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​​​​​​Holland Bloorview Kids Rehabilitation Hospital has adopted the Patient Safety Education Program – Canada (PSEP – Canada) to create a hospital-wide patient safety vision and strategy that is aligned with organizational goals and outcomes.  The PSEP – Canada concepts and language are helping to build a patient safety vocabulary that everyone understands.

“We needed a framework that was tried, tested and successful that we could implement,” says Sonia Pagura, Senior Director of Quality, Safety and Performance (Holland Bloorview). “Our philosophy is that patient safety sits with everyone and PSEP – Canada provides a vehicle to share this information with all of our stakeholders. We are aligning strategy with capacity and execution in a systematic and step-wise approach to improve reporting, increase good catches and reduce harm.”

Holland Bloorview has leveraged its Falls data with the PSEP – Canada module on falls, linking practice to safety by conducting advance analysis of the data and translating that into a meaningful reduction in falls. Linking collaborative practice and creating practice standards has integrated safety and risk into a standard of care across all disciplines.  A preventative maintenance program has been developed for all therapeutic equipment (such as plinths, toys, etc.) and a framework for collection, analysis and process has been implemented to minimize risk. Simulation is used as a vehicle to ensure standards of care are maintained and safety principles integrated.

Medication reconciliation has been implemented across all moments within inpatient and outpatient settings.  The medication safety strategy has been aligned with external agencies and in community programming. Holland Bloorview’s approach to medication safety has been aligned with the Institute of Safe Medication Practices – Canada recommendations in outpatient settings and recognized as an Accreditation Canada leading practice.  Their work in medication safety has also been recognized in poster presentations submitted to the International Forum on Quality and Safety in 2013 and 2014.

An essential component of the Holland Bloorview strategy is to engage families in patient safety as equal partners. “Having family members at the table and included in the conversation is important. Families have great insight, including the process perspective and user perspective,” says Sonia Pagura.  So far, one family leader has completed the full training and Holland Bloorview’s strategy is to have many more engage in this framework for patient safety.

“Our patient safety culture would not be what it is without senior leadership and board support,” says Sonia Pagura.  “Patient safety can’t be a fragmented approach.  To build a strong patient safety culture, you need a plan that defines what you are going to do, then invest in it, commit to it and evaluate it.” 

As a next step, Holland Bloorview will continue to build the number of trainers and build internal capacity.  A program is being developed to learn by doing where individuals will work on an initiative they want to improve locally.