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Teamwork and Communication2360Publication;Framework7/22/2009 8:44:35 PM ​​​Effective teamwork and communication are critical for ensuring high reliability and the safe delivery of care. Teamwork and communication techniques can improve quality and safety, decrease patient harm, promote cross-professional collaboration and the development of common goals, decrease workload issues, and improve staff and patient satisfaction. Building effective teams and improving communication through standardized tools will move effective teamwork forward in Canada and contribute to a culture of patient safety. CPSI is developing a Canadian Framework for Teamwork and Communication to help healthcare providers and organizations integrate tools and resources into practice. Canadian Framework for Teamwork and CommunicationAppendix A Teamwork and Communication in Healthcare A Literature ReviewAppendix B Consultation with Health Professionals and Administrators Regarding Teamwork and CommunicationAppendix C Report on Summary of Team Training Programs Download Canadian Framework for Teamwork and CommunicationEffective Teamwork and Communication to Enhance Patient Safety11/9/2016 8:44:39 PM
Hospital Harm Improvement Resource27904/14/2015 5:37:10 PMIntroduction Patients expect hospital care to be safe and for most people it is. However, a small proportion of patients experience some type of unintended harm as a result of the care they receive. The Canadian Institute for Health Information (CIHI) and the Canadian Patient Safety Institute (CPSI) have collaborated on a body of work to address gaps in measuring harm and to support patient safety improvement efforts in Canadian hospitals. The Hospital Harm Improvement Resource was developed by the Canadian Patient Safety Institute to complement the Hospital Harm measure developed by CIHI. It links measurement and improvement by providing evidence-informed practices that will support patient safety improvement efforts. The purpose of measuring quality and safety is to improve patient care and optimize patient outcomes. The Hospital Harm measure should be used in conjunction with other sources of information about patient safety, including patient safety reporting and learning systems, chart reviews or audits, Accreditation Canada survey results, patient concerns and clinical quality improvement process measures. Together, this information can inform and optimize improvement initiatives. The Improvement Resource is a compilation of evidence-informed practices linked to each of the clinical groups within the Hospital Harm measure to help drive changes that will make care safer. Through extensive research and consultation with clinicians, experts and leaders in quality improvement (QI) and patient safety, the Improvement Resource is intended to make information on improving patient safety easily available, so teams spend less time researching and more time optimizing patient care. The Improvement Resource is a dynamic tool that the Canadian Patient Safety Institute will continue to develop and review every two years, or as new evidence emerge. If you have any suggestions for the Improvement Resource, please send your ideas to The layout of the Improvement Resource reflects the framework of the Hospital Harm measure (Figure 1) and focuses on actions that can be taken to decrease the likelihood of harm. The measure includes four major categories of harm and within each category is a series of individual clinical groups, or types of harm, each of which connects to evidence-informed practices for improvement. For each clinical group, the Improvement Resource provides the followingAn overview of the clinical group and goal for improvement.Implications for patients experiencing the type of harm and their importance to patients and family.Evidence-informed practices to reduce the likelihood of harm. Outcome and process improvement measures. Associated Accreditation Canada standards and Required Organizational Practices and Global Patient Safety Alerts recommended search terms.Success stories from organizations.References and key resources, including guidelines and select research articles.Definitions As patient safety terminology evolves it is important to be clear on the meaning and differences of specific words. For the purposes of the Hospital Harm measure, the following definitions apply Harm – An unintended outcome of care that may be prevented with evidence-informed practices and is identified and treated in the same hospital stay. Occurrence of harm – Harmful event is synonymous with occurrence of harm. Patient Safety – The reduction of risk of unnecessary harm associated with healthcare to an acceptable minimum. An acceptable minimum takes into consideration current knowledge, resources available and the context in which care was delivered weighed against the risk of non-treatment or other treatment. Hospital Harm Measure – Acute care hospitalizations with at least one unintended occurrence of harm that could be potentially prevented by implementing known evidence-informed practices. For harm to be included in the measure, it must meet the following three criteria It is identified as having occurred after admission and within the same hospital stay.It requires treatment or prolongs the patient's hospital stay.It is one of the conditions from the 31 clinical groups in the Hospital Harm Framework. Download Back to Hospital Harm MeasureHospital Harm Improvement Resource Introduction Patients expect hospital care to be safe and for most people it is. However, a small proportion of patients experience some type of10/25/2016 7:23:53 PM5130
Concise Incident Analysis Method Pilot Study4648Publication;Research7/1/2015 1:59:51 AM ​​In recent years, many healthcare organizations have developed local methods for responding to patient safety incidents with processes that are more rigorous than a simple incident report but less rigorous than a Root Cause Analysis (RCA) or similar comprehensive review. The World Health Organization (WHO) Patient Safety Programme is developing a tool and methodology for the conduct of concise incident analyses, termed the Concise Incident Analysis (CIA) Tool. The concise method included in the Canadian Incident Analysis Framework is one of the main resources on which the CIA Tool is based on. The Canadian Patient Safety Institute (CPSI), in partnership with the Johns Hopkins’ Armstrong Institute for Patient Safety and Quality and the WHO Patient Safety Programme, pilot tested this tool with healthcare organizations around the world. Click to access version 1 and version 2 of the tool. Click here to download the final version of the concise analysis tool and workbook (in English only). Download Click on the citation below to read a journal article featuring this research. Jt Comm J Qual Patient Saf. 2016;42(1)26-36.A Tool for the Concise Analysis of Patient Safety Incidents.Pham JC, Hoffman C, Popescu I, Ijagbemi OM, Carson KA.To learn more about concise analysis and other incident analysis methods access the Canadian Incident Analysis Framework and/or the Patient Safety and Incident Management Toolkit.TeamLead(s)Dr. Julius Pham, Armstrong Institute for Patient Safety and Quality Carolyn Hoffman Alberta Health ServicesResearch coordinatorMayowa Ijagbemi, Armstrong Institute for Patient Safety and QualityInternational Advisory Team Ross Baker (Canada),Gerry Castro (US), Noel Elridge (US), Donna Forsyth (UK), Ed Kelley (WHO)Sandi Kossey (CPSI) SF Lui (Hong-Kong), Ioana Popescu (CPSI)Jean-Marie Rodrigues (France) Bill Runciman (Australia), This project was made possible through the cash and in-kind contributions of theCanadian Patient Safety Institute Johns Hopkins’ Armstrong Institute for Patient Safety and Quality Alberta Health ServicesWorld Health Organization Patient Safety ProgrammeConcise Incident Analysis Method Pilot StudyIn recent years, many healthcare organizations have developed local methods for responding to patient safety incidents   with processes1/27/2016 6:19:09 PM
Post-Marketing Surveillance of Drug Safety4652Report;Research7/1/2015 2:01:25 AM ​​​​What are the ways in which health services and policy research related to prescription drug safety and effectiveness in the post-marketing period have been supported? This research provides a synthesis of existing evidence and how it is used internationally, while looking at the potential for applying other jurisdictions’ experiences/models in Canada. Download Research Results Post-Marketing Surveillance of Drug SafetyPost-Marketing Surveillance of Drug Safety11/9/2016 4:30:01 PM
Safety at Home: A Pan-Canadian Home Care Study4654Research7/1/2015 2:02:05 AM ​​One out of every six seniors receives home care services in Canada. As the aging population continues to grow there is a greater need to ensure the delivery of Home Care in Canada is safe. The release of The Safety at Home A Pan- Canadian Home Care Study is the first of its kind that examines adverse events in the home and includes recommendations on how to make care safer. Dr. Diane Doran, professor at the Faculty of Nursing at the University of Toronto, co-lead Dr. Régis Blais, professor at the Department of Health Administration at the University of Montreal, and their team spent the last two years examining administrative databases and reviewing charts across the country which showed the rate of adverse events in Canadian Home Care clients was 10 -13 per cent, over a period of one year. Extrapolating to the over one million home care recipients, that is up to 130,000 Canadians, who have experienced an adverse event, with half being deemed to be preventable. The Canadian Patient Safety Institute partnered with other sponsoring organizations for the study including, the Canadian Institutes of Health Research (CIHR), Institutes of Health Services and Policy Research (IHSPR), The Change Foundation, and the Canadian Foundation for Healthcare Improvement (CFHI). The study examined the reasons for harmful incidents, determined the impact on families and clients and made suggestions on how to make home care safer. The research team in collaboration with CPSI and national partners such as Canadian Home Care Association, Accreditation Canada, and Victoria Order of Nurses will be developing tools and resources for various audiences including clients, caregivers, Home Care organizations, and policy makers. Watch for the launch of these tools on the CPSI website. Download Journal article Assessing adverse events among home care clients in three Canadian provinces using chart review Click here to access the News Release.Safety at Home: A Pan-Canadian Home Care Study One out of every six seniors receives home care services in Canada.   As the aging population continues to grow there is a greater need to11/9/2016 4:52:19 PM
Safety in Long-Term Care Settings4655Research7/1/2015 2:02:50 AM ​​How can we improve patient safety in long-term care? While there is a growing body of literature on patient safety, there has been less emphasis on the long-term care (LTC) setting than the acute care sector. Recognizing the gap in our understanding of patient/resident safety issues in LTC, the Canadian Patient Safety Institute, Capital Health (Edmonton), and CapitalCare (Edmonton) collaborated to create a research and action agenda for improving safety in the LTC setting. Download Research Results Safety in Long-Term Care SettingsSafety in Long-Term Care Settings11/9/2016 4:35:33 PM
Economics of Patient Safety4656Research;Report7/1/2015 1:59:06 AM​​​​​​​​​How much do adverse events cost? New research report estimates the cost of preventable patient safety incidents is $397 million. The human burden associated with adverse patient safety events has been well established for years; however, until recently, it has been unclear how much adverse events impact the cost to the Canadian acute care system. Relatively little attention has been directed toward the economic impact of such events, and few studies have attempted to estimate the additional costs of adverse events in hospital care. In an effort to understand the true financial costs of adverse events in acute care, the Canadian Patient Safety Institute (CPSI) commissioned research to investigate the literature on the economics of patient safety. Lead Investigators Dr. Edward Etchells, Associate Director of the University of Toronto Centre for Patient Safety and Dr. Nicole Mittmann, Executive Director of HOPE Research Centre at Sunnybrook Health Sciences Centre reviewed published studies related to the economic burden of adverse events and to comparative economic evaluations. Their findings enabled them to calculate an estimate of economic burden of adverse events in Canada for 2009 – 2010 to be $396,633,936. They also recommend certain patient safety improvement strategies that could be considered economically attractive such as pharmacist led medication reconciliation, chlorhexidine for vascular catheter site care, standard counting strategy for detecting surgical forign bodies, and Keystone ICU patient safety program to prevent central line-associated blood stream infections. Understanding the benefits and costs associated with patient safety and adverse events is imperative for enabling policy and decision makers to explore the potential for improving patient safety to help avoid unnecessary healthcare expenditures. The report entitled, Economics of Patient Safety in Acute Care, is available below Click ​here to access the News Release. Click here to access the research results. Click here to access information on the Economics of Patient Safety in Acute Care Webinar. (program is only being offered in English) Download Economics of Patient SafetyEconomics of Patient Safety
Patient Safety in Mental Health4657Report;Research7/1/2015 2:00:00 AM ​​​What patient safety issues are unique to mental health care in Canada?The Canadian Patient Safety Institute (CPSI) and the Ontario Hospital Association (OHA) collaborated and commissioned a team from British Columbia Mental Health and Addiction Services to prepare a research paper that defines the patient safety issues unique to mental health care in Canada.Together with a Canadian advisory committee, CPSI and the OHA engaged experts and stakeholders from across Canada and internationally to contribute their expertise and advice throughout the research process. Download Research Results Patient Safety in Mental HealthWhat patient safety issues are unique to mental health care in Canada? The Canadian Patient Safety Institute (CPSI) and the Ontario Hospital11/9/2016 4:25:17 PM
Patient Safety in Primary Care4658Report;Research7/1/2015 2:01:44 AM ​​How can we advance patient safety in primary care? While there is increasing evidence on patient safety in acute care settings, less is known about the safety of healthcare services in the community, particularly within primary care. In 2009, the Canadian Patient Safety Institute (CPSI) partnered with the BC Patient Safety & Quality Council (BCPSQC) to commission a research report on the current state of knowledge of patient safety in primary care with the goal of identifying the key issues, priorities, opportunities and strategies for advancing patient safety in primary care in Canada. Through a competitive process, a research team from the Institute of Health Economics was commissioned to develop the report, “Patient Safe​ty in Primary Care”. Together with a pan-Canadian Advisory Group, experts and stakeholders from across Canada and internationally were engaged to contribute information and expertise throughout the research process. Research Results Download Patient Safety in Primary Care Background Research PaperPatient Safety in Primary Care Background Research Paper9/23/2016 5:41:08 PM
Events458Events6/4/2015 6:09:31 AM ​​Events8/14/2017 4:14:34 PM29103
“You can ask me to clean my hands” buttons help to reduce healthcare infections9341News6/3/2015 3:52:40 PM5/7/2012 6:00:00 AM​​​​Asking healthcare workers to clean their hands can be an uncomfortable request, yet Alberta Health Services Mazankowski Alberta Heart Institute and CK Hui Heart Centre in Edmonton, are making it easier for their patients to do just that.The staff are wearing buttons that say, “You can ask me to clean my hands” in an effort to get patients and families more involved in their care. Renee Delera, RN wearing the “You can ask me to clean my hands” button Mme Renee Delera, IA porter l'insigne qui dit « Vous pouvez me demander de me laver les mains ». The Cardiac Sciences Edmonton team is participating in the Safer Healthcare Now! Stop Infections Now! Collaborative, an 18-month virtual learning program to reduce healthcare-associated infections. During a weekly meeting on how to get patients and families involved in hand hygiene and make them feel more comfortable in asking staff to clean their hands, a Plan-Do-Study-Act cycle was prepared where the idea to create buttons was developed. The buttons were designed onsite and produced using a button-maker borrowed from the Friends of University Hospitals. “Although we developed and made the buttons together, we have taken different approaches in implementing the button,” says Meagann Dunn, Clinical Nurse Educator, CK Hui Heart Centre At one Centre the buttons were distributed to all staff on the unit; at the other about 30 champions from cardiac sciences, the lab, respiratory and other areas were identified to trial the buttons initially, and to spread the message to other staff and sustain the momentum of the initiative. This approach has really spurred a lot of interest and when other staff see the button, they ask, how can I get one? “We have a whole raft of things going on to reduce infections and we are having a lot of fun doing it,” says, Darlene Bartkowski, Clinical Nurse Educator at the Mazankowski Alberta Heart Institute. Infection control articles are regularly featured in a monthly newsletter, Rhythm and News, and hand hygiene education is promoted through face-to-face discussions, computer-based simulation training, monthly audits, and weekly positively deviant meetings with liberating structure exercises. A collection box promotes contests and encourages staff to bring ideas forward that promote good hand hygiene and the environment. With the assistance of a student on a rotation from a local university, a Patient and Family Hand Hygiene Guide was recently developed using materials from Safer Healthcare Now! “We also interviewed staff and patients for input on the Guide and that really opened up the lines of communication between patients, families and staff,” add Bartkowski. For more information on the Stop Infections Now! Collaborative, visit To learn more about improving hand hygiene practises or to take the hand hygiene assessment, visit​​​Asking healthcare workers to clean their hands can be an uncomfortable request, yet Alberta Health Services Mazankowski Alberta Heart Institute and11/24/2015 3:19:22 AM
10,000 Reasons to Race for Infection Prevention9342News12/22/2015 3:23:31 PM12/22/2015 4:00:00 PM Of more than 200,000 surgeries performed in British Columbia annually where the Safe Surgery Checklist is used, some 95 per cent of patients don't get an infection. However, the British Columbia Patient Safety & Quality Council (BCPSQC) knows that 4.4 per cent of patients do get a surgical site infection (SSI), or surgical urinary tract infection (UTI). That translates to 10,000 patients per year. Fourteen teams from nine sites across British Columbia are participating in the 10K Race for Infection Prevention, a quality improvement collaborative to cut the number of surgical site and surgical urinary tract infections in half by November 2016. The teams are implementing best practices to prevent surgical UTIs (catheter and non-catheter associated), and using four key prevention strategies that significantly reduce the risk of SSIs perioperative antimicrobial coverage, appropriate hair removal, maintenance of perioperative glucose control, and perioperative normothermia. "Rather than re-teaching the evidence, we are getting teams to focus on the evidence using a team-based care approach," says Geoff Schierbeck, Quality Leader, Surgery, BCPSQC. "There is a lot of information out there, but it does not necessarily get to everyone on the team and we need to get everyone on the same page." What makes this collaborative unique is that it is frontline and clinically driven. The individuals driving the work are the physicians, nurses, anesthesiologists, operating room cleaners, porters, and other care providers. It brings the whole team together to make improvements. Teams decide what they would like to work on together, and have the support and encouragement of their managers to free up the time to do the perioperative improvements. Schierbeck says that they looked at the Safer Healthcare Now! Preventing Surgical Site Infections Getting Started Kit and the Institute for Healthcare Improvement's How-to Guide Prevent Catheter-Associated Urinary Tract Infection to create a driver diagram. The driver diagram takes all of the evidence around prevention of SSIs and surgical UTIs and incorporates it into one document, which identifies change ideas and what teams can work on. From there a work sheet was created that allows the teams to identify their priorities and create an aim statement. The teams initially got together in Vancouver on October 29 and 30, 2015 to kick-start their efforts. Ongoing support is provided by a quality improvement team with clinical experience, and teams will share their successes and challenges through regular webinars over the next year. Teams dictate the topics to be covered for the webinars. The first webinar, held on December 1, 2015, focused on gynecological surgery UTIs, highlighting the successful work being done at the Royal Inland Hospital in Kamloops. The webinar was well-attended and participants asked a plethora of questions around this troubling issue. The January 2016 webinar will feature work around SSI normothermia. Data collection is an integral part of understanding and improving systems, at both the individual site and provincial levels. Each site shares its data for learning and provincial analysis. Data from existing sources, including the Safer Healthcare Now! Patient Safety Metrics and the National Surgical Quality Improvement Program (NSQIP) are being used to reduce the data collection burden. An Apple and Android-driven app, called "The10K", has been created that provides the teams with a Race Page where they can track their progress compared to other teams. Other information, TED Talks, webinars, articles, resources, and measurement processes are also available on the app. "The app puts the information at the point of care. If you want to look up information quickly, the app will show what the driver diagram says, or what evidence there is to support the care that is being given," says Schierbeck. "By sharing our successes and challenges we have found that most teams are having the same problems in changing evidence into practice and the culture aspect of doing both," says Schierbeck. "A lot of our efforts are going into culture improvement, teamwork, and communication, and how that will help facilitate implementation of the best practice guidelines. As well, we are showing people real-time data on how they are performing. Displaying and sharing that information publicly where everyone can see it will help the teams stay engaged in this work." To learn more about the 10K - 10,000 Reasons to Race for Infection Prevention, visit www.10Kreasons.caOf more than 200,000 surgeries performed in British Columbia annually where the Safe Surgery Checklist is used, some 95 per cent of patients don't3/8/2016 4:19:07 PM
10 more Interprofessional teams trained to enhance patient safety education9343News6/14/2015 7:20:55 AM3/10/2011 7:00:00 AM ​​​​​​​​​​​The Patient Safety Education Project (PSEP) Canada recently completed a second pilot session and certified an additional 10 interprofessional teams as PSEP-Canada Patient Safety Trainers to support patient safety and quality improvement work. The two-and-a-half day conference focuses on core patient safety content and effective teaching approaches to effectively drive patient safety improvements in healthcare organizations. Executive leaders from all participating organizations joined their teams for the last half-day of the program to build-on the session learning’s and gain momentum for implementing Action Plans developed by each team on a quality improvement or patient safety issue in their organization. “The program stimulated a lot of thought and provided the support we need to customize patient safety education tailored to our needs,” says John McKeekin, Project Manager from Correctional Services Canada (CSC). The CSC team included seven participants who will now develop a project plan and ‘train the trainers’ across five regions to sustain the program and roll out the patient safety training modules to the 57 federal penitentiaries across the country. “The facilitation techniques and the Canadian-focused curriculum will be invaluable as we move forward,” says John. “We now have a huge repository of information that will be our go-to resource, and methodologies and tools for training on patient safety topics,” says Eileen Chang, Patient Safety and Risk Management Specialist, Baycrest Geriatric Health Care System in Toronto, ON. Baycrest is developing a patient safety plan aligned with the organization’s strategic plan and will use the learnings to develop an education program for health professionals that is aligned with day-to-day practice. “This program pulls it all together into a formalized framework with bite-size pieces that can be utilized across health disciplines,” says Eileen. “This program fills a gap and provides a solid foundation to help take patient safety education to the front-line,” says Kristi Chorney, Manager of Quality, Patient Safety and Risk, Brandon Regional Health Authority, one of the 12 Master Facilitators completing certification as a PSEP-Canada Master Facilitator; 24 Master Facilitators have now been certified to lead the program. “This group was very energetic. There was excellent discussion about methods to advance from attitudes about patient safety into cultural change or the normal way of performing our work. We went away with a feeling that something good was going to happen in terms of being proactive rather than reactive in our approach to patient safety education.” Some 41 participants from across Canada completed the Become a PSEP-Canada Patient Safety Trainer program in Ottawa, February 8 to 10, 2011. The first pilot session, held in November 2010, also certified eight interprofessional teams as PSEP Canada trainers.. PSEP-Canada is a partnership between the Canadian Patient Safety Institute and Northwestern University, with content adapted for Canadian healthcare settings. Learnings from the two pilot sessions will be considered in finalizing the PSEP-Canada Patient Safety Trainer program, to be officially launched in the Fall of 2011. For more information, visit or contact Abigail Hain 613-738-4779 or email​10 more Interprofessional teams trained to enhance patient safety education7/29/2015 5:00:35 PM
10 years of partnering for patients – a message from the Patients for Patient Safety Canada Co-Chairs9344News4/7/2016 9:03:39 PM4/7/2016 6:00:00 AM​​​Sharon Nettleton​Denice Klavano Partnerships, at least the good ones, take time and energy to build. They are forged over time as trust and respect are earned. Many fail when the work is too difficult, when there isn't a shared vision or when success isn't realized quickly enough. Misunderstandings can create barriers large enough to derail efforts and change the course of action. Negativity can prevail. Systems remain unchanged. Unsafe care continues. This is unacceptable. Building strong partnerships is the hallmark of Patients for Patient Safety Canada. It is ingrained in our DNA. As members, we partner with each other to accomplish something greater than what we could alone. As patients and family members, many of whom have suffered grief and loss from healthcare errors, we partner with healthcare systems, in an effort to make improvements. We are volunteers. We choose this work and to be part of this incredible team; a team focused on doing some amazing things to make care safer for all. Not only are we committed to our cause, but we are also committed to each other. When it may have been easier to choose other pursuits, and where gratification may have been more instantaneous elsewhere, many of our initial members continued. Along the way, many others have joined our journey. Our supporters remind us that "changing a culture takes a decade". They encourage us to "stay the course." Volunteering to build a culture of safety in healthcare is an extraordinary thing. It is one of the most unique volunteer experiences that most of us have ever had. We've seen remarkable changes to the culture of patient safety over the last 10 years. Providers and leaders now invite us to be collaborators in communication, education, resource development, and safety design. These invitations extend beyond simply hearing our stories; the collaborators want us to be directly involved with shaping improvements. We took the time to build trust and earn respect, and now we have a partnership that is allowing us to make a real difference. For many of us, the phrase "Nothing about us without us," is starting to be realized. We are confident that the next 10 years will be very different – a faster pace of progression. With a shared vision, understanding of purpose, and strong partnerships, we believe something remarkable is on the horizon. In fact, we're already seeing a glimpse of this now shorter timelines, measurement of outcomes and experiences, transparency of results – good or bad – all so that swift actions can occur to keep things on track. We need to see what is working and what isn't. We need to know that resources aren't being wasted and that lives are not being needlessly harmed; that the healthcare system really 'cares' about its patients. Patient safety, patient experience, health outcomes and patient engagement are all connected. We may be patients, but 'patience' isn't our strong suit. As volunteers, we no longer hope to be involved in transforming healthcare, we expect it. Our destination is safe care. Our vision is 'Every Patient Safe'. Best regards, Denice Klavano and Sharon NettletonCo-Chairs, Patients for Patient Safety Canada Sharon Nettleton Denice Klavano Partnerships, at least the good ones, take time and energy to build. They are forged over time4/8/2016 2:26:24 PM
1,400 hands on deck for STOP! Clean Your Hands Day9345News6/14/2015 7:20:57 AM5/21/2014 6:00:00 AM​Put your hands together for the more than 1,400 sites that participated in STOP! Clean Your Hands Day 2014 to create awareness about the importance of hand hygiene. The national event took place on Monday, May 5th to coincide with a global initiative of the World Health Organization, “Save Lives Clean Your Hands.”Participating organizations were provided with an electronic package of materials to promote optimal hand hygiene practices at their sites. Purell® Mini Hand Hygiene Kits were also distributed courtesy of STOP! Clean Your Hands Day sponsor, GOJO.A webinar was held on STOP! Clean Your Hands Day to provide preliminary results of the Canadian Hand Hygiene Audit, designed to establish a national perspective on hand hygiene. As of May 5th, 46 organizations had submitted observations for 7,894 moments and the average compliance rate was 71 per cent. Findings from the Canadian Hand Hygiene Audit will be presented during a webinar on Tuesday, May 20, 2014. Click here for more information and to register. The Canadian Hand Hygiene Audit is an initiative of the Canadian Patient Safety Institute, Accreditation Canada, the Public Health Agency of Canada and Infection Prevention and Control Canada. During the webinar, finalists for the What’s Your Hand In It? competition made their pitches to the Dragon’s Den-style panel to win a $500 educational credit from GOJO. The organizations to be applauded for their creative ideas for evidence-based hand hygiene improvement include Hôpital Montfort (two entries), British Columbia Provincial Infection Control Agency (PICNet) and the Cape Breton District Health Authority. Congratulations to PICNet who was selected the winner for their photo contest, Clean Shots. Watch Crosswalk for an upcoming article on this innovative photo contest. Healthcare organizations across the country were active tweeting #stopcleanyourhandsday to promote hand hygiene. To view the tweets, visit https// For more hand hygiene tools and resources, visit ​​Put your hands together for the more than 1,400 sites that participated in STOP! Clean Your Hands Day 2014 to create awareness about the11/24/2015 3:32:24 AM
2012 Notice of Annual Business Meeting of Members9346News6/14/2015 7:20:59 AM11/19/2012 7:00:00 AM​​Notice is hereby given that the Annual Business Meeting of the Canadian Patient Safety Institute (CPSI) will be held at the Westin Hotel, December 7th, 2012, 1230-1430 ET, at the Westin Hotel, Newfoundland/Nova Scotia Room, 11 Colonel By Drive, Ottawa. The business to be transacted at this meeting includes the following Business Meeting Agenda Receipt of the report of the Board of Directors and the report of the Chief Executive Officer; Receipt and approval of the financial statements of CPSI for the period ending March 31, 2012, and the report of the auditors; Appointment of auditors for CPSI and authorization for Board of Directors to establish remuneration for the auditors; Election of Directors; Ratification of all acts and proceedings of directors and officers since the date of the 2011 Annual Business Meeting, and; Such other business as may properly be brought before the meeting or any adjournment. A Voting Member of CPSI may be represented at the meeting by the designate in that Voting Member’s application for membership or in any subsequent update. If that representative is unavailable, or if the Voting Member wishes to have a different representative for this year’s Annual Business Meeting, the Voting Member may, and is encouraged to, complete and return the provided proxy form appointing another person to act and vote on behalf of the Voting Member. A Voting Member may appoint anyone it wishes to act as proxy. To be recognized as valid for the meeting, a signed proxy form must either Be returned to CPSI at the following address by fax, mail or delivery by December 3rd, 2012 to the following address Suite 410, 1150 Cyrville RoadOttawa, Ontario, K1J 7S9Attention David H. Hill, Board SecretaryFax 613-730-7323 OR; Be presented by the proxy holder immediately prior to the meeting at the registration desk established by CPSI for that purpose at the location of the meeting. CPSI strongly encourages the return of completed proxies. Without more than 25% of the Members represented in person or by proxy, the meeting cannot proceed. We cordially ask for the cooperation of the members in this regard. The accompanying information circular forms a part of this notice. Dated at the City of Edmonton, in the Province of Alberta, this 23rd day of November, 2012, by order of the Board of Directors. Notice is hereby given that the Annual Business Meeting of the Canadian Patient Safety Institute (CPSI) will be held at the Westin Hotel, December7/29/2015 5:05:44 PM
2017: The year of the possible9347News1/6/2017 6:01:53 PM1/6/2017 8:00:00 PM I'm always excited by possibility and really enjoy the challenge of taking something possible and making it into a reality. Never more so than when I think about patient safety for the people of Canada. We are a skilled and conscientious nation, so safety for all patients is most definitely possible. Here are some of the ways we at the Canadian Patient Safety Institute work with our partners to change possible to realShift to Safety After a huge launch in 2016, we know you expect big things from SHIFT to Safety moving forward. We have a lot planned for SHIFT to Safety this year and are excited to bring it to you. If you haven't discovered SHIFT to Safety yet, you can learn all about it here. With this program, the possibilities are endless!National Patient Safety Action Plan To date, we have nearly 70 per cent of objectives listed in the National Patient Safety Action Plan complete and with the outstanding organizations that have come to the table and taken the lead on some of this work, we're well on our way to 100 per cent. There's to much happening to list here but I encourage you to learn more.Atlantic Learning Exchange The Atlantic Provinces are small but mighty and when they come together they can accomplish great things. This will be on display this May as the 4th Atlantic Health Quality and Patient Safety Learning Exchange is held in Charlottetown, PEI. Held every two years, this event is a prime example of what makes the Atlantic Provinces special and why they lead by example when it comes to partnering for patient safety. Let's build on the successes of the past to truly make 2017 the year of the possible. I know that with the incredible support we receive from our partners, our leaders, and our fellow citizens, patient safety will be at the forefront of our Canadian healthcare system. We know it's possible, let's make it a reality together. As always, please send me your thoughts and join in the patient safety conversation Yours in patient safety, Chris PowerI'm always excited by possibility and really enjoy the challenge of taking something possible and making it into a reality. Never more so than when I1/6/2017 6:08:22 PM
20 ways to make the most of your Canadian Patient Safety Week celebration9348News6/14/2015 7:21:01 AM9/18/2013 6:00:00 AM​​How can you make the most of your participation in Canadian Patient Safety Week (CPSW) and Canada’s Forum on Patient Safety and Quality Improvement? It’s never too late to start planning. These helpful hints will help you get started Register for the CPSW and Canada’s Forum at Assemble a team – recruit a planning group to help with the planning and spark new ideas Research what has been done by other organizations and brainstorm on ideas of how you can make CPSW a success in your organization Set a budget; create a work plan and delegate tasks Enter the ASK.LISTEN.TALK video competition (Deadline to submit a video is September 20, 2013) Encourage safe medication use -- emphasize the importance of carrying a medication record at all times – hand out Knowledge is the Best Medicine booklets and medication records; recommend that patients download the MyMedRec app for the iPhone Participate in the Canadian MedRec Quality Audit Day on October 1, 2013 Book areas needed for displays and meeting rooms for Virtual Forum sessions; arrange for the necessary equipment Download the tools, resources, templates and ideas from, select News & Events and click on Canadian Patient Safety Week Arrange for a local patient to tell their story at your event. To arrange for a speaker from Patients for Patient Safety Canada, email Promote your events – send out an email blast or memo to staff announcing CPSW and Canada’s Forum; and patient safety games and activities as teasers to create a buzz (use the CPSW communication templates to promote events within your organization and to your local media) Secure prizes to entice participation in your local events Tweet what you are doing using hashtag #asklistentalk (Follow patient safety on twitter @Patient_Safety) Create a poster for the Canada’s Forum on Patient Safety and Quality Improvement Virtual Poster Competition (Deadline for submissions is October 18, 2013) Endorse CPSW by emailing (include your intent to endorse and your website address) Display posters, tent cards, Hands in Healthcare magazines and any other resources in high traffic areas throughout your organization Hand out ASK.LISTEN.TALK tattoos to staff, patients, clients and family members. Take pictures and share your activities with others across the country -- email to, post your photos to Facebook, or tweet them with the hashtag #asklistentalk Ask for feedback to evaluate your activities and thank those who helped you Complete our evaluation survey – your feedback is important to help us plan for next year! If you are already registered for Canadian Patient Safety Week, a package of promotional materials is on its way to help you mark the annual celebration within your organization. To access additional tools and resources to promote your event, visit Plan to watch the live broadcast of Canada’s Virtual Forum on Patient Safety and Quality Improvement beginning at 1200 Noon (EST), during CPSW -- October 28 to November 1, 2013. The 20 hours of live presentations and panel discussions delivered by leaders and experts in healthcare and patient safety are streamed online throughout the week, for four hours a day. Click here for more information on the daily themes and to view the program. For assistance in planning your activities, download a Checklist, or contact cpsw@cpsi-icsp.caHow can you make the most of your participation in Canadian Patient Safety Week (CPSW) and Canada’s Forum on Patient Safety and Quality Improvement?7/29/2015 5:08:52 PM
78.3 per cent of healthcare workers clean their hands9349News6/14/2015 7:21:04 AM6/17/2014 6:00:00 AM​​Sharing results of the Canadian Hand Hygiene Audit The Canadian Hand Hygiene Audit was held during the month of April 2014, to gain a national perspective on hand hygiene. Results from the audit show that the national compliance rate for hand hygiene is 78.3 per cent. The Canadian Hand Hygiene Audit observed hand hygiene practices (rub, wash, or miss) for all four moments of hand hygiene in acute care, long term care and home care, and for all healthcare provider categories. The Canadian Patient Safety Institute’s online data collection tool Patient Safety Metrics was used to collect and analyze the data for the audit. Data was collected from 64 sites, with 17,166 opportunities from 207 areas analyzed from acute care (84 per cent), long term care (15 per cent) and home care (one per cent) settings. The number of observed hand hygiene opportunities that were submitted by province included Alberta (2,647), British Columbia (346), Manitoba (1,116), New Brunswick (2,036), Nova Scotia (1,516), Nunavet (92), Ontario (7,228), Quebec (2,130) and Saskatchewan (56). “Although the overall number of healthcare organizations who participated in the audit is disappointing, a benchmark has been established that can be used to compare trends over time,” says Jim Gauthier, Past President, Community and Hospital Infection Control Association Canada (CHICA – Canada). “Observations for Moments 2 and 3 (before aseptic procedure and after body fluid exposure risk)are more difficult to collect as the observer has to enter the bed space of the patient during a patient encounter, therefore the majority of the observations provided for the audit focused on Moments 1 and 4 (prior to and after patient/patient environment contact).” The individual compliance rate for Moment 1 was 69 per cent and for Moment 4, 79 per cent. Jim Gauthier discussed findings from the Canadian Hand Hygiene Audit during a webinar on May 20, 2014. Click here to listen to the archived webinar and access the presentation. During the webinar, a number of practical suggestions for improving hand hygiene compliance were discussed. Jim Gauthier reinforces that the culture of a healthcare organization has an affect hand hygiene practices and auditing. “It is almost like a Hawthorne effect, when people know that they are being observed they will change their behavior,” says Jim Gauthier. “There is no magic number to reach as an acceptable compliance rate. It is important to use teachable moments to improve hand hygiene practices every time you observe commonly missed opportunities, and to involve patients in your hand hygiene programs.” The Canadian Hand Hygiene Audit was held as a part of STOP Clean Your Hands Day 2014, a joint initiative of the Canadian Patient Safety Institute, Accreditation Canada, the Public Health Agency of Canada (PHAC), and Infection Prevention and Control Canada (IPAC).Sharing results of the Canadian Hand Hygiene Audit The Canadian Hand Hygiene Audit was held during the month of April 2014, to gain a national7/29/2015 5:13:16 PM
Accreditation Canada recognizes increasing compliance with VTE prophylaxis9350News6/2/2016 7:54:31 PM6/2/2016 6:00:00 AM Successful approaches by Peterborough and Regina Qu'Appelle In the 2015 Accreditation Canada Report on Required Organization Practices (ROP), Quality and Safety in Healthcare Organizations, the Venous Thromboembolism (VTE) Prophylaxis ROP showed the greatest change in compliance from 2012 to 2014, increasing from 77 to 85 per cent. The ROPs are evidence-informed practices that mitigate risk and contribute to the quality and safety of health services. VTE is a condition that includes both deep vein thrombosis, the formation of a blood clot usually in the leg or pelvic veins, and pulmonary embolism when that clot dislodges and travels to the lungs. Thrombosis affects thousands of Canadians each year, and many are preventable. Dr. William Geerts, Director of the Thromboembolism Program at Sunnybrook Health Sciences Centre and lead of the Safer Healthcare Now! VTE intervention was the driving force behind the VTE required organizational practice. He has worked tirelessly to help hospitals, doctors and pharmacists across the country and around the world that are implementing quality improvement initiatives in the prevention of VTE. "While VTE is a common complication in hospitalized medical and surgical patients, the evidence clearly shows that it is preventable," says Dr. Geerts. "It is gratifying to see that the ROP has helped Canadian hospitals to recognize the risks of VTE and put comprehensive policies in place to protect patients from death due to pulmonary embolism after a surgical procedure, or an acute illness requiring admission." Peterborough aims for 100 per cent VTE compliance The VTE prevention program at Peterborough Regional Health Centre (PHRC) is well-established and showing impressive results. Quarterly reporting by service is collected through random audits. Evidence-based VTE prevention is a key component of the Quality Improvement Plan, aiming for 100 per cent compliance by March 31, 2016. The year-end results achieved an overall 93 per cent (Medicine 96 per cent; Surgery (epidural) 93 per cent, Surgery (non-epidural) 90 per cent, and Gynaecology 84 per cent). Prior to 2012, VTE prevention at the PHRC was rather a hit and miss approach. Standalone order sets on the patient's chart were often lost or incomplete. The Director of Quality, Risk and Patient Relations challenged teams to come up with a plan and get buy-in from their peers. A VTE Task Force was formed, led by corporate physician champion, Dr. Lynn Mikula, who continues to provide support throughout the sustainability phase. Having a committed and enthusiastic champion onboard was key to achieving buy in from physicians. The approach taken was to first educate physicians and medical staff on the evidence, showing why VTE prophylaxis was important and how it could help. All medical departments signed off on a new policy and guidelines. VTE prophylaxis is now embedded in order sets and has become part of regular orders for patients. The order set also preauthorizes changes so that the pharmacist can adjust dosages based on body size and weight and includes a quick guideline to follow. Now, if VTE prophylaxis it is not administered, it is up to the physician to indicate on the patient's chart, why not. "Once we got things rolling, it snowballed and has been a success," says pharmacist Greg Soon (now leading the antimicrobial stewardship program at PRHC). "Initially, we implemented a Risk Stratification Scoring System that made it simple. With this approach, there were significantly fewer exceptions. We also had a pharmacist trained in anti-coagulation as a part of the team and that provided our physicians with the comfort and evidence to move ahead." Clinical educators conduct monthly random audits. When anything that looks like a potential failure or inappropriate results are shown, discussions with nurses, pharmacists and physicians take place to determine the why. "The PRHC has a fantastic culture of collaboration where everyone is encouraged to work together," says Mitch Peart, Clinical Pharmacist responsible for VTE prevention at PHRC. "When you can open conversation on the topic and find out reason behind prescribing patterns, that discussion is what drives the change going forward." Regina Qu'Appelle Health Region system-wide approach to VTE The pharmacy department at Regina Qu'Appelle Health Region (RQHR) were the motivators behind a region-wide change in VTE prophylaxis. The journey began in 2001, with a process comprised of three phases over a 10-year period preparation, active intervention, and maintenance and improvement. From 2004 to 2009, hospital pharmacy residency projects were conducted and preprinted orders were implemented. Through a multi-disciplinary approach, VTE prophylaxis is now engrained into physician, nurse and pharmacist practices. The rate of appropriate in-patient VTE prophylaxis is currently at 92 per cent in surgery and 89 per cent in medical. "We were successful because we really tried to understand our culture at RQHR," says Bill Semchuk, lead pharmacist. "Initially we tried to reach out to medicine, nursing and pharmacy in an identical manner, but we were unsuccessful. The medical culture is different from the nursing and pharmacy cultures. As an organization we are now working together as a team." Pharmacists are more black and white, and it was an evidence-based approach that worked for that group. The medical group and physicians are very evidence-informed and experientially-based. They base their decisions on their experience; therefore a case-based format was used for this group. Nurses are protective of their patients; therefore linking VTE prophylaxis to specific patient cases where negative outcomes occurred was a significant motivator for nurses. Annual VTE audits are mandated by the hospitals Pharmacy and Therapeutic Committee. For the past decade, RQHR has used pharmacy students to collect the data. The students spend a couple of days being educated on VTE prophylaxis and the parameters around who should get it and who should not get it. This year, 16 pharmacy students visited the wards to collect data for all adult in-patient populations, excluding mental health. "By auditing on an annual basis, we can identify trends in VTE prophylaxis administration and areas of concern at any given time," says Bill Semchuk. "Whenever an area of concern comes up, we will meet with the individual group and discuss corrective actions." Semchuk says that the prevention of VTE is an ongoing journey. You continually have to look at the why when your numbers drift down and have discussions on how to fix it. Support from national groups such as Safer Healthcare Now! has helped them to benchmark their results against other healthcare institutions and that has been so powerful. Finally, they are thankful to be able to connect with national leaders like Dr. Geerts, who share their expertise and that has helped them to engrain VTE prevention into the RQHR culture.Successful approaches by Peterborough and Regina Qu'Appelle In the 2015 Accreditation Canada Report on Required Organization Practices (ROP), 6/6/2016 5:06:09 PM
Achieving Excellent Care for All9351News6/14/2015 7:21:06 AM3/31/2011 6:00:00 AM ​​​The Ontario Hospital Association (OHA) and the Ontario Ministry of Health and Long-Term Care have teamed up with the Canadian Health Services Research Foundation (CHSRF) and the Canadian Patient Safety Institute (CPSI) to offer a unique and comprehensive education curriculum to support Ontario hospital boards in their ongoing efforts to improve governance for quality and patient safety. This program is geared toward hospital board chairs, CEOs and members of healthcare board quality committees. The one and a half -day session builds on the Effective Governance for Quality and Patient Safety program, developed by CHSRF and CPSI, and has been tailored to address Ontario-focused issues and legislation. During the sessions, participants will explore evidence-informed approaches to governance and leadership and share innovative health governance practices, resources and tools Learn how to apply the principles of the Excellent Care for All Act (ECFAA) Understand a Board’s core functions related to quality and patient safety Identify approaches to measuring the quality of care Recognize how an organizational culture of quality and patient safety can be led, supported and sustained by the Board Develop tools, structures and processes that will assist participants in improving their organizations’ governance practices related to quality and patient safety Access the CPSI/CHRSF and OHA quality and patient safety toolkits Education sessions have been scheduled throughout Ontario. To register for the following sessions, click on the applicable link April 6-7 – North Bay (Best Western)https// April 13-14 – Thunder Bay (Victoria Inn)https// May 5-6 – Toronto (Estates of Sunnybrook)https// This program is supported by the Government of Ontario and space is limited; there is no registration fee. For additional registration and program details email, or call (416) 205-1362.Achieving Excellent Care for All Healthcare Partners build specialized Governance Education Program7/29/2015 5:27:21 PM
Adult learning techniques help to engage your audience9352News6/14/2015 7:21:09 AM12/6/2011 7:00:00 AM​​​How do you ensure that the information you are presenting is engaging to your audience? That is the challenge that inspired Barbara Saunders, Managing Consultant of Operational Improvement and Accreditation, Quality Improvement and Patient Safety at Fraser Health in lower mainland British Columbia to sign up to become a Master Facilitator for the Patient Safety Education Program (PSEP-Canada). Barbara is one of the 23 PSEP-Canada Master Facilitator’s helping healthcare professionals become Patient Safety Trainers and guide patient safety education in their home organization. When Barbara first learned about PSEP-Canada, Fraser Health was developing an educational framework for quality and patient safety that would include formal education, online learning and self-directed learning. “We were trying to develop a more comprehensive and effective approach as to how we were providing coaching and education, says Barbara. “The PSEP-Canada caught my eye because it focused on adult learning principles. I’ve worked in the quality and patient safety field for many years, so it was not the content of the program that was appealing, rather it was the style in which the program was being delivered and the skills that I would be able to learn to do a better job of providing an environment that would foster that learning.” Barbara says that it took a while to realize what was different about the PSEP-Canada program. When she signed up to become a Master Facilitator, she thought she was going to learn adult learning principles in a more traditional way “As Master Facilitators, I think all of us were a little confused at first, because we saw the curriculum being taught in a non-linear way and we didn’t at first appreciate that the impact of the program is not only content, but the purposeful manner in which it is delivered. It took us a bit of time to make sense of what was being presented to us. What we quickly came to realize was that it not about the content of the curriculum, it is about learning how to convey that to others in a way that will support them to adopt, to learn, and to apply. The curriculum provides the core content, but it is the method of acquiring that makes the PSEP-Canada program unique. It is a way of presenting any material that will enable the learner to make sense of it, to shift their attitude, to acquire new knowledge, and to practice their development of new skills.” The PSEP-Canada program provides a comprehensive way of encouraging, assisting and supporting people to adopt and apply learning to their situation that will change behaviours, change the way healthcare services are structured and delivered, and change the outcomes that patients, families, residents, clients will experience for the better. “That whole change will shift our healthcare system to be more effective and safe,” adds Barbara. “That is what makes the PSEP-Canada program different from other educational programs. It is creating this cadre of leaders at two levels, master facilitators and trainers who are capable facilitating, coaching, mentoring, and assisting healthcare practitioners to move toward a more effective, efficient healthcare system that is truly supporting patient outcomes and a culture of safety and quality improvement.” To learn more about the PSEP-Canada program, or to bring the program to your area, please visit the Canadian Patient Safety Institute website, or email do you ensure that the information you are presenting is engaging to your audience?   That is the challenge that inspired Barbara7/29/2015 8:48:29 PM
Advocate applauds release of ‘Patient Safety in Primary Care’ research paper9353News6/14/2015 7:21:11 AM12/16/2010 7:00:00 AM ​​​​​​Paper highlights patient safety risks in primary care settings Johanna Trimble and her family are all too familiar with the patient safety risks that exist in primary care. In 2006, Trimble’s mother-in-law Fervid, was diagnosed with MRSA stemming from a persistent infection in one eye and subsequently contracted another superbug, C. difficile, from an outbreak in her nursing home. After six rounds of powerful antibiotics to combat the infection, Fervid’s health deteriorated and she died in October 2008, at 92 years of age. Trimble, a member of the BC Patient Voices Network and a member of Patients for Patient Safety Canada, is applauding the recent release of the ‘Patient Safety in Primary Care’ Background Research Paper. Commissioned by the Canadian Patient Safety Institute (CPSI) and the BC Patient Safety & Quality Council, the paper explores the current state of knowledge, as well as the key issues, priorities, opportunities and strategies for advancing patient safety in primary care in Canada. “Because our system is so fragmented, there has been little ability to report safety issues in primary care. It is difficult to change something you can’t measure,” Trimble says. “Our family has experienced this directly.” She says the paper brings the extent of the issue to awareness and proposes ways to address it — an important first step. “I hope that the paper will inspire Canadians to pay attention to how safety programs in other places, for example the U.K., have been developed and have made a real impact. We can learn from these experiences and see that it can be done.” Dr. John Maxted, Assistant Professor in the Department of Family & Community Medicine at University of Toronto and the chair of the pan-Canadian Advisory Group that guided the research process, says the goal of the paper is to give momentum to the safety issues and ultimately compel leaders and providers towards system improvements. “It’s an issue that needs attention – this kind of research has to move people to take action,” Maxted says. “If the paper is reviewed and causes people to pay attention and it stimulates people to take action to improve patient safety in primary care, then we will have accomplished what we wanted to.” In the meantime, patient safety advocates such as Trimble will continue to rally people around the cause in an effort to ensure what happened to Fervid doesn’t happen to anyone else. “Let’s drop the negative and passive attitudes of ‘it’s so big we can’t do anything about it’, or ‘it’s not so bad’ or ‘we keep trying but it doesn’t work’. There’s a saying – ‘make it easier to do the right thing and harder to do the wrong thing,’” she says. “Let’s give this priority and resources and change it!” The report, ‘Patient Safety in Primary Care,’ is available on the BC Patient Safety & Quality Council’s website at and the Canadian Patient Safety Institute website at applauds release of ‘Patient Safety in Primary Care’ research paper10/6/2015 7:06:57 AM
A final note from Halifax 109354News6/14/2015 7:21:15 AM11/2/2010 6:00:00 AM ​​​​The 10th Anniversary meeting marked the end of the Halifax Series The Canadian Healthcare Safety Symposium. More than 400 participants gathered in Halifax, Nova Scotia from October 21-23, for the final meeting. For this tenth anniversary, some of the great faculty from earlier symposia were invited back and challenged to reflect on what they had previously presented. They were also asked to provide an update in light of current thinking and to share their perspectives on the next decade for patient safety. Canadian and international leaders and experts guided delegates through conversations about the personal experiences of patients and families in the health system; lessons from other industries, disciplines and perspectives; and critical patient safety challenges such as measurement and apology. Highlights included keynote presentations from Professors James Reason and Charles Vincent, both largely credited with pioneering and advancing the understanding of patient safety internationally. Over the past decade the Halifax Symposia have been a major contributor to the patient safety landscape in Canada, contributing knowledge, tools, products and innovations; creating collaborative relationships that have resulted in both new and innovative programs, research and knowledge translation opportunities across many care delivery contexts; and providing information and insights on the challenges and opportunities for the use of evidence in policy and practice. These activities have had a significant impact on patient safety improvements across Canada. Thank you to all who contributed to and supported the Halifax symposia over the past decade. As this inspiring series ends, your continuing efforts will help accelerate the improvement of healthcare safety in Canada. Halifax 10 Pre-Conference Disclosing, Informing and Investigating Supporting a Culture of Safety This interactive workshop gave the 100 participants practical experience in applying theoretical knowledge about providing information to different audiences following an adverse event. The session used participative methods such as role-play and creation of briefing notes to conduct team de-briefings, disclosure to patients and families, informing the Board and the public. The workshop wrapped up with the development of themes and questions that organizations should consider when preparing to investigate an event. Additionally, the participants were provided concrete examples of how simulation techniques can enhance the learning environment for individuals participating in the disclosure process.The setting for this dynamic workshop was created through a video of a wrong-side surgery which formed the basis of discussion and a specific focus for the day. The simulation concept was developed collaboratively by the workshop moderator Dr. Viren Naik, Medical Director for the University of Ottawa Skills and Simulation Centre and a team from the EHS Atlantic Health Training and Simulation Centre led by Derek Leblanc, Emergency Health Services Nova Scotia Department of Health. Initial feedback for the workshop celebrated the key differences about the information that needs to be passed at different levels of organizations. Guest speakers brought a wealth of personal and professional experience to the discussion, providing excellent perspectives of these different levels. Speakers included Sabina Robin (Patients for Patient Safety Canada); Joan Dawe (Eastern Health, Newfoundland & Labrador); Cecilia Bloxom (Canadian Patient Safety Institute); Chuck Husak (August, Lang & Husak, Bethesda, Maryland); and Amir Ginzburg (Trillium Health Centre, Mississauga, ON). Pre-conference Symposium 2 – The Economics of Healthcare Safety The pre-conference symposium focused on the challenges related to the cost of unsafe care in Canada, the lessons that healthcare can learn from other industries about improving safety while reducing or maintaining costs, and models for improving quality and safety used by other countries.The economics of healthcare safety is a topic area that is still in early development. There was general consensus that traditional economic models are not yet sufficient to fully describe opportunities in this area of healthcare improvement. The speakers and attendees explored opportunities where Canada could advance this formative yet vitally important area. Handouts for all speaker presentations are available at Halifax 10 Poster winners The team from Mount Sinai Hospital led by Jody Tone was awarded “Best Poster” at the Halifax 10 Patient Safety Symposium. “Standardizing Nursing Shift Handovers” was selected by a panel of judges as making the best contribution to knowledge on a patient safety issue. The best “Student Poster” was awarded to Natasha Scott from Saint Mary’s University in Halifax. The poster profiled Patient versus Occupational Safety Culture Competing forces or two sides of the same coin? There were more than 77 posters displayed from across Canada. The judging panel included Dr. Ed Etchells (Sunnybrook Health Science Center), Dr. Anne Matlow (Hospital for Sick Children), Dr. Micheline Ste.-Marie (Montreal Children’s Hospital), G. Ross Baker (University of Toronto), Laurel Taylor and Sandi Kossey (Canadian Patient Safety Institute). Congratulations to the team and to Mount Sinai Hospital and to Natasha Scott for their contributions to advance patient safety! For more information on these posters, contact Laurel Taylor at ltaylor@cpsi-icsp.caA final note from Halifax 1010/6/2015 7:07:35 AM
A framework for analyzing patient safety incidents9355News6/14/2015 7:21:16 AM10/17/2012 6:00:00 AM​​​The foundation begins with an apology Claire Smith was only 10-years-old when she unexpectedly died in a Pediatric Intensive Care Unit (PICU). Claire died following a planned surgery to correct a malformation at the base of her brain which was causing her spine to erode and curve significantly, and a myriad of other severe neurological signs and symptoms. Claire’s tragic death was ultimately attributed to serious issues in care and in the system. Her parents, Raeline McGrath and David Smith, openly talk about what happened, not to find fault, but rather to bring about positive systemic and cultural change. Raeline and David asked for and then invited to participate in an external analysis of Claire’s death. The analysis team met with them first to learn from their perspective before interviewing others. When the findings were about to be released, the process was structured to have the report shared with Claire’s parents first. The meeting opened with an apology and that formed the foundation for the post-analysis disclosure about what happened, how and why it happened and what will be done to make care safer. “For us as Claire’s parents, it acknowledged our place in the process,” says Raeline. “The analysis process was objective, thorough, accurate and startlingly candid which enabled us to have an open, clear and honest understanding of the events that led to our daughter’s death,” adds Raeline. “This disclosure led to further apologies and opened up a series of other actions and meetings with the people directly involved in Claire’s care that resulted in improvements in the safety of care at the hospital.” Raeline reinforces the importance of sharing information as openly and quickly as possible and to involve families in the discussion as to what happened. “With everything we did, we wanted to ensure it would not compromise another analysis. We set out to find where the system and the processes went astray and to make it better for those who would come behind. The apology is foundational. With the analysis and follow-up we were able to move to the next phase ‒ taking Claire’s 16-day episode of care and looking at it as a catalyst for change.” Raeline and David applaud the Eastern Regional Integrated Health Authority in Newfoundland and Labrador for carrying out a timely and fulsome review of what happened and why, fully sharing the report’s contents, and implementing the recommendations. Effective management and analysis of patient safety incidents provides an opportunity to make care safer. The learning gained from a potentially very difficult situation can lead to something positive by reducing the likelihood of recurrence. The Canadian Incident Analysis Framework is a valuable resource that individuals and organizations can use to analyze and learn from patient safety incidents. Originally developed as a Root Cause Analysis Framework in 2006, the revised Canadian Incident Analysis Framework contains lessons learned from practitioners and researchers, and better reflects the realities and needs of healthcare organizations to analyze and manage patient safety incidents. Key enhancements to the framework include the patient/family perspective, multiple methods to analyze incidents, placing analysis in the incident management continuum, innovative diagramming, and a new section on developing and managing recommended actions. The Canadian Incident Analysis Framework and supporting resources can be found by visiting The framework can be downloaded for free and printed copies are available for purchase. Feedback and questions are welcome via email at Send comments and questions related to medication safety to The foundation begins with an apology   Claire Smith was only 10-years-old when she unexpectedly died in a Pediatric Intensive Care Unit7/29/2015 5:47:16 PM
A Grass Roots Approach to Improving Patient Safety: Innovation or back to basics?9356News6/3/2015 3:52:41 PM ​​​​​​French only patient safety conference Safer Healthcare Now! Quebec Node / Campagne québécoise Ensemble améliorons la prestation sécuritaire des soins de santé! is hosting a three-day conference on patient safety to support francophone teams across Canada working on Safer Healthcare Now! The sessions will be delivered in French only from 830 am to 400 pm EST, November 18, 19 and 20, at the Jewish General Hospital in Montreal, QC. If you cannot attend in person, video conferencing of the sessions is also available. Conference Highlights Hear about the future direction for Safer Healthcare Now! Learn more about the CPSI tools and resources Learn about Getting Started Kits on Preventing Falls Medication Reconciliation in Home Care Acquire strategies for success in challenging times Human factors in patient safety Positive Deviance A grounds up approach to safety improvement Influencing and leading change Using incident / accident reporting systems to improve patient safety Cost to attend is $325 per participant, or $100 per site for video conferencing. Click here for more information, registration and the program of events.A Grass Roots Approach to Improving Patient Safety: Innovation or back to basics?10/6/2015 7:08:19 AM
Alberta embraces Safe Surgery Checklist: Audit confirms 95 per cent compliance in its use9357News6/14/2015 7:21:18 AM3/31/2015 6:00:00 AM​​Alberta Health Services (AHS) has obtained 95 per cent compliance in using the Safe Surgery Checklist. The Safe Surgery Checklist has been applied in 59 sites across Alberta; data was compiled using observational audits. The AHS Safe Surgery Checklist is based on the World Health Organization (WHO) approach of a briefing, a time-out and a debriefing. “The Safe Surgery Checklist is a valuable quality and patient safety vehicle,” says Tracy Wasylak, Senior Program Officer, Strategic Clinical Networks (SCNs), AHS. “As an example, the Calgary zone has seen a decrease in never-events in the last three years and that speaks to the kind of safety we are able to demonstrate by using the Safe Surgery Checklist.” The SCN also compiles a good catch list through use of the Safety Surgery Checklist, such as documenting when equipment is not in the operating room when needed, or when antibiotics are not administered on time. “The Safe Surgery Checklist is truly a team effort - both physicians and nursing champions at the local level are making a difference in achieving results," says Dr. Douglas Hedden, Senior Medical Director, Surgery Strategic Clinical Network. “Surgeons and surgical teams across the province have taken this on as an important safety effort and we are proud of the frontline staff who have adopted the Checklist into their everyday practice.” "Physician leadership has been a critical success factor in achieving compliance of the Safe Surgery Checklist," says Dr. John Kortbeek, Senior Medical Director, Surgery Strategic Clinical Network. “We have recruited physician champions across the five zones in Alberta and that has made a difference in ensuring consistency at a local level." When the Safe Surgery Checklist was initially implemented, it did not include patient input or involvement at any level. Sandra Zelinsky, a graduate of the Patient and Community Engagement Research (PaCER) program at the Institute for Public Health (IPH) at the University of Calgary was recruited to conduct focus groups to determine the impact of the Safe Surgery Checklist and explore the patient’s experience. “We found that patients were experiencing anxiety and concern because they did not understand the Safe Surgery Checklist,” says Sandra Zelinsky, Patient Engagement Researcher, AHS Surgery SCN. “Anything that can be done to eliminate that anxiety prior to and during surgery to help patients be better-informed is a step in the right direction.” A nurse now explains the Safe Surgical Checklist to patients beforehand, on the morning prior to their surgical procedure. Posters were developed and a video was produced as a unique way of talking to patients, families and residents about the Safe Surgery Checklist. Under the leadership of Dr. Jonathan White, 3M National Teaching Fellow and Senior Director of Undergraduate Surgical Education at the University of Alberta, a new “Muppet Surgery 101” video is available on iTunes and YouTube, and can also be downloaded from or “Including patients in the Safe Surgery Checklist is a way to involve them on the team to address safety, rather than being an innocent bystander,” says Tracy Wasylak. “If for whatever reason anyone on the surgical team chooses not to use the surgical checklist, we expect our patients to ask them about it.” Click here to download the Canadian Patient Safety Institute’s Safe Surgery Saves Lives Checklist. Alberta Health Services (AHS) has obtained 95 per cent compliance in using the Safe Surgery Checklist . The Safe Surgery Checklist has been11/24/2015 3:40:30 AM
Alberta Health Services sets target for 100 per cent Hand Hygiene Compliance9358News6/14/2015 7:21:20 AM3/27/2013 6:00:00 AM​​​If you walk down the halls of the Cardiac Science units at the Alberta Health Services Mazankowski Alberta Heart Institute and CK Hui Heart Centre in Edmonton, you can’t help but notice the reminders to clean your hands. Alberta Health Services have challenged healthcare facilities in each of their five zones across the province to come up with a plan for 100 per cent hand hygiene. The Mazankowski and CK Hui sites had the advantage of a head start on developing their plan. Last year, they joined the Safer Healthcare Now! Stop Infections Now Collaborative (SINC). Their hand hygiene compliance rates were at an all-time low – about 26 per cent and they wanted to help influence change. As a result, in the last year, compliance rates have at times reached 76 per cent at the Mazankowski site and 80 per cent at the CK Hui site. “We have been able to integrate many of the ideas and our work from the Collaborative to our zone meetings and we are thrilled that the work we started is now spreading throughout the Edmonton zone,” says Darlene Bartkowski, Clinical Nurse Educator at the Mazankowski Alberta Heart Institute. “Some of the things we are doing are not revolutionary, but it is the sharing that makes the difference. You realize that you are not the only one with that problem.” The AHS SINC team produced buttons for staff that say, “You can ask me to clean my hands”, in an effort to get patients and families more involved in their care. They invited all staff from the Edmonton zone to participate in a flash mob and music video to promote effective hand hygiene. The AHS Edmonton zone is using hand hygiene observation as a way to improve things, rather than a way to punish people for not doing something. And, they have a formed a working group to look at cleaning of equipment. “It can be difficult starting a process like this and initially we did not have as much frontline representation as we would have liked to have,” says TobieGuinez, Clinical Nurse Educator. “Once the frontline staff got involved, we started to see change. Frontline staff are now more diligent about cleaning their hands, and they are asking questions about the observations and getting more involved in them.” “For the Collaborative, we formed a multidisciplinary group and that really changed the team dynamic,” says Inger Eakin, Project Manager. “There is a lot more engagement. In fact, one physician responded to a question in a recent engagement survey that being part of this Collaborative was the first time he felt engaged and part of the team.” The AHS multidisciplinary team includes representatives from Medical staff (physicians), nurses, educators, environmental services, diagnostic imaging, laboratory, respiratory services, food services, protective services, a service attendant and more. The Edmonton zone has set targets in education and hand hygiene compliance and meets bi-weekly to talk about the various methods to reach their goals, and to discuss issues and problems. Overall zone compliance has gone up and the Edmonton zone leads in provincial hand hygiene compliance. The Stop Infections Now Collaborative was led by experts from the University Health Network (IGNITE ) in conjunction with other behavioural change consultants from Canada and the U.S. To learn more about the Stop Infections Now Collaborative, visit For information on effective hand hygiene, visit www.handhygiene.caIf you walk down the halls of the Cardiac Science units at the Alberta Health Services Mazankowski Alberta Heart Institute   and   7/29/2015 7:27:02 PM
Amazing enthusiasm and energy at Atlantic Learning Exchange9359News6/3/2015 3:52:41 PM6/29/2011 6:00:00 AM​​ Theresa Fillatre (left) looks on as Hugh MacLeod, CEO of the Canadian Patient Safety Institute (right) is assisted by Sir John A. MacDonald from the Confederation Players (middle) in launching the Atlantic Health Quality and Patient Safety CollaborativeBringing together healthcare providers and policy makers from each of the Atlantic Provinces, the Atlantic Learning Exchange, held in Charlottetown, PEI, on May 11 and 12, 2011, provided an opportunity for attendees to learn and share the latest efforts and activities related to patient safety and quality improvement.Over 150 participants, including frontline staff, physicians, quality and system performance support staff, individuals focused on governance, CEOs, senior leaders, health department and Government representatives and interested members of the public took part in the two day event. “Every province and organization has amazing pockets of excellence and good practices,” says Theresa Fillatre, one of the Learning Exchange organizers and Senior Director, Atlantic Canada and National Leader Safer Healthcare Now! , Canadian Patient Safety Institute (CPSI). “The enthusiasm to come together on common quality and patient issues and solutions was remarkable.” The Learning Exchange provided participants with an overview of Atlantic provincial quality and patient safety frameworks, structures and priorities, “Setting the Stage Where Are Ye To?”, which included a panel discussion with Chairs/Designates from each of the four provinces Francine Bordage, NB; Dr. Pat Croskerry, NS; Wayne Miller Newfoundland and Labrador; and Keith Dewar, PEI. “To varying degrees, we have all experienced adverse events in our organizations and have learned a great deal by managing those, sometimes well and sometimes not so well,” says Blaise MacNeil, President and CEO of South West Health in Yarmouth, Nova Scotia. “The sharing and group discussions in the Atlantic context were a powerful vehicle for learning.” Providing insight on how an adverse event affects personal and professional lives, a presentation by Dale Nixon and Dr. Rick Singleton, “The Healing of Hurts and the Hurts of Healing” resonated strongly with conference participants.“The session put a human face on adverse events, focusing on what can be done to learn from them and the importance of engaging with patients and families on disclosure, apology and system improvements,” says Wayne Miller, Vice-President of Quality, Patient Safety and Planning, Eastern Health in St. John’s, Newfoundland and Labrador. For Dr. Brian Wheelock, Chief of Staff for the St. John zone, Horizon Health Network, New Brunswick, one of the highlights was the presentation on medication reconciliation. “Med Rec is one of the most difficult issues we face in quality and patient safety and I was pleased to hear what others are doing and to learn about the emphasis that CPSI is putting on medication reconciliation to help us in our work.”Nancy Roberts, VP Health Services Planning, Quality and Research, Horizon Health Network in New Brunswick emphasized how important events like the Exchange are for the healthcare system. “With all of the restructuring over the last three years, there has been significant attention focused on the sustainability and financial aspects of the system. We need to maintain a balance and ensure patient safety and quality care remains our primary focus. The Learning Exchange provided over 15 concrete examples of processes that are being used successfully in healthcare facilities across Atlantic Canada that we can adapt and apply within our own organizations.”The Atlantic Health Quality and Patient Safety Collaborative (AHQPSC) was also officially launched during the Learning Exchange. Comprised of representatives from each of the Atlantic Provinces, the goal of the Collaborative is to develop common strategies that will improve the safety of healthcare and bring recommendations back to their respective Health Ministries. The AHQPSC had its first annual face-to-face meeting on June 22nd to review feedback from the Learning Exchange and prioritize what they will address together. “Patient safety and quality improvement transcends jurisdictional boundaries,” says Keith Dewar, CEO of Health PEI. “When you cut to the chase, these are issues that we all have to deal with and we can all learn from one another.”New Brunswick will be the host province for the next Atlantic Learning Exchange, to take place in 2013. To access copies of the presentations given at the Atlantic Learning Exchange, click here.Amazing enthusiasm and energy at Atlantic Learning Exchange11/24/2015 3:49:53 AM
Ambassadors and peer-to-peer spread help to shift the culture of patient safety9360News6/14/2015 7:21:21 AM3/23/2012 6:00:00 AM​​​Patient safety is viewed as everyone’s role at The Credit Valley Hospital and Trillium Health Centre, located in the Mississauga-Halton Local Health Integration Network (LHIN). The Trillium Health Centre site is using the Patient Safety Education Program ‒ Canada (PSEP ‒ Canada) to bring patient safety education into the clinical domain and plant the seeds to enhance their patient safety culture. Dr. Amir Ginzburg, Physician Director, Patient Safety and Quality at the Trillium Health Centre site became a PSEP ‒ Canada Master Facilitator in 2010. Over the last year, members of an interprofessional team from Trillium were certified as PSEP ‒ Canada Patient Safety Educators to build the resources needed to launch a patient safety education program locally. Based on a needs assessment to identify high yield educational opportunities, a 14-hour curriculum was developed that is being delivered in two different streams in a concurrent timeframe. The first stream is a series of Lunch and Learn sessions open to all staff, where the curriculum is being offered in 45-minute to one-hour sessions; the second stream is the development of a cadre of 45 PSEP ‒ Canada Ambassadors from across the various health systems at Trillium, to whom the course is deployed in three half-day sessions over a four-month period. During Canadian Patient Safety Week in November 2011, the PSEP ‒ Canada program was launched at two Trillium Health Centre sites, located in Mississauga and West Toronto. “We have reached about 300 people in the organization thus far and it has snowballed in an organic way that is very exciting,” says Dr. Ginzburg. “There has been a lot of peer-to-peer spread reinforcing that this education is of high value. We are using techniques aimed at adult learners and our staff are walking away from the sessions with two or three usable concepts that translate into changes in behaviour and practice.” Dr. Ginzburg says that the amount of energy and planning that goes into rolling out the curriculum is quite significant. They ensure that the information presented is appropriate for the diverse inter-professional experiences of their participants; and when delivering the program they try to blend different teaching styles every 15 to 20 minutes to reach adult learners where they live. “A lot of preparation goes into making this work, both for the organization as a whole and for the outcomes we are expecting to materialize, but also to make it a high quality event for the participants and the learners,” says Dr. Ginzburg. The Lunch and Learn sessions, held twice per month, are attracting 35 to 60 people at the Mississauga site and another 20 to 30 at the West Toronto site. Topics have included gaps in patient safety, patient safety and leadership, organizational culture, patients as partners, human factors, medication safety, falls, teamwork and communication, and the effects of technology on patient safety. The Trillium PSEP ‒ Canada Ambassadors come from each Health System within the organization and are being trained to act as a safety net for the entire organization. “The robust PSEP ‒ Canada accordion curriculum provides enough material to really galvanize interest,” says Jo-Anne Copeland, Quality and Patient Safety Advisor. “You have trigger tapes to help spark some of the topics and discussion, as well as some creative interactive tabletop exercises to choose from. The PSEP ‒ Canada materials provide a good core to start with, so that you can pick and choose and customise it to reach your audience. You certainly see a difference using the adult education model as it gives you several different tools for people to learn from and there is significantly more interaction. As a presenter, it helps me keep it fresh for the participants.” Sonya Pak, Director of Quality and Patient Safety, reinforces that physician engagement upfront is critical to the success and rollout of their education program. “Trillium has the luxury of having Dr. Ginzburg as a Master Facilitator and that has been extremely helpful,” says Pak. “Having physician leadership that is visible as an educator and someone we can bounce ideas off just enriches the program.” Pak says that the program has surpassed their expectations. “The conversations that have emerged from the PSEP – Canada Ambassador program and the Lunch and Learn workshops have been very stimulating. And we are now doing things on the frontline to move in a positive direction and advance the culture of patient safety.” The program educators are now looking at ways to sustain the momentum and use the training materials throughout the entire organization. The focus moving forward is to put the right structure behind those that have been trained to ensure that they are supported to continue the culture change that has been initiated. During Canadian Patient Safety Week 2012 this fall, the PSEP ‒ Canada Ambassadors will be asked to share their stories through poster or verbal presentations on what they have done in their respective areas based on the knowledge gained through the PSEP ‒ Canada program. “We are looking for peer-to-peer spread of the concepts and some of our ambassadors are motivated to provide in-services on the wards to their colleagues or other staff,” adds Dr. Ginzburg. “We plan to do walk-arounds with middle and senior leaders to showcase the lens that the ambassadors are now bringing to their care areas and to deal with safety issues in real time. PSEP ‒ Canada is the vehicle that we feel will help take our patient safety culture to the next level.” This article is the first in a series on the Patient Safety Education Program ‒ Canada to highlight how healthcare organizations have adapted the curriculum to advance the culture of patient safety. Click here for more information on PSEP ‒ Canada or visit Patient safety is viewed as everyone’s role at The Credit Valley Hospital and Trillium Health Centre , located in the Mississauga-Halton Local7/29/2015 7:30:28 PM