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Atlantic Learning Exchange mobilizes energy and enthusiasm for patient safety and quality3770212/1/2020 5:08:35 PMSuper SHIFTERS #SuperSHIFTER Leslie Ann Rowsell was Chair of the Atlantic Learning Exchange held in St. John's, Newfoundland and Labrador, in October 2019. The Atlantic Learning Exchange brings together healthcare professionals from the four Atlantic provinces to discover innovative and emerging trends in patient safety and quality improvement. What can you tell us about the Atlantic Learning Exchange? The Atlantic Learning Exchange (ALE) is a wonderful opportunity for people in Atlantic Canada to come together to discuss their work in patient safety and quality. We offer the opportunity for people to showcase their work and what they are doing in their respective regions. To engage ALE delegates, our presenters go through a rapid-fire process to talk about their projects for about five minutes as well as display poster and story boards. It also opens doors for people who are in this line of work to meet with various vendors and sponsors. It provides conversation time and exposure to things that our delegates may not necessarily see every day. In a nutshell, the ALE is a great networking opportunity for like-minded individuals to connect, broaden their knowledge, and take that knowledge translation back to their workplace. Tell us about your experience as Chair of the event? It was great fun to be the Chair of such a phenomenal event. I haven't been on the planning side of many healthcare conferences, so I was a newbie when it comes to this level of work. In 2015, I was approached by our Vice-President Clinical Supports and the Director of Quality Risk and Patient Safety, who were responsible for Quality at Eastern Health to be the provincial representative on the planning committee for these conferences. I attended the 2015 and 2017 conferences before taking on the Chair role for the Conference here in Newfoundland and Labrador in 2019. Everyone on the planning committee works full-time and the conference planning is in addition to our regular work. It requires the help of everyone in all the Atlantic provinces to help ensure there is adequate representation from each province attending the event, and for the storyboards and rapid-fire presentations. But the ALE also needs a commitment of organizations to send people to the Conference. It's definitely a team effort to pull an event like this together. In the beginning days, we thought it may have been difficult to attract delegates because air travel is expensive and it's not easy to drive to our province at that time of the year. The response was overwhelming and in the end we maximized the room capacity and had to turn people away. What makes the Atlantic Learning Exchange unique? The ALE is designed by Atlantic Canadians, for Atlantic Canada. Because the geography of Atlantic Canada is somewhat small, we bring a grassroots perspective with people on the planning committee representing all four provinces. As a group, we pick the theme and design the agenda. We have a lot of flexibility when it comes to our speakers and how we spend the money entrusted to us to run the ALE. Because there is so much input from all provinces, the agenda is very relevant and applicable for everyone in the room. The Atlantic Learning Exchange has been successful because we have been able to work together and network together. We have been able to help keep the costs down so that people can afford to come. And, we have made the event something meaningful that happens every second year. What were some of the highlights of the 2019 ALE for you? Jeffrey Braithwaite was one of our keynote speakers and he wowed the audience with his knowledge on patient safety. There was so much rich content in his presentation, and I have become quite interested in his work in systems improvement and now follow him on Twitter. To encourage resilience, Braithwaite suggests Look at what goes right, not just what goes wrong; When something goes wrong, begin by understanding how it (otherwise) usually goes right. Look at frequent events, not just severe ones; Be proactive about safety - try to anticipate developments and events; and Be thorough, as well as efficient (the ETTO principle – efficiency-thoroughness trade-off). Marlies van Dijk from Alberta Health Services Design Lab delivered a powerful presentation demonstrating how the biggest opportunities to transform health care lie not within strategies or processes, but within mindsets. Marlies reinforced the importance of knowing your team, and networking within work to build your own resources and strengths. When you connect with people who build you up and you find those people to trust, brainstorm and work with, you will find your supporters! There was also an interesting presentation from the Hacking Health team at Eastern Health and their work to hack no-show rates. Hacking Health fosters collaborative innovation by engaging key groups of stakeholders to create solutions to healthcare challenges as a mindset, not a skill-set. Where can we go for more information? Copies of the presentations from the 2019 ALE are available on the Canadian Patient Safety Institute's website. Click here to access the presentations. If you have questions about the ALE, contact me at LeslieAnnRowsell@EasternHealth.ca. 12/1/2020 7:00:00 AM#SuperSHIFTER Leslie Ann Rowsell was Chair of the Atlantic Learning Exchange held in St. John's, Newfoundland and Labrador, in October 2019. The12/2/2020 8:25:30 PM433https://www.patientsafetyinstitute.ca/en/NewsAlerts/News/Pages/Forms/AllItems.aspxhtmlFalseaspx
CFHI and CPSI welcome Government of Canada’s $6.4 million investment in pandemic preparedness and response long-term care and retirement homes3770812/1/2020 11:06:09 PM "Yesterday, the Honourable Chrystia Freeland, Deputy Prime Minister and Minister of Finance, tabled Supporting Canadians and Fighting COVID-19 Fall Economic Statement 2020. We welcome the $6.4 million investment the Government of Canada is making to expand the LTC+ Acting on Pandemic Learning Together initiative which is helping long-term care and retirement homes strengthen their pandemic preparedness and response. This additional funding is part of their commitment to help provinces and territories protect long-term care and other supportive care facilities. The funding will allow LTC+ to support up to 1000 teams delivering care for adults in congregate living settings across Canada. Through LTC+, teams are able to rapidly share with and learn from each other, prepare for possible future outbreaks, and work to mitigate the pandemic's effects through coaching, funding, virtual learning opportunities and peer-to-peer support. We owe it to those affected by early outbreaks of COVID-19 in long-term care and retirement homes to learn from their experiences and hard-won lessons. These homes all have the common goal of protecting their residents and staff and LTC+ is helping them to come together quickly and efficiently. Teams are focusing on six promising practices to strengthen pandemic preparedness and response preparation; prevention; people in the workforce; pandemic response and surge capacity; planning for COVID-19 and non-COVID-19 care; and presence of family. LTC+ is being delivered by the newly amalgamated organization that brings together the Canadian Foundation for Healthcare Improvement and Canadian Patient Safety Institute. LTC+ is supported by our partners the BC Patient Safety and Quality Council, New Brunswick Association of Nursing Homes and CADTH and with funding support from the CMA Foundation. If your team is delivering care to older adults in congregate care settings and interested in LTC+, you can find out more details here or reach out to the team via LTC-SLD@cfhi-fcass.ca." Jennifer Zelmer President and CEO The newly amalgamated organization that brings together CFHI and CPSI works with partners to share proven healthcare innovations and best practices in patient safety and healthcare quality. Working together with patients and other partners, we can deliver lasting improvement in patient experience, work life of healthcare providers, value for money and the health of everyone in Canada. The organization is a not-for-profit charity funded by Health Canada. Visit cfhi-fcass.ca and patientsafetyinstitute.ca for more information. The views expressed here do not necessarily represent the views of Health Canada. 12/1/2020 7:00:00 AM"Yesterday, the Honourable Chrystia Freeland, Deputy Prime Minister and Minister of Finance, tabled Supporting Canadians and Fighting12/2/2020 2:13:40 PM30https://www.patientsafetyinstitute.ca/en/NewsAlerts/News/Pages/Forms/AllItems.aspxhtmlFalseaspx
In Jennifer Zelmer’s Words: Adaptation and Amalgamation 1396811/18/2020 9:09:06 PMPatient Safety News ​The Canadian Patient Safety Institute and the Canadian Foundation for Healthcare Improvement recently amalgamated. CEO of CPSI Chris Power retired, and CFHI CEO Jennifer Zelmer was named President and CEO for the newly amalgamated organization. In this monthly blog, Jennifer shares her thoughts about this month's Digital Magazine topic. Across the country, many regions are facing another wave of the COVID-19 pandemic. It's a tough time - one that is forcing all of us to call on our own resilience, as well as that of our communities, organizations, and healthcare systems. Our ability to adapt to change is being tested. We are grateful to those working to ensure the health of everyone in Canada and globally and wish to recognize the innovative ways that healthcare systems and healthcare workers are responding to the needs of the people they serve. In turn, we are working hard to support their efforts, building on hard-won lessons from the pandemic. Safety in long-term care has emerged as an important issue. To respond, we launched LTC+ Acting on Pandemic Learning Together, which is already supporting hundreds of long-term care and retirement homes as they strengthen their pandemic preparedness and response. We welcome others to join, develop an action plan, and access resources and tools, coaching, and a nationwide community of practice. Teams that join before December 18 can receive up to $10,000 to accelerate implementation of six promising practices. Also upcoming is policy guidance to support the safe reintegration of essential care partners into healthcare facilities during a pandemic, developed in partnership with patients, families, caregivers, policy makers, administrators, and healthcare providers. This comprehensive approach balances risks, while embodying the principles of patient- and family-centred and partnered care. We hosted a webinar to preview the guidance and will be publishing the report next week. During the pandemic and beyond, we also need to continue to work on a broad range of patient safety challenges. We were delighted to engage with so many committed to doing so during the recent Canadian Patient Safety Week (CPSW). Over the course of the week, our social media engagement and public service announcements reached millions of people with the #ConquerSilence campaign and how to keep ourselves safe in #VirtualCare, along with the webinar "What does ideal virtual care look like?" During the Safety Improvement Projects Closing Congress that week, teams from across the country met to share their successes and collaborate as they connected with experts in knowledge translation, quality improvement, patient engagement, and resiliency. I invite you to watch the highlights video to find out what all the buzz was about, and reach out to learn about the 18-month projects. And the week ended with a successful Canadian Quality and Patient Safety Framework launch, in conjunction with our partners at Health Standards Organization. Endorsed by the Honourable Patty Hajdu, Federal Minister for Health, the Framework offers a shared focus on 5 enduring goals people-centred, safe, accessible, appropriate, and integrated care. Finally, I want to share a bit about the progress we have been making with the amalgamation of the Canadian Patient Safety Institute and Canadian Foundation for Healthcare Improvement. The pandemic has highlighted the importance of health systems with a strong focus on quality and safety improvement. Creating a single quality and safety organization with an expanded capacity to improve healthcare for everyone in Canada seems even more relevant now than when we first embarked on this journey. We began CPSW by announcing our new Board, my own appointment as CEO and President, and our Senior Leadership Team. We remain committed to completing our current plans and programs while engaging with stakeholders to develop our new strategy and plan for next year. The commitment to partnerships that was central to both CPSI and CFHI will continue into the new organization. That includes partnering with patients, families, and caregivers, as well as being guided by the perspectives of First Nations, Inuit, and Métis peoples in enhancing cultural safety in health systems. We are looking forward to introducing our new organization to you in the upcoming months, along with exploring with you the ways that we can partner to improve healthcare quality and patient safety. Take care, be well, and stay safe, Jennifer Zelmer 11/18/2020 9:00:00 PM The Canadian Patient Safety Institute and the Canadian Foundation for Healthcare Improvement recently amalgamated. CEO of CPSI Chris Power retired,12/1/2020 4:53:23 PM192https://www.patientsafetyinstitute.ca/en/NewsAlerts/News/Pages/Forms/AllItems.aspxhtmlFalseaspx
Together, let’s #ThinkDigitalHealth1418511/18/2020 9:21:30 PMPatient Safety News ​ Digital Health Week (November 16-22, 2020) is an annual celebration and recognition of how digital health is transforming the delivery of care across Canada as more and more of our health care system becomes digital. In a turbulent 2020, we have shown we are resilient and innovative. Adoption of digital health tools — from virtual consultations to new apps to access to your personal health information — has accelerated. As a result, people across the country have been able to access the care that they need, and digital health will continue to play an important role in a brighter future. Check out our valuable digital health resources for patients and healthcare providers to improve virtual care appointments. We are proud to partner with Canada Health Infoway during Digital Health Week 2020, a time for Canadians to celebrate this progress and show their support for digital health. Join the Digital Health Week conversation and share your story. #ThinkDigitalHealth 11/18/2020 9:00:00 PM Digital Health Week  (November 16-22, 2020) is an annual celebration and recognition of how digital health is transforming the delivery of11/18/2020 10:29:26 PM121https://www.patientsafetyinstitute.ca/en/NewsAlerts/News/Pages/Forms/AllItems.aspxhtmlFalseaspx
Handle With Care: Doing Our Part to Preserve Antimicrobials1387411/16/2020 9:14:01 PMPatient Safety NewsAntimicrobial Awareness Week, November 18-24 Antimicrobial Substances such as antibiotics, antivirals, antifungals, and antiparasitics, used to destroy or inhibit the growth of respective microbes. In the face of the pandemic, worldwide attention has been placed on health, illness and death, and the burden containment has on our livelihoods. We are pressured to consider our personal health and the health of our family and community in ways we are unaccustomed to. We are reminded that being healthy, in the context of a pandemic, is important, but may not be enough. Polarized views exist on prevention, immunity, vaccination, infection control, safeguarding health versus safeguarding the economy, and whether enough is being done to protect Canadians, particularly the vulnerable. While many are immersed in media reportage, others say they are tired of the inundation and unsolicited advice. The week of November 18-24 is Antimicrobial Awareness Week. Although we are rightfully focused on COVID-19, we cannot forget the impact of antimicrobial resistance and its effects, particularly as more Canadians are hospitalized with COVID-19. Unfortunately, some individuals infected with the SARS-CoV-2 virus may require prolonged hospitalization. Furthermore, they may develop additional bacterial or fungal infections that are resistant to first line antimicrobial treatment. Longstanding overuse and misuse of antimicrobial drugs in humans, animals, plants, food, animal feed, and the environment has resulted in the evolution of these stubborn, resistant organisms. Antimicrobial resistant organisms may be transmitted in healthcare environments putting patients receiving standard care, such as dialysis, surgery, or a C-section at risk. Antimicrobial drugs are highly valued, but sometimes inappropriately used. Dr. Hanan Balkhy, Assistant Director General for the WHO, emphasises the importance of the right drug, for the right person, at the right time. "Never is someone given an antihypertensive drug or cancer therapy without being diagnosed with cancer or hypertension. Yet, antibiotics are given [at times, unnecessarily] as a gesture of love or care." Unnecessary prescriptions, sharing antibiotics with others, or not completing our prescription contributes to the reduced effectiveness of antimicrobials. Replenishing the shelves with alternative antimicrobial medications is an arduous research process; therefore as a society, we cannot count on a rapid production of new medications for each resistant organism. We can however, try to avoid infections. In the context of the pandemic there are proven practices we can participate in—deliberate hand hygiene, distance, don a mask, disinfect, diagnose and detect contacts, and "do not" go out if ill (7Ds). If we must enter a healthcare facility including longterm care, as a patient or to support loved ones, we must protect ourselves and those we care about. In addition to the 7Ds don't be shy about reminding healthcare workers to wash their hands and thank them when they do; if the environment doesn't seem clean or equipment such as a thermometer or stethoscope hasn't been disinfected between patients—speak up, until you are satisfied; if you are instructed to wear and subsequently remove a gown, mask and gloves (PPE), ensure you are given the training and support you need to do this safely. A healthy lifestyle and illness prevention are more important now than ever. We have authority over our health and our behaviours. Healthcare has authority over appropriate antimicrobial use and environmental cleanliness. Let's unite to prevent infection. Let's unite to preserve antimicrobials. By Kim Neudorf We thank and acknowledge AMMI Canada for their revisions to this article. 11/16/2020 9:00:00 PMAntimicrobial Awareness Week, November 18-24 Antimicrobial: Substances such as antibiotics, antivirals, antifungals, and antiparasitics, used11/23/2020 5:22:55 PM488https://www.patientsafetyinstitute.ca/en/NewsAlerts/News/Pages/Forms/AllItems.aspxhtmlFalseaspx

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Preventable Tragedies: Two Pediatric Deaths Due to Intravenous Administration of Concentrated Electrolytes1573138151/16/2029 7:00:00 AMMedicationInstitute for Safe Medication Practices CanadaThis alert discusses two fatal medication incidents involving high alert drugs of concentrated electrolytes. IV administration of concentrated electrolytes has been identified as a “never event” where patient safety incidents result in serious patient harm or death, and can be prevented by using organizational checks and balances. In these cases concentrated potassium phosphates and potassium chloride were administered under separate circumstances. Each incident is described: Incident No. 1: Concentrated potassium phosphates solution for injection, available in a patient care area, was mistakenly used to flush a child’s IV line; a flush solution of normal saline (0.9% sodium chloride) was intended. The child immediately became pulseless and later died, despite intensive resuscitation efforts. The error was recognized when blood tests revealed severe hyperkalemia and hyperphosphatemia. Incident No. 2: An infant required IV replacement of potassium during a hospital stay. The medical resident contacted the staff pediatrician by phone for direction. The resident subsequently gave a verbal order to the nurse to administer IV potassium chloride (KCl) to the infant. The prescribed dose was not available in a premixed format, so the nurse used a vial of concentrated KCl solution for injection (stocked on the ward) to prepare the IV infusion for administration. However, the verbal order was misinterpreted, and 10 times the amount of KCl required was added to the IV bag. The IV solution was administered overnight, and the infant went into cardiac arrest and subsequently died. Several identifying contributing factors were identified: • Availability of concentrated injectable potassium solution in patient care areas • Non-standardized processes for the prescription and preparation of IV electrolyte solutions • Lack of independent double checks • Similar physical appearance of the electrolyte solutions and vials due to a product shortage Recommendations directed at health care facilities and health care practitioners are provided in the alert to reduce the likelihood of recurrence of such never events.7/9/2020 3:37:01 PMhttps://www.patientsafetyinstitute.ca/en/NewsAlerts/Alerts/Lists/Alerts/AllItems.aspxFalse
Necessity to check sterilization of sterile medical materials37713391411/27/2020 7:00:00 AMInfection ControlKorea Patient Safety Reporting & Learning SystemThis alert describes an incident where a non-sterile compression bandage was used on a patient. Non-sterile medical materials can cause severe harm due an increased risk of infection with their use. Caution and steps to verify the sterility of medical materials is required prior to providing patient care. 12/2/2020 5:15:46 PMhttps://www.patientsafetyinstitute.ca/en/NewsAlerts/Alerts/Lists/Alerts/AllItems.aspxFalse
Errors in administering antithrombotic agents in the period of pre and post surgery/procedure15740391311/12/2020 7:00:00 AMMedicationKorea Patient Safety Reporting & Learning SystemThis alert describes a medication incident involving a patient following a change in the medication regimen during an outpatient clinic visit prior to a scheduled surgery for an artificial joint replacement. Recommendations are provided to prevent recurrence when temporarily discontinuing an antithrombotic agent for more than a necessary period for patients with antithrombotic agent adaptation.11/17/2020 6:46:47 PMhttps://www.patientsafetyinstitute.ca/en/NewsAlerts/Alerts/Lists/Alerts/AllItems.aspxFalse
Delay or Omission of Critical Value Report (CVR)15738391110/6/2020 6:00:00 AMDiagnostic ImagingKorea Patient Safety Reporting & Learning SystemFollowing a biopsy of a mass on the left elbow, a patient was discharged from hospital and was to be contacted following a pathological test of the sample. The biopsy result was confirmed as a malignant tumor two weeks later but was not classified as a critical value report (CVR). As a result, the diagnosis was omitted from the report to the physician and not discovered until six months later causing a significant delay in treatment for the patient. Recommendations and examples of related preventive activities are included to prevent patient safety incidents that cause disturbance of precise diagnosis and delay of treatment due to a lack of action taken immediately on the result of CVR.10/16/2020 9:57:42 PMhttps://www.patientsafetyinstitute.ca/en/NewsAlerts/Alerts/Lists/Alerts/AllItems.aspxFalse
Errors in management of tissue and cell pathology samples1573939129/27/2020 6:00:00 AMCare ManagementKorea Patient Safety Reporting & Learning SystemThis alert describes three cases of mismanagement of tissue and cell pathology samples (switched samples, lost samples, errors in barcodes) that led to suboptimal and potentially harmful care management. The alert includes recommendations to prevent recurrence, precautions to take before/during/after sample collection, and precautions for receiving and labelling samples. 11/2/2020 5:36:27 PMhttps://www.patientsafetyinstitute.ca/en/NewsAlerts/Alerts/Lists/Alerts/AllItems.aspxFalse