​​Manitoba Health, Healthy Living and Seniors (MHHLS), on behalf of all regional health authorities and provincial organizations,  is the newest contributor to Global Patient Safety Alerts (GPSA), a publicly available, web-based platform for patient safety alerts developed by the Canadian Patient Safety Institute. MHHLS is the fifth Canadian contributor and one of 26 healthcare organizations contributing to the global repository for learning from potential patient harm.

“The Manitoba Institute for Patient Safety commends the Ministry for participating in such an important initiative that will help improve patient safety globally,” says Laurie Thompson, Executive Director of the Manitoba Institute for Patient Safety.

“Joining Global Patient Safety Alerts was a natural extension to talk about what has happened and build awareness on how to make our systems safer,” says Kristi Chorney, Regional Manager of Quality, Patient Safety and Risk, Prairie Mountain Health. “Our patient safety culture in Manitoba has evolved and our leadership is more transparent and willing to share information and see the value in that. It is a way to renew our learnings and share them more broadly.”

The Manitoba Quality and Patient Safety Council (Council) is a body of health care administrators from every regional health authority and provincial organization with responsibility for patient safety. They saw an opportunity to piggyback and expand on how critical incident information was being shared. The Winnipeg Regional Health Authority had been contributing patient safety summaries to GPSA for a few years. Safety Learning Summaries resulting from process reviews within other parts of the province were being shared among regional health authorities (RHAs) within the province, but not publicly. There was also a lot of variability in the summaries being developed with respect to content and details. In addition, some of the smaller RHAs were hesitant to post patient safety learning advisories on their regional websites because of a risk that the individual that suffered the trauma would be easily identified in their community.

The Council decided that their scope needed to be broader than critical incidents, to include process reviews, sentinel events, non-critical incidents and other events that did not meet the critical incident threshold, but where there were improvement opportunities. A Working Group with representatives from each RHA was formed to develop processes, look at the format and standardize content of their summaries in order to share the information more broadly. The Working Group developed a template so that all learning advisories were sent to MHHLS for distribution to GPSA.

“Having Manitoba Health post these events on our website helps to maintain confidentiality and eliminate the potential for patient identification within the RHAs,” says Angela Bachynski, Quality and Patient Safety Analyst, Manitoba Health.  “We ensure the summaries have a similar format, the information shared and writing style is consistent, and most importantly, that the patient information is de-identified.”

“It helps to have one key person as the conduit, managing all of the learning advisories, sending out reminders and doing the submissions,” says Diana Kokorudz, Patient Safety and Quality Improvement Coordinator, Prairie Mountain Health. 

Kristi Chorney also credits the Canadian Patient Safety Institute (CPSI) for their in help transitioning information to GPSA. “CPSI was very willing to help out, providing webinars, education and answering our questions as we developed and implemented our process.”

To gain a better insight on critical incidents, Diana Kokorudz has been using the Global Patient Safety Alerts repository to gather information on critical events and link with other organizations that have had a similar occurrence.

“When we have an event, I will search the GPSA database to collect information and gain a better understanding,” says Diana Kokorudz. “Often, there will be recommendations or actions for improvement that have already been implemented elsewhere and I can draw from their experiences. I would like to see more national input on GPSA and would encourage other provinces to join. I can learn from what has happened internationally, but I really want to know what has happened in my own country. Often the systems we are using are similar in nature and the repository would be more relevant to our practice and learning if we had more information available from our sister provinces.”

The Manitoba Quality and Patient Safety Council has developed guidelines and a process for posting patient safety learning advisories to Global Patient Safety Alerts that they would be willing to share with others.  For more information, contact angela.bachynski@gov.mb.ca

Global Patient Safety Alerts features a comprehensive collection of timely, searchable patient safety alerts, advisories and recommendations for healthcare providers, organizations and individuals who are interested in the analysis, management and learning from patient safety incidents.  Visit www.globalpatientsafetyalerts.com for more information.