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#SuperSHIFTERS Advocating for Patient Safety: Patients for Patient Safety Canada Government Relations Committee689963/15/2019 9:32:30 PMSuper SHIFTERS ​#SuperSHIFTERS Brian Penner, Government Relations Committee Chair, and Linda Huges, Co-Chair of Patients for Patient Safety Canada (PFPSC), shared their insights on advocating for patient safety. The Government Relations Committee is made up of these two individuals, along with PFPSC members Judy Birdsell, Katarina Busija, Allison Kooijman, Maryanne Murray, Sharon Nettleton, and Donna Penner. This group of energetic patient safety advocates work tirelessly to elevate the profile of patient safety in Canada, to raise expectations for improvement among governments, the public and patients themselves. Why did Patients for Patients Safety Canada form a Government Relations Committee? About two years ago, we had an in-person meeting of PFPSC members, where we established our priorities over the next few years. One of those priorities was to increase public awareness of patient safety and patients as partners. A key initiative that came out of that discussion was to increase awareness with federal, provincial and territorial governments. To fully engage with politicians we needed to be organized. From that, the Government Relations Committee was formed; eight PFPSC members volunteered to sit on the Committee. Our mandate is to connect with government officials at the national, provincial and local level. What can you tell us about your Patients at Parliament campaign? On October 30, 2018, in conjunction with Canadian Patient Safety Week (CPSW), 13 patients from across Canada travelled to Ottawa to participate in Patients at Parliament, a unique campaign to raise awareness of patient safety with parliamentarians. Five teams of patient advocates met face-to-face with 31 members of Parliament and Senators in ten buildings across the parliamentary precinct over the course of eight hours. Participants spoke about their personal experience with harm and delivered medication safety messages from the CPSW campaign. Members of the Standing Committee on Health were selected as a priority and we looked for both regional and all-party representation in selecting the parliamentarians to visit. We provided copies of the Five Questions to Ask About Your Medications and asked them to share it widely. We talked about the importance of a national reporting system to report adverse events and a pharmacare program to collect and disseminate information on medication errors. We also asked them to support the Health Canada petition calling for Plain Language labelling on medications. A lot of groundwork happened to make our visits productive. We were armed with an information package prepared by the Government Relations staff at the Canadian Patient Safety Institute that provided us with background data, biographies and talking points to keep our discussions on track, and of course maps so that we did not get lost as we moved from one building to another. We were accompanied by CPSI staff who kept our meetings on track and helped us to move efficiently between the scheduled appointments. Were there any key learnings from the Patients at Parliament meetings? First and foremost, the meetings reinforced the power of the narrative story. For each meeting, one member of the team told a personal story about patient safety and how they were harmed by the healthcare system. That really resonated with the politicians and many of them had personal stories to tell us as well. Second, while we made a fairly big impact with this inaugural campaign, our work does not stop there. Some of the MP offices contacted us in the days following the meetings to ask for more information, but overall the range of awareness and understanding of patient safety as a significant issue varied. It reinforced the value of a personal connection and the importance of following up. Third, an event like this is a great way to build awareness and start to build a relationship with government officials. We took away some dos and don'ts that will provide a template that we can apply for future meetings with MPs and MLAs. What's next for the Government Relations Committee? As a follow-up to our meetings on Parliament Hill, we want to make a presentation to the Standing Committee on Health to reinforce the importance of patient safety. We want to reinforce the need for legislation and regulations on mandatory reporting of adverse events and medication errors. We made a good start in increasing awareness on the widespread and serious problem of harm in healthcare. We will continue our outreach to federal parliamentarians and expand our efforts to include provincial elected officials. We are still at an early stage of planning our provincial campaign, and are looking to hold a number of round table discussions to raise awareness of patient safety across the country. We have developed a draft guide to serve as a template for patient engagement with governments. The guide is currently being tested with PFPSC members and is expected to be made available by mid-2019. The Government Relations Committee will be working closely with the PFPSC Communications Committee to implement a major public awareness campaign. A recent IPSOS survey confirmed that once people know that patient safety incidents are the third leading cause of death in Canada, they become very concerned. We will advocate for the consolidation and dissemination of data on patient safety incidents; and push for legislation and regulations to ensure full disclosure to patients and families when a harmful event occurs. Every patient safety incident should involve the patient and family at the outset and throughout the process. How can we get more information? Direct your questions and comments to More information is available at 3/15/2019 9:00:00 PM #SuperSHIFTERS Brian Penner, Government Relations Committee Chair, and Linda Huges, Co-Chair of Patients for Patient Safety Canada (PFPSC), shared3/15/2019 9:54:19 PM315
Patient Safety Power Play: Will you be joining our Learning Collaboratives?7113/7/2019 10:10:13 PMPatient Safety Power Plays<img alt="" src="/en/NewsAlerts/News/PublishingImages/Chris%20Power.jpg?Width=140" width="140" style="BORDER&#58;0px solid;" /> I have no doubt that, if you are a regular reader of my Patient Safety Power Plays, you are aware of our three, brand new, Safety Improvement Projects. These learning collaboratives have been designed by patient safety experts from around the world with CPSI to deliver the most up to date information and techniques to improve patient safety outcomes in your organization. Are you part of a healthcare team that could benefit from medication safety best practices – especially among the frail or elderly – at transitions of care, enhanced recovery outcomes after colorectal surgery, or proven teamwork and communication improvements? We have posted project summaries on this webpage, along with a recording of our one-hour webinar to give details of each project and explain it's Knowledge Translation approach. However, if you prefer to discuss the Safety Improvement Project that interests you with one of the Project Leaders, simply fill out this three-question, one-minute survey and your Lead will get back to you right away. The deadline for Expression of Interest forms is March 15, to give your team time to get the approvals you need. Teams from across Canada are participating in these projects, and I believe they will be of benefit to you and your organization. I am also delighted to mention an initiative that will benefit our nation and the rest of the world. On February 1, 2019 the WHO executive board approved a resolution to advance patient safety. It asks the WHO Director General to provide leadership and support while asking Member Countries to take actions to advance safety. Among many educational and infrastructure recommendations, the resolution endorses a global Patient Safety Day on September 17, 2019 and requests a Global Patient Safety Plan of Action that will commit every nation to reducing the crisis of patient harm. CPSI, as a WHO Collaborating Centre, has contributed to the Ministerial Summits that shaped this work, to requests for data collection, and has participated in collaborative events. We will continue to support this work, while already helping to implement many of the recommendations. Please voice your support online for our Safety Improvement Projects and the WHO resolution, and use the hashtag #PatientSafetyRightNow in any social media you share. If you have a story about preventable patient harm, please share it with your audiences through social media – and use the hashtag. Questions? Comments? My inbox is open to you anytime at, and you can follow me on Twitter @ChrisPowerCPSI. Yours in patient safety, Chris Power 3/7/2019 10:00:00 PMI have no doubt that, if you are a regular reader of my Patient Safety Power Plays, you are aware of our three, brand new, Safety Improvement3/7/2019 10:22:38 PM295
#SHIFTtalks Andrew’s legacy of care6643/5/2019 4:09:03 PMSHIFT Talks<img alt="" src="/en/NewsAlerts/News/PublishingImages/2019/Melissa%20Sheldrick.jpg?Width=140" width="140" style="BORDER&#58;0px solid;" /> My name is Melissa Sheldrick and I am a wife, mom, teacher and patient safety advocate. I came into the role of advocate when our eight-year-old son Andrew was taken from us two and a half years ago due to a substitution error made at our pharmacy. Andrew was a healthy little boy who was diagnosed with parasomnia and was prescribed five tryptophan tablets daily before bed. Parasomnia refers to all the abnormal things that can happen to people while they sleep and in Andrew's case, he went into his REM sleep twice as quickly as he should have which disrupted his whole night's sleep cycle. The large chalky tryptophan tablets were too big for him to swallow at the tender age of six, so I asked the doctor about a different kind of ingestion method. She suggested that we find a compound pharmacy so that they could make it into a liquid for him. We did so for a year and a half, and on Friday March 11, 2016, I called the pharmacy to order a refill. We picked up the bottle Saturday afternoon, put it in our fridge and it stayed there until bedtime. When it was time for bed, I gave Andrew his dose, tucked him in and kissed him goodnight. What unfolded the next morning, is what nightmares are made of. For four months, we did not know why Andrew died and we then learned that the bottle of medication that the police seized from our fridge on Sunday, March 13th, contained no Tryptophan at all, but contained Baclofen, mixed to the same concentration as Andrew's prescription, three times the lethal dose for an adult. Careless errors cost the life of our little boy. When I learned that the pharmacy was not mandated to report their error, I couldn't live with even the idea that nothing would change and another pharmacy could make a mistake that cost a life or caused harm and no one would know about it. I petitioned for change in Ontario, and the College of Pharmacists swiftly created an anonymous error reporting program that is a part of a larger continuous quality improvement program through a company called Pharmapod . Soon, every pharmacy in Ontario will be required to report all medication incidents and near misses so that data can be collected and reports can be compiled to help prevent future errors. Medication errors are common, everyday occurrences that are harming patients of all ages. These errors are avoidable and preventable and we must work harder and have regulations and policies in place that reduce their number, frequency and severity. When examining the errors, there has to be a, "what happened and why?" system instead of a, "who did this?" stance. This system aims to build preventative measures into the pharmacy's processes so that the same errors do not recur. Communication and collaboration are key to maintaining and increasing patient safety, and the learnings must be shared. When incidents are recorded, analyzed and learnings are shared, medication delivery becomes safer. This is Andrew's legacy of care. Melissa Sheldrick is an elementary school teacher and a member of Patients for Patient Safety Canada. She was a member of the Ontario College of Pharmacists' Medication Safety Task Force and provided an invaluable perspective as a patient advocate in the development and implementation of a continuous quality assurance program for medication safety. 3/7/2019 7:00:00 AMMy name is Melissa Sheldrick and I am a wife, mom, teacher and patient safety advocate. I came into the role of advocate when our eight-year-old son3/6/2019 4:08:45 PM780
CAMH and BC Children’s Hospital to Showcase Leading Patient Safety Practices at National Health Leadership Conference7013/7/2019 8:16:10 PMPatient Safety News Two teams from the Centre for Addiction and Mental Health (CAMH) and BC Children's Hospital (an agency of the Provincial Health Services Authority) will present their leading practices in patient engagement for patient safety at the National Health Leadership Conference (NHLC) on June 5th in St. John's NL. The two teams, each formed by a patient partner and a health leader, have been chosen as part of a new recognition program called the Excellence in Patient Engagement for Patient Safety Recognition Program. Developed in partnership by the Canadian Patient Safety Institute (CPSI), HealthCareCAN and Health Standards Organization (HSO) with support from Patients for Patient Safety Canada, the new annual program aims to identify, celebrate and disseminate leading practices in patient engagement for patient safety. A number of additional leading practices, identified through the nomination and scoring process, will also be identified each year and added to HSO's Leading Practices Library. The program provides all travel expenses and full registration to NHLC for members of the selected teams. The team from CAMH will present on its Successful Patient Engagement in Development of Identification Strategies to Improve Medication Safety and the team from BC Children's Hospital will present on its Patient's View Engaging Patients and Families in Patient Safety Incident Reporting. In addition, teams from the following organizations have been formally identified and celebrated as leading practices and added to HSO's Leading Practices Library Alberta Health Services Provincial Health Services Authority (BC Patient Safety & Learning System (BCPSLS)) Health Quality Council, Saskatchewan Kidney Health, Saskatchewan Health Authority BC Children's Hospital (an agency of PHSA) Eastern Health Newfoundland Holland Bloorview Montfort Hospital McMaster Children's Hospital Hamilton Health Sciences BC Autism Assessment Network, Sunny Hill Health Centre for Children, BC Children's Hospital Sunnybrook Health Sciences Centre Health Quality Ontario Fraser Health Descriptions of these initiatives will be available on the HSO website by June 1st. The partners are excited to continue working together to further advance exceptional patient safety work through partnership with patients and families. About HealthCareCAN HealthCareCAN is the national voice of healthcare organizations and hospitals across Canada. We foster informed and continuous, results-oriented discovery and innovation across the continuum of healthcare. We act with others to enhance the health of the people of Canada; to build the capability for high quality care; and to help ensure value for money in publicly financed, healthcare programs. About Canadian Patient Safety Institute The Canadian Patient Safety Institute (CPSI) is a not-for-profit organization that exists to raise awareness and facilitate implementation of ideas and best practices to achieve a transformation in patient safety. Funded by Health Canada, CPSI reflects the desire to close the gap between the healthcare we have and the healthcare we deserve. About HSO Health Standards Organization (HSO) builds world-class standards and innovative assessment programs, new technologies and activation services for accreditation bodies, governments, associations and others. Our standards are designed in partnership with clinicians, policy makers, technical experts and patients to ensure they provide effective health services and overall value. We create global standards that help people in their local jurisdictions save and improve lives. About Patients for Patient Safety Canada Patients for Patient Safety Canada is a patient-led program of the Canadian Patient Safety Institute and the Canadian arm of the World Health Organization's Patients for Patient Safety programme. We are the voice of the patient and bring our safety experiences to help improve patient safety at all levels in the health system. Media contact Christopher Thrall, Communications Officer, CPSI 780-566-8375 3/7/2019 7:00:00 AMTwo teams from the Centre for Addiction and Mental Health (CAMH) and BC Children's Hospital (an agency of the Provincial Health Services Authority)3/7/2019 9:13:34 PM70
#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, 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 Learn more about hospital-based simulation at the 2019 National Forum on Simulation for Quality & Safety, May 28, 2019 in Vancouver, BC. Visit 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 PM1010
#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 PM1393
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, 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 PM463
#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; or contact me by email at, 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 PM989
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 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 PM277
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 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 PM199