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Nova Scotia Health Authority implements the Patient Safety Culture Bundle to help provide safe, reliable and effective quality care779813/24/2020 8:47:58 PMSuper SHIFTERS<img alt="" src="/en/NewsAlerts/News/PublishingImages/2020/Gail%20Blackmore.jpg?Width=140" width="140" style="BORDER&#58;0px solid;" /> #SuperSHIFTER Gail Blackmore is the Senior Director of Quality Improvement and Safety with Nova Scotia Health Authority (NSHA). NSHA has adopted the Patient Safety Culture Bundle for CEOs and Senior Leaders to develop a positive patient safety and quality culture strategy and is implementing a dashboard to monitor their culture of quality and patient safety. Why did Nova Scotia Health Authority choose the Patient Safety Culture Bundle to support its patient safety and quality improvement work? Our patient safety and culture strategy framework is modeled from the Canadian Patient Safety Institute's Patient Safety Culture Bundle for CEOs and Senior Leaders (Bundle). The Bundle is a good match for us. It provides clarity and direction to healthcare leaders on the components involved in providing safe, reliable and effective care. The vital practices that are embedded into the Bundle are evidence-based and this is important from our perspective. We are committed to fostering existing practices and identify and implement new approaches, and the Bundle presents a way to do that. The Bundle has three key elements – Enabling, Enacting and Learning – and actions to focus on in each of the elements that cover the key concepts of patient safety. There are also additional resources available, if you want to learn more about the key concepts. The Bundle is very comprehensive. It really acknowledges that there are multiple inputs and complexity in a safety culture for healthcare. Can you provide examples of how the Bundle has helped to better align your work? Since the activities noted in the Bundle are based on best practices and are found to have a positive impact on improving patient safety culture, it facilitated alignment of internal activities to focus our actions. Examples include patient stories, which are now being used across the organization to begin team meetings, start a discussion on quality and safety, and refocus the work on the experience of the patient and family. Through the Bundle, we have also been able to do a deeper dive into just culture and expand the use of safety huddles and leadership safety rounds. A partnership with NHS Scotland/Education for Scotland to pilot safety culture discussion cards for healthcare teams, educators and leaders was highlighted at the 2019 Institute for Healthcare Improvement (IHI) National Forum on Quality Improvement in Health Care through a poster presentation by Erin Beaton, a Quality Director in our team. Safety Huddles were confirmed as an organizational priority to create system-wide and patient-specific changes and to support teamwork. An established working group continues to augment NSHA resources and processes to support Safety Huddles and evaluate their effectiveness. Reinforcing the goal of improving patient safety culture, Leadership Safety Rounds were additionally noted as an organizational priority initiative. The expansion of this practice has demonstrated Leadership commitment to building a culture of safety. The role of our patient and family advisors (PFAs) has also evolved – we have created a focused system to recruit and retain advisors, and to nurture meaningful engagement. PFAs are now an integral part of the decision-making working group for disclosure. They participate fully in this process, bring the patient and family perspective and are an equal voting member to determine recommendations from the working group. Patients and families are also involved in prospective reviews, as full members of the system-wide Failure Mode and Effects Analysis (FMEA) review team, with leaders, physicians and staff. This work in patient engagement is recognized as leading practices with the Health Standards Organization (HSO). Can you tell us about the dashboard you have developed to monitor and evaluate your quality and patient safety culture? The quality improvement and safety team and the performance and analytics team collaborated to develop the dashboard concept. The intention was to bring data from various sources together in a single location and provide NSHA with a user friendly, simple, yet comprehensive visual on important patient safety culture information that can be used to examine and understand performance at the organizational and zone levels. An Excel spreadsheet outlines the three Bundle elements and their associated evidence-based practices, along with selected indicators and the most current data. Aligned indicators were chosen from existing HSO and Accreditation Canada surveys, such as the patient safety culture, workplace and governance survey tools. A question from the Canadian Patient Experiences survey, an in-patient survey provided by the Canadian Institute for Health Information (CIHI), was selected to track patient engagement. Where existing Accreditation survey questions could not be aligned, we looked to internal processes and data already being collected to identify measurable indicators for each element of the Bundle. Examples include data reported within the organization's Safety Improvement and Management System (SIMS) and from monitoring patient and family advisor engagement on quality improvement and safety teams. The number of indicators per key concept was kept to a minimum, however in certain cases we did find it useful to map more than one question to a concept because it allowed a greater depth of information for those really complex areas, like just culture as an example. With the data organized in a visual way, it's a lot easier to analyze and translate data for action. To further ease analyzing a large amount of data points, colour-code formulas have been built in, similar to the red, yellow, green flag color scheme used in the accreditation surveys. The color coded flags provide a good visual of where we are doing well and where the opportunities for improvement are as it quickly brings important information together in a comprehensive way. We are still in early days of using the dashboard and the Bundle to look at our actions. We continue to seek opportunities to learn more from each other within our health system, through evidence-based tools like the Bundle, and by continuing to spread best practices. It takes perseverance, but we can do more together from that perspective. Can others replicate this evaluation process? Yes. The Bundle can be used to align and develop organizational frameworks. The dashboard indicators were chosen from existing HSO and accreditation tools wherever possible, so that is quite transferrable to other organizations. Indicators that did not map to an existing survey or tool were aligned to organizational priorities, and others would be able to do that as well. To learn more about the dashboard, contact Gail.Blackmore@nshealth.ca. 3/24/2020 8:00:00 PM#SuperSHIFTER Gail Blackmore is the Senior Director of Quality Improvement and Safety with Nova Scotia Health Authority (NSHA). NSHA has adopted the3/24/2020 9:00:00 PM194https://www.patientsafetyinstitute.ca/en/NewsAlerts/News/Pages/Forms/AllItems.aspxhtmlFalseaspx
CPSI signs agreement advancing First Nations health priorities687443/18/2020 8:22:05 PMPatient Safety News<img alt="" src="/en/NewsAlerts/News/PublishingImages/2020/Partnership%20Agreement%20Photo%20-%20advancing%20First%20Nations%20health%20priorities.JPG?Width=140" width="140" style="BORDER&#58;0px solid;" />​ ​(Left to right) Marion Crowe, Executive Director, FNHMA; Maryanne D’Arpino, Senior Director, Canadian Patient Safety Institute; and Patricia Thomson, President, FNHMA ​ The Canadian Patient Safety Institute and the First Nations Health Managers Association (FNHMA) have signed a memorandum of understanding (MOU) to work together to advance First Nations health. The MOU pledges shared interests in client/patient safety, health system improvement and capacity development for First Nations leaders and communities, and ultimately working toward reconciliation for First Nations health. "This is an exciting juncture for both the FNHMA and the Canadian Patient Safety Institute," says Marion Crowe, Chief Executive Officer, FNHMA. On behalf of the FNHMA Board of Directors, we are thrilled to be moving forward on this partnership agreement and see it as a very fruitful, reciprocal relationship where we are working together toward health equity and accessibility for First Nations." "We are truly inspired by and grateful for this opportunity to work in partnership, to take this journey with the FNHMA to advance patient safety and quality in First Nations communities," says Maryanne D'Arpino, Senior Director, Canadian Patient Safety Institute. "This partnership is about gaining a better understanding of how patient safety is defined and what that means to the Indigenous population. It is a very collaborative, open relationship where we can learn from each other in a patient safety context." As the partners see opportunity and agree on joint activities, an annual work plan will be developed. The partnership will address collaboration and cooperation in three key areas Information sharing and capacity development initiatives to develop and deliver information, knowledge, training and development services that reduces the harm experienced by people and increases the presence of safety for the benefit of people served by both organizations; Health system initiatives to enhance relationships between First Nations communities; and Health leadership initiatives to support continued development of leaders in First Nations health and to foster shared learnings of health system leaders across Canada. "There are some great synergies and opportunities between our organizations to build capacity with the goal of preventing harm," says Maryanne D'Arpino. "For example, we can draw from lessons through our partnership with Indigenous Services Canada in building capacity in incident management for healthcare professionals working in communities across Canada. Building on this momentum, we will better understand how the patient safety competencies can be translated and integrated within health professional training and education. Our opportunity to partner with Indigenous patients and listen to their advice guides our true north," Maryanne continues. "Patients for Patient Safety Canada, a patient-led program of the Canadian Patient Safety Institute, recently welcomed Samaria Cardinal as a new member. Samaria's story is a way to bring awareness as we begin to shape and define what patient safety means to Indigenous people. Patient safety and patient engagement need to be synonymous, and this will be foundational to our journey in improving patient safety." "These are the types of synergies that we hope to unpack through this partnership agreement," says Marion Crowe. "Overall, working with the team at the Canadian Patient Safety Institute will open up opportunities in patient safety that our communities may not have engaged in before. Anything that is grounded in patient safety will ultimately benefit and enhance our service delivery." FNHMA provides training, certification, and professional development opportunities in First Nations health management and serves the needs of individuals working for, or aspiring to, health manager positions with First Nations organizations. Each year, some 350 individuals are trained as Certified First Nations Health Managers (CFNHM), including non-Indigenous partners of the First Nation community (such as representatives from Regional Health Authorities). "Our curriculum is grounded in community and culture and it is always a valuable experience for our non-Indigenous allies to attend our program," says Marion Crowe. "It gives us an opportunity to learn from one another and to showcase what we have worked on for the past 10 years as an organization." Currently, there are 225 CFNHMs working in First Nations communities from coast to coast. Health managers serve in an administrative capacity in the delivery of health services to their First Nation communities, much like the role of a CEO in a traditional hospital setting. They are responsible to their funders, community and the general population of the membership on the reserves. The FNHMA provides leadership in First Nation health management activities by developing and promoting knowledge, quality standards, practices, research, certification, networking and professional development to expand capacity for its members and First Nations communities. "The pen I am holding was a gift, used as a tool to pledge our public commitment and to bind our agreement," says Maryanne D'Arpino as she prepares to sign the MOU on behalf of CPSI. "It symbolizes the culture that FNHMA creates as a mark of true leadership and comradery. The pen is made of maple, which is a symbol of strength. Maple bark is used as a medicinal herb and the Rocky Mountain Maple is considered one of the Sacred Life medicines. This gift holds special meaning as a symbol of strength and solidarity as partners. Thank you, Marion, Patricia and the FNHMA!" 3/18/2020 8:00:00 PM (Left to right) Marion Crowe, Executive Director, FNHMA; Maryanne D’Arpino, Senior Director, Canadian Patient Safety Institute; and Patricia3/18/2020 8:49:32 PM154https://www.patientsafetyinstitute.ca/en/NewsAlerts/News/Pages/Forms/AllItems.aspxhtmlFalseaspx
Progress with the Policy, Legal and Regulatory Affairs Advisory Committee5753/6/2020 10:18:00 PMPatient Safety News<img alt="" src="/en/NewsAlerts/News/PublishingImages/2020/PLRA%20Committee%20with%20Guests%20Dr.%20Chris%20Hacker,%20Harry%20Cayton%20and%20Greg%20Lamonthe.jpg?Width=140" width="140" style="BORDER&#58;0px solid;" /> ​On February 11 and 12, 2020 the Policy, Legal and Regulatory Affairs Advisory Committee (PLRA) met in person in wonderful, spring-like Vancouver. The committee is mandated to provide strategic advice that enables CPSI to influence patient safety issues and directions as they relate to federal, provincial, and territorial health priorities and policy, health law and legislation, and regulatory systems and processes. Membership of the inter-professional committee consists of experts with health care leadership and policy experience from across Canada, including representation from Patients for Patient Safety Canada, government, legal and policy expertise, and regulatory bodies. Rob Attwell, cofounder and COO of Careteam, led the committee on a tour of the Careteam Dev Hub during the afternoon of the 11th. That evening Dr. Alexandra Greenhill, CEO of the Careteam, presented on Artificial Intelligence (AI) in support of patient safety and quality. Discussion followed the fascinating presentation regarding AI, its uses, and issues to be considered for the future. The PLRA then participated in a full day meeting on February 12th to provide guidance on current and emerging issues in a policy context. Special guests Dr. Chris Hacker, Registrar/CEO of the College of Dental Surgeons (CDS) of BC, and Mr. Harry Cayton, International Advisor to the Professional Standards Authority, provided details about the recommended overhaul of CDS regulations and changes to the BC Health Professions Act to prioritize patient safety as mandated by the provincial government. Mr. Cayton also provided a presentation on how regulations can inform and improve patient safety. The day concluded with an interactive exercise that centered on the CPSI Policy Framework’s five policy levers. CPSI developed a conceptual model to identify, implement and evaluate policy levers that would improve patient safety legislation, regulations, standards, organizational policies and public engagement. The PLRA Committee reviewed initiatives advancing each of the policy levers to advise on priorities, potential roadblocks, and ways to overcome the roadblocks. Moving the needle on patient safety in Canada requires an overall shift in culture, values and expectations at all levels of the health system and the active engagement of various policy actors. Patient safety does not just depend on specific improvement efforts, practices and rules, but on achieving a culture of trust, reporting, transparency and discipline across the healthcare system. What will be key to the effectiveness of the policy levers, such as legislation and public awareness, is the ongoing evaluation of policies and mechanisms for knowledge exchange. CPSI published this new policy framework in November 2019 click here to learn more. 3/6/2020 10:00:00 PM On February 11 and 12, 2020 the Policy, Legal and Regulatory Affairs Advisory Committee (PLRA) met in person in wonderful, spring-like Vancouver. 3/11/2020 7:35:05 PM248https://www.patientsafetyinstitute.ca/en/NewsAlerts/News/Pages/Forms/AllItems.aspxhtmlFalseaspx
Patient Safety Power Play: On the coronavirus, clean hands, and collaboration28713/5/2020 7:04:43 PMPatient Safety Power Plays<img alt="" src="/en/NewsAlerts/News/PublishingImages/Chris%20Power.jpg?Width=140" width="140" style="BORDER&#58;0px solid;" /> Since the beginning of the COVID-19 outbreak, more and more countries – including Canada – are reporting cases. Localized and even internationally coordinated efforts to stop the spread of the disease may not be enough to prevent a global outbreak of coronavirus.1 While the risk to Canadians is still low, it is important to be prepared at the individual and community levels for all possible scenarios. The Canadian Patient Safety Institute has a serious responsibility to respond to this potential pandemic. As part of our role in helping to keep the people of Canada safe within our healthcare system, we must perform two tasks and perform them well We must reach out through our networks of healthcare system partners and social media followers to share information about how people can keep safe. We must rely on only the highest-quality information on how to stay safe in order to counter the spread of misinformation. Fortunately, CPSI is well placed to accomplish the first task. Not only have we spent years building connections within the healthcare industry, but our recent focus on public engagement through the #ConquerSilence campaign has resulted in a much higher public profile. In addition, we have partnered with the World Health Organization (WHO) in the areas of infection prevention and control as well as in patient engagement.The outcome of these efforts can be best seen in STOP! Clean Your Hands Day, the Canadian aspect of the WHO's global "Clean Hands Save Lives" campaign that runs every May 5th. We have been delivering this event for 13 years. We know that one of the most effective ways to contain the spread of infections – including the flu, healthcare-acquired infections, and the coronavirus – is to clean your hands, and we are ideally positioned to share that message.You can help. You can register for STOP! Clean Your Hands Day so that you receive updated information about the campaign and information about infection prevention activities happening in Canada that day. You can also share effective messages like this on social media, to reinforce the importance of clean hands for safe care.Our second task could be more difficult for our small organization to research by ourselves. However, we know exactly where to turn. You can find the most accurate, updated information about the COVID-19 outbreak on Health Canada's website. The site includes cases identified in Canada, as well as prevention, symptoms and treatment, and advice for travellers. To draw on only one example, I focused on what each of us can do as individuals to stop the spread of infection. The website complied with excellent, common-sense instructions such as Stay home if you are sick. Encourage those you know are sick to stay home until they no longer have symptoms. Respiratory viruses are spread through contact. Change your regular greeting from handshakes, hugs and kisses to a friendly wave or elbow bump. Practice frequent hand hygiene and coughing/sneezing etiquette. Clean and disinfect frequently touched objects and surfaces, such as toys and doorknobs. As you can see, the site offers practical solutions as well as information on the disease that is based on scientific fact from healthcare research. You will not find colloidal silver or sesame oil "cures" here. In order to mitigate the impact of the coronavirus, everyone has a role to play. CPSI will continue to reach out through our vast partner networks to share only the best information to keep people safe. I thank you so much for your help in our efforts. My inbox is open to you anytime at cpower@cpsi-icsp.ca, and you can follow me on Twitter @ChrisPowerCPSI. Yours in patient safety, Chris Power 1 Health Canada, Coronavirus disease (COVID-19) Being prepared https//www.canada.ca/en/public-health/services/diseases/2019-novel-coronavirus-infection/being-prepared.html 3/5/2020 7:00:00 PMSince the beginning of the COVID-19 outbreak, more and more countries – including Canada – are reporting cases. Localized and even internationally3/5/2020 8:39:20 PM611https://www.patientsafetyinstitute.ca/en/NewsAlerts/News/Pages/Forms/AllItems.aspxhtmlFalseaspx
CPSI and PFPSC shine in global expert meeting28753/5/2020 6:25:11 PMPatient Safety News<img alt="" src="/en/NewsAlerts/News/PublishingImages/2020/Sandi%20and%20Ioana.jpg?Width=140" width="140" style="BORDER&#58;0px solid;" /> In May 2019, the 72nd World Health Assembly adopted resolution WHA72.6 “Global Action on Patient Safety” recognizing patient safety as a key global health priority. This was a watershed moment for patient safety around the world… It is truly time for Patient Safety Right Now! The resolution established World Patient Safety Day to be observed annually on September 17th and Canada rose to the challenge with our celebration! Amongst several key actions, the resolution requests that the WHO Director-General to formulate a global patient safety action plan by May 2021 and report on its progress every two years at the World Health Assembly. ​ ​Sandi Kossey and Ioana Popescu at the World Health Organization headquarters in Geneva To begin formulating this Global Patient Safety Action Plan, WHO brought together global experts, stakeholders and partners for three days in Geneva, Switzerland. As a revered national and global authority on patient safety improvement and as a WHO Collaborating Centre on Patient Safety and Patient Engagement, the Canadian Patient Safety Institute (CPSI) was a critical contributor to the meeting. Sandi Kossey, Senior Director of Strategic Partnerships & Priorities, and Ioana Popescu, Senior Program Manager, joined other experts, advisors, researchers, academicians and representatives from all WHO Regions and Headquarters. More than 45 countries, 20 international organizations and associations, economic organizations, foundations and patient groups were represented, including members of the Patients for Patient Safety Advisory Group and Global Network which CPSI supports through its WHO Collaborating Centre Terms of Reference. During the meeting, which was chaired by Sir Liam Donaldson with support from Ed Kelly and Neelam Dhingra, CPSI’s longstanding global leadership on patient partnership through its support to Patients for Patient Safety Canada was regarded as a gold standard which should be emulated and spread around the world via the action plan. Our successes with the Integrated Action Plan, the Conquer Silence Campaign, the Patient Alliance for Patient Safety, and the many foundational patient safety and patient engagement frameworks and resources were highlighted as potential contributors to the plan. The Global Patient Safety Action Plan is a commitment of WHO, international health agencies and Member States to definitive action to reduce the overall burden of patient harm due to unsafe care and will be based on the guiding principles of equity, sustainability and accountability. The action plan will seek inspiration from and coherence with other global priorities and patient safety challenges. It will be strategically positioned to advance WHO’s work to achieve Universal Health Coverage and is aligned with the United Nations’ Sustainable Developmental Goals. The plan will be a roadmap for “A Decade of Patient Safety 2020-2030” as a WHO Flagship Initiative. ​ ​ In the Executive Board Room of the World Health Organization headquarters in Geneva, experts from 40 countries set the foundation for “A Decade of Patient Safety 2020-2030 Formulating the Global Patient Safety Action Plan”. Patient safety is finally being given the attention and priority it deserves. Canada should be proud of our commitment and successes so far, and of our global leadership in patient safety and patient engagement, and we should be inspired to join the global community in making care as safe as possible, as soon as possible. By the end of the decade, in 2030, we believe Canada and the world will have much to celebrate. A PFPSC patient partner noted once that “the knowledge and energy within those who have experienced harm is like Niagara Falls before they were harnessed to produce the great social benefits that they have for so many years. There exists no more powerful experience than this to provide motivation to have something good come of something tragic – to honour the loved one that we have lost and to prevent others from suffering similar harm”. The global patient safety action plan, “A Decade of Patient Safety 2020-2030” is set to harness the power of patients, providers and leaders from around the world to create visible and sustained patient safety improvement. We can only do this with you. Reach out to Patients for Patient Safety Canada at patients@cpsi-icsp.ca 3/5/2020 6:00:00 PMIn May 2019, the 72nd World Health Assembly adopted resolution WHA72.6 “Global Action on Patient Safety ” recognizing patient safety as a key3/5/2020 10:03:12 PM377https://www.patientsafetyinstitute.ca/en/NewsAlerts/News/Pages/Forms/AllItems.aspxhtmlFalseaspx
Canadian Foundation for Healthcare Improvement and Canadian Patient Safety Institute Pursue Amalgamation757352/20/2020 6:49:27 PMPatient Safety News Recognizing the tremendous opportunity to achieve safer, higher quality, more efficient, coordinated and patient-partnered healthcare, the Canadian Patient Safety Institute (CPSI) and the Canadian Foundation for Healthcare Improvement (CFHI) are pursuing an amalgamation that would create a single quality and safety organization with an expanded capacity to improve healthcare for everyone in Canada. CPSI and CFHI have complementary mandates and goals as pan-Canadian quality and safety improvement organizations, as well as shared stakeholders. Our organizations bring unique knowledge, approaches, and assets to the table. "This is the beginning of the next chapter for patient safety in Canada, one where we build on the achievements of the Canadian Patient Safety Institute to turn the page on preventable harm in healthcare," said Chris Power, CEO, CPSI. "By coming together, our organizations can achieve even greater improvements in safety and quality." The organizations are jointly undertaking additional due diligence and engagement with key stakeholders. A transition Board of Directors for the amalgamated organization is being appointed and a CEO-selection process will take place. In the coming months, both organizations will hold separate member meetings to vote on the decision. "We are excited about the opportunity to create a robust pan-Canadian quality and safety improvement organization that expands our capacity to be a valued partner in shaping the future of healthcare in Canada," said Jennifer Zelmer, President and CEO, CFHI. "Over the coming months, we look forward to engaging with stakeholders across the country and building an organization that delivers lasting improvement for more people." The amalgamated organization would build on CFHI's and CPSI's responsiveness to the needs of federal, provincial and territorial governments and other health system stakeholders. As we proceed down the path to amalgamation, we remain committed to our existing partnerships and to seeing through our partnership agreements. We will continue to provide updates as we move forward with amalgamation. We are excited about the opportunity to combine our efforts towards better care, working with and for more people across Canada. 2/20/2020 8:00:00 PMRecognizing the tremendous opportunity to achieve safer, higher quality, more efficient, coordinated and patient-partnered healthcare, the Canadian2/20/2020 8:01:18 PM1234https://www.patientsafetyinstitute.ca/en/NewsAlerts/News/Pages/Forms/AllItems.aspxhtmlFalseaspx
#SHIFTTALKS: Overcoming an unconscious bias in patient care336462/19/2020 10:54:32 PMSHIFT Talks<img alt="" src="/en/NewsAlerts/News/PublishingImages/2020/Changs.jpg?Width=140" width="140" style="BORDER&#58;0px solid;" /> By Eileen Chang It was midnight over twenty years ago; the nurse brought my crying newborn son, Daniel, to my hospital room so that I could breastfeed. As the nurse handed Daniel to me and left the room, he stopped crying. I whispered to him, "It's just you and me, kid." Little did I realize that those words would echo the lonely journey we would experience through the healthcare system many years later. Growing up, Daniel always challenged himself; he performed well in academics, and excelled in various individual and team sports. He was emotionally mature for his age and defended the 'underdog'. Unfortunately, when it came to navigating the healthcare system, he was treated with an "unconscious bias" from the start. A couple of months after a high school camping trip, he experienced ongoing nausea and gastrointestinal symptoms for several weeks. He was told by his physician that "growth hormones" were affecting him. The prescribed antacids did not seem to help. After finally convincing the physician to order fecal testing, I received a letter from the City querying the origin of Daniel's drinking water. He had tested positive for a fresh water parasite, Giardia lamblia. Daniel told me years later that during the camping trip, he had unknowingly drank untreated water from a canister that was erroneously labeled. After his first year of university, Daniel was preparing for a trip to South America for summer work in an orphanage. He received a series of travel vaccines, one of which included a live vaccine. His whole body seemed to 'short-circuit' and crash. Over the course of a few years, his varying and multiple symptoms worsened and he later suffered severe and debilitating pain. Unfortunately all the 'routine' diagnostic tests did not produce any positive findings for a diagnosis, nor a referral to a specialist. Many healthcare providers tended to compartmentalize his symptoms to come up with a diagnosis. It was only after a false positive on an immunoglobulin test that he was finally referred to an immunologist. I happened to stumble upon a health journal article describing a disease listing the exact symptoms Daniel was experiencing. We had a year-long wait list to see other specialists. After much perseverance and through vigorous assessment, Daniel was diagnosed with Myalgic Encephalomyelitis (ME). Even though we finally had a 'name' to this disease, the medical management of his disease was not done in a collective and consultative manner. Often Daniel felt 'mocked' even though he was able to clearly articulate his symptoms with the physicians and other healthcare providers, and identify key factors which would cause those symptoms to flare up. Daniel and I both knew we had to take complete ownership of his treatment plan, as we continued to encounter more gaps with his care. We assembled and summarized all test results and medical notes to ensure that physician visits were meaningful, productive and efficient. Daniel requested a psychological referral as he had read up on ME and knew there was no known testing or cure. His first request was denied. He started taking matters into his own hands, by producing and posting four ME videos on social media, attending support groups where others had ME, and joining the ME Association. We sought alternative types of therapy/treatment. He tried to ease his physical pain by meditating, and through massage therapy, acupuncture, chiropractic treatment and yoga. Daniel started journaling and charting his symptoms, activities and medication. He scored his energy and pain levels every hour of every day. We wanted to have data to help the health professionals help him! As a healthcare leader, I am all too familiar with the challenges and complexities healthcare providers face, coupled with existing gaps in systems and processes, and reduced resources. With over 25 years of combined clinical and progressive leadership experience in major academic, research and teaching hospitals, followed by over a decade of a focus on patient safety, I am not a stranger in navigating through the healthcare system. I know the importance of teamwork, critical thinking and respectful communication. I know that teamwork also includes the patients and their families or caregivers. Hospitals are currently scrambling to become high reliability organizations (HROs). One of the key attributes of HROs is "deference to expertise". That expertise also rests with the patient. In healthcare, we all need to raise the bar – not just "give' patients and their families or caregivers a voice. We need to raise their voices so that they can truly work as a team with the healthcare practitioners to provide the best quality of care possible. There may not be evidence-based solutions for diseases that do not have a present-day cure; however, we must also consider the value of "experience-based". Critical thinking in the clinical setting needs to be coupled with collective mindfulness – with the patient and family/caregiver – so that we can all inform and engage with each other. Much of the learnings in my role as a patient safety leader come from working with multidisciplinary teams, especially when facilitating quality of care reviews, where contributing factors that lead to negative outcomes in the patient's care are identified. The identification of gaps in systems and processes that lead to recommendations are paramount in ensuring that system improvements and learnings are spread to mitigate any further risk to other patients. The patient's or family/caregiver's input to those recommendations is also key in ensuring optimal quality of care and patient experience. Eileen Chang is a member of Patients for Patient Safety Canada. She hopes to leverage the learnings from her son's experience and her work experience to truly improve team collaboration at all levels of healthcare.2/19/2020 10:00:00 PMBy Eileen Chang It was midnight over twenty years ago; the nurse brought my crying newborn son, Daniel, to my hospital room so that I could2/28/2020 8:57:23 PM1443https://www.patientsafetyinstitute.ca/en/NewsAlerts/News/Pages/Forms/AllItems.aspxhtmlFalseaspx
#SuperSHIFTER Betty Scharf: Reflections on nursing then and now87622/7/2020 9:16:10 PMSuper SHIFTERS<img alt="Betty Scharf" src="/en/NewsAlerts/News/PublishingImages/2020/Betty%20Scharf.jpg" width="143" style="BORDER&#58;0px solid;" /> A graduate of the Misericordia Hospital School of Nursing, Betty Scharf recently celebrated 60 years as a nurse. Of the 24 students in the class of 1959, six graduates attended the reunion to reminisce and brought their daughters along to hear their stories. The 84-year old Edmontonian shares her thoughts on what is was like to be a nurse and provides some sage advice for patients today. Tell us about your nursing career. When I graduated from a two-year nursing program in 1959, I initially worked as an Emergency Room (ER) nurse, and was occasionally called on to be a ward nurse at the Misericordia Hospital in Edmonton. I then worked at a doctor's office, where I did blood pressure tests, gave allergy shots and the like. After that, I worked at the old Sturgeon Hospital in St. Albert, again as both an ER and ward nurse. When the hospital moved to 12-hour shifts, I had to leave as I had a young family and it was difficult working those long hours. I moved to the Medi-Center walk-in clinics and was the Head Nurse there for almost 20 years. What challenges did you face in your early years of nursing? When working on wards and even in emergency, the nurse was responsible for the sole care of the patient. We provided more of what I call total care. From daily changing of bedding; three backrubs per patient per day; bathing patients daily, or as called for; distributing and assisting with all meals and medications; and moving patients to the operating room, or from room to room. There were orderlies in those days, but they were mostly assigned to the men's wards to assist with bathing or the occasional bed move. (Betty Scharf (left) with her daughter Charlene at the reunion) Nurses did two rounds per day, assessing their patients and recording the results on paper after each round – there were no computers then. Checks were frequent to ensure patients were doing okay and that the equipment was functioning – we did not have the bells and whistles to alert you to any problems or if the patient was in distress. During the day you could call on another nurse to help if they were available, but at night, there was only one nurse assigned to a ward of 30 to 35 patients. Needless to say, some nights were a bit crazy, especially when you had wanderers or patients with special needs. I remember one gentleman who possibly had PTSD from the Second World War. He would hide under his bed and you had to figure out how to get him back to bed. When I worked in Emergency in the 60s and early 70s, there were two to three nurses per shift during the day, and only one or two at night. During the night shift, the doctors were on call. This meant the nurses had to triage and keep the patient stable until the doctor arrived. If the injuries were really serious, you could try and grab a doctor from the floor. Mostly, you had to rely on your training, past experience, and gut instinct. How would you compare your days of nursing to the nursing today? There are more teams now. I like how the role of the Licensed Practical Nurse (LPN) has evolved and their connection with the patient. The equipment is amazing and that makes it much easier to keep a watch on patients and monitor their progress. There seems to be a different kind of busyness today. There are so many different people coming and going. The staff are doing more with less. There is no real time to establish a patient/caregiver relationship, or have real communication or face time with any of the team. The relationship element is vital for the patient, both physically and mentally. Chats and time for real observation of a patient can tell a caregiver far more than what a machine will tell you. What did you learn from nursing that you are most proud of? I would say my ability to engage with people. I was able to truly communicate and empathize with people from all walks of life – you never knew who would come through the ER door – from biker gangs who had been in a knife fight, to a family with a sick child, etc. When I worked in ER, there was no doctor at your elbow and I am proud of the triage skills that I developed. When you become a nurse, you never stop caring about people. Once I retired, I kept on working with people, serving tea to patients in the hospital and listening to them; driving and caring for those with Meals on Wheels; and doing foot care and taking blood pressure readings at the Senior Centre. What advice would you give to others about being a partner in their care? Ask questions and don't stop until you get clearly explained answers. For example, if you need a surgical procedure, ask why it is being done, what can be expected, and what you must do as the patient after the surgery. Always bring an advocate with you to an appointment. It is always better to have two sets of ears. The same goes for medications. Ask why am I being prescribed this drug; how will it help me; are there any side effects; and what do I do if I think there is an issue. 2/7/2020 9:00:00 PMA graduate of the Misericordia Hospital School of Nursing, Betty Scharf recently celebrated 60 years as a nurse. Of the 24 students in the class of3/27/2020 6:27:47 PM1119https://www.patientsafetyinstitute.ca/en/NewsAlerts/News/Pages/Forms/AllItems.aspxhtmlFalseaspx
Conquer Silence: Speak Up to Prevent Falls1153802/5/2020 10:21:50 PMPatient Safety News<img alt="Your inner voice can save lives " src="/en/NewsAlerts/News/PublishingImages/2020/Your%20inner%20voice%20can%20save%20lives.png" width="140" style="BORDER&#58;0px solid;" /> ​ There was an elderly woman in the bed. Her face was badly swollen and bruised. Her lip was stitched and her knee gashed. She looked like an assault victim. "I looked at her and could hardly believe it was my mom," says Anne Findlay. "She was that badly bruised. She looked awful." Her mom was conscious, but terrified, says Anne. She couldn't speak much, because her tongue was swollen. How could this happen? Falls are the leading cause of injury among older Canadians. Consider these facts Falls account for up to 40% of inpatient incidents 30% of falls result in physical injury, with 2-5% resulting in moderate to serious injury including hip fractures or even death Falls can result in longer lengths of stay, increased health care cost and staff workload, and staff and family distress Approximately 50% of patients sustaining a in-hospital hip fracture die within one year of the fracture.One in three Canadians has suffered from preventable healthcare harm, including falls, and yet collectively most people are unaware that the problem exists. That is the silent epidemic. If we do nothing, 1.2 million Canadians will die from preventable patient harm in the next 30 years. You can help battle this systemic silence in our collective efforts to reduce patient harm. Anne's mother had been sent for a third X-ray in 24 hours, which was very taxing for the fragile old woman. During the procedure, for reasons still not clear, she rolled off the gurney and dropped to the floor. Paramedics were called and transferred her to the emergency department where she was treated for her injuries. The emergency room doctor said he'd been told the wheels on Beth's gurney were not properly locked down. The nurses looking after Beth, though clearly upset, couldn't provide any answers. No one seemed to know the exact reason why the gurney had moved, resulting in Beth's fall. How can falls be prevented? Small changes in the environment can help to address potential harms. You can identify threats and take simple actions to mitigate them, by asking yourself Is care safe today? #ConquerSilence aims to prevent patient harm before it happens. The campaign focuses on topical themes to encourage patients, providers and the public to speak up for safe care, so others can learn from their experiences. If something looks wrong, feels wrong, or is wrong – you need to speak up! One tool that can help you to communicate and get the attention to a problem before a fall happens is called CUS. These are three assertive statements to communicate with your healthcare provider. They begin with "I'm Concerned that…", "I'm Uncomfortable with…", and "This is a Safety issue…". This acronym – and these conversations – are ways that patients and advocates can help providers identify safety concerns, then take action to fix them. "When somebody is injured in the hospital," says Anne, "if you don't feel that the people involved are being honest with you about what happened, you lose trust. You're this individual, or this family, and you feel like you're up against a huge system. Trust is all you've got to go on." Anne decided to #ConquerSilence and get involved as a volunteer. She sits on Alberta Health Service's Patient/Family Advisory Group, the Health Quality Council of Alberta's Patient/Family Safety Advisory Panel, and is a member of Patients for Patient Safety Canada. For more information on strategies to reduce falls, visit www.patientsafetyinstitute.ca. To speak up about falls and trauma, visit www.conquersilence.ca 2/5/2020 10:00:00 PM There was an elderly woman in the bed. Her face was badly swollen and bruised. Her lip was stitched and her knee gashed. She looked like an2/7/2020 9:49:51 PM566https://www.patientsafetyinstitute.ca/en/NewsAlerts/News/Pages/Forms/AllItems.aspxhtmlFalseaspx
CPSI at the National Health Leadership Conference, June 15-161153782/5/2020 9:46:11 PMPatient Safety News<img alt="" src="/en/NewsAlerts/News/PublishingImages/2020/Chris_Power.jpg" width="140" style="BORDER&#58;0px solid;" /> Presented by HealthCareCAN and the Canadian College of Health Leaders, the National Health Leadership Conference will be held June 15-16 in Edmonton, Alberta. This patient-included conference is the largest national gathering of health system decision-makers in Canada. Attendees include trustees, chief executive officers, directors, managers, department heads and other health leaders representing various sectors and professions in health regions, authorities and alliances, hospitals, long-term care organizations, public health agencies, community care, mental health and social services. As well, the conference draws participants from government, education and research organizations, professional associations, consulting firms and industry. (CEO of the Canadian Patient Safety Institute, Chris Power.) This year’s theme is “Adaptive leadership in complex times.” The program features health reporter Andre Picard from the Globe and Mail, McMaster professor of strategic management Dr. Nick Bontis, and advocate for student mental health Donovan Taplin. However, of particular interest, is a breakfast session to be held at 715 am on the morning of Tuesday, June 16. 5 goals, 13 objectives & 28 outcomes that will save lives! Breakfast Session Serves Up Actions to Guide Quality and Patient Safety Improvement Unintended patient harm occurs every 1 minute and 18 seconds throughout our healthcare system, resulting in a death every 13 minutes and 14 seconds. Come and hear how two of Canada’s most powerful heath leaders are driving change through collective action. The Canadian Patient Safety Institute and Health Standards Organization CEOs, Chris Power and Leslee Thompson, have spearheaded the development of the Canadian Quality and Patient Safety Framework. Join us to learn how the #qualitypatientsafety Framework will improve care for ALL people in Canada. Don’t miss this opportunity to hear these two national health leaders discuss the future of healthcare in Canada. Register today for the National Health Leaders Conference, and then register for the complimentary breakfast session with CPSI and HSO! 2/5/2020 9:00:00 PMPresented by HealthCareCAN and the Canadian College of Health Leaders, the National Health Leadership Conference will be held June 15-16 in Edmonton,2/6/2020 9:09:29 PM408https://www.patientsafetyinstitute.ca/en/NewsAlerts/News/Pages/Forms/AllItems.aspxhtmlFalseaspx