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CPSI Share                                                  
6/30/2010 6:00 PM


Inside this Issue:

Safer Healthcare Now! VTE intervention receives educational grant

A $150,000 educational grant has been awarded to the Canadian Patient Safety Institute by Pfizer Canada Inc. to advance the Safer Healthcare Now! venous thromboembolism (VTE) intervention. This funding will be divided between Sunnybrook Health Sciences Center, supporting the work of the Safer Healthcare Now! VTE Intervention Lead Dr. Bill Geerts and his team, and to support the implementation of VTE prevention programs within Safer Healthcare Now! 

Pfizer is also supporting VTE prevention through the Safer Healthcare Now! VTE Prevention Hospital Award launched in October 2009. A $5,800 award will be presented during Canadian Patient Safety Week held in November 2010, to three hospitals that have demonstrated a commitment to prevent VTE and have dedicated the necessary resources to achieve this goal. Click here to apply for the Safer Healthcare Now! VTE Prevention Hospital Award.


We want to hear from you!  VTE Needs Assessment Survey

Venous thromboembolism (VTE) is one of the most common complications of hospitalization and one of the most preventable causes of hospital death. While there is strong evidence to support the use of thromboprophylaxis for most patients in hospital, audits reveal that many patients at risk for VTE do not receive thromboprophylaxis. Accreditation Canada has recently added VTE prevention to their list of required organizational practices (ROPs). Safer Healthcare Now! would like to assist Canadian hospitals with implementation of their own thromboprophylaxis policy/protocol and optimize their use of appropriate thromboprophylaxis.

Help us help you!

To serve you better, we have prepared a short survey to help us further understand what you need to implement VTE at your hospital. In the survey, we would like to hear your suggestions, insights and success stories.  We will summarize and send the responses to participants, as well as post them on the Safer Healthcare Now! website.

Take the Survey Now!


New Approach to Controlling Superbugs –
Virtual Learning Wave 2 now available!


Join wave 2 of the New Approach to Controlling Superbugs virtual learning initiative. With the help of our expert faculty, learn how to bring about positive culture change and engage healthcare communities in reducing infections using the Positive Deviance approach. This new approach is meant to add onto the more traditional quality improvement techniques, not to replace them entirely.

Over 20 teams across Canada enrolled for the first wave. Join them and others as we work with our frontline staff towards eliminating hospital-acquired infections. The New Approach to Controlling Superbugs initiative is designed for acute or long-term care, or anyone who wants to help their institution reduce healthcare-associated infections.

This initiative will include:

  • Call to Action for all individuals and teams interested in participating
  • Five virtual learning sessions – These five-hour learning sessions are scheduled using WebEx technology
  • Weekly office hours to support improvement efforts
  • Opportunity to learn from experts and share cutting-edge knowledge
  • Opportunity to collaborate with peers
  • Access to faculty and topic experts throughout the program

Join the Call to Action on Thursday, August 26th. The learning sessions are scheduled for September to December 2010. 

For more information, contact Leah Gitterman:


Medication Reconciliation in Home Care Update

The Medication Reconciliation in Home Care Pilot Project (2008 -2009) demonstrated a 45.2 per cent discrepancy rate. Within this percentage there was an average of 2.3 discrepancies per client.  Throughout the pilot, clinician told stories of potential adverse events being prevented directly related to the Medication Reconciliation process.  Successes and lessons learned were harnessed and built on; challenges were identified and strategies where tested.  

Safer Healthcare Now! in partnership with the Canadian Patient Safety Institute, the Victorian Order of Nurses Canada and the Institute for Safe Medication Practice Canada are pleased to announce that the Medication Reconciliation in Home Getting Started Kit has been finalized.  A draft version of the kit is posted on the Communities of Practice and the final version will soon be available on the Safer Healthcare Now! website. Home Care organizations are eagerly awaiting this new kit so they can get started! 

How will we share the new Getting Started Kit?

The official launch of this kit will coincide with the announcement and launch of the Medication Reconciliation in Home Care Virtual Learning Series, “Medication Reconciliation: Home is where the Heart is!” Based on this new kit, the series will be offered through five learning sessions (1.5 hours in length) supported with weekly office hours where teams can consult with experts and work together to resolve challenges that arise. 

Planning for the virtual series is underway and recruitment will take place over the summer months. Information on the “Call to Action” will soon be posted to the Safer Healthcare Now! website. The learning session dates are being finalized and the first session is set to commence late September.

For more information please contact Debbie Conrad at


"MedRec to Go: A Reliable Discharge Process" Virtual Learning Series – Starting January 2011

Hospitals are working hard to ensure patient’s medications are ordered accurately and correctly at admission, but what happens when patients are discharged? Do patients and their next care providers understand everything they need to know about their medications at discharge?

This virtual learning series will assist teams to begin implementation of medication reconciliation at discharge.  Learn from experts in the field, hear real life success stories and receive tools and resources to help you get started.

Recruitment begins in September 2010.  Stay tuned for more information!

For more information, contact Brenda Carthy at


Medication Reconciliation at Kennedy Lodge Long Term Care Centre:

Commitment to excellence wins Revera’s Annual Medication Systems Improvement Award

Kennedy Lodge team members (left to right): Dian Cairns, Regional Manager of Clinical Services; James Zulueta, Staff Educator; and Regeetha Rasalingam, RN.
In January 2010, Kennedy Lodge in Scarborough (Ontario) joined the Medication Reconciliation Webinar Learning Series (WLS) led by the Ontario Node of Safer Healthcare Now! This intensive virtual program was designed to assist organizations in the implementation of medication reconciliation within their care homes. The program facilitated sharing of expertise and data, and lived by the mantra, “everyone teaches, everyone learns.”  As the WLS progressed, Kennedy Lodge methodically implemented the process of medication reconciliation for new admissions and re-admissions on all units throughout their facility. In June 2010, the team learned that they were this year’s recipient of Revera’s Annual Medication Systems Improvement Award!

Kennedy Lodge identified two key factors in their success. First, application of the Plan, Do, Study, Act (PDSA) cycle led them to consider what they were trying to accomplish and how to measure if a change was actually an improvement.  Second, the initiative was led by a dedicated Improvement Team comprised of a team leader, their Director of Care; Nurse Managers, who were on-the-ground leaders, driving the process every day; a Staff Educator; a Clinical Pharmacist; and a registered nurse who took responsibility for tracking data and results.

By participating in the Webinar Learning Series, Kennedy Lodge developed a greater network with other long-term care facilities while gaining access to information about quality improvement and patient safety that they can now use to inform other programs and services at their long-term care home.

Kennedy Lodge’s success story shows how a strong approach to implementing medication reconciliation plus  planning, dedicated resources, and information sharing all led to successful implementation and added capacity for ongoing improvement at a long-term care home.


Don’t Slip Up!  Reduce Falls and Injuries from Falls

Safer Healthcare Now! and the Canadian Patient Safety Institute in partnership with the Registered Nurses’ Association of Ontario invites you to participate in a Falls Prevention Virtual Learning Collaborative designed to reduce falls and injury from falls in Canadian healthcare settings.

About 40 per cent of older adults who are hospitalized have suffered from a fall and approximately seven per cent of these admissions result in death (Smartrisk, 2004). Falls are the primary cause of injury admissions, accounting for 54.4 per cent of all injury hospitalizations and 75.7 per cent of all in-hospital deaths for clients admitted for injuries (Canadian Institute for Health Information, 2000). Identifying possible risk factors and implementing a falls prevention program can lead to a measurable reduction in falls and injury from falls. 

Registration now!  The Falls Prevention Virtual Collaborative will run from October 2010 through to March 2011.  For further information please visit:


One Step Further: The Falls Prevention Program at Jewish Eldercare Centre

Contributed by: Jacqueline Gilbert, Occupational Therapist M.A. and Brigitte Lavoie, Rehabilitation Therapist, Jewish Eldercare Centre (CHSLD juif de Montréal)

(Front row, left to rightOriginal members who are continuing their good work: Bertha Désire (nurse unit), Cornélia Combiescou (pharmacist), Jacqueline Gilbert (Co-leader, Occupational Therapist), Miriam Samson (Rehabilitation Therapist), Caroline Romano (Rehabilitation Therapist), Palma Lento (Dietician), Mona Beck ( Assistant to the Nursing Director and Specialized Services), and Andrea Rubin (Dietician).  (Back row, left to right) New Members: Josée Parent (Resident Attendant/Preposée aux bénéficaires), Margarette Vertues (Head nurse), and Isabelle Samson (Rehabilitation Therapist) Missing: Brigitte Lavoie (Rehabilitation Therapist)
The mission of the Jewish Eldercare Centre in Montreal (Quebec) is to provide the highest possible quality of care and quality of life for our clients in a safe and secure homelike environment. The Centre participated in the National Falls Collaborative to support the development and implementation of a fall prevention program, which includes: a restraint-free environment; using restraint alternatives; taking vitamin D and calcium; environmental measures such as transfer poles, low beds with four bedrails; educational sessions for all staff; and ongoing follow-up. Since the closing of the Safer Healthcare Now! National Falls Collaborative, the rehabilitation team continues to coordinate falls prevention initiatives and work on new opportunities as they arise.

Additional falls prevention strategies being implemented at the Jewish Eldercare Centre are::

  • Ensuring everyone, not just the care team, is involved and responsible to assess if a resident is in danger when a bell or bed sensor rings.
  • Identifying all residents with an elevated risk of falling with a red star, that is placed on their door frame and on their chart.
  • Completing a medication review is standard procedure where the interdisciplinary team conducts a risk/benefit analysis to determine if the benefit of taking specific medications is greater than the risk of not taking them.
  • Communication amongst the care team post-fall. 

Our recommendation to all facilities – do not hesitate to join the Falls Prevention Virtual Learning Collaborative starting in the Fall 2010. Our participation in the National Collaborative on Falls Prevention in Long-Term Care has been invaluable. Three learning opportunities on testing for change and quality improvement methodology directed the successful implementation of our program based on best practices.


Safer Healthcare Now! gets new Visual Identity Guidelines

Safer Healthcare Now! has new Visual Identity Guidelines.  The guidelines, which were developed to help achieve visual consistency, will be available soon at They include information on how to use the Safer Healthcare Now! logo, intervention icons, Safer Healthcare Now! tagline, colours, and font. In addition, new  templates are available, such as letterhead and a PowerPoint presentation.

Everyone involved in Safer Healthcare Now! is encouraged to make use of the templates available and to replace old templates in an effort to brand Safer Healthcare Now! consistently across the country. Over the coming months, changes will be made to certain documents and the Safer Healthcare Now! newsletter and website will begin to reflect the new identity.

If you have questions or comments related to the Visual Identity Guidelines, please do not hesitate to contact or


Improve AMI care through virtual learning

Time is Myocardium is a virtual learning collaborative designed for teams that want to improve acute myocardial infarction (AMI) care. Timely reperfusion therapy is associated with better outcomes, as a substantial portion of patients do not receive fibrinolysis or primary percutaneous coronary intervention (PPCI) within recommended times (Lambert et al 2010). Safer Healthcare Now! is offering a Virtual Leaning Collaborative that will create an opportunity to work with colleagues, content experts, and improvement faculty to achieve timely reperfusion.  A Call to Action is scheduled for Wednesday, September 8th.  Sessions begin on October 20th.  Register today!

Teams working with emergency AMI care, including Emergency Room nurses, Emergency Room Physicians, Cardiologists, Cardiology Technologists, Paramedics; Department/Service Mangers, Clinical Nurse Specialists or Educators, Respiratory Therapists, Quality Coaches and any other healthcare professionals who have an interest in improving AMI care will benefit from this Collaborative.

Click here for more information.


National Calls

Tuesday, September 21, 2010 – “Association Between Timeliness of Reperfusion Therapy and Clinical Outcomes in ST-Elevation Myocardial Infarction” AMI National Call – Ms. Laurie Lambert, PhD. of the Cardiology Evaluation Unit, Quebec Healthcare Assessment Agency (Agence d’evaluation des technologies et des modes d’interventions en santé) will present the current Canadian research on the timeliness of reperfusion therapy and discuss practice implications.  The 30-minute presentation will be followed by a question and answer session.


Ontario teams invited to lunch and learn about Medication Reconciliation

Safer Healthcare Now! Ontario teams are invited to join a lunch and learn teleconference to learn more about safer medication practices:

Friday, July 9, 2010
A Conversation with Accreditation Canada – The Short and Skinny on the Medication Reconciliation Required Organizational Practice for Accreditation
Gregory Kennedy, Research and Product Development Specialist, Accreditation Canada
Focus on Medication Reconciliation as part of the Accreditation process: busting the myths, frequently asked questions, and tips for success.

Monday, July 12, 2010
Successful Strategies for Medication Reconciliation from Across Canada
Marg Colquhoun, ISMP Canada, Safer Healthcare Now!
Medication Reconciliation Intervention Leader

The sessions take place from 12:10 to 12:50 on the above dates.  No formal registration is required. To join dial 1‐800‐808‐0861 or 416‐507‐1616 and use access code 939599.

For more information on these medication reconciliation sesions, contact Clara Ballantine at or at 613-736-9142.