PM349http://www.patientsafetyinstitute.ca/en/NewsAlerts/News/Pages/Forms/AllItems.aspxhtmlFalseaspx
A collaborative to decrease readmissions related to medication safety at care transitions29720Patient Safety News ​This safety improvement project is designed for acute care organizations that care for frail elderly. Participating teams will learn how to decrease readmissions related to medication safety issues at discharge among frail patients with poly-morbidity. The Canadian Alliance for a National Seniors Strategy notes that 65 per cent of older Canadians are taking medications belonging to five or more medication classes, while 39 per cent of adults over the age of 85 are taking medications belonging to 10 or more medication classes. Nearly 40 per cent of older Canadians are found to be taking at least one inappropriate medication. An additional 12 per cent take multiple inappropriate medications, the use of which is associated with avoidable hospitalization and hospital readmissions due to adverse drug events. Often, reducing an older adults' intake of inappropriate medications could help reduce their risk for becoming frail. A Safety Improvement Project focused on medication safety at care transitions to help healthcare teams to make a significant impact on readmission rates will run from January 2019 to October 2020. The Medication Safety at Care Transitions Safety Improvement Project is a learning collaborative that will support better outcomes for frail elderly patients including better health outcomes, reduced length of stay, fewer hospital readmissions, and overall cost savings to Canada's healthcare system. “Despite the best intentions of healthcare providers and the design of healthcare systems, medications can cause patient safety incidents, says” Mike Cass, Senior Program Leader, Canadian Patient Safety Institute. “The Medication safety collaborative will help participants to identify frail clients who are at risk for medication safety issues and learn to apply new processes for medication management at discharge.” Core teams, each of four-members, will attend two in-person learning sessions and seven virtual learning sessions, and be supported by expert faculty and coaches from across Canada. Teams will receive key content on implementation and knowledge translation that will assist in their implementation efforts to ensure success and sustainability of project gains. Only eight teams from across the country will be selected to participate in the Med Safety Collaborative. Don't miss out on this opportunity! Join an information webinar at 1200 ET on Tuesday, February 5th or Tuesday, February 12th. Click here to register to learn more! Register Now (Tuesday, February 5th) Register Now (Tuesday, February 12th) The deadline for applications is March 1, 2019. For more information, email medsafety@cpsi-icsp.ca The Medication safety collaborative is one of three Safety Improvement Projects being offered to support healthcare organizations in advancing patient safety. 1/10/2019 5:00:00 PM This safety improvement project is designed for acute care organizations that care for frail elderly. Participating teams will learn how to1/16/2019 4:10:53 PM339http://www.patientsafetyinstitute.ca/en/NewsAlerts/News/Pages/Forms/AllItems.aspxhtmlFalseaspx
New learning opportunity to reduce the risk of complications for surgery patients 29722Patient Safety News ​Over an 18-month period, participating teams will be empowered and equipped with tools, resources and strategies to effectively implement Enhanced Recovery best practices in their clinical settings, with improved patient outcomes as a catalyst. A new Safety Improvement Project focused on surgical best practices to help healthcare teams to make a significant impact on surgical safety is set to launch in January 2019. The Enhanced Recovery Canada (ERC) Safety Improvement Project is a learning collaborative that will support better outcomes for surgical patients including an improved patient experience, reduced length of stay, decreased complication rates and fewer hospital readmissions. Enhanced Recovery Canada has adapted evidence-based best practices for colorectal surgeries known to help patients receive optimal care. Teams will learn how to implement the Enhanced Recovery Canada patient-inclusive, standardized, evidence-based clinical pathways. Within each pathway are six core principles that are known to improve care patient and family engagement, nutrition, early mobilization, hydration, pain and symptom control, and surgical best practices. "Most quality improvement projects are viewed as medical projects and not geared toward changing the culture of safety," says Dr. Claude Laflamme, Physician Lead, Surgical Care Safety Best Practices, Canadian Patient Safety Institute (CPSI). "The approach is usually not comprehensive, and the work often vanishes after the project is completed. Enhanced Recovery principles shatter conventional siloed practice. It is a comprehensive approach, from the top down, that is multidisciplinary and includes both patients and healthcare providers." "We want to take the ERAS learnings and evidence that has been acquired internationally and within Canada, and move it across the country," says Carla Williams, Senior Program Manager, CPSI. "The collaborative will help you to become a site-based champion for enhanced recovery and a leader for change in your organization." Core teams, each of four-members, will attend two in-person learning sessions and seven virtual learning sessions over an 18-month period, and be supported by expert faculty and coaches from across Canada throughout the collaborative. Teams will receive key content on implementation and knowledge translation that will assist in their implementation efforts to ensure success and sustainability of project gains. A maximum of twelve teams from across the country will be selected to participate in this unique learning opportunity. Will one of them be you? Join an information webinar at 1200 Noon ET on Tuesday, February 5th or Tuesday, February 12th to learn more! Click here to register. Register Now (Tuesday, February 5th) Register Now (Tuesday, February 12th) The deadline for applications is March 1, 2019. For more information, email erc@cpsi-icsp.ca The ERC collaborative is one of three Safety Improvement Projects created to support healthcare organizations in advancing patient safety. 1/10/2019 5:00:00 PM Over an 18-month period, participating teams will be empowered and equipped with tools, resources and strategies to effectively implement Enhanced1/11/2019 5:25:22 PM289http://www.patientsafetyinstitute.ca/en/NewsAlerts/News/Pages/Forms/AllItems.aspxhtmlFalseaspx
Patient Safety Power Play: Make a resolution to prevent patient harm29718Patient Safety Power Plays Welcome back from holidays, everyone. I sincerely hope you shared some wonderful memories together with friends and family. Now that we're back, I am delighted to finally share with you my two resolutions for 2019. This year, we will lead and inspire all Canadians to sit up and take notice of the preventable patient harm crisis in Canada's healthcare system! My First Resolution Share What Works With People Who Can Make Changes If you have read ahead in this issue of our Digital Magazine, you already have a good sense of what I mean. This year, we are launching three outstanding Safety Improvement Projects for our colleagues in healthcare across the country. Whether you are a healthcare provider, clinical support staff, or a vital administrator, we have developed evidence-based practices that you can implement immediately to start improving patient safety right now! For our colorectal surgical care teams, the Enhanced Recovery Canada project will improve outcomes and system efficiencies. For our colleagues in acute care organizations, we developed our Medication Safety at Care Transitions project, with an emphasis on preventing harm to frail patients. Finally, for every team in healthcare, we are introducing a special project on Teamwork and Communication based around the popular and hugely successful TeamSTEPPS Canada™ program. On January 22, these three Safety Improvement Projects will open for registration. Each one boasts internationally renowned faculty and coaches, unique collaborative virtual spaces, and will equip participants with actionable, reportable plans. These 18-month projects will be offered for a set fee for teams from across Canada, using integrated knowledge translation and implementation science principles. I want to make sure you don't miss out sign up here to learn about them as soon as they are announced! My Second Resolution Tell Everybody About Preventable Patient Harm This year, I also committed to telling everyone about our mission. We know that as soon as someone learns that preventable patient harm is the third leading cause of death in Canada, it becomes their number one healthcare priority. So this year, it is my mission to tell as many people as possible. If you help me, together we will make a change in 2019. Will you follow my lead? If you tell two people the following five facts – and ask them to do the same – I believe we can set the country on fire! 1 in 3 Canadians has experienced preventable patient harm or has a loved one who did. Every 13 minutes, someone in this country dies from preventable patient harm. One out of 18 Canadian hospital visits results in preventable patient harm. Preventable patient harm costs $2.75 billion every year. There are actions you can take to keep you and your loved ones safer in our healthcare system. If every person in Canada knew these five facts, I truly believe that we could transform our healthcare system. Patient safety would become the number one healthcare priority for the public, for the media, for the healthcare system, and for our regulators. So will you join me in my 2019 resolutions? If you are working within healthcare, will you make sure that the right people know about the upcoming Safety Improvement Projects? And whether you work within the healthcare system or not, will you tell two people those five facts on preventable patient harm – and ask them to do the same? Together, we can make 2019 a milestone year in patient safety. If you decide to join me, will you let us know? Could you hashtag #PatientSafetyRightNow in any social media you share? If you have a story about preventable patient harm, would you share it with your audiences through social media – and use the hashtag as well? Help us make this year count. Help us improve patient safety and prevent patient harm. Questions? Comments? My inbox is open to you anytime at cpower@cpsi-icsp.ca, and you can follow me on Twitter @ChrisPowerCPSI. Yours in patient safety, Chris Power 1/10/2019 7:00:00 AMWelcome back from holidays, everyone. I sincerely hope you shared some wonderful memories together with friends and family. Now that we're back, I am1/10/2019 8:45:00 PM135http://www.patientsafetyinstitute.ca/en/NewsAlerts/News/Pages/Forms/AllItems.aspxhtmlFalseaspx
#superSHIFTERS Sepsis: Pearls of wisdom23956Super SHIFTERS ​Kim Neudorf has been a patient champion with Patients for Patient Safety Canada since 2009. Her areas of interest include health promotion, patient safety, patient engagement, infection prevention and control, and antimicrobial stewardship. Kim recently co-authored a paper that provides an overview of patient advisors' perspectives on the state of antimicrobial resistance and stewardship in Canada, Engaging patients in antimicrobial resistance and stewardship. Each time I tell this story, it seems more unbelievable. I wonder if this experience had to be extreme for me to take notice and realize patient safety isn't something that can be taken for granted. And later it made me realize that I needed to be a part of the solution. I took immediate notice of the change in Mom, as I met her at her front door. Her usual welcoming smile was replaced by a grim, puffy face and swollen, blue-tinged lips. I tried to make sense of the dark brown mittens she wore on that warm June morning. Her soft moans and one-word replies to my probing questions told me everything was an effort for her—that she was really sick. Barely audible, she whispered these words, "Backache…flu…fever…weak." It was clear to me she needed to be seen in emerg. I am a retired nurse and viewed her situation to be pretty straightforward. I expected her to receive the required diagnostics and treatment, and be treated well. I trusted the system that I'd worked in all those years prior. I did not expect my seventeen-year-old daughter to ask this question days later "Doesn't anybody care about her?" Mom walked into the emergency room. I was with her, concerned about what was percolating in her body and her mental decline. She was diagnosed with a urine infection, given a large bolus of IV fluid to correct her dehydration, an oral antibiotic (Ciprofloxacin), an opioid for her back pain, and released. The slippery slope began on that first day. The urine culture test was missed, she vomited right after she received the antibiotic pill, her pulse was well above her usual rate, and the necessary tests to diagnose sepsis weren't ordered, even though the physician mentioned it was a possibility. She returned to the emergency department the following two days. The second day she arrived by wheelchair. The intravenous bolus of fluid she received the day before made her legs so swollen, none of her shoes fit and her breaths were crackling with fluid. The doctor asked if she had dementia. I worried that his assessment was overshadowed by how she presented at that moment. He would have seen an older adult, slumped in a chair, barely capable of answering questions—because as she told him, "my brain is in a fog." I knew I needed to be her voice, her eyes and ears, and in time understood that I would also hold her memories. I made a point of speaking about her previous vitality at every opportunity—at each history taking, during assessments, with each new interaction. I wanted them to be clear—what they were seeing now wasn't who she'd been. On the third day she arrived by ambulance. She fell in her bedroom in the middle of the night, as she helplessly searched for her socks and pills—pills she'd already taken. She wasn't harmed, but she was in such a muddle and could not carry a thought through to complete a sentence. She had a fine rash over her body and the nurses had a difficult time getting an oxygen reading from her finger. The high intake of fluids washed the salts from her blood. Her heart rhythm was rapid and erratic. I informed the staff that on the first day she was seen in the ER, the physician considered sepsis. She was admitted to the hospital with the diagnosis of urinary tract infection and hyponatremia. Mom's mental decline and extreme fatigue became a touchy point. I saw Mom as someone who needed more intensive monitoring and surveillance, so when the nurses popped in and said, "Oh good she's sleeping." I retaliated with, "She's almost sleeping around the clock—it's not a good thing. She seems toxic." I believe the medical team trusted that once the antibiotic took hold, Mom's condition would improve; so we were told, "Slowly," and that they would "Wait and see." The twelve day course of Ciprofloxacin may have contributed to the complications that evolved. I asked the team to investigate deeper, and offered many suggestions. They seemed to be missing something. I thought I was a partner participating in Mom's care, in her best interest. I was wrong. This experience can be described as watching someone drown with a life preserver on. You expect it will help, but it's not, and you're watching that person die in front of you. As a nurse, I could influence the system—make good things happen in the worst of circumstances, but as a family member I was powerless. Therefore, I second-guessed my own ability to judge the situation objectively. There was tension, I tried to be delicate and wanted to trust the team, but they didn't seem to see the changes we did. After repeated requests for improved care including a handwritten letter that was placed on the front of Mom's chart, I worried about the chasm developing between Mom's family and the staff, and wondered how Mom ever got into this quagmire. On day ten as I fed my debilitated mother lunch, I noticed subtle, but ominous signs her skin and eyes were tinged with a sickening yellow hue, her urine dark orange. These new findings were reported to the charge nurse. I believed it was a call to action—the action never came. My brother called me that evening and said, "Mom looks like she's dying. She looks like Dad did when he died." Indeed she was. She was in a hemodynamic crisis—her red blood cells were self-destructing , and components of her blood dropped to levels incompatible with life. I had a hard time reconciling how my brother, a carpenter, could see that death was eminent, yet health professionals could not. I won't forget her desperation hours later—her struggle to live. She looked like an apparition buried in stark white sheets, her skin pale, transparent with a yellow cast. When she saw me, she sat straight up, her eyes fixed with fear. Her hoarse, loud voice pleaded, "I'm glad you're here... I'm so sick." Mom wasn't sleepy any longer. Although her body systems were depleted, her resolve was fierce. I ran to the desk and called for help. Her room became an instant hub of activity. Several physicians poured over her chart and concluded she developed autoimmune hemolytic anemia, pneumonia and was in a coronary crisis that resulted in a heart attack. An amazing team took over. She was in the hospital for five weeks and it took six months before her vitality returned—she lived, but there was functional loss. That was ten years ago. **** Today sepsis protocols and early warning assessment tools have improved the odds of surviving sepsis. Sepsis takes infection to another dimension. Pneumonia is the most common cause, but any infection can trigger the body's varied and complex response, that can either eradicate the infection or lead to multi-organ damage and death. Sepsis is the leading cause of death in hospitalized patients. In 2011, Health Canada reported 30 to 50 per cent of people who develop sepsis die from it.[1] While complete recovery is possible, the after effects can linger with conditions that affect the heart, kidneys, muscle strength and mental health, and there is a predisposition to recurrent infections. Research indicates patients may acquire neurological damage resulting in long-term moderate to severe cognitive impairment.[2] These effects are devastating consequences to an individual's quality of life. The severity and duration of a septic reaction to an infection is determined by a variety of factors. Children under one year are at greater risk, as are people with weakened immune systems, or chronic health conditions, and those over sixty-five years of age.[3] Sepsis is not a new disease, and fortunately fewer people die from it today. However, sepsis remains difficult to diagnose because it mimics other conditions, infectious or otherwise. For the public, the best defence is a good offence maintain good health and avoid infections, practice hand hygiene, keep vaccinations current, and cuts clean and covered. Learn to recognize the telltale symptoms of sepsis temperature more than 38.3 C or less than 36 C, a heart rate more than 90 beats per minute, more than 20 breaths per minute, tissue swelling, confusion, and discomfort.[4] If these symptoms exist in whole or in part, go to the emergency department, and be prepared to announce, "I'm worried I may have sepsis,"[5] to avoid being placed to the back of the queue. In order to beat the odds and survive sepsis, it must be recognized as a medical emergency. The longer there is a treatment delay, the greater the likelihood of progressive organ failure and death. Organ failure manifests itself with signs such as low blood pressure, an altered mental state, high blood sugar values in the absence of diabetes, low oxygen levels, changes in lab values associated with the blood's ability to coagulate, and a raised lactate level that indicates organs are not receiving enough oxygen.[6] A standardized approach to the medical management of sepsis is reducing complications and death. Intravenous fluid infusion and diagnostic tests to determine the source of infection is strongly recommended for the best possible outcome. Intravenous administration of the most appropriate antimicrobial drugs, such as antibiotics should should occur within one hour. This appears to be the single most important intervention. Specialized monitoring systems and medications may be necessary to prevent organ dysfunction.[7]**** Mom remembered little of those weeks in the hospital. Together, we've shared her story with the public, health professionals and students. During our presentations we identified "pearls of wisdom" to ensure patients receive the right care at the right time. At the podium, Mom would describe her health goals and demonstrated her heartfelt gratitude to her family and all healthcare workers with her closing comment "We need all of you!" [1] Tanya Navaneelan, Sarah Alam, Paul A Peters, Owen Phillips, "Deaths Involving Sepsis in Canada. 2016"; Release date January 21, 2016, http//www.statcan.gc.ca/pub/82-624-x/2016001/article/14308-eng.htm [2] Hallie C Prescott, Derek C Angus, "Enhancing Recovery from Sepsis A Review," JAMA 319 no. 1 (2018)62-75. [3] "Protect Yourself and Your Family from Sepsis," CDC, accessed February 1, 2018, https//www.cdc.gov/sepsis/pdfs/Consumer_fact-sheet_protect-yourself-and-your-family_508.pdf [4] Derek C Angus and Tom van der Poll, "Severe Sepsis and Septic Shock," New England Journal of Medicine 369 (2013)840-51. [5] "Protect Yourself." [6] Angus and van der Poll, "Severe Sepsis." [7] Andrew Rhodes et al.,"Surviving Sepsis Campaign International Guideline for Managing Severe Sepsis and Septic Shock 2016," Critical Care Medicine 45 no. 3 (2017)486-552. https//journals.lww.com/ccmjournal/Fulltext/2017/03000/Surviving_Sepsis_Campaign___International.15.aspx 1/8/2019 6:00:00 PM Kim Neudorf has been a patient champion with Patients for Patient Safety Canada since 2009. Her areas of interest include health promotion, patient1/10/2019 10:36:28 PM505http://www.patientsafetyinstitute.ca/en/NewsAlerts/News/Pages/Forms/AllItems.aspxhtmlFalseaspx

 Upcoming Events

 

 

Western Canadian One Health Antimicrobial Stewardship Conference3149https://www.eventbrite.com/e/western-canadian-one-health-antimicrobial-stewardship-conference-tickets-530224515801/22/2019 2:00:00 PM1/24/2019 11:00:00 PMBringing together interested antimicrobial stewards from both human and animal health sectors to exchange ideas and take action. 12/14/2018 9:58:50 PM9http://www.patientsafetyinstitute.ca/en/Events/Lists/Events/calendar.aspxFalseConferenceFalse
Safety Improvement Project Information Webinars33868WebExhttp://www.patientsafetyinstitute.ca/en/toolsResources/Safety-Improvement-Projects/Pages/Upcoming-Webinars-2019-01-11.aspx2/5/2019 5:00:00 PM2/5/2019 6:00:00 PMThese webinars will be a great opportunity for you and your team members to get more information about the learning collaboratives and get answers to any questions.1/15/2019 9:47:36 PM5http://www.patientsafetyinstitute.ca/en/Events/Lists/Events/calendar.aspxFalseWebcastFalse
Deadline to apply - EXTRA: Executive Training Program33702https://www.cfhi-fcass.ca/WhatWeDo/extra/application2/12/2019 6:00:00 PM2/12/2019 7:00:00 PMThe EXTRA Executive Training Program is a team-based fellowship in quality improvement (QI) and leadership open to participants from across Canada. This program is hosted by CFHI11/29/2018 5:33:52 PM20http://www.patientsafetyinstitute.ca/en/Events/Lists/Events/calendar.aspxFalseWorkshopFalse
TeamSTEPPS Canada™ Master Trainer Training Course33716Douglas College, New Westminster Campus 700 Royal Avenue, New Westminster, BChttp://www.patientsafetyinstitute.ca/en/education/TeamSTEPPS/Pages/TeamSTEPPS-Master-Trainer-Training-Course---2018-12-04.aspx2/20/2019 3:00:00 PM2/21/2019 11:30:00 PMA TeamSTEPPS Canada™ Master Training course is coming to the Vancouver area in February 2019! This course will help you to improve team collaboration, clinical outcomes and patient safety at your organization. Learn about the TeamSTEPPS® tools – what they are and how to use them – so that you can make a difference in your workplace.12/5/2018 7:22:25 PM23http://www.patientsafetyinstitute.ca/en/Events/Lists/Events/calendar.aspxFalseWorkshopFalse
Maternal morbidity and mortality surveillance in Canada - where we are and where we are not25771http://www.patientsafetyinstitute.ca/en/events/pages/maternal-morbidity-and-mortality-surveillance-in-canada---where-we-are-and-where-we-are-not-2019-01-08.aspx2/20/2019 5:00:00 PM2/20/2019 6:00:00 PMMaternal morbidity and mortality surveillance in Canada - where we are and where we are not Objectives 1. To discuss the history and latest initiative of maternal mortality and morbidity monitoring in Canada 2. To inform of possible solutions that are currently underway across the country1/8/2019 8:47:14 PM21http://www.patientsafetyinstitute.ca/en/Events/Lists/Events/calendar.aspxFalseWebcastFalse