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CPSI Share                                                  
5/11/2010 6:00 PM


Inside this Issue:

Safer Healthcare Now! celebrates its 5th Anniversary!

On Monday, April 12, 2010, Safer Healthcare Now! celebrated its fifth year of improving patient safety in Canada.  Over 150 Safer Healthcare Now! leaders, staff, teams and participants gathered on that day in Toronto (Ontario) to celebrate their achievements in the interventions.

Attendees heard from Hugh MacLeod, CEO of the Canadian Patient Safety Institute, Joe McCannon, Faculty of the Institute for Healthcare Improvement and Rabih Darouiche, patient safety author and researcher. Participants also had an opportunity to learn the latest news from the Safer Healthcare Now! interventions, and the three new projects being launched:  Medication Reconciliation in Homecare, Falls Prevention, and a New Approach to Controlling Superbugs. The first ever Safer Healthcare Now! Awards were also presented. Congratulations to Eastern Health and the Royal Jubilee/Victoria General Hospitals!

Safer Healthcare Now! Anniversary 

Top row (left to right):  Hugh MacLeod, CEO – Canadian Patient Safety Institute (CPSI); the Birthday cake; Safer Healthcare Now! Node and Intervention representatives take the stage. Bottom row (left to right): Marie Owen (CPSI), Sheena Leonard and Joanne Butler (Eastern Health); Rabih Darouiche; Hand sanitizers at the Safer Healthcare Now! display booth; Anne Marie Carli (BD), Cynthia Turner (Royal Jubilee/Victoria General Hospital), Marg Colquhoun (ISMP-Canada) and Hugh MacLeod


Teamwork is key for Eastern Health:  Reducing Healthcare Associated Infections Safer Healthcare Now! Award recipient

Eastern Health, located in Newfoundland and Labrador (NL) is the recipient of the 2010 Reducing Healthcare Associated Infections Safer Healthcare Now! Award sponsored by Cardinal Health. In 2006, Eastern Health set a goal to reduce their Ventilator-Associated Pneumonia (VAP) rate by 50 per cent in one year.  In January 2010, they revised that goal to reduce their VAP rate by 90 per cent from baseline. Baseline data was collected from two locations, the Health Science Centre and St. Clare’s Hospital in St. John’s, NL.

By maintaining compliance to the four components that help prevent VAP, the Health Science Center has achieved an 87 per cent decrease from baseline (from 17.8 to 2.3 per 1000 ventilator days) and St. Clare’s has decreased 83 per cent from baseline (from 8.6 to 1.5 per 1000 ventilator days).



Safer Healthcare Now! has helped move evidence into practice by providing the structure, expertise and implementation to prevent VAP,” says Sheena Leonard, Research Coordinator at Eastern Health.  “We could not have achieved such fantastic results without the support and commitment of the dedicated staff at both our sites, within and beyond the ICU. Teamwork and consistency in measuring and reporting has kept this strategy front and center for improving our patient’s safety.”

Our thanks to Cardinal Health for sponsoring the inaugural Reducing Healthcare Associated Infections Safer Healthcare Now! Award.


Vancouver Island Health Authority Medication Reconciliation team wins Improving the Safety of Patient Care in Canada Team Award

The Safer Healthcare Now!  Improving the Safety of Patient Care in Canada Team Award for 2010, sponsored by BD, was presented to the Medication Reconciliation Implementation and Spread Team at the Royal Jubilee and Victoria General Hospitals. These hospitals, located in Victoria, British Columbia, are part of the Vancouver Island Health Authority (VIHA). Their goal was to prevent adverse drug events from occurring by reconciling home mediations upon admission and reduce the number of unintentional discrepancies by 75 per cent within the first year of implementation.

A multidisciplinary team was formed and they achieved a 98 percent decrease in unintentional discrepancies (from 1 to 0.02 per patient) within their first month of implementation and have enjoyed this continued success three and a half years later!  VIHA is now in the process of spreading medication reconciliation to medical wards and Emergency Department (with baseline data of 1.3 and 1.9 unintentional discrepancies/patient respectively).  Over time, they will also expand to include more admission patients, transfer/discharge patients, and other hospitals.




“We measure our success by the decrease in unintentional discrepancies, as well as our ability to expand our program without compromising quality,” says Cynthia Turner, Clinical Pharmacist / Medication Reconciliation Lead at Royal Jubilee Hospital. “We have incredible support from our senior management and the leadership of Safer Healthcare Now! They have been integral to our success, along with the timely and invaluable insight we receive from our medication reconciliation colleagues across the country. We are truly honoured to be recognized for our achievements and this award will fuel our continued efforts to improve medication safety and quality of patient care at VIHA.”

Many thanks to BD for sponsoring the inaugural Improving the Safety of Patient Care in Canada team award.



Making an IMPACT!

Safer Healthcare Now! has a new publication available to support your improvement work and promote the 10 interventions. This eight-page newspaper highlights healthcare providers who are making an IMPACT in improving patient safety.  Visit the website to view a copy of IMPACT.  To order copies of the publication for your teams, please send an email to:


National Calls

Tuesday, May 18, 2010 – 12:00 Noon EST - MedRec Ideas That Spread: MedRec Implementation across a Region.  Guest Speakers: Christine Foote, Safer Healthcare Now! Coordinator, Corporate Improvement - Central Health and Julie Johnson, Director, Quality Improvement, Regina Qu’Appelle Health Region.

Tuesday, May 18, 2010 – 2:00 pm EST - Early Mobilization in the ICU. VAP National Webinar hosted by the Canadian ICU Collaborative Faculty.  Guest speakers: Vicki Spuhler and Polly Bailey, Intermountain Medical Center.



Virtual Learning Opportunities 

Are you looking for web-based learning opportunities for 2010? We invite you and your team to gather around your computer screens and get connected to valuable information to support your improvement efforts!

We have compiled a list of learning opportunities to support you in implementing the Safer Healthcare Now! interventions.  Don’t miss out on these valuable learning opportunities!  Visit the website for a complete list of Safer Healthcare Now! virtual learning opportunities.


Controlling Superbugs: e-learning opportunity using Positive Deviance

The New Approach to Controlling Superbugs will allow teams across Canada to learn about Positive Deviance and how to use it in their own facility as part of their efforts to reduce the spread of nosocomial infections.

Through a series of five learning sessions teams will learn how to use an evidenced based behaviour change approach called Positive Deviance in their own facilities, get the message out to those they want to influence and measure progress.

This virtual learning activity is designed for acute or long-term care, or anyone who wants to help their institution reduce healthcare-associated infections. 

There are five learning sessions scheduled:

  1. Intro to Positive Deviance: May 17th (12-2pm ET)
  2. Using Discovery and Action Dialogues:  June 7th (12-1:30pm ET)
  3. Data-Measuring progress:  July 12th (12-1pm ET)
  4. Other tools including Improv and TRIZ:  August 30th (12-1pm ET)
  5. Successes/Spread/Coaching: To be scheduled

To support teams in the implementation, weekly office hours are scheduled on Mondays between 1-2pm ET.

The cost for teams to join is $250 for the five learning sessions and office hours. For more information, click here.


Improving Acute Myocardial Infarction (AMI) care: Virtual Learning Collaborative

Registration opens on May 17, 2010 for the Safer Healthcare Now! Acute Myocardial Infarction (AMI) Virtual Learning Collaborative - Time is Myocardium, designed to improve the timely administration of Thrombolytic agents. Teams from regional and community hospitals that are unable to provide primary percutaneous coronary intervention (PCI), within 90 minutes would benefit from this Collaborative.

Participants will attend four learning sessions and a closing congress scheduled over the course of the year, beginning in June 2010 and ending in February 2011. The learning sessions and team calls will be held using WebEx technology.

Click here for more information.


Atlantic Node Virtual Learning Collaborative: A resounding success

The Atlantic Node Acute Myocardial Infarction (AMI) Virtual Learning Collaborative was made up of 21 teams from seven health authorities in Nova Scotia, Newfoundland and Labrador. Over a six-month period, the participants adapted the traditional learning collaborative methodology to the virtual environment using Internet and phone connections with a WebEx platform. A volunteer planning committee and expert faculty worked many hours to facilitate a meaningful learning experience for participants in the Collaborative.

The clinical focus of the initiative was the timely administration of thrombolytic agents for AMI patients. A secondary focus was developing and testing the use of the virtual learning environment and to assess whether it could be as effective as face-to-face learning Collaboratives. At Learning Session 2 (LS) the team average self -assessment of progress towards their AIM was 2.3 and 4.09 at the Closing Congress. The self-rating is similar to face-to-face Collaboratives at the Closing Congress and much higher than the typical six-month self-rating. “Intra-team relationship ratings” showed improvement from 2.4 to 3.55, whereas “inter-team relationships” ratings showed modest improvement from 2.1 to 2.27. Teams are now working to maintain their gains and will participate in a follow-up call in October 2010.

When asked what worked well one team wrote, “Learning from others and knowing we are not alone in the work we are doing. Everyone faces the same or similar challenges.” This speaks to a fundamental premise of learning collaboratives – ‘everyone teaches, everyone learns’.


Speakers Bureau: Do you need help with your SSI initiative?

SSI speakers (left to right):  Bonnie McLeod, President of ORNAC, Fraser Health, BC; Cari Egan, Safer Healthcare Now! Consultant; Nick Leyland, Safer Healthcare Now!  SSI faculty, Chief Obstetrics and Gynecology, St. Joseph’s Health Centre, ON; Marlies van Dijk, Safer Healthcare Now!  SSI Intervention Lead, Western Node Leader; Claude Laflamme, Physician Lead Safer Healthcare Now! SSI intervention, Director of Cardiac Anesthesia, Sunnybrook & Women’s College Health Science Centre, ON; Shirley Gobelle, Safer Healthcare Now!  SSI faculty, Winnipeg Regional Health Authority Patient Safety Consultant; Gillian Gravely, OR Nurse Manager, University Health Network, ON; Matthew Alexander, Cardinal Health Canada; Martin Wale, Executive Medical Director, Quality and Patient Safety Infection Prevention and Control, Vancouver Island Health Authority, BC; and Matthew Saltzman, Orthopedic Surgeon, Chicago, USA

Safer Healthcare Now! has teamed up with Cardinal Health Canada to create a “Preventing Surgical Site Infection” Speakers Bureau.  A team of Safer Healthcare Now! faculty members and other clinical experts came together in Vancouver on March 26, 2010 to design a compelling presentation.  Speakers are able to come to you to spread the surgical site infection (SSI) message at no cost to you!

The speaker can share key messages around:

  • Latest evidence on skin prep, weight-based dosing, antibiotic prophylaxis with C-sections, and the latest updates from the SSI Getting Started Kit (to be released in May 2010)
  • Cost benefit analysis on preventing SSIs
  • Key change management strategies that have worked in healthcare centres across Canada

Request a presenter to come to your conference or organization if:

  • You are stalled moving from antibiotic timing to normothermia and glucose control to all surgical procedures
  • Some key leaders in your organization need to be convinced that preventing SSI will save you money
  • You are still not using Chlorhexidine for surgical preparation

Please contact Marlies van Dijk, Western Node Leader at or call 403-521-7106 for more information!


Moving forward with the Communities of Practice

Check out what we have been working on for the Safer Healthcare Now! Communities of

Web Coordinator Abisaac Saraga (left) and Norma Freeman (right) viewing what’s new on the Safer Healthcare Now! Communities of Practice

  • Recent document updates section
  • Recent discussions section

Also watch for new features being tested in selected communities for enhanced summary views for:

  • Announcements
  • Calendar & Events

Visit the Communities of Practice to find out more. Have feedback or questions? Visit the CoP Help section.


Patient Safety in Community Pharmacy Practice

Those who are actively involved in medication reconciliation can readily attest that the community pharmacy can be an important source of information for the patient’s medication history. While medication reconciliation is now an established practice in both the hospital and long-term care setting, some may be curious about implementation of patient safety initiatives in community pharmacies.

Recently, the Nova Scotia College of Pharmacists (NSCP) became the first regulatory body in Canada to establish standards of practice related to the establishment of a continuous quality improvement (CQI) process for the purpose of optimizing patient safety. These standards include, among other things, anonymous reporting of quality-related events to an independent and objective third party organization, quarterly staff meetings to discuss medication safety, and completion of a medication safety self-assessment tool annually.

A research project, SafetyNET-Rx, is currently evaluating the impact of these new standards of practice. SafetyNET-Rx is collaboration between St. Francis Xavier University and Dalhousie University, partnering with the NSCP and ISMP-Canada. The project co-leads are Dr. Todd Boyle and Dr. Neil MacKinnon. SafetyNET-Rx has been developed, in part, based on the experience of a pilot study with 13 pharmacies in Nova Scotia in 2008 and 2009. SafetyNET-Rx is funded by the Social Sciences and Humanities Research Council (SSHRC/CRSH) and Nova Scotia Health Research Foundation (NSHRF) and includes 70 pharmacies.

If you are interested in learning more about this project, please check out the new website for this initiative:


One Bite at a Time: Eating the Medication Reconciliation Elephant

The Ontario Node continues to welcome new enrollments in the Safer Healthcare Now! Medication Reconciliation (Med Rec) interventions. Most new enrollments are long-term care (LTC) homes or smaller acute-care organizations that are early in the early stages of Med Rec; others are moving to Med Rec at transfer and discharge.  To assist these organizations and provide an opportunity to exchange experiences, the Ontario Node offered workshops at Ontario Shores Centre for Mental Health Sciences, Whitby with 80 participants and at The Perley and Rideau Veterans’ Health Centre, Ottawa with 60 participants.

The workshop faculty included staff from ISMP-Canada, Accreditation Canada and presenters from the field who are having success with Med Rec. An additional half-day session was available, Taking the First Bite: Training on obtaining the Best Possible Medication History (BPMH), led by ISMP Canada, supported by a grant from the Ontario Ministry of Health and Long Term Care.

This is what participants had to say about the workshop:

  • 100% of survey respondents said they would recommend the workshop to others
  • “Great variety of content and places of practice”
  • “It was great to see that many people are in the beginning stages of this”
  • “It would be very helpful to anyone just starting Med Rec”

The Ontario Node thanks our partners and sponsors for these workshops: Accreditation Canada, Canadian Patient Safety Institute, ISMP-Canada, Ontario Shores Centre for Mental Health Sciences and The Perley and Rideau Veterans’ Health Centre.

The Whitby workshop was also the venue for the Closing Congress for the Ontario Node’s Webinar Learning Series on Medication Reconciliation in LTC, celebrating the hard work and accomplishments of 14 Homes enrolled in this initiative.


Safer Healthcare Now! goes mushing in Newfoundland and Labrador

Be careful what you wish for!  When Safer Healthcare Now! Atlantic Node Leader Theresa Fillatre confirmed a recent visit to Newfoundland and Labrador (NL), she wrote, “We will be there with bells on. Get the dog sleds out!”  Theresa was joined by Dannie Currie, Safety Improvement Advisor and Virginia Flintoft, from the Central Measurement Team.  Meetings were held in St. Anthony, Happy Valley-Goose Bay and Labrador City. The group was hosted by Norma Forsey, Jan Dearing, Marge Learning, Paula March, and CEO, Boyd Rowe, from the Labrador Grenfell Health (LGH) Region.


Left to right: Virginia Flintoft, Dannie Currie, Norma Forsey and Theresa Fillatre mushing in the “Goose” 
“Teamwork is alive and well in Labrador Grenfell,” says Theresa. Eight months of SSI data on two surgical patient populations in both Labrador City and Happy Valley-Goose Bay had been collected in a few short weeks by Infection Control Practitioners and other healthcare team members; a regional action plan for implementation of medication reconciliation across the continuum of care at transfer and discharge was mapped using an inter-relationship diagraph; and admission medication reconciliation is well-established and measures show that LGH is exceeding national performance means.
The highlight of the visit – our Safer Healthcare Now! colleagues were treated to an evening dog sled adventure. Dannie quickly had to overcome a fear of dogs and for Norma Forsey, a 27-year resident of NL this was her first dog-sled adventure. According to Virginia, the quality of care and commitment to Safer Healthcare Now! they observed in the “Goose” spilled over to the quality of hospitality provided by their hosts: “On a glorious Labrador evening, we were appropriately dressed for the dog sled adventure – evidence of their commitment to maintaining normothermia. We were provided with the appropriate footwear – prevention of Falls.  Once we were prepared, they set us out with the dogs – our own Rapid Response Team.  What a fun experience; we had a blast!”