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Patient Safety Power Play: The Presence of Psychological Safety495397/10/2020 4:16:41 PMPatient Safety Power Plays ​Regular readers of Power Play will remember last month's theme. Patient safety is, of course, more important than ever. However, after months spent witnessing our healthcare system strain under the weight of the pandemic, we concluded that right now patient safety should not focus on the absence of harm. Instead, we will lead the effort to emphasize the presence of safety in healthcare. Every person in the healthcare journey should be equipped and encouraged to identify patient safety, celebrate it, and share the successes throughout the system. We invite each of you to explore the Presence of Safety web pages for resources you can use. We also invite you to use the communications toolkit to help us spread the word about the Presence of Safety in healthcare. In this month's Digital Magazine, we are introducing a series of the resources available through the Presence of Safety campaign. Each of them is intended to emphasize safety under the effects of COVID-19. One particular tool, however, focuses on the safety and wellbeing of the people providing care. Cumulative stress, compassion fatigue, and trauma due to experiences with patient safety incidents impact the mental wellness of our healthcare providers. These factors contribute to inadvertent patient care errors, mental health issues, and attrition which compromise patient safety. In partnership with the Mental Health Commission of Canada, we explored peer support options that not only help healthcare workers with their experiences with patient safety incidents but which also improve the system and help make patient care safe. The result is "Creating a Safe Space Addressing the Psychological Safety of Healthcare Workers." In exploring the resources available, you will discover A robust series of documents in four Sections along the side of the page. These include healthcare worker responses to healthcare harm, a scan of peer support programs and best practices, as well as the legal advice in their development. A toolkit of resources and templates from organizations across the globe who have successfully implemented their own peer support programs for healthcare providers. A webinar series of experts explaining the need for, and value of, peer support programs. If you are part of a healthcare organization considering peer-to-peer support programs to improve the emotional well-being of healthcare workers, this is the perfect place to start. Backed by research into programs from around the world and across Canada, this is the way to provide the best and safest care to patients. At the end of your journey of discovery, you can reach out to the Canadian Peer Support Network. This group is intended as a forum for healthcare organizations seeking guidance in the development of their peer support programs to assist providers who have experienced a patient safety incident. We ask you to spread word about these resources, and to support the healthcare providers who have been struggling during this pandemic. My inbox is open to you anytime at, and you can follow me on Twitter @ChrisPowerCPSI. Yours in patient safety, Chris Power 7/10/2020 4:00:00 PM Regular readers of Power Play will remember last month's theme. Patient safety is, of course, more important than ever. However, after months spent7/10/2020 4:42:41 PM679
CPSI CEO Chris Power Co-Authors Paper on Supporting Healthcare Workers During the Pandemic347617/3/2020 4:42:34 PMPatient Safety NewsSupporting the Emotional Well-being of Health Care Workers During the COVID-19 Pandemic ​Chris Power, CEO of the Canadian Patient Safety Institute, co-authored a paper published in the Journal of Patient Safety and Risk Management. Please find the details and abstract below. Authors Albert W. Wu, Peter Buckle, Elliott R. Haut, Tomasso Bellandi, Shunzo Koizumi, Alpana Mair, John Øvretveit, Chris Power, Hugo Sax, Eric J. Thomas, David Newman-Toker, Charles VincentFirst Published June 17, 2020 Abstract The COVID-19 pandemic is emerging as the defining health crisis of our generation. Health care organizations were already a high-risk environment for workers, who are exposed on a daily basis to the suffering of their patients, tragedy, and the potential for failure. Now, health care staff of all kinds are straining to meet the demands of caring for patients with the novel coronavirus. Caring for patients with COVID-19 places them at personal risk for infection, and also poses a threat to their emotional well-being. In the short term, caring for patients during the pandemic provokes fear, anxiety, and worry for workers and their loved ones. Workers may develop anger and frustration about working in suboptimal conditions, and anguish over difficult decisions. They may be thrown off balance by new and changing work requirements and routines. They may re-deployed away from their home units, and thus deprived of their usual network of social support. Their workplace may change in front of them, as when general wards are converted to biocontainment units for COVID-19 patients. All of these stresses can cause self-doubt and fears about competence. And it is difficult to care for severely ill and dying patients, and to witness those separated from their loved ones by infection control measures. If workers are not provided with sufficient emotional support, the distress can be disabling. It may render them less able to work to their full ability. This in turn can threaten the integrity of the health care workforce to deliver the volumes of care required by the pandemic. In the longer term individual workers are at risk for accelerated burnout, and for mental health problems like Post Traumatic Stress Disorder (PTSD). We consulted with health care experts on our international editorial board. We asked them to provide advice for health care leaders and managers and frontline clinicians for meeting the emotional needs of health care workers and supporting one another. Please read the full article on the Journal of Patient Safety and Risk Management. 7/3/2020 4:00:00 PMSupporting the Emotional Well-being of Health Care Workers During the COVID-19 Pandemic Chris Power, CEO of the Canadian Patient Safety Institute,7/3/2020 5:04:21 PM422
Patient Safety Power Play: The Presence of Safety609986/19/2020 7:09:56 PMPatient Safety Power Plays ​In the past few months, the healthcare world has changed dramatically. At the Canadian Patient Safety Institute, we have spent those months listening and thinking about what a Canadian healthcare system looks like after it has adapted to the realities of an ongoing pandemic. Patient safety is more important than ever. However, we cannot demand any additional strain, burden, or distraction from an overwhelmed healthcare system. We must adapt our thinking and approach to safety in Canada and globally. Our conclusion is that patient safety should not focus on the absence of harm. We should not simply count the number of incidents in hopes that those numbers go down next year. Instead, the Canadian Patient Safety Institute will lead the effort to emphasize the presence of safety in healthcare. Every person in the healthcare journey should be equipped and encouraged to identify patient safety, celebrate it, and share the successes throughout the system. The Presence of Safety can be hard to see, but each of us can learn to recognize it. We can learn to ask for it. Each of us – whether a patient or family member, a healthcare provider, an administrator, or leader – can learn to become an advocate for the presence of safety. Once you learn to look for it, you will find safety present everywhere, and know what to do if it is absent. In order to embrace this new focus, CPSI has had to reprioritize several campaigns to provide maximum support to patients, providers, and leaders during Canada's pandemic response. You will see a renewed emphasis on infection prevention and control – our recent STOP! Clean Your Hands Day campaign featured messaging to help flatten the curve to reduce the pandemic's impact and tools to show how to clean hands effectively. You will see frequent mentions of our partnership to support the psychological health and safety of healthcare workers, including peer support programs. Additionally, you will start seeing new work on topics shared among all of the pan-Canadian Healthcare Organizations, such as patient partnership and engagement, safety systems and guidance, as well as patient safety in virtual care. We are hoping that you can join us, to help be our voice as we focus on the Presence of Safety in healthcare. Have you witnessed the presence of safety in peer support? What would you consider the presence of safety in virtual healthcare? Help us identify patient safety in patient partnerships, in moments of hand hygiene, and in all aspects of healthcare, wherever it is provided. Safety needs to be top of mind for all of us. This presents opportunities for positioning patient safety in our new world order. We will use this campaign to share tools, resources, and programs from CPSI and our partners to ensure they get into the hands of those who need them most! Help us spread the message that safety can be hard to see, but you can learn to see its presence – or to speak up if it's absent. My inbox is open to you anytime at, and you can follow me on Twitter @ChrisPowerCPSI. Yours in patient safety, Chris Power 6/19/2020 7:00:00 PM In the past few months, the healthcare world has changed dramatically. At the Canadian Patient Safety Institute, we have spent those months7/10/2020 4:41:33 PM1007
FOR THE LOVE OF NURSING, Featuring Chris Power609025/11/2020 7:54:34 PMPatient Safety Power Plays ​The World Health Organization declared 2020 the International Year of the Nurse and Midwife. In Canada, National Nurses Week takes place in the second week of May. During all the pressures and uncertainty of COVID-19, we have relied on nurses at the front lines of healthcare more than ever before – in these stories, we celebrate our staff, friends, and partners who have chosen this heroic life of sacrifice and service. “When I was in nursing,” said Chris Power, CEO of the Canadian Patient Safety Institute. “I had the unique privilege of being in people’s lives at their most vulnerable times. In their happiest moments, or to hold their hands while they died, I was part of an inside look in so many lives.” Chris Power graduated in 1977 with a four-year degree in Nursing from Mount St. Vincent and started work immediately at the Old Halifax Infirmary. As one of only three nurses there with a degree, she found herself recommended for supervisory or management roles. Eventually, that progress led her to her work as CEO of Capital Health in Halifax for nine years. When that role ended, she took the final professional position she will hold before retirement – the pan-Canadian, patient safety advocacy role with CPSI. While she misses the patient contact that was a priority for her throughout her career – as nurse, manager, or CEO, she made sure she spoke to a patient every day – there are so many benefits to her position. However, when she is asked for her advice on career paths for young people, she always recommends nursing. “Nursing is the best training you can get,” Chris stated. “A nurse learns but is also trained in resiliency. We problem-solve, juggle tremendous workloads, figure out workarounds, and must display both leadership and followership. It grounds you so much. I take my lessons in listening, collaboration, and observation and still use them every day.” This training, along with their position as the healthcare providers who engage with patients more than any other, means that nurses have enormous roles to play in patient safety. Whether in community care, hospitals, or long-term care, their training is what keeps patients and themselves safe. In fact, Chris’ nursing training helped prepare her for even this unprecedented pandemic. “As a nurse, you must be ever ready for a crisis,” she said. “A patient gets sicker, a cardiac arrest – you have to be adaptive every single day. I’ve also provided leadership through a number of crises – SARS, H1N1, and SwissAir.” Her best advice, even during this global panic, is to not sweat the small stuff. Stay calm, collect the best evidence, and apply it. “I developed a plan for myself, for my family, and for CPSI,” Chris said. “There is a light at the end of the tunnel and this too shall pass.” The Canadian Patient Safety Institute honours the efforts of all nurses – indeed, all healthcare providers – across Canada and around the world. They are some of our strongest advocates for patient safety and patient care. The safety of patients is absolutely essential to proper healthcare, and we rely on nurses every day. Thank you. 5/11/2020 7:00:00 PM The World Health Organization declared 2020 the International Year of the Nurse and Midwife. In Canada, National Nurses Week takes place in the5/21/2020 5:54:05 PM891
STOP! Clean Your Hands Day a Success!609075/11/2020 5:20:38 PMPatient Safety News ​This was the best STOP! Clean Your Hands Day to date in terms of social media engagement. The hashtag #stopcleanyourhands had 7.822 million Twitter impressions. This is not only the best SCYHD use of a hashtag, this is CPSI's best day ever for use of a hashtag. Government Relations on Social Media There was no shortage of government relations supporting STOP! Clean Your Hands Day from all levels of government, Federal, Provincial and Municipal. The hashtag #stopcleanyourhands had the highest government use in CPSI's event history. Campaign Participation Over 2,200 people in Canada completed the Clean Hand Self-Assessment to ensure they are cleaning their hands properly to protect themselves and their loved ones from infections. Plus, 403 people in Canada pledged clean hands to tell the world they are committed to cleaning their hands. Plus we had a tremendous amount of people accessing hand hygiene resources from CPSI to help people keep themselves and others safe. Media 47 online publications, with a total reach of around 13M mentioning STOP! Clean Your Hands Day A mention on CTV News at 5 in Montreal and a story on CHCH Hamilton, for a 2.8M person reach (broadcast/online) Over 300 social media references to @patient_safety, with the highest reach accounts including Timothy Caulfield, Canadian Nurses Association and the Durham District School Board. In addition, Dr. Theresa Tam took time in her daily update to speak about STOP! Clean Your Hands Day. This is a GR activity that came to light in the media. Watch a broadcast link picked up by CHCH in Hamilton, Ontario.Thanks to everyone who participated in STOP! Clean Your Hands Day this year. Special thanks to Natalie Nymark for her terrific social media posts. As a token of gratitude, IPAC Canada will be providing her with free registration for the 2021 IPAC conference.Did you take the Clean Hands Self-Assessment? Did you Pledge Clean Hands? Share your experience with #STOPCleanYourHands – clean care matters now, more than ever, on May 5 and every day! 5/11/2020 5:00:00 PM This was the best STOP! Clean Your Hands Day to date in terms of social media engagement.  The hashtag #stopcleanyourhands had 7.822 million5/11/2020 10:10:05 PM503

 Latest Alerts



Preventable Tragedies: Two Pediatric Deaths Due to Intravenous Administration of Concentrated Electrolytes4944138151/16/2029 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 PM
Pediatric fall incidents in hospitals4956539096/9/2020 6:00:00 AMFallsKorea Patient Safety Reporting & Learning SystemThis alert describes an analysis of pediatric fall incidents. Reports from July 2016-Apr. 2020 indicated that there were 291 reported falls incidents for children aged 0-9 years. Environmental factors that contributed to these pediatric fall incidents include misuse of bed rails (36.1%), absence of carers (25.7%), pedestrian aids (6.9%), chairs (3.0%), and medical devices (1.2%). Recommendations for preventing recurrence include implementing a fall risk assessment, active participation of patients and carers, and using training materials in eyesight of patients. 7/20/2020 4:51:00 PM
Managing Mild COVID-19 Symptoms at Home4853239085/14/2020 6:00:00 AMCOVID-19Institute for Safe Medication Practices CanadaThis newsletter provides information for consumers who have mild symptoms of COVID-19 or are caring for someone with such symptoms. It advises that they may be able to recover at home in isolation without needing hospital care. A telephone call or virtual appointment with a doctor, nurse practitioner, family health team member or public health unit can provide consumers with instructions. This might include advice on treatment, monitoring, isolation/quarantine, and safety precautions for other family members in the consumers home. Mild symptoms such as fever and pain may be managed with nonprescription medications such as acetaminophen (e.g. Tylenol®). The newsletter provides safety tips for using acetaminophen as well as isolating at home or caring for someone with COVID-19 symptoms.6/15/2020 4:00:06 PM
Strategies for Safer Telephone and Other Verbal Orders in Defined Circumstances4855439055/7/2020 6:00:00 AMMedicationInstitute for Safe Medication Practices CanadaThis Safety Bulletin addresses the safety strategies that should be implemented when prescribing and dispensing verbal medication orders. ISMP Canada encourages the use of written orders, including electronic orders, to prevent medication errors. However, the current pandemic has increased the need for and frequency of telephone and other verbal orders. An incident is described. A community pharmacy reported to ISMP Canada that a miscommunication in a telephone order for hydromorphone led to dispensing of the oral liquid formulation instead of the intended injectable formulation. The oral product was injected by a home care nurse, which resulted in harm to the patient. The bulletin describes a number of contributing factors that may lead to medication errors associated with verbal orders. This bulletin shares recommendations for practitioners to minimize the risk of errors when communicating medication orders verbally.7/22/2020 4:18:30 PM3
COVID-19 Alerts, Advisories and Recommendations Coming Soon4904239025/7/2020 6:00:00 AMCOVID-19With the ongoing health crisis, CPSI is committed to providing information related to the COVID-19 pandemic. Alerts and recommendations from our contributors are coming soon. Stay tuned. 5/11/2020 3:49:35 AM