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Creating a Safe Space: Psychological Safety of Healthcare Workers28651/16/2020 9:52:31 PMPatient Safety News<img alt="" src="/en/NewsAlerts/News/PublishingImages/2020/Creating%20a%20Safe%20Space-Psychological%20Safety%20of%20Healthcare%20Workers%20-%20Photo.png?Width=140" width="140" style="BORDER&#58;0px solid;" /> ​​Creating a Safe Space Psychological Safety of Healthcare Workers is a comprehensive guide and toolkit that provides Canadian healthcare organizations with the resources they need to develop and sustain a peer-to-peer support program. The Canadian Patient Safety Institute has created a comprehensive guide and toolkit that provides Canadian healthcare organizations with the resources they need to develop and sustain a peer-to-peer support program (PSP). Creating a Safe Space Strategies to Address the Psychological Safety of Healthcare Workers provides a broad overview of what peer support is available in Canada and internationally. The guide outlines best practices, tools, and resources. These help policy makers, accreditation bodies, regulators, and healthcare leaders assess what healthcare workers need in terms of support, and to create PSPs to preserve their emotional well-being. The result enables healthcare organizations to provide the best and safest care to their patients. Some healthcare organizations are unable to provide the support needed to their staff and managers to maintain a healthy and resilient workforce. Albert Wu coined the term "second victim"1 to describe a healthcare worker after a patient safety incident. The "second victim phenomenon"1, 2 describes healthcare providers who are psychologically traumatized by events during the provision of care, resulting in anxiety and depression, decreased performance, high turnover rates, and increased patient safety incidents3. Various studies estimate that the prevalence of the second victim phenomenon ranges from 10.4 per cent up to 43.3 per cent3. Healthcare is a high stress environment. Healthcare providers are expected to work efficiently and safely in often difficult and pressured settings. Over the past decade, research has identified the clear link between a provider's mental health and healthcare outcomes, including patient safety, with the probability of contributing to a preventable incident increased when the provider is suffering from psychological distress4. For example, a healthcare professional may feel emotionally traumatized after a sudden or unexpected bad outcome, a patient safety incident, the loss of a patient with whom they feel close, workplace conflict, or dealing with multiple trauma cases. "While patients and families will always be the first priority in healthcare, workers also need to be supported as a result of what they experience in their profession," says Markirit Armutlu, Senior Program Manager, Canadian Patient Safety Institute. "Peer-to-peer support programs, where health professionals can discuss their emotional distress in a nonjudgmental environment with colleagues who can relate to what they are going through, are now seen as an effective approach to helping health professionals cope and provide a safe space where they can get extra support." Creating a Safe Space is divided into four sections Section 1 provides the results of a pan-Canadian survey of healthcare workers to determine what support they needed and identified gaps in that support. Section 2 includes knowledge from international literature so that we can learn from those who have established or studied healthcare PSPs. Section 3 addresses confidentiality and legal privilege for peer support programs. It provides clear explanations about what is and is not privileged information and how best to strengthen confidentiality. Section 4 provides a step-by-step approach to help healthcare organizations succeed in creating a PSP. It includes recommendations on how to recruit and train peer supporters and how to ensure spread and sustainability of the program. A webinar series has also been created to learn from others who have implemented PSP programs. In partnership with the Mental Health Commission of Canada, the Canadian Patient Safety Institute has compiled the Creating a Safe Space Toolkit with input from experts and contributing organizations. "The Toolkit is an excellent source of information for healthcare workers, leaders, regulators, and policy makers that includes templates, examples, and recommendations for anyone who is embarking on creating a PSP," says Armutlu. "The searchable database provides links to documents and examples from existing peer support programs for healthcare providers." 1 Wu AW. (2000) Medical error the second victim. The doctor who makes the mistake needs help too. BMJ. 320726-727. 2 Scott SD. (2011). The second victim phenomenon A harsh reality of health care professions. Perspectives on Safety. Patient Safety Network. AHRQ. 3 Edrees H, Connors C, Paine L, Norvell M, Taylor H, Wu A. Implementing the RISE second victim support programme at the Johns Hopkins Hospital a case study. BMJ Open. 2016;(6);1-12. doi 10.1136/bmjopen-2016-011708 4 Burlison, JD et al. (2018). The Effects of the second victim phenomenon on work-related outcomes Connecting self-reported caregiver distress to turnover intentions and absenteeism. J Patient Safety. Author manuscript; avail. in PMC. 1/16/2020 10:00:00 PM Creating a Safe Space: Psychological Safety of Healthcare Workers is a comprehensive guide and toolkit that provides Canadian healthcare1/17/2020 6:32:53 PM118
#SHIFTTALKS Building Engagement Capacity in Atlantic Canada9021/15/2020 9:04:34 PMSHIFT Talks<img alt="" src="/en/NewsAlerts/News/PublishingImages/2020/Kelli%20O%27Brien.jpg?Width=140" width="140" style="BORDER&#58;0px solid;" /> by Kelli O'Brien Little did I know, when I volunteered to help with the planning and implementation of the Atlantic Health Quality and Patient Safety Collaborative's Engaging Patients in Patient Safety Collaborative in 2018, that I would be joining forces with such amazing experts with varied backgrounds. The collaborative included a knowledgeable faculty of patient partners and healthcare providers, leaders from the Canadian Patient Safety Institute committed to making healthcare safer, and specialists in science and the art of quality improvement from the Improvement Associates. It was truly a humbling and inspirational experience working with the faculty, the Canadian Patient Safety Institute, Improvement Associates, and the healthcare teams involved. Seventeen teams, representative of all four Atlantic Canadian provinces, were enrolled in the 12-month virtual collaborative, designed to increase the effectiveness of patient engagement in improving patient safety and quality. Building upon the Engaging Patients in Patient Safety A Canadian Guide, the teams accepted the challenge to improve patient engagement within their complex, ever-changing environments. The teams selected change ideas to increase effectiveness of patient engagement at point of care, at the organizational level, and/or to enable effective leadership to support patient engagement. Interestingly, nine teams focused either on strategies to increase effectiveness at the organizational level, and eight focused on strategies to increase effectiveness within specific care processes. The collaborative was unique in that all the learning and collaboration between teams occurred virtually as the teams never came together face-to-face for any of the learning events. The opening and closing events, as well as all the other activities, including the planning for the engagement, occurred remotely. The teams were certainly up to the challenges of working together within a virtual world and the planning group worked diligently to try to create the conditions to support collaboration. An active ingredient contributing to the success of the collaborative was the everyone teaches, everyone learns approach. Although the evaluation results are not yet finalized, informal discussions with team members suggest that the opportunity to learn from each other and from patient partners about successful strategies, as well as to share common struggles, was invaluable for participants. Flexibility and time were key enablers of the collaborative. Congratulations to the participating teams! I am hopeful for the future based on the teams' commitment to "conquer silence" – to hear and listen to the voices of patients and providers and empower and enable patients to be partners in care. This deep belief in engagement will help transform the healthcare system for exceptional care experiences with better outcomes for patients. Sustaining and building on the important work of the collaborative will indeed support the creation of "engagement capable environments" in our provinces.1 The Engaging Patients in Patient Safety Collaborative was co-chaired by Kelli O'Brien, Vice-President of Long Term Care, Rural Health and Quality, Western Health (Newfoundland) and Ioana Popescu, Senior Program Manager, Canadian Patient Safety Institute. 1https// 1/15/2020 9:00:00 PMby Kelli O'Brien Little did I know, when I volunteered to help with the planning and implementation of the Atlantic Health Quality and Patient1/15/2020 10:06:08 PM247
Patient Safety Power Play: A New Decade of Patient Safety590831/9/2020 10:42:57 PMPatient Safety Power Plays<img alt="" src="/en/NewsAlerts/News/PublishingImages/Chris%20Power.jpg?Width=140" width="140" style="BORDER&#58;0px solid;" /> In the message I shared with you before the holidays, I spent some time looking back at progress we have made in patient safety over the past year. As we step forward to embrace a new year – indeed, a new decade – I want to cast our gazes forward to what we are doing at CPSI to improve patient safety… and how you can help! First of all, regular readers of Power Play will be familiar with our new public engagement campaign, #ConquerSilence. We asked every person in Canada to share the healthcare message that if something feels wrong, looks wrong or is wrong, speak up—in the moment. We launched the initiative last year during Canadian Patient Safety Week to wonderful response, but that was only the first step. Over the next year, we will ask you to #ConquerSilence within specific issues in healthcare. This month, we continue our focus on medication safety and the Five Questions To Ask About Your Medications. Next month, we will focus on Trauma and Falls – the biggest driver of patient safety incidents in the home care setting, accounting for roughly 115,000 patient safety incidents per year. Among other themes will be infection prevention, surgical errors, and misdiagnosis. We invite you to share your stories and advice on how others can keep themselves safe at This year will be significant for patient safety on another front as well, as our 18-month Safety Improvement Projects wrap up the formal collaborative sections and move into six-month monitored implementation phases. Guided by a Knowledge Translation/Quality Improvement integrated approach, our thirty teams across the country will apply the strategies they learned in our four projects to lead safety improvement in their institutions. We will continue to offer support and guidance as the teams implement their programs. We will also report on their progress and celebrate their successes! Finally, we are in the planning stages for several events that will help shine the spotlight on patient safety in Canada this year. In early May, we will ask you to help us celebrate STOP! Clean Your Hands Day in our effort to reduce preventable infections in healthcare. The second annual World Patient Safety Day arrives in September, only a month before our Canadian Patient Safety Week at the end of October. Each of these events will be opportunities for you to join us in our efforts to confront the third leading cause of death in Canada preventable patient harm. On behalf of the Canadian Patient Safety Institute, I continue to be delighted and empowered by your support in making patient safety a priority for our political leaders, for our healthcare institutions, and for everyone across the country. Watch for information about our new policy framework document next month. Together, we will make this new year count in our ongoing mission to reduce harm and ensure that every patient is safe. Questions? Comments? My inbox is open to you anytime at, and you can follow me on Twitter @ChrisPowerCPSI. Yours in patient safety, Chris Power 1/9/2020 10:00:00 PMIn the message I shared with you before the holidays, I spent some time looking back at progress we have made in patient safety over the past year.1/9/2020 10:52:37 PM248
#SuperSHIFTER Dr. Doug Cochrane: when it comes to patient safety, we can always do better590781/9/2020 4:08:47 PMSuper SHIFTERS<img alt="" src="/en/NewsAlerts/News/PublishingImages/2020/Doug%20Cochrane.jpg?Width=140" width="140" style="BORDER&#58;0px solid;" /> #SuperSHIFTER Doug Cochrane, MD is the Board Chair of Interior Health in British Columbia. He served as Board Chair for the British Columbia Patient Safety and Quality Council, from its inception in 2008 until October 2019. He also served as the Provincial Patient Safety and Quality Officer for British Columbia, and is a former Board member and Board Chair of the Canadian Patient Safety Institute. A pediatric neurosurgeon, Cochrane obtained his medical degree at the University of Toronto, and completed a pediatric neurosurgery fellowship at the University of Toronto's Hospital for Sick Children. What professional accomplishment are you most proud of? There are two. The first is having the skills, ability and the opportunity to help as many children as I did who had neurosurgical ailments that could be treated effectively with surgery. This was all about decision-making and technical skill, but more importantly supporting families and their kids. The second is the establishment BC Patient Safety & Quality Council (BCPSQC). This came about because a group of care providers and administrators believed that we, health care professionals, have an obligation to improve care for patients, clients and peers, and that we had the knowledge and tools to do it. Creating an organization that supports this ideal has focused our health system on the "relentless pursuit of quality" so that we can provide the best care we can. Tell us about your work with the British Columbia Patient Safety and Quality Council. The BCPSQC is a facilitator of change. It is an active, vibrant and in my opinion (biased as it is) very influential organization that looks to opportunities worldwide – across Canada, to colleagues in the United States, Great Britain, New Zealand, Australia, and elsewhere to help inform how our health care system can be improved. The Council supports the understanding of issues and provides to partners the support, the best frameworks, and tools to achieve improvement. The Council is singly focused on improving care for patients and, with partners, acts to make health care better. It is also an organization that provides expert advice and confidential reviews for governmental organizations, colleges, and health authorities when requested. Is there a "personal passion" you are working on now? My greatest passion at the moment is trying to understand the world view and life experiences of indigenous peoples in the BC interior. The BC Interior has more indigenous people than in other health authorities elsewhere in British Columbia. The Interior has extraordinarily poor and extremely wealthy populations within our First Nations. Coming to appreciate the indigenous perspective of health has been an eye-opener for me. It has broadened my perspective to health, beyond health care, and certainly beyond the narrow field of neurosurgery. I look forward to this lifelong learning opportunity. What inspired your work in patient safety? While I chaired the BCPSQC, I had a number of frontline administrative roles. I was lead surgery at the Children's Hospital in Vancouver and grew through that organization, and numerous reorganizations, that eventually led to the current BC health authority structure. I provided neurosurgical care and was a senior administrator supporting the care that was being delivered by others. As the Vice-President of Medicine and the Vice-President of Safety and Quality for the Provincial Health Services Authority, I had the unique opportunity to see care being delivered and to be the person responsible for delivering care in the province-wide and diverse health care system that I and others were working to make better. There was an event where British Columbia and the leadership at the Children's Hospital led the country in openness, transparency, honouring of patients and learning from adverse events. This tragedy, a child's death, occurred following an error in the administration of chemotherapy. At the time, Lynda Cranston (President & CEO, Children's and Women's Health Centre), David Matheson (VP of Medicine) and Pat Evans (Head of Communications) were so very instrumental in showing me what my responsibilities were as a manager in care delivery – to undertake a comprehensive and respectful investigation; to provide open and ongoing communication with the patient's family; and to make the event known publicly so that others could learn from this experience. I learned that the cornerstone of the organization's responsibility was respectful, open and transparent communication with the family, the commitment to foster learning amongst other care providers and using our experience to develop system changes that would prevent similar events in the future. What important lesson have you learned about patient safety? We can always make it better. If we have the right mindset and commitment, and if we understand the context and nature of the care we deliver, we can make care better. We will never have everything perfect, yet, if you made a commitment to improve care, you always can. What is the best advice you ever received that helped shape your career? The best things that I have learned in my career – blending both my side of the scalpel and my side of the conversation – have come from families. Families know what is important to them, in comparison to my surgeon's perspective that is focused on the illness or technology. While I had a surgical contribution to make, I also needed to bring realism, in an appropriate and sensitive way, to my discussions with families and my recommendations. What matters to patients and families is the most important question that needs to be asked. If you choose not to ask the question, then the only perspective you will have is your own; too often a perspective that is not relevant to those to whom we are providing care. This philosophy respects the autonomy of the patient supported by respectful and honest realism that defines for care givers, what's important to our patients. For more insights, email Dr. Doug Cochrane at 1/9/2020 4:00:00 PM#SuperSHIFTER Doug Cochrane, MD is the Board Chair of Interior Health in British Columbia. He served as Board Chair for the British Columbia Patient1/9/2020 4:24:44 PM735
Patients Meet with Ministers of Health39012/19/2019 3:08:49 PMPatient Safety News<img alt="" src="/en/NewsAlerts/News/PublishingImages/2019/Patient%20Roundtables%202019-1.jpg" width="140" style="BORDER&#58;0px solid;" /> It has been an incredible fall for Patients for Patient Safety Canada (PFPSC), whose efforts have made significant strides to raise awareness with elected officials and senior leaders in governments across Canada. During the months of October and November, PFPSC hosted four Patient Roundtables with Ministers of Health and senior policy makers in Newfoundland and Labrador, Manitoba, Nova Scotia and Prince Edward Island. As volunteers working for more than a decade with providers and health care leaders in Canada, PFPSC members have been and continue to be deeply concerned about what the recent patient safety data is telling us. RiskAnalytica’s 2017 report found that patients are harmed in Canada every minute and 18 seconds, and a patient safety related death occurs every 13 minutes and 14 seconds. For these reasons, PFPSC members felt that it was critical to take this message to elected officials across Canada. Through the creation of the Provincial and Territorial Patient Roundtables, PFPSC’s objective is to promote awareness and understanding about patient safety with Ministers of Health; begin open, honest and frank conversations about what is truly needed to make care safer; and raise concerns about the need for transparency and collaborations that are possible to achieve PFPSC’s vision - ‘Every Patient Safe’.   The first Patient Roundtable was in early October in Newfoundland and Labrador with Minister of Health Dr. John Haggie. Later that month, PFPSC hosted Patient Roundtables in Manitoba with Assistant Deputy Minister Avis Gray, Nova Scotia’s Minister of Health and Wellness, Randy Delorey, and Deputy Minister Mark Spidel on Prince Edward Island. Each roundtable has one overarching goal to strengthen provincial government commitment to safer care. In the 90-minute roundtable conversations, patients share their stories and recommendations for policy action. The conversations centre around three policy requests Do no harm prevention and learning through reporting Prevent further harm disclosure principles Engagement of patients active partners for safer care Each roundtable involves local patient partners from each province. Some are PFPSC members and some are new friends that have been made along the way. Overall, the huge success of these meetings tops off nearly a year of work from our dedicated PFPSC leadership, CPSI team members, and collaborators. The next stage is to focus on the connections made through this initiative with engaged provinces and territories and continue to move the needle on patient safety with more Patient Roundtables to be scheduled in 2020. Learn more about initiatives such as these on the Patients for Patient Safety Canada website. 12/19/2019 3:00:00 PMIt has been an incredible fall for Patients for Patient Safety Canada (PFPSC), whose efforts have made significant strides to raise awareness with12/19/2019 4:28:46 PM532
Cecilia Bloxom named to CPRS College of Fellows6856512/5/2019 9:27:03 PMPatient Safety News<img alt="" src="/en/NewsAlerts/News/PublishingImages/2019/Cecilia%20Bloxom.jpg?Width=140" width="140" style="BORDER&#58;0px solid;" /> ​The Canadian Patient Safety Institute’s Cecilia Bloxom, Senior Director of Strategic Communications, has been named to the Canadian Public Relations Society College of Fellows, a pinnacle of achievement for members of the Society. An induction ceremony will be held in Quebec City on May 24, 2020, during the Canadian Public Relations Society (CPRS) National Conference. College of Fellow members have at least 20 years of professional experience and at least 10 years of Society involvement. They have demonstrated that they are leaders in the public relations profession, but also have demonstrated outstanding leadership in CPRS. Fellows devote their time and undertake tasks that advance the state of public relations in Canada, including mentoring others, speaking and writing about the value of effective public relations and being involved in other College initiatives. Cecilia is a dynamic communications professional with boundless energy and creativity; she is known to raise the bar and quick to approach every task with the same drive and commitment. She truly upholds the status of leadership in public relations. “Cecilia’s career has flourished over the last two decades as she has consistently challenged herself to grow her skills to become a dynamic and well-respected communications professional,” says Chris Power, CEO, Canadian Patient Safety Institute. “She is constantly looking toward the next big challenge and accomplishment, while providing inspiration to her team and peers. Her unwavering commitment to improve patient safety is evident in the campaigns she has spearheaded and the issues she has tackled. She has the unique ability to bring together diverging opinions and ensure people feel heard, respected and valued, leading to successful outcomes for everyone involved.” An award winning Senior Communications Professional with 20 years of experience in regional, provincial and national organizations, Cecilia is highly skilled in developing and landing memorable strategic plans, creating lasting brands, and routinely building awareness on a national level. She is one of a few hundred communicators in Canada with dual accreditation from both the International Association of Business Communicators and the Canadian Public Relations Society. Cecilia is a true leader in the Communications industry with a solid background in leadership development, including a Masters of Arts in Leadership from Royal Roads University. Cecilia has a solid understanding of Governance, supporting the Canadian Patient Safety Institute’s national Board of Directors, serving as the current Past President of the Canadian Public Relations Society (Edmonton), current Director on the CPRS Foundation Board (formerly Communications + Public Relations Foundation), and past Director with the Nina Haggerty Centre for the Arts. Over the past ten years, Cecilia has shared advice, experience and guidance as a mentor to protégés in the CPRS mentorship program. Cecilia also chaired the Local Advisory Committee for the Canadian Public Relations Society National Conference, Evolving Expectations, welcoming over 300 delegates to Edmonton in June 2019. Cecilia has made a mark in healthcare communications, locally, nationally and internationally. The knowledge, passion and energy that Cecilia brings to her position with the Canadian Patient Safety is evident through the branding and the development of numerous initiatives including the development of a Strategic Communication Plan for a national strategy on patient safety. In addition to her professional accomplishments, Cecilia cherishes being a mother to her beautiful daughter Cyr and lives in the heart of Edmonton’s Little Italy with her husband Jesse and standard poodle, Walker. Cecilia loves all things active including skiing and yoga and is very involved in transforming her community. Congratulations, Cecilia! 12/5/2019 9:00:00 PM The Canadian Patient Safety Institute’s Cecilia Bloxom, Senior Director of Strategic Communications, has been named to the Canadian Public Relations12/5/2019 9:42:09 PM643
How safe is our care?4614312/2/2019 5:13:12 PMPatient Safety News<img alt="Bar chart" src="/en/NewsAlerts/News/PublishingImages/News%20Feed%20Icons/Consortium%20Thumbnail.jpg?Width=140" width="140" style="BORDER&#58;0px solid;" /> By Anne MacLaurin, Virginia Flintoft, Wayne Miller and Alex Titeu All healthcare leaders, providers, patients, and the public should wrestle with a fundamental question How safe is our care? The typical approach has been to measure harm as an indicator of safety, implying that the absence of harm, is equivalent to the presence of safety. But, are we safe, or just lucky? Jim Reinertsen, MD, a past CEO of complex health systems and a leader in healthcare improvement, suggests that past harm does not say how safe you are; rather it says how lucky you have been. After learning about the Measurement and Monitoring of Safety (MMS) Framework, Reinertsen found the answer to his question, "Are we safe or just lucky?" "The Measurement and Monitoring of Safety Framework challenges our assumptions in terms of patient safety," says Virginia Flintoft, Senior Project Manager, Canadian Patient Safety Institute. "The Framework helps to shift our thinking away from what has happened in the past, to a new lens and language that moves you from the absence of harm to the presence of safety." Professor Charles Vincent, Professor of Psychology at Oxford University, advocates that assessing safety is not the same as counting harm. As the first author of the Measurement and Monitoring of Safety framework, he believe it is critical for us to ask five questions, each related to a specific dimension of safety, in order to determine whether an organization is safe. This approach is one often used by industry that looks at leading and lagging indicators, and relies on soft intelligence. A holistic view of safety prompts leaders and providers to be inquisitive and empowers everyone to take a proactive role in safety. The five critical questions are Has patient care been safe in the past? Systematically reviewing existing measurement and monitoring of past harm can increase your understanding and help you to respond appropriately to harm when it occurs. Are our clinical systems and processes reliable? This dimension gauges the probability that a task, process, intervention or pathway will be carried out or followed as specified. Is care safe today? Sensitivity to operations focuses on the day-to-day, hour-by-hour and even minute-by-minute management of safety, bringing together a mix of intelligence to help staff, clinicians, managers and leaders assess and act upon safety in real time. Will care be safe in the future? By focusing on the identification of possible sources of future harm, you can work to become more resilient to them. Don't wait for things to go wrong before trying to improve safety. Are we responding and improving? The development of systems to promote a cycle of learning and sharing from safety incidents, multiple sources of safety intelligence and insights developed through the other domains. Integration and learning is the glue that holds a rounded safety picture together. "The Framework changes the nature of the conversation to being more mindful and forward-thinking," says Wayne Miller, Senior Project Manager, Canadian Patient Safety Institute and MMS coach. In 2017, the Canadian Patient Safety Institute launched a measurement and monitoring of safety demonstration project, led by Dr. Ross Baker at the University of Toronto. An 18-month Safety Improvement Project was subsequently launched in 2018, to support healthcare teams in rewiring their thinking on patient safety and to work within their organizations to foster and promote this new approach to safety. The coaches supporting the MMS collaboratives have learned that this expanded view, helps to provide a shared and consistent understanding of safety. It empowers everyone to take a proactive role and promotes a culture of collective responsibility for safety. MMS promotes the importance of the contribution that patients and carers make to safer care. Most importantly, it reinforces the message that safety is more than counting harm. "It is exciting to see the transformation within the teams and their understanding and focus on patient safety," says Anne MacLaurin, Senior Program Manager, Canadian Patient Safety Institute and MMS coach. Danielle Bellamy, Director of Continuing Care, Yorkton & District Nursing Home (Saskatchewan Health Authority) participated in the MMS collaborative. She says that the value of this work is how it empowers team members to focus on the presence of safety. "We often speak about how safety is everyone's responsibility, but team members have historically told us that they don't feel they have the tools to take action," says Bellamy. "This Framework has given us the opportunity to co-create a tool to empower our frontline team to not only identify the potential for harm, but to work towards reducing or eliminating the harm. As a result, we are witnessing a shift in the culture of safety within our care home, and providing a safer environment for both our residents and team." Crystal Browne, Director Clinical Operations, Alberta Health Services – Area 4 (North Zone) says, "I think the biggest takeaway I have gained from this learning collaborative is that safety is not a 'project' with a defined beginning, middle and end. It's an ethos of constant inquiry at all levels of the organization as we try to answer the questions of is care safe today? and will it be safe tomorrow?" Virginia Flintoft, Anne MacLaurin, Wayne Miller and Alex Titeu are coaching the 11 teams from across the country participating in the MMS Safety Improvement Project, helping them to implement this new approach to measuring and monitoring of safety. For more information, visit 12/2/2019 7:00:00 AMBy Anne MacLaurin, Virginia Flintoft, Wayne Miller and Alex Titeu All healthcare leaders, providers, patients, and the public should12/2/2019 8:53:28 PM616
Educational modules available for hospitals and the public to support new mandatory reporting requirements4615812/2/2019 8:56:27 PMPatient Safety News<img alt="" src="/en/NewsAlerts/News/PublishingImages/News%20Feed%20Icons/Hospital%20Thumbnail.jpg?Width=140" width="140" style="BORDER&#58;0px solid;" /> Effective December 16, 2019, reporting of adverse drug reactions (ADRs) and medical device incidents (MDIs) within 30 calendar days of first documentation will be mandatory for all Canadian hospitals. The Protecting Canadians from Unsafe Drugs Act, also known as Vanessa's Law, is intended to increase drug and medical device safety in Canada by strengthening Health Canada's ability to collect information and to take quick and appropriate action when a serious health risk is identified. Four educational modules have been developed to support and raise awareness of mandatory reporting requirements. Available in PowerPoint and PDF formats, these presentations were developed collaboratively by Health Canada, Institute for Safe Medication Practices Canada (ISMP Canada), Health Standards Organization (HSO), and the Canadian Patient Safety Institute. The materials can be used as entire modules, individual slides or selected content for individual learning, or incorporated into presentations for information-sharing. The modules include Module 1 – Overview of Vanessa's Law and Reporting Requirements explains the purpose of Vanessa's law, describes the regulations for mandatory reporting of serious ADRs and MDIs by hospitals, and outlines the required data elements for mandatory reporting. Module 2 – Reporting Processes to Health Canada describes the expectations for mandatory reporting, provides samples of the forms for reporting and how to submit reports to Health Canada, and includes a number of case studies as examples. The module also includes a Guidance document for reporting and options for voluntary reporting. Module 3 - Strategies to Promote and Support Mandatory Reporting identifies potential barriers to serious ADR and MDI reporting, how to facilitate documentation and reporting, and outlines strategies to support implementation. Examples of various reporting systems in place are also included. Module 4 – Health Canada's Review and Communication of Safety Findings summarizes the importance of health product vigilance, the process that will be used to share information on ADR and MDI reporting, and how data will be secured and shared. All four modules can be accessed on the Canadian Patient Safety Institute website at https// Patients for Patient Safety Canada have also created a presentation to help patients and the public understand and promote the reporting of serious adverse drug reactions and medical device incidents. Click here Click here to download the presentation. For the purposes of mandatory reporting, a serious adverse drug reaction is defined as a noxious and unintended response to a drug that occurs at any dose and that requires in-patient hospitalization or prolongation of existing hospitalization, causes congenial malformation, results in persistent or significant disability or incapacity, is life threatening, or results in death. The mandatory reporting requirements for hospitals apply to therapeutic products, including Pharmaceuticals (prescription and non-prescription drugs), Biologic drugs (biotechnology products, fractionated blood products, plasma proteins and vaccines (excluding vaccines administered under a routine immunization program of a province or territory), Radiopharmaceutical drugs, Disinfectants, Medical devices, and Drugs for an urgent public health need. Mandatory reporting does not apply to natural health products, however reporting is encouraged. A medical device incident is an incident related to a failure of a medical device or a deterioration in its effectiveness, or any inadequacy in its labelling or its directions for use that has led to the death or a serious deterioration in the state of health or a patient, user, or other person, or could do so were it to recur. All classes of medical devises are included in mandatory reporting by hospitals, including those classified as Class I (lowest risk) to Class IV (highest risk). Examples are Class I – Hospital beds, wheelchairs, leg prostheses, Class II – infusion sets, syringes, tracheostomy tubes, urethral catheters, Class III – infusion pumps anesthesia gas machines, intrauterine devices, and Class IV – pacemakers, defibrillators, breast implants, bone grafts. More information on mandatory reporting is available on the Health Canada website. 12/2/2019 7:00:00 AMEffective December 16, 2019, reporting of adverse drug reactions (ADRs) and medical device incidents (MDIs) within 30 calendar days of first12/2/2019 9:48:05 PM596
Patient Safety Power Play: Thank you for helping us #ConquerSilence7084511/25/2019 8:33:57 PMPatient Safety Power Plays<img alt="" src="/en/NewsAlerts/News/PublishingImages/News%20Feed%20Icons/Chris%20Power%202016.jpg?Width=140" width="140" style="BORDER&#58;0px solid;" /> This year, I have discussed our new public engagement campaigns several times since our mandate at the Canadian Patient Safety Institute is evolving. We continue to research and supply healthcare organizations with effective patient safety tools; we still encourage strong patient safety policy for leaders; and now we also focus on connecting with the public and patients about this silent epidemic – and what we can all do to keep ourselves safe. We have had some wonderful successes in our efforts to connect. Over the past few months, we have organized four round table meetings with provincial Ministers and Deputy Ministers of Health. Hosted by members of Patients for Patient Safety Canada, we have meet in Winnipeg, St. John’s, Halifax and Fredericton to give local patient partners the opportunity to tell their stories of harm and to ask that provincial governments commit to making care safer. Safer care has certainly caught the public’s attention. On November 6, the Canadian Institute for Health Information released a biannual comparison of healthcare performance among over 30 first-world nations. Compared with other countries, Canada does a good job of documenting, reporting, and acting on patient safety issues. However, we still have much room for improvement, since the report stated that not only are patients twice as likely to experience tears during childbirth and develop lung clots after hip and knee surgery, but that Canada also reported the highest number of items left behind inside patients after surgery. In response to media requests, CPSI highlighted that the public doesn’t know much about patient safety incidents. We called for a higher commitment to safer care, not by placing blame, but instead by inviting everyone concerned to learn about healthcare harm and make it a priority. We have to work together to identify the patient safety gaps, share ways to resolve them, and establish a patient safety culture in Canada. The messages we shared in response to the report were similar to those declared during this year’s Canadian Patient Safety Week. We launched our #ConquerSilence campaign to improve communication in the healthcare system to help reduce preventable patient harm in Canada. We engaged both new and existing audiences, built partnerships founded on patient safety, and heard from many people about the popularity of #ConquerSilence. This popularity assured us that we are headed in the right direction, as #ConquerSilence did not end with Canadian Patient Safety Week it is also our first long-term public engagement campaign. We built a platform that will stand against silence and build momentum over time. We will continue to encourage members of the public, healthcare providers, and healthcare leaders to anonymously record and listen to stories and advice about preventable harm at #ConquerSilence will feature different patient safety issues throughout the year, plus offer resources to help the public and healthcare providers battle systemic silence. The first issue we are tackling is medication safety, featuring materials on how to speak up when issues arise with medications. Other issues we will tackle through the campaign will include misdiagnoses and miscommunication, traumas, infections, pressure wounds, and deteriorating patient condition. I am thrilled that you have joined us to keep making safe healthcare a priority. Questions? Comments? My inbox is open to you anytime at, and you can follow me on Twitter @ChrisPowerCPSI. Yours in patient safety, Chris Power 11/25/2019 7:00:00 AMThis year, I have discussed our new public engagement campaigns several times since our mandate at the Canadian Patient Safety Institute is evolving.11/25/2019 8:52:20 PM309
#SuperSHIFTER Janet Bradshaw helps to ensure the patient voice is heard7066011/19/2019 9:33:49 PMSuper SHIFTERS<img alt="" src="/en/NewsAlerts/News/PublishingImages/2019/Abisaac%20and%20Janet.jpg?Width=140" width="140" style="BORDER&#58;0px solid;" /> #SuperSHIFTER Janet Bradshaw is the Project Coordinator supporting the work of Patients for Patient Safety Canada, a patient-led program of the Canadian Patient Safety Institute. Respectfully referred to as Mama Bear by her colleagues, Janet's passion, empathy, and creativity is what drives her to ensure the patient voice is heard in healthcare. What can you tell us about your role at the Canadian Patient Safety Institute? ​ ​Janet Bradshaw (right) with Abisaac Saraga at a Patients for Patient Safety Canada meeting As a Project Coordinator, I have the privilege of supporting the Patients for Patient Safety Canada program; that is the major part of my job. When a request comes in for patient involvement, I match the patient members with the engagement opportunities to advance patient safety. Last year, there were over 100 requests for patient volunteers to support patient safety and quality work. I support the Patients for Patient Safety Canada co-chairs and build relationships with all the volunteers. I am also fortunate to coordinate the in-person meetings for Patients for Patient Safety Canada. What does a typical day look like for you? Generally, there is no typical day. At the moment, a lot of my time is spent on planning and arranging logistics for the next Patients for Patient Safety Canada in-person meeting taking place in November. I try and go above and beyond to bring a little extra to the table to let the patient members know how much they are appreciated. In my spare time, I am always busy creating something. I do a lot of crafts and enjoy knitting and crocheting. In the past, I have made flower and maple leaf lapel pins as a way to give a little piece of myself to the patient members to take home with them. This year, I am making poppies for everyone as I feel it is an important way to honour the hours of volunteer time that the patient members have given to us. What do you like most about working at the Canadian Patient Safety Institute? The organization is so supportive and a great place to work. They ensure we have the skills that we need to do our job and that we are comfortable in our position. I enjoy the people that I work with. We are a small team that does very important work and I feel we are making a difference. There is always a lot happening and everyone is so passionate about what they do. We are not here solely for the job; we are here because we believe in what we do. Everyone cares so much and wants to make the healthcare system safer. What I enjoy most about my job is the interaction with patients and hearing their stories. Their stories are so touching and truly help to spread the word about the importance of patient involvement to advance safe care. Those stories inspire me too. What are your hidden talents? I am positive and look for the good in every situation. I like to bring people together and am always looking for ways to help people work together. There is the Mama Bear side of me that is nurturing, and shows a lot of empathy and patience. What is your proudest moment with the Canadian Patient Safety Institute? I get a lot of fulfillment in doing a good job, keeping that spark alive and igniting the passion of the patient members in telling their stories. Every time I watch one of the patient videos, I am proud of the role that I played behind the scenes to help patients to share their experiences and make a difference to other patients and to the healthcare system. With the launch of #ConquerSilence, the patient voice is one of the most important voices of this campaign. I have been working with the patients that are so brave in sharing their stories. Those stories are so powerful and help to get the message out. I am proud that I have been able to lift them up and help them to find their voice and do their part in making the campaign successful. What are your hopes for patient safety? Family is very important to me. I have a large family, five children and seven grandchildren. I do the job that I do to ensure that they are safe too. In the next five years, I would like to see the healthcare system get safer and the public become more aware of the magnitude of the problem so that they can be vigilant and keep themselves safe. Janet is celebrating her 5th Anniversary with the Canadian Patient Safety Institute. To learn more about her work with Patients for Patient Safety Canada, email Janet at 11/19/2019 9:00:00 PM#SuperSHIFTER Janet Bradshaw is the Project Coordinator supporting the work of Patients for Patient Safety Canada, a patient-led program of the11/25/2019 3:47:11 PM1247