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​​The Hospital for Sick Children, Toronto

Source: Janice Campbell

In 2001, the Hospital for Sick Children (SickKids) in Toronto, Ontario implemented a systematic process for reviewing serious patient safety events. This process was implemented following series of inquests and in response to the Institute of Medicine’s report focusing on reducing harm especially related to sentential events. 

Guided by increasing public discussion and emerging evidence, courageous leaders set out to change the focus from blaming and shaming to a culture of safety founded in systems thinking.  These efforts led to the development of a comprehensive process for responding to patient safety incidents and conducting systems reviews with an emphasis on disclosure, transparency and learning. 

The process stresses the critical nature of the immediate response.  The belief is that getting this part of the process right is essential; the rest will follow if the right people are involved early. 

  • A key first step is to contact Risk Management so they can provide support, coaching and direction from the very beginning.  There is always someone available, eliminating the need for staff to have to read through the policy or navigate the process on their own during a crisis.  Risk Management can also facilitate any immediate actions required such as notifications, removal of equipment or practice changes.
  • The first priority is always caring for the patient/family and facilitating good communication.  A point person is determined (ideally someone who knows the family) who explains to the family when and how they will touch base, and how they can be contacted.
  • Several user-friendly tools are available to staff including algorithms and checklists that reinforce the patient/family as the first priority and that Risk Management should be contacted as soon as possible.
  • Staff (second victim) support is not prescriptive allowing for adaptation to the specific team and situation.  Immediately after the incident, there is a discussion as to whether the staff members involved can continue to work.  Employee assistance can meet with staff as soon as possible to debrief and offer support.  Local managers inform their teams about the event to maintain transparency.  They work with Risk Management to address needs at the local level and organizationally, if applicable.

An example of an immediate response that worked well is an incident where a child suffered harm due to an unsafe sleep environment. The child was very sick with a complex chronic illness.  The child’s condition started to improve but one day without anyone expecting it, the child turned over on the soft surface in the hospital bed and suffered a hypoxic event.  Because Risk Management was notified right away, a notice was immediately issued to all patient care areas.  Sleep surfaces were quickly changed  or replaced, the infant safe sleep policy was subsequently refreshed (flat crib, no pillows, stuffed toys, blankets, no co-bedding) and an education campaign targeting staff and families was launched.  The incident was shared at the board level with frequent updates and follow up presentations. Throughout the process, everyone was forthcoming, willing to engage, and took the matter very seriously.  The immediate response to this event served to strengthen the safety culture in the hospital.

SickKids acknowledges that managing serious patient safety events is an ongoing journey whereby processes are continuously refined and revised.  There is still a lot of work to be done.  Each experience creates an opportunity for organizational learning. There are however, indications that the new incident management process has had a positive impact.  Staff members routinely call Risk Management when an incident occurs, without hesitation.  It is felt that this shift is a direct result of seeing how people are treated and how staff members are supported after an incident.  In fact, staff members frequently reach out to Risk Management proactively with “what do you think about…?” questions and concerns.   Although there are many factors at play, it can also be noted that there has not been a coroner’s inquest involving SickKids since 2000 and the number of new legal claims 2000 to present is, overall, trending downwards.