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#SuperSHIFTER Embracing simulation and its untapped potential706172/14/2019 10:31:32 PMSuper SHIFTERS<img alt="" src="/en/NewsAlerts/News/PublishingImages/2019/Tim%20headshot.jpg?Width=140" width="140" style="BORDER&#58;0px solid;" /> #SuperSHIFTER Tim Willett is the President and CEO of SIM-one, the Canadian Network for Simulation in Healthcare (CNSH), the member-based network that supports and unites simulation programs across the country. Tim sees simulation as both an educational tool and a change agent to advance healthcare education, patient safety and care quality. What can you tell us about SIM-one/CNSH? We are the non-profit network of healthcare simulation centers and personnel across Canada and beyond. I would estimate there are 200 to 250 simulation centers and programs in Canada, found at university faculties, colleges, hospitals, and other care agencies. Our membership is currently comprised of 52 organizations and close to 300 individuals. Our subscriber base currently sits at 1,950, with 25 per cent of that being international. Our network's vision is exceptional healthcare through simulation. Our mission is to advocate and advance simulation for healthcare education, patient safety and care quality. Our role is to support and expand the scope and quality of simulation, and to help improve the sustainability of simulation programs. We bring people together for knowledge exchange and collaboration, resource sharing, and offer a suite of education programs that teaches people how to use simulation as an educational tool. It requires special skills to facilitate simulations; it is not the same as a traditional teaching paradigm. What makes simulation unique and innovative? Simulation does not just deliver knowledge for individual learning. It has evolved far beyond that. At the team and system level, it provides experience that helps people to understand current practices, challenges to the current culture, ways to make things better, and opportunities to practice new ways so that improvements can be more easily implemented. People working in simulation are powerful change agents. When you are looking to change educational paradigms, improve quality, change an organization's culture, or change the way processes and spaces are designed, you will find that simulationists are very passionate, forward-thinking, open to change and skilled at facilitating change. What opportunities do you see for simulation? There is incredible potential for simulation to improve care in hospitals and other care settings. An important part of our mandate is our advocacy role. We work with other groups, like the Canadian Patient Safety Institute, to help them understand the role that simulation can play to advance their mission. Increasingly, we are seeing that implementation and culture change are bottlenecks to improvement in healthcare. Simulation is a powerful tool for implementation, and can help to change behaviours, improve teamwork and transform a culture. We want to ensure that our stakeholders understand the role simulation can play and find ways through collaboration that we can help to advance their work. In the education world, the evidence of simulation is well-established, and Canada is a world leader in the use of simulation within healthcare education curricula. Simulation is improving how healthcare students learn and develop as professionals. From a patient safety and education perspective, practicing on mannequins and actors is far more desirable than practicing on patients or other healthcare professionals. While simulation has a strong foothold in education, there is a tremendous untapped potential for simulation on the healthcare delivery side. There are only a handful of hospitals and healthcare agencies in Canada who are really embracing simulation to improve safety and quality at the point of care delivery. That is where the opportunity lies and Canada is just at the beginning of taking advantage of the possibilities. This includes using simulation to design healthcare spaces, refining healthcare processes, identifying safety threats before they occur, just-in-time training to ensure staff are refreshed on the skills needed before going into a critical healthcare procedure, improving the quality of continuing professional development, assisting in the implementation of a quality improvement plan, improving teamwork in interprofessional care, and improving safety cultures. Traditionally, simulation has been thought of as an education tool and we are advocating that the use simulation for these system-level opportunities can improve healthcare. How has simulation evolved and what is needed today to advance simulation? Twenty years ago, when simulation was just taking off, the focus was on equipment. After five or 10 years, it became quite apparent that having the human resources to design and implement simulation was paramount. The focus shifted from equipment to personnel and training people to become simulation experts. The next steps to advance simulation in Canada are twofold one is a broader awareness of the opportunities and evidence, especially in the healthcare delivery setting, and the other is to increase the human capacity to implement simulation throughout education and healthcare delivery. In your work in simulation, what have been your major learnings and takeaways? The first is that simulation does not have to be expensive. More thought is needed around simulation programs, rather than simulation laboratories. Creation of a simulation program is not expensive if you invest in people before you invest in equipment. I would be very cautious about treading into simulation without that investment in human resources. Simulation by its nature is immersive and you want to deeply engage people in doing simulations. There is a specific skill set for creating and facilitating simulations. Again, that focus on creating the resource capacity and skill set to implement simulation is both critical and more feasible than many may realize. The other thing that I have learned over the past six years is that as large as Canada is, the simulation community at a national level is not that big. It is a niche area. Collaboration among organizations and professionals is becoming increasingly essential to improve the quality and sustainability of simulation across the country. Finally, there are a lot of aspects of simulation that can be shared – everything from policies within a simulation lab, organizational structures, staffing models, simulation scenarios, and validation tools for assessing simulation. What challenges are you seeing? There is continued skepticism about the value for investment in simulation. The perception of leaders and decision-makers is that it is a nice-to-have program that is expensive. We need to better understand the barriers to overcome this perception, and help our leaders to recognize that it is an investment with demonstrated returns and an essential tool for quality and safety improvement. There is also a perception around the necessary expense of equipment over resources. We need to improve buy-in and investment in simulation at the leadership level. Can others adopt or replicate what SIM-one/CNSH has to offer? I absolutely want to see more engagement across the country in simulation and more organizations involved is this network because the more people contributing to the shared knowledge, resources and insight, the more all benefit and the stronger our collective voice on simulation. There is a lot of value in regional simulation networks as it is not always feasible to travel to national conferences and there is power in establishing regional collaborations. I would encourage groups across Canada to look in their area and build those relationships within their cities and provinces, and build bridges with the national network. I hesitate to say that the model we have developed could be replicated. The history of any group like this is going to be unique. In our case, we grew out of two prior networks SIM-one, which had the luxury of government funding for a number of years to establish programs and an infrastructure. About a year ago, SIM-one integrated with the Canadian Network for Simulation in Healthcare, which had developed national level relationships. Our backgrounds are unique and have provided the foundation to where we are now. What is needed to start the conversation and create a ripple effect to advance simulation? I would like to see two related and parallel conversations at a national level. The first would be a conversation with organizations like the Canadian Patient Safety Institute, the Healthcare Insurance Reciprocal of Canada, the Canadian Foundation for Healthcare Improvement, and other national stakeholders on how to better inform decision makers in government and healthcare delivery settings about the opportunity and value, and to advance the scope and quality of simulation in that setting. The parallel conversation would be among decision-makers and leaders in the educational sphere for healthcare professions. Again, what are the issues that they are grappling with currently and where do they see those issues in five or 10 years from now, and looking at what ways will expanding simulation help to address those issues. Are those issues human resource shortages, education quality, patient safety, and/or increased expectations from the public and employers around highly trained healthcare professionals? Where can I go to learn more? Anyone can look at our website, www.sim-one.ca to get more information and access resources, but I would like people to contact me. My virtual door is always open! Our success will come from community relations and collaboration -- and the best way to establish that is in how we connect with people. Send me an email or give me a call so that we can learn more about your context and discuss how we might support your vision. Tim Willett, President and CEO SIM-one/CNSH Mobile 647-448-7119 Email twillet@sim-one.ca Learn more about hospital-based simulation at the 2019 National Forum on Simulation for Quality & Safety, May 28, 2019 in Vancouver, BC. Visit www.sim-one.ca for more information. 2/14/2019 10:00:00 PM#SuperSHIFTER Tim Willett is the President and CEO of SIM-one, the Canadian Network for Simulation in Healthcare (CNSH), the member-based network2/14/2019 10:46:27 PM359https://www.patientsafetyinstitute.ca/en/NewsAlerts/News/Pages/Forms/AllItems.aspxhtmlFalseaspx
#SHIFTtalks Breaking down the wall of silence for victims of medical errors695272/7/2019 8:16:07 PMSHIFT Talks<img alt="" src="/en/NewsAlerts/PublishingImages/Allison%20Kooijman.jpg?Width=140" width="140" style="BORDER&#58;0px solid;" /> ​My first experience with medical harm dates back to my teenage years and early adulthood. When I was 16 years old, my mother was diagnosed with metastatic colon cancer. She had been seeing the doctor for a year and a half prior to her diagnosis with complaints of rectal bleeding. Despite a family history of colon cancer, her symptoms were dismissed as a simple case of hemorrhoids. By the time she was sent for a colonoscopy, the cancer had metastasized. My mother fought a valiant fight, but passed away after a whopping dose of chemotherapy that her body couldn't handle. In 2012, I became the victim of a medical error that changed my life irrevocably. At that time, I was working as a Licensed Practical Nurse, a profession I loved and was well-suited for. I received an erroneous pathology result which precipitated a very invasive and unnecessary surgery, and as a result I am no longer able to function in the capacity required to be a nurse. As a healthcare professional, I expected reparations and a swift systemic response to such an egregious error. Instead, I was met with a wall of silence and to this day, I still have not seen the results of the internal investigation into my case. As I have sought information for many years since my unnecessary surgery, I have found that there are certain impediments to fulsome disclosure after a medically adverse event occurs. I would argue that, in my case, the poor systemic response only served to compound the injury inflicted and, as such, I now find myself in an advocacy role for certain reforms. It is difficult for me to reconcile that the third leading cause of death in Canada is medical error, and yet there is not a nationwide system for a) collecting information and statistics on the prevalence of medical error; or, b) legislation which requires the mandatory reporting of medical errors. I find it further concerning that there is legislation that exists in most provinces (Sec. 51 of The Evidence Act in British Columbia) where information surrounding discussions pertaining to individualized medically adverse events are prohibited from being disclosed externally. As difficult as this situation has been for me personally, I find strength in a community of like-minded individuals who are elevating the narratives of patients and striving to improve our healthcare system across this country. I am cautiously optimistic that our collective voices will resonate and our efforts will not be in vain. Allison Kooijman is a patient advocate, co-Chair of Patients for Patient Safety Canada, and a member of the British Columbia Patient Safety and Health Quality Council's Patient Voices Network. 2/8/2019 7:00:00 AM My first experience with medical harm dates back to my teenage years and early adulthood. When I was 16 years old, my mother was diagnosed with2/8/2019 8:31:43 PM824https://www.patientsafetyinstitute.ca/en/NewsAlerts/News/Pages/Forms/AllItems.aspxhtmlFalseaspx
Patient Safety Power Play: 2019 is the year for Patient Safety695292/7/2019 8:33:18 PMPatient Safety Power Plays<img alt="" src="/en/NewsAlerts/PublishingImages/Power%20Play%20Featured%20News%20-%20Sub%20Landing%20Page%20Feature.jpg?Width=140" width="140" style="BORDER&#58;0px solid;" /> February 2019 is a very exciting time with the Canadian Patient Safety Institute! During the shortest, darkest and coldest month of the year, we are busy sharing information about three amazing new initiatives that are attracting attention across the country. Last month, I told you about my resolutions for this year. I mentioned sharing what works with people who can make changes in our healthcare system, and so many of you stepped up to be included! To date, we have had more than 450 people register for our information webinars on the upcoming 18-month learning collaboratives we’re calling Safety Improvement Projects. Healthcare providers, clinical support staff, and administrators are interested in ways to improve patient safety during these two webinars, they will learn about evidence-based practices they can implement immediately to start improving patient safety right now. For our colorectal surgical care teams, the Enhanced Recovery Canada project will improve outcomes and system efficiencies. For our colleagues in acute care organizations, we developed our Medication Safety at Care Transitions project, with an emphasis on preventing harm to frail patients. Finally, for every team in healthcare, we are introducing a special project on Teamwork and Communication based around the popular and hugely successful TeamSTEPPS Canada™ program. If you missed our February 5 webinar, you are welcome to register for our February 12 session. The program managers from each project will talk about their internationally renowned faculty and coaches, unique collaborative virtual spaces, and how they will equip participants with actionable, reportable plans. These 18-month projects will be offered for a set fee for teams from across Canada, using integrated knowledge translation and implementation science principles. I want to make sure you don’t miss out sign up here for our February 12 webinar and become an ambassador for patient safety in your organization! Finally, I did want to thank you for the tremendous positive feedback we have been receiving for our work on Vanessa’s Law. In partnership with the Institute for Safe Medication Practices Canada and the Health Standards Organization we have been supporting this Health Canada initiative that requires certain healthcare institutions across Canada to identify and report on serious adverse drug reactions (ADRs) and medical device incidents (MDIs). The Protecting Canadians from Unsafe Drugs Act – named Vanessa's Law in honour of the late daughter of Terence Young (previously a Conservative MP) – amends the Food and Drug Act and strengthens the regulation of therapeutic products including prescription and over-the-counter drugs, vaccines, gene therapies, cells, tissues and organs, and medical devices. We can’t improve what we don’t measure. I have been delighted to hear your support for Vanessa’s Law. If you decide to voice your support online for either the Safety Improvement Projects or Vanessa’s Law, will you let us know? Could you hashtag #PatientSafetyRightNow in any social media you share? If you have a story about preventable patient harm, would you share it with your audiences through social media – and use the hashtag as well? Help us make this 2019 count. Help us improve patient safety and prevent patient harm. Questions? Comments? 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 2/7/2019 8:00:00 PMFebruary 2019 is a very exciting time with the Canadian Patient Safety Institute! During the shortest, darkest and coldest month of the year, we are2/7/2019 8:41:43 PM245https://www.patientsafetyinstitute.ca/en/NewsAlerts/News/Pages/Forms/AllItems.aspxhtmlFalseaspx
#superSHIFTERS Global Patient Safety Alerts: learning locally and sharing globally689801/25/2019 8:27:31 PMSuper SHIFTERS<img alt="" src="/en/NewsAlerts/News/PublishingImages/2019/Steve_Routledge.jpg?Width=140" width="140" style="BORDER&#58;0px solid;" /> ​SuperSHIFTER Stephen Routledge is a health/public policy professional with expertise leading multi-stakeholder projects and building partnerships at the regional, national and international level. Stephen is a Senior Program Manager at the Canadian Patient Safety Institute, leading the next evolution of the Global Patient Safety Alerts program. What is Global Patient Safety Alerts? Global Patient Safety Alerts (GPSA) is a publicly-available online collection of indexed patient safety incidents, containing more than 1,500 alerts and 7,500 recommendations from 26 contributing organizations around the world. The program supports global efforts on patient safety reporting, learning and sharing through the Canadian Patient Safety Institute's designation as a World Health Organization Collaborating Centre for Patient Safety and Patient Engagement. The tool promotes cross-jurisdictional learning and encourages transparency and a culture of improvement among the global patient safety community. Contributing organizations publicly share information about identified patient safety risks and their recommendations on effective strategies to prevent reoccurrence and patient harm. Users can access evidence-informed recommendations to help them analyze, manage and learn from patient safety incidents, and connect with organizations that have valuable insight and strategies to reduce harm. The database also includes information on emerging and trending patient safety risks, quality improvement methodologies and risk communication strategies. Global Patient Safety Alerts is free to use! Users can search by keyword, browse through general topic areas such as medications or surgery, or access submissions from a specific contributor. Last year alone, there were more than 13,000 views of specific GPSA summaries, by users from over 40 countries. What makes Global Patient Safety Alerts innovative? GPSA is a learning system, not a reporting system; it promotes cross-jurisdictional learning and transparency. We take information that other organizations have compiled on what they have learned from serious incidents and serious harm, and provide the platform to share that information with other organizations, so that they can learn from it. I don't know of another program that does that. Patient harm doesn't have to occur repeatedly because the information on how to minimize or prevent harm stays locally. When organizations are willing to share information, learn from one another, and implement the recommendations that come out of patient safety reviews that demonstrates their commitment to a patient safety culture of learning and improving. Can you tell us more about the Global Patient Safety Alerts contributions? Any kind of patient safety or health organization can contribute and the contributor has the final say on what alerts, advisories and information are shared globally. Currently, our contributors are primarily regional health authorities, quality councils and governments. We don't include drug and medical device recalls, because the level of detail is so different from country to country and regulatory agencies are better to manage the recalls. The wealth and the style of information are different among contributors. There are some outstanding contributions that include large-scale aggregate and trending analyses of 1,000 incidents that have occurred, and then we have a lot of contributions that provide an analysis of a single event, which is useful for users as well. Some advisories or alerts look a little more academic, while others include pictures and animations, but the intent is the same among all of them. Simply, it is an aggregate or single patient safety event that we include. How do you address concerns about confidentiality? There is always that concern. As part of Global Patient Safety Alerts we have a review process to ensure that under no circumstances is there any kind of patient information included. And, if privacy is an issue, that is not anything that we post. We take confidentiality and privacy very seriously so anything that could compromise that is not posted. One of the barriers we run into with potential contributing organizations is that the information could be perceived negatively in the public in the sense that they're being open with things that have gone wrong in their health system. But, really with transparency it is demonstrating that willingness to be better, in both quality improvement and patient safety. We work with those contributing organizations to help them understand how this is a positive push for patient safety and how it will help other organizations facing a similar challenge. What advancements can we look forward to in the evolution of Global Patient Safety Alerts? We did an evaluation last year that will inform the next phase of the program. In a nutshell, we would like to further embed the program throughout the health system and grow the network of users and contributors. We have developed a communications and marketing plan and will be reaching out to health organizations, patient safety organizations, quality teams and others to increase both the awareness and use of Global Patient Safety Alerts. Together with our web team, we will improve some of the analytical and technological aspects of the database. Stay tuned! To grow GPSA internationally and globally, we are also working with the WHO Collaborating Centre for Human Factors in Patient Safety based in Florence, Italy, to integrate the alerts, recommendations, advisories and information from Global Patient Safety Alerts into their Global Knowledge Sharing Platform. How can we learn more about Global Patient Safety Alerts? If you are interested in becoming a contributor, visit our website, watch the infographic video and/or reach out to me and I can walk you through the process. Contributing is quite easy and we work with each organization on how they can start or continue to contribute. More information is available on our website www.patientsafetyalerts.com; or contact me by email at sroutledge@cpsi-icsp.ca, or call 780.616.5320. 1/25/2019 8:00:00 PM SuperSHIFTER Stephen Routledge is a h ealth/public policy professional with expertise leading multi-stakeholder projects and building partnerships1/25/2019 8:45:35 PM846https://www.patientsafetyinstitute.ca/en/NewsAlerts/News/Pages/Forms/AllItems.aspxhtmlFalseaspx
A collaborative to decrease readmissions related to medication safety at care transitions484771/10/2019 8:49:53 PMPatient Safety News ​This safety improvement project is designed for acute care organizations that care for frail elderly. Participating teams will learn how to decrease readmissions related to medication safety issues at discharge among frail patients with poly-morbidity. The Canadian Alliance for a National Seniors Strategy notes that 65 per cent of older Canadians are taking medications belonging to five or more medication classes, while 39 per cent of adults over the age of 85 are taking medications belonging to 10 or more medication classes. Nearly 40 per cent of older Canadians are found to be taking at least one inappropriate medication. An additional 12 per cent take multiple inappropriate medications, the use of which is associated with avoidable hospitalization and hospital readmissions due to adverse drug events. Often, reducing an older adults' intake of inappropriate medications could help reduce their risk for becoming frail. A Safety Improvement Project focused on medication safety at care transitions to help healthcare teams to make a significant impact on readmission rates will run from January 2019 to October 2020. The Medication Safety at Care Transitions Safety Improvement Project is a learning collaborative that will support better outcomes for frail elderly patients including better health outcomes, reduced length of stay, fewer hospital readmissions, and overall cost savings to Canada's healthcare system. “Despite the best intentions of healthcare providers and the design of healthcare systems, medications can cause patient safety incidents, says” Mike Cass, Senior Program Leader, Canadian Patient Safety Institute. “The Medication safety collaborative will help participants to identify frail clients who are at risk for medication safety issues and learn to apply new processes for medication management at discharge.” Core teams, each of four-members, will attend two in-person learning sessions and seven virtual learning sessions, and be supported by expert faculty and coaches from across Canada. Teams will receive key content on implementation and knowledge translation that will assist in their implementation efforts to ensure success and sustainability of project gains. Only eight teams from across the country will be selected to participate in the Med Safety Collaborative. Don't miss out on this opportunity! Click here to download the Expression of Interest. Join an information webinar at 1200 ET on Tuesday, February 5th or Tuesday, February 12th. Click here to register to learn more! Register Now (Tuesday, February 5th) Register Now (Tuesday, February 12th) The deadline for applications is March 1, 2019. For more information, email medsafety@cpsi-icsp.ca The Medication safety collaborative is one of three Safety Improvement Projects being offered to support healthcare organizations in advancing patient safety. Click here to learn more about the Enhanced Recovery Canada and Teamwork and Communication collaboratives. 1/10/2019 5:00:00 PM This safety improvement project is designed for acute care organizations that care for frail elderly. Participating teams will learn how to1/23/2019 6:39:59 PM238https://www.patientsafetyinstitute.ca/en/NewsAlerts/News/Pages/Forms/AllItems.aspxhtmlFalseaspx
New learning opportunity to reduce the risk of complications for surgery patients 487271/10/2019 5:44:19 PMPatient Safety News ​Over an 18-month period, participating teams will be empowered and equipped with tools, resources and strategies to effectively implement Enhanced Recovery best practices in their clinical settings, with improved patient outcomes as a catalyst. A new Safety Improvement Project focused on surgical best practices to help healthcare teams to make a significant impact on surgical safety is set to launch in January 2019. The Enhanced Recovery Canada (ERC) Safety Improvement Project is a learning collaborative that will support better outcomes for surgical patients including an improved patient experience, reduced length of stay, decreased complication rates and fewer hospital readmissions. Enhanced Recovery Canada has adapted evidence-based best practices for colorectal surgeries known to help patients receive optimal care. Teams will learn how to implement the Enhanced Recovery Canada patient-inclusive, standardized, evidence-based clinical pathways. Within each pathway are six core principles that are known to improve care patient and family engagement, nutrition, early mobilization, hydration, pain and symptom control, and surgical best practices. "Most quality improvement projects are viewed as medical projects and not geared toward changing the culture of safety," says Dr. Claude Laflamme, Physician Lead, Surgical Care Safety Best Practices, Canadian Patient Safety Institute (CPSI). "The approach is usually not comprehensive, and the work often vanishes after the project is completed. Enhanced Recovery principles shatter conventional siloed practice. It is a comprehensive approach, from the top down, that is multidisciplinary and includes both patients and healthcare providers." "We want to take the ERAS learnings and evidence that has been acquired internationally and within Canada, and move it across the country," says Carla Williams, Senior Program Manager, CPSI. "The collaborative will help you to become a site-based champion for enhanced recovery and a leader for change in your organization." Core teams, each of four-members, will attend two in-person learning sessions and seven virtual learning sessions over an 18-month period, and be supported by expert faculty and coaches from across Canada throughout the collaborative. Teams will receive key content on implementation and knowledge translation that will assist in their implementation efforts to ensure success and sustainability of project gains. A maximum of twelve teams from across the country will be selected to participate in this unique learning opportunity. Will one of them be you? Click here to download the Expression of Interest. Join an information webinar at 1200 Noon ET on Tuesday, February 5th or Tuesday, February 12th to learn more! Click here to register. Register Now (Tuesday, February 5th) Register Now (Tuesday, February 12th) The deadline for applications is March 1, 2019. For more information, email erc@cpsi-icsp.ca The ERC collaborative is one of three Safety Improvement Projects created to support healthcare organizations in advancing patient safety. Click here to learn more about the Teamwork and Communication, and Medication safety collaboratives. 1/10/2019 5:00:00 PM Over an 18-month period, participating teams will be empowered and equipped with tools, resources and strategies to effectively implement Enhanced1/23/2019 6:55:47 PM185https://www.patientsafetyinstitute.ca/en/NewsAlerts/News/Pages/Forms/AllItems.aspxhtmlFalseaspx
Optimize your Team's performance and outcomes with Teamwork and Communication487431/10/2019 7:00:37 PMPatient Safety News ​The Teamwork and Communication Safety Improvement Project will empower participating teams to actively solve local level teamwork and communication issues that are impacting patient safety outcomes. Teamwork and Communication can mean different things to different people. Effective teamwork and communication are critical for ensuring high reliability and the safe delivery of care. Teamwork and communication can improve quality and safety, decrease patient harm, promote cross-professional collaboration and the development of common goals, decrease workload issues, and improve staff satisfaction and patient engagement. A new Safety Improvement Project focused on teamwork and communication is set to launch in January 2019. This collaborative learning approach will be delivered by expert faculty and coaches, and mentoring with be provided over 18 months. Participating teams will be provided TeamSTEPPS Canada Master Training, enabling them to roll-out TeamSTEPPS tools and resources at their local healthcare organization.“Communication is only ONE of the teamwork skills that TeamSTEPPS addresses,” says Rhonda Shea, Collaborative Learning and Education Lead, Health Quality Council of Alberta. “Leadership, situational monitoring and mutual support are all equally important to successful teamwork and positive patient outcomes. There are pivotal moments in all tragic patient outcome stories where it is clear that working together as a team could have improved the situation.” “This Safety Improvement Project will significantly improve teamwork and communication skills within the healthcare team,” says Tricia Swartz, Senior Program Manager, Canadian Patient Safety Institute. “Effective teamwork skills are essential for safe, quality healthcare that prevents and mitigates harm. By focusing on teamwork, communication and on a patient safety culture, you can truly raise the patient safety bar at your organization.” Core teams, each of four-members, will attend two in-person learning sessions and seven virtual learning sessions. Teams will receive key content on implementation and knowledge translation that will assist in their implementation efforts to ensure success and sustainability of project gains. This learning collaborative is sure to attract a lot of interest! Only eight teams from across the country will be selected to participate. Click here to download the Expression of Interest. Join an information webinar at 1200 Noon ET on Tuesday, February 5th or Tuesday, February 12th to learn more! Click here to register. Register Now (Tuesday, February 5th) Register Now (Tuesday, February 12th) The deadline for applications is March 1, 2019. For more information, email teamworkandcommunication@cpsi-icsp.ca The Teamwork and Communication is one of three Safety Improvement Projects being launched in January 2019 to support healthcare organizations in advancing patient safety. Click here to learn more about the Enhanced Recovery After Surgery and Medication Safety collaboratives. 1/10/2019 5:00:00 PM The Teamwork and Communication Safety Improvement Project will empower participating teams to actively solve local level teamwork and communication1/24/2019 8:15:07 PM129https://www.patientsafetyinstitute.ca/en/NewsAlerts/News/Pages/Forms/AllItems.aspxhtmlFalseaspx
Patient Safety Power Play: Make a resolution to prevent patient harm488241/10/2019 8:39:45 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;" /> Welcome back from holidays, everyone. I sincerely hope you shared some wonderful memories together with friends and family. Now that we're back, I am delighted to finally share with you my two resolutions for 2019. This year, we will lead and inspire all Canadians to sit up and take notice of the preventable patient harm crisis in Canada's healthcare system! My First Resolution Share What Works With People Who Can Make Changes If you have read ahead in this issue of our Digital Magazine, you already have a good sense of what I mean. This year, we are launching three outstanding Safety Improvement Projects for our colleagues in healthcare across the country. Whether you are a healthcare provider, clinical support staff, or a vital administrator, we have developed evidence-based practices that you can implement immediately to start improving patient safety right now! For our colorectal surgical care teams, the Enhanced Recovery Canada project will improve outcomes and system efficiencies. For our colleagues in acute care organizations, we developed our Medication Safety at Care Transitions project, with an emphasis on preventing harm to frail patients. Finally, for every team in healthcare, we are introducing a special project on Teamwork and Communication based around the popular and hugely successful TeamSTEPPS Canada™ program. On January 22, these three Safety Improvement Projects will open for registration. Each one boasts internationally renowned faculty and coaches, unique collaborative virtual spaces, and will equip participants with actionable, reportable plans. These 18-month projects will be offered for a set fee for teams from across Canada, using integrated knowledge translation and implementation science principles. I want to make sure you don't miss out sign up here to learn about them as soon as they are announced! My Second Resolution Tell Everybody About Preventable Patient Harm This year, I also committed to telling everyone about our mission. We know that as soon as someone learns that preventable patient harm is the third leading cause of death in Canada, it becomes their number one healthcare priority. So this year, it is my mission to tell as many people as possible. If you help me, together we will make a change in 2019. Will you follow my lead? If you tell two people the following five facts – and ask them to do the same – I believe we can set the country on fire! 1 in 3 Canadians has experienced preventable patient harm or has a loved one who did. Every 13 minutes, someone in this country dies from preventable patient harm. One out of 18 Canadian hospital visits results in preventable patient harm. Preventable patient harm costs $2.75 billion every year. There are actions you can take to keep you and your loved ones safer in our healthcare system. If every person in Canada knew these five facts, I truly believe that we could transform our healthcare system. Patient safety would become the number one healthcare priority for the public, for the media, for the healthcare system, and for our regulators. So will you join me in my 2019 resolutions? If you are working within healthcare, will you make sure that the right people know about the upcoming Safety Improvement Projects? And whether you work within the healthcare system or not, will you tell two people those five facts on preventable patient harm – and ask them to do the same? Together, we can make 2019 a milestone year in patient safety. If you decide to join me, will you let us know? Could you hashtag #PatientSafetyRightNow in any social media you share? If you have a story about preventable patient harm, would you share it with your audiences through social media – and use the hashtag as well? Help us make this year count. Help us improve patient safety and prevent patient harm. Questions? Comments? 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 1/10/2019 7:00:00 AMWelcome back from holidays, everyone. I sincerely hope you shared some wonderful memories together with friends and family. Now that we're back, I am1/10/2019 8:45:00 PM45https://www.patientsafetyinstitute.ca/en/NewsAlerts/News/Pages/Forms/AllItems.aspxhtmlFalseaspx
ISMP Canada, HSO and CPSI Come Together to Support Vanessa’s Law, the Protecting Canadians from Unsafe Drugs Act689751/10/2019 8:02:26 PM The Institute for Safe Medication Practices Canada (ISMP Canada), Health Standards Organization (HSO), and the Canadian Patient Safety Institute (CPSI) are working together to support Vanessa's Law; a Health Canada initiative that requires certain healthcare institutions across Canada to identify and report on serious adverse drug reactions (ADRs) and medical device incidents (MDIs). Each year, millions of Canadians access healthcare services and/or medications. Vanessa's Law will help keep these services and medications safe by ensuring organizations report on ADR and MDI occurrences, thereby allowing Health Canada to take timely, appropriate action when a serious health risk is identified. The Protecting Canadians from Unsafe Drugs Act – named Vanessa's Law in honour of the late daughter of Terence Young (previously a Conservative MP) – amends the Food and Drug Act and strengthens the regulation of therapeutic products including prescription and over-the-counter drugs, vaccines, gene therapies, cells, tissues and organs, and medical devices. In 2016, one in 143 Canadian seniors were hospitalized due to harmful effects from medications1. The three organizations –ISMP Canada, HSO, and CPSI – have come together to support Vanessa's Law by developing educational resources and outreach to help healthcare organizations across Canada in identifying and reporting ADR and MDI occurrences. The project is funded by Health Canada. Carolyn Hoffman, President and CEO of ISMP Canada considers this work to be a key priority. In her own words "The Joint Venture partnership leverages the strengths of our organizations, in collaboration with Health Canada, to support provinces and territories, hospitals and health care providers in preparing for implementation of the Vanessa's Law mandatory reporting requirements. Patient and family members are integral partners in this project to increase reporting and learning related to ADRs and MDIs." "We are extremely proud to be working with Health Canada in partnership with ISMP and CPSI to address serious gaps in safety reporting in hospitals," says Leslee Thompson, CEO of HSO. "The education and outreach activities that arise out of this work will be invaluable to improving the safety of Canadians. HSO is looking forward to collaborating with patients, providers and policy makers to further advance our common goals of achieving meaningful and measurable improvements that honor the legacy of Vanessa and her family." "Vanessa's Law is essential to Canada's healthcare systems," says Chris Power, CEO of the Canadian Patient Safety Institute. "We can't improve what we don't measure. These new reporting requirements will help contribute to improving the safety of drugs and medical devices. Everyone in Canada deserves safe healthcare." Learn more about Vanessa's Law on the Health Canada website.ABOUT THE ORGANIZATIONS ISMP Canada is an independent, national not-for-profit organization committed to the advancement of medication safety in all health care settings. ISMP Canada's mandate includes a national role in receiving and analyzing medication incident reports, making recommendations for the prevention of harmful medication incidents, and facilitating quality improvement initiatives. HSO develops standards, assessment programs and methodologies to enable health and social service providers around the world to improve quality while doing what they do best; saving and improving lives. CPSI is the only national organization solely dedicated to reducing preventable harm and improving the safety of the Canadian healthcare system. CPSI's bold new strategy, "Patient Safety Right Now", aims to reduce medication errors in Canada by 50% over the next five years. 1 Canadian Institute for Health Information. Drug Use Among Seniors in Canada, 2016. Ottawa, ON CIHI; 2018. 1/10/2019 7:00:00 AMThe Institute for Safe Medication Practices Canada (ISMP Canada) , Health Standards Organization (HSO) , and the Canadian Patient1/24/2019 9:10:39 PM187https://www.patientsafetyinstitute.ca/en/NewsAlerts/News/Pages/Forms/AllItems.aspxhtmlFalseaspx
#superSHIFTERS Sepsis: Pearls of wisdom493671/8/2019 6:18:10 PMSuper SHIFTERS<img alt="" src="/en/NewsAlerts/News/PublishingImages/Kim%20Neudorf.jpg?Width=140" width="140" style="BORDER&#58;0px solid;" /> ​Kim Neudorf has been a patient champion with Patients for Patient Safety Canada since 2009. Her areas of interest include health promotion, patient safety, patient engagement, infection prevention and control, and antimicrobial stewardship. Kim recently co-authored a paper that provides an overview of patient advisors' perspectives on the state of antimicrobial resistance and stewardship in Canada, Engaging patients in antimicrobial resistance and stewardship. Each time I tell this story, it seems more unbelievable. I wonder if this experience had to be extreme for me to take notice and realize patient safety isn't something that can be taken for granted. And later it made me realize that I needed to be a part of the solution. I took immediate notice of the change in Mom, as I met her at her front door. Her usual welcoming smile was replaced by a grim, puffy face and swollen, blue-tinged lips. I tried to make sense of the dark brown mittens she wore on that warm June morning. Her soft moans and one-word replies to my probing questions told me everything was an effort for her—that she was really sick. Barely audible, she whispered these words, "Backache…flu…fever…weak." It was clear to me she needed to be seen in emerg. I am a retired nurse and viewed her situation to be pretty straightforward. I expected her to receive the required diagnostics and treatment, and be treated well. I trusted the system that I'd worked in all those years prior. I did not expect my seventeen-year-old daughter to ask this question days later "Doesn't anybody care about her?" Mom walked into the emergency room. I was with her, concerned about what was percolating in her body and her mental decline. She was diagnosed with a urine infection, given a large bolus of IV fluid to correct her dehydration, an oral antibiotic (Ciprofloxacin), an opioid for her back pain, and released. The slippery slope began on that first day. The urine culture test was missed, she vomited right after she received the antibiotic pill, her pulse was well above her usual rate, and the necessary tests to diagnose sepsis weren't ordered, even though the physician mentioned it was a possibility. She returned to the emergency department the following two days. The second day she arrived by wheelchair. The intravenous bolus of fluid she received the day before made her legs so swollen, none of her shoes fit and her breaths were crackling with fluid. The doctor asked if she had dementia. I worried that his assessment was overshadowed by how she presented at that moment. He would have seen an older adult, slumped in a chair, barely capable of answering questions—because as she told him, "my brain is in a fog." I knew I needed to be her voice, her eyes and ears, and in time understood that I would also hold her memories. I made a point of speaking about her previous vitality at every opportunity—at each history taking, during assessments, with each new interaction. I wanted them to be clear—what they were seeing now wasn't who she'd been. On the third day she arrived by ambulance. She fell in her bedroom in the middle of the night, as she helplessly searched for her socks and pills—pills she'd already taken. She wasn't harmed, but she was in such a muddle and could not carry a thought through to complete a sentence. She had a fine rash over her body and the nurses had a difficult time getting an oxygen reading from her finger. The high intake of fluids washed the salts from her blood. Her heart rhythm was rapid and erratic. I informed the staff that on the first day she was seen in the ER, the physician considered sepsis. She was admitted to the hospital with the diagnosis of urinary tract infection and hyponatremia. Mom's mental decline and extreme fatigue became a touchy point. I saw Mom as someone who needed more intensive monitoring and surveillance, so when the nurses popped in and said, "Oh good she's sleeping." I retaliated with, "She's almost sleeping around the clock—it's not a good thing. She seems toxic." I believe the medical team trusted that once the antibiotic took hold, Mom's condition would improve; so we were told, "Slowly," and that they would "Wait and see." The twelve day course of Ciprofloxacin may have contributed to the complications that evolved. I asked the team to investigate deeper, and offered many suggestions. They seemed to be missing something. I thought I was a partner participating in Mom's care, in her best interest. I was wrong. This experience can be described as watching someone drown with a life preserver on. You expect it will help, but it's not, and you're watching that person die in front of you. As a nurse, I could influence the system—make good things happen in the worst of circumstances, but as a family member I was powerless. Therefore, I second-guessed my own ability to judge the situation objectively. There was tension, I tried to be delicate and wanted to trust the team, but they didn't seem to see the changes we did. After repeated requests for improved care including a handwritten letter that was placed on the front of Mom's chart, I worried about the chasm developing between Mom's family and the staff, and wondered how Mom ever got into this quagmire. On day ten as I fed my debilitated mother lunch, I noticed subtle, but ominous signs her skin and eyes were tinged with a sickening yellow hue, her urine dark orange. These new findings were reported to the charge nurse. I believed it was a call to action—the action never came. My brother called me that evening and said, "Mom looks like she's dying. She looks like Dad did when he died." Indeed she was. She was in a hemodynamic crisis—her red blood cells were self-destructing , and components of her blood dropped to levels incompatible with life. I had a hard time reconciling how my brother, a carpenter, could see that death was eminent, yet health professionals could not. I won't forget her desperation hours later—her struggle to live. She looked like an apparition buried in stark white sheets, her skin pale, transparent with a yellow cast. When she saw me, she sat straight up, her eyes fixed with fear. Her hoarse, loud voice pleaded, "I'm glad you're here... I'm so sick." Mom wasn't sleepy any longer. Although her body systems were depleted, her resolve was fierce. I ran to the desk and called for help. Her room became an instant hub of activity. Several physicians poured over her chart and concluded she developed autoimmune hemolytic anemia, pneumonia and was in a coronary crisis that resulted in a heart attack. An amazing team took over. She was in the hospital for five weeks and it took six months before her vitality returned—she lived, but there was functional loss. That was ten years ago. **** Today sepsis protocols and early warning assessment tools have improved the odds of surviving sepsis. Sepsis takes infection to another dimension. Pneumonia is the most common cause, but any infection can trigger the body's varied and complex response, that can either eradicate the infection or lead to multi-organ damage and death. Sepsis is the leading cause of death in hospitalized patients. In 2011, Health Canada reported 30 to 50 per cent of people who develop sepsis die from it.[1] While complete recovery is possible, the after effects can linger with conditions that affect the heart, kidneys, muscle strength and mental health, and there is a predisposition to recurrent infections. Research indicates patients may acquire neurological damage resulting in long-term moderate to severe cognitive impairment.[2] These effects are devastating consequences to an individual's quality of life. The severity and duration of a septic reaction to an infection is determined by a variety of factors. Children under one year are at greater risk, as are people with weakened immune systems, or chronic health conditions, and those over sixty-five years of age.[3] Sepsis is not a new disease, and fortunately fewer people die from it today. However, sepsis remains difficult to diagnose because it mimics other conditions, infectious or otherwise. For the public, the best defence is a good offence maintain good health and avoid infections, practice hand hygiene, keep vaccinations current, and cuts clean and covered. Learn to recognize the telltale symptoms of sepsis temperature more than 38.3 C or less than 36 C, a heart rate more than 90 beats per minute, more than 20 breaths per minute, tissue swelling, confusion, and discomfort.[4] If these symptoms exist in whole or in part, go to the emergency department, and be prepared to announce, "I'm worried I may have sepsis,"[5] to avoid being placed to the back of the queue. In order to beat the odds and survive sepsis, it must be recognized as a medical emergency. The longer there is a treatment delay, the greater the likelihood of progressive organ failure and death. Organ failure manifests itself with signs such as low blood pressure, an altered mental state, high blood sugar values in the absence of diabetes, low oxygen levels, changes in lab values associated with the blood's ability to coagulate, and a raised lactate level that indicates organs are not receiving enough oxygen.[6] A standardized approach to the medical management of sepsis is reducing complications and death. Intravenous fluid infusion and diagnostic tests to determine the source of infection is strongly recommended for the best possible outcome. Intravenous administration of the most appropriate antimicrobial drugs, such as antibiotics should should occur within one hour. This appears to be the single most important intervention. Specialized monitoring systems and medications may be necessary to prevent organ dysfunction.[7]**** Mom remembered little of those weeks in the hospital. Together, we've shared her story with the public, health professionals and students. During our presentations we identified "pearls of wisdom" to ensure patients receive the right care at the right time. At the podium, Mom would describe her health goals and demonstrated her heartfelt gratitude to her family and all healthcare workers with her closing comment "We need all of you!" [1] Tanya Navaneelan, Sarah Alam, Paul A Peters, Owen Phillips, "Deaths Involving Sepsis in Canada. 2016"; Release date January 21, 2016, http//www.statcan.gc.ca/pub/82-624-x/2016001/article/14308-eng.htm [2] Hallie C Prescott, Derek C Angus, "Enhancing Recovery from Sepsis A Review," JAMA 319 no. 1 (2018)62-75. [3] "Protect Yourself and Your Family from Sepsis," CDC, accessed February 1, 2018, https//www.cdc.gov/sepsis/pdfs/Consumer_fact-sheet_protect-yourself-and-your-family_508.pdf [4] Derek C Angus and Tom van der Poll, "Severe Sepsis and Septic Shock," New England Journal of Medicine 369 (2013)840-51. [5] "Protect Yourself." [6] Angus and van der Poll, "Severe Sepsis." [7] Andrew Rhodes et al.,"Surviving Sepsis Campaign International Guideline for Managing Severe Sepsis and Septic Shock 2016," Critical Care Medicine 45 no. 3 (2017)486-552. https//journals.lww.com/ccmjournal/Fulltext/2017/03000/Surviving_Sepsis_Campaign___International.15.aspx 1/8/2019 6:00:00 PM Kim Neudorf has been a patient champion with Patients for Patient Safety Canada since 2009. Her areas of interest include health promotion, patient1/10/2019 10:36:28 PM281https://www.patientsafetyinstitute.ca/en/NewsAlerts/News/Pages/Forms/AllItems.aspxhtmlFalseaspx