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#SuperSHIFTER Embracing simulation and its untapped potential706172/14/2019 10:31:32 PMSuper SHIFTERS #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 PM305
#SHIFTtalks Breaking down the wall of silence for victims of medical errors695272/7/2019 8:16:07 PMSHIFT Talks ​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 PM759
Patient Safety Power Play: 2019 is the year for Patient Safety695292/7/2019 8:33:18 PMPatient Safety Power Plays 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 PM166
#superSHIFTERS Global Patient Safety Alerts: learning locally and sharing globally689801/25/2019 8:27:31 PMSuper SHIFTERS ​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 PM842
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 PM238

 Latest Alerts



Bed Alarms-Safe use and configuration4714537194/26/2018 6:00:00 AMDeviceAlberta Health ServicesThis alert addresses a patient safety incident of a fall related to bed alarms which may not function properly. The following points are relevant to the incident of a patient fall:  Bed alarms are an alternative strategy for falls prevention.  Alarms may be permanently integrated into the bed or applied as an external device.  Most alarm sensor/pressure pads have a limited life expectancy.  The process for resetting bed alarms varies from brand to brand.  Each brand of alarm has a unique interface with the call bell system Recommendations to prevent similar incidents are provided. As well, specific actions are provided for staff to reduce the likelihood of falls related to bed alarms which do not funcion properly.2/11/2019 10:53:35 PM3
Vaccine storage and cold chain management7050835402/9/2018 7:00:00 AMMedicationNew South Wales Department of Health (Australia)This alert discusses the importance of maintaining a cold chain with the use and distribution of vaccines. Most vaccines used in Australia are temperature-sensitive substances that must be stored between +2ºC and +8ºC at all times to ensure they work effectively. There may be loss of potency if vaccines have been stored at temperatures outside this range. The alert provides reccommendations on necessary education and policies / procedures to ensure that no vaccines are compromised prior to use.2/11/2019 11:02:04 PM
Risk of death and severe harm from failure to obtain and continue flow from oxygen cylinders7039835581/9/2018 7:00:00 AMMedical GasNHS Commissioning BoardThis alert discusses the patient safety incidents that can occur when healthcare staff cannot deliver oxygen from cylinders to patients in a timely manner. The design of oxygen cylinders has changed over recent years. Cylinders with integral valves are now in common use and require several steps (typically removing a plastic cap, turning a valve and adjusting a dial) before oxygen starts to flow. To reduce the risk of fire valves must be closed when cylinders are not in use. Cylinders are often carried in special holders that can be out of the direct line of sight and hearing of staff caring for the patient. An unintended consequence of these changes is that staff may believe oxygen is flowing when it is not, and/or may be unable to turn the oxygen flow on in an emergency. Over a three year period, over 400 incidents involving incorrect operation of oxygen cylinder controls were reported. Six patients died, although most were already critically ill and may not have survived even if their oxygen supply had been maintained. Five patients had a respiratory and/or a cardiac arrest but were resuscitated, and four became unconscious. Incidents involved portable oxygen cylinders of all sizes on trolleys, wheelchairs, resuscitation trolleys and neonatal resuscitaires, and larger cylinders in hospital areas without piped oxygen. A typical incident was as follows: “Patient arrived on coronary care unit with oxygen saturations of 72%. Oxygen in situ and set to correct rate on the flow dial but unfortunately [the valve] was not opened and the patient was not therefore receiving oxygen. Peri-arrest on arrival, [crash team] called …..condition improved …..registered nurse continued to check cylinder was not running out but failed to notice not turned on as indicator green.” Recommendations to prevent similar incidents are provided.2/11/2019 11:01:28 PM
Echoes of Past Disasters4712537031/1/2018 7:00:00 AMMedicationCalifornia Hospital Patient Safety OrganizationThis alert addresses patient safety incidents that result when a chemotherapy medication is given by the wrong route. Wrong medication errors for intrathecal chemotherapy fortunately are rare, but, when they occur, can have severe consequences. The alert provides three cases of wrong route administration or near misses. The alert identifies several challenges associated with intrathecal chemotherapy and highlights the need to learn from near miss events.2/11/2019 10:53:48 PM3
Medication Error – Phenytoin 750 mg infusion was given at faster rate than prescription7003436421/1/2018 7:00:00 AMMedicationHong Kong Hospital AuthorityThis alert briefly describes a medication error where phenytoin was administered faster than the recommended infusion rate. A patient was admitted for tonic convulsions and fast AF. A loading dose was prescribed of phenytoin 750 mg followed by an intermittent infusion to be given over 30 minutes using the inpatient medication order entry (IPMOE) system. The infusion was administered over 10 – 15 minutes. The patient developed cardiac arrest and was successfully resuscitated. It was determined that the cardiac arrest may have been related to the patient’s underlying cardiac conditions or the faster infusion rate of phenytoin. A recommendation is provided to mitigate the risk of recurrence of similar events.2/11/2019 10:56:32 PM