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Nova Scotia Health Authority implements the Patient Safety Culture Bundle to help provide safe, reliable and effective quality care779813/24/2020 8:47:58 PMSuper SHIFTERS #SuperSHIFTER Gail Blackmore is the Senior Director of Quality Improvement and Safety with Nova Scotia Health Authority (NSHA). NSHA has adopted the Patient Safety Culture Bundle for CEOs and Senior Leaders to develop a positive patient safety and quality culture strategy and is implementing a dashboard to monitor their culture of quality and patient safety. Why did Nova Scotia Health Authority choose the Patient Safety Culture Bundle to support its patient safety and quality improvement work? Our patient safety and culture strategy framework is modeled from the Canadian Patient Safety Institute's Patient Safety Culture Bundle for CEOs and Senior Leaders (Bundle). The Bundle is a good match for us. It provides clarity and direction to healthcare leaders on the components involved in providing safe, reliable and effective care. The vital practices that are embedded into the Bundle are evidence-based and this is important from our perspective. We are committed to fostering existing practices and identify and implement new approaches, and the Bundle presents a way to do that. The Bundle has three key elements – Enabling, Enacting and Learning – and actions to focus on in each of the elements that cover the key concepts of patient safety. There are also additional resources available, if you want to learn more about the key concepts. The Bundle is very comprehensive. It really acknowledges that there are multiple inputs and complexity in a safety culture for healthcare. Can you provide examples of how the Bundle has helped to better align your work? Since the activities noted in the Bundle are based on best practices and are found to have a positive impact on improving patient safety culture, it facilitated alignment of internal activities to focus our actions. Examples include patient stories, which are now being used across the organization to begin team meetings, start a discussion on quality and safety, and refocus the work on the experience of the patient and family. Through the Bundle, we have also been able to do a deeper dive into just culture and expand the use of safety huddles and leadership safety rounds. A partnership with NHS Scotland/Education for Scotland to pilot safety culture discussion cards for healthcare teams, educators and leaders was highlighted at the 2019 Institute for Healthcare Improvement (IHI) National Forum on Quality Improvement in Health Care through a poster presentation by Erin Beaton, a Quality Director in our team. Safety Huddles were confirmed as an organizational priority to create system-wide and patient-specific changes and to support teamwork. An established working group continues to augment NSHA resources and processes to support Safety Huddles and evaluate their effectiveness. Reinforcing the goal of improving patient safety culture, Leadership Safety Rounds were additionally noted as an organizational priority initiative. The expansion of this practice has demonstrated Leadership commitment to building a culture of safety. The role of our patient and family advisors (PFAs) has also evolved – we have created a focused system to recruit and retain advisors, and to nurture meaningful engagement. PFAs are now an integral part of the decision-making working group for disclosure. They participate fully in this process, bring the patient and family perspective and are an equal voting member to determine recommendations from the working group. Patients and families are also involved in prospective reviews, as full members of the system-wide Failure Mode and Effects Analysis (FMEA) review team, with leaders, physicians and staff. This work in patient engagement is recognized as leading practices with the Health Standards Organization (HSO). Can you tell us about the dashboard you have developed to monitor and evaluate your quality and patient safety culture? The quality improvement and safety team and the performance and analytics team collaborated to develop the dashboard concept. The intention was to bring data from various sources together in a single location and provide NSHA with a user friendly, simple, yet comprehensive visual on important patient safety culture information that can be used to examine and understand performance at the organizational and zone levels. An Excel spreadsheet outlines the three Bundle elements and their associated evidence-based practices, along with selected indicators and the most current data. Aligned indicators were chosen from existing HSO and Accreditation Canada surveys, such as the patient safety culture, workplace and governance survey tools. A question from the Canadian Patient Experiences survey, an in-patient survey provided by the Canadian Institute for Health Information (CIHI), was selected to track patient engagement. Where existing Accreditation survey questions could not be aligned, we looked to internal processes and data already being collected to identify measurable indicators for each element of the Bundle. Examples include data reported within the organization's Safety Improvement and Management System (SIMS) and from monitoring patient and family advisor engagement on quality improvement and safety teams. The number of indicators per key concept was kept to a minimum, however in certain cases we did find it useful to map more than one question to a concept because it allowed a greater depth of information for those really complex areas, like just culture as an example. With the data organized in a visual way, it's a lot easier to analyze and translate data for action. To further ease analyzing a large amount of data points, colour-code formulas have been built in, similar to the red, yellow, green flag color scheme used in the accreditation surveys. The color coded flags provide a good visual of where we are doing well and where the opportunities for improvement are as it quickly brings important information together in a comprehensive way. We are still in early days of using the dashboard and the Bundle to look at our actions. We continue to seek opportunities to learn more from each other within our health system, through evidence-based tools like the Bundle, and by continuing to spread best practices. It takes perseverance, but we can do more together from that perspective. Can others replicate this evaluation process? Yes. The Bundle can be used to align and develop organizational frameworks. The dashboard indicators were chosen from existing HSO and accreditation tools wherever possible, so that is quite transferrable to other organizations. Indicators that did not map to an existing survey or tool were aligned to organizational priorities, and others would be able to do that as well. To learn more about the dashboard, contact 3/24/2020 8:00:00 PM#SuperSHIFTER Gail Blackmore is the Senior Director of Quality Improvement and Safety with Nova Scotia Health Authority (NSHA). NSHA has adopted the3/24/2020 9:00:00 PM184
CPSI signs agreement advancing First Nations health priorities687443/18/2020 8:22:05 PMPatient Safety News​ ​(Left to right) Marion Crowe, Executive Director, FNHMA; Maryanne D’Arpino, Senior Director, Canadian Patient Safety Institute; and Patricia Thomson, President, FNHMA ​ The Canadian Patient Safety Institute and the First Nations Health Managers Association (FNHMA) have signed a memorandum of understanding (MOU) to work together to advance First Nations health. The MOU pledges shared interests in client/patient safety, health system improvement and capacity development for First Nations leaders and communities, and ultimately working toward reconciliation for First Nations health. "This is an exciting juncture for both the FNHMA and the Canadian Patient Safety Institute," says Marion Crowe, Chief Executive Officer, FNHMA. On behalf of the FNHMA Board of Directors, we are thrilled to be moving forward on this partnership agreement and see it as a very fruitful, reciprocal relationship where we are working together toward health equity and accessibility for First Nations." "We are truly inspired by and grateful for this opportunity to work in partnership, to take this journey with the FNHMA to advance patient safety and quality in First Nations communities," says Maryanne D'Arpino, Senior Director, Canadian Patient Safety Institute. "This partnership is about gaining a better understanding of how patient safety is defined and what that means to the Indigenous population. It is a very collaborative, open relationship where we can learn from each other in a patient safety context." As the partners see opportunity and agree on joint activities, an annual work plan will be developed. The partnership will address collaboration and cooperation in three key areas Information sharing and capacity development initiatives to develop and deliver information, knowledge, training and development services that reduces the harm experienced by people and increases the presence of safety for the benefit of people served by both organizations; Health system initiatives to enhance relationships between First Nations communities; and Health leadership initiatives to support continued development of leaders in First Nations health and to foster shared learnings of health system leaders across Canada. "There are some great synergies and opportunities between our organizations to build capacity with the goal of preventing harm," says Maryanne D'Arpino. "For example, we can draw from lessons through our partnership with Indigenous Services Canada in building capacity in incident management for healthcare professionals working in communities across Canada. Building on this momentum, we will better understand how the patient safety competencies can be translated and integrated within health professional training and education. Our opportunity to partner with Indigenous patients and listen to their advice guides our true north," Maryanne continues. "Patients for Patient Safety Canada, a patient-led program of the Canadian Patient Safety Institute, recently welcomed Samaria Cardinal as a new member. Samaria's story is a way to bring awareness as we begin to shape and define what patient safety means to Indigenous people. Patient safety and patient engagement need to be synonymous, and this will be foundational to our journey in improving patient safety." "These are the types of synergies that we hope to unpack through this partnership agreement," says Marion Crowe. "Overall, working with the team at the Canadian Patient Safety Institute will open up opportunities in patient safety that our communities may not have engaged in before. Anything that is grounded in patient safety will ultimately benefit and enhance our service delivery." FNHMA provides training, certification, and professional development opportunities in First Nations health management and serves the needs of individuals working for, or aspiring to, health manager positions with First Nations organizations. Each year, some 350 individuals are trained as Certified First Nations Health Managers (CFNHM), including non-Indigenous partners of the First Nation community (such as representatives from Regional Health Authorities). "Our curriculum is grounded in community and culture and it is always a valuable experience for our non-Indigenous allies to attend our program," says Marion Crowe. "It gives us an opportunity to learn from one another and to showcase what we have worked on for the past 10 years as an organization." Currently, there are 225 CFNHMs working in First Nations communities from coast to coast. Health managers serve in an administrative capacity in the delivery of health services to their First Nation communities, much like the role of a CEO in a traditional hospital setting. They are responsible to their funders, community and the general population of the membership on the reserves. The FNHMA provides leadership in First Nation health management activities by developing and promoting knowledge, quality standards, practices, research, certification, networking and professional development to expand capacity for its members and First Nations communities. "The pen I am holding was a gift, used as a tool to pledge our public commitment and to bind our agreement," says Maryanne D'Arpino as she prepares to sign the MOU on behalf of CPSI. "It symbolizes the culture that FNHMA creates as a mark of true leadership and comradery. The pen is made of maple, which is a symbol of strength. Maple bark is used as a medicinal herb and the Rocky Mountain Maple is considered one of the Sacred Life medicines. This gift holds special meaning as a symbol of strength and solidarity as partners. Thank you, Marion, Patricia and the FNHMA!" 3/18/2020 8:00:00 PM (Left to right) Marion Crowe, Executive Director, FNHMA; Maryanne D’Arpino, Senior Director, Canadian Patient Safety Institute; and Patricia3/18/2020 8:49:32 PM148
Progress with the Policy, Legal and Regulatory Affairs Advisory Committee5753/6/2020 10:18:00 PMPatient Safety News ​On February 11 and 12, 2020 the Policy, Legal and Regulatory Affairs Advisory Committee (PLRA) met in person in wonderful, spring-like Vancouver. The committee is mandated to provide strategic advice that enables CPSI to influence patient safety issues and directions as they relate to federal, provincial, and territorial health priorities and policy, health law and legislation, and regulatory systems and processes. Membership of the inter-professional committee consists of experts with health care leadership and policy experience from across Canada, including representation from Patients for Patient Safety Canada, government, legal and policy expertise, and regulatory bodies. Rob Attwell, cofounder and COO of Careteam, led the committee on a tour of the Careteam Dev Hub during the afternoon of the 11th. That evening Dr. Alexandra Greenhill, CEO of the Careteam, presented on Artificial Intelligence (AI) in support of patient safety and quality. Discussion followed the fascinating presentation regarding AI, its uses, and issues to be considered for the future. The PLRA then participated in a full day meeting on February 12th to provide guidance on current and emerging issues in a policy context. Special guests Dr. Chris Hacker, Registrar/CEO of the College of Dental Surgeons (CDS) of BC, and Mr. Harry Cayton, International Advisor to the Professional Standards Authority, provided details about the recommended overhaul of CDS regulations and changes to the BC Health Professions Act to prioritize patient safety as mandated by the provincial government. Mr. Cayton also provided a presentation on how regulations can inform and improve patient safety. The day concluded with an interactive exercise that centered on the CPSI Policy Framework’s five policy levers. CPSI developed a conceptual model to identify, implement and evaluate policy levers that would improve patient safety legislation, regulations, standards, organizational policies and public engagement. The PLRA Committee reviewed initiatives advancing each of the policy levers to advise on priorities, potential roadblocks, and ways to overcome the roadblocks. Moving the needle on patient safety in Canada requires an overall shift in culture, values and expectations at all levels of the health system and the active engagement of various policy actors. Patient safety does not just depend on specific improvement efforts, practices and rules, but on achieving a culture of trust, reporting, transparency and discipline across the healthcare system. What will be key to the effectiveness of the policy levers, such as legislation and public awareness, is the ongoing evaluation of policies and mechanisms for knowledge exchange. CPSI published this new policy framework in November 2019 click here to learn more. 3/6/2020 10:00:00 PM On February 11 and 12, 2020 the Policy, Legal and Regulatory Affairs Advisory Committee (PLRA) met in person in wonderful, spring-like Vancouver. 3/11/2020 7:35:05 PM242
Patient Safety Power Play: On the coronavirus, clean hands, and collaboration28713/5/2020 7:04:43 PMPatient Safety Power Plays Since the beginning of the COVID-19 outbreak, more and more countries – including Canada – are reporting cases. Localized and even internationally coordinated efforts to stop the spread of the disease may not be enough to prevent a global outbreak of coronavirus.1 While the risk to Canadians is still low, it is important to be prepared at the individual and community levels for all possible scenarios. The Canadian Patient Safety Institute has a serious responsibility to respond to this potential pandemic. As part of our role in helping to keep the people of Canada safe within our healthcare system, we must perform two tasks and perform them well We must reach out through our networks of healthcare system partners and social media followers to share information about how people can keep safe. We must rely on only the highest-quality information on how to stay safe in order to counter the spread of misinformation. Fortunately, CPSI is well placed to accomplish the first task. Not only have we spent years building connections within the healthcare industry, but our recent focus on public engagement through the #ConquerSilence campaign has resulted in a much higher public profile. In addition, we have partnered with the World Health Organization (WHO) in the areas of infection prevention and control as well as in patient engagement.The outcome of these efforts can be best seen in STOP! Clean Your Hands Day, the Canadian aspect of the WHO's global "Clean Hands Save Lives" campaign that runs every May 5th. We have been delivering this event for 13 years. We know that one of the most effective ways to contain the spread of infections – including the flu, healthcare-acquired infections, and the coronavirus – is to clean your hands, and we are ideally positioned to share that message.You can help. You can register for STOP! Clean Your Hands Day so that you receive updated information about the campaign and information about infection prevention activities happening in Canada that day. You can also share effective messages like this on social media, to reinforce the importance of clean hands for safe care.Our second task could be more difficult for our small organization to research by ourselves. However, we know exactly where to turn. You can find the most accurate, updated information about the COVID-19 outbreak on Health Canada's website. The site includes cases identified in Canada, as well as prevention, symptoms and treatment, and advice for travellers. To draw on only one example, I focused on what each of us can do as individuals to stop the spread of infection. The website complied with excellent, common-sense instructions such as Stay home if you are sick. Encourage those you know are sick to stay home until they no longer have symptoms. Respiratory viruses are spread through contact. Change your regular greeting from handshakes, hugs and kisses to a friendly wave or elbow bump. Practice frequent hand hygiene and coughing/sneezing etiquette. Clean and disinfect frequently touched objects and surfaces, such as toys and doorknobs. As you can see, the site offers practical solutions as well as information on the disease that is based on scientific fact from healthcare research. You will not find colloidal silver or sesame oil "cures" here. In order to mitigate the impact of the coronavirus, everyone has a role to play. CPSI will continue to reach out through our vast partner networks to share only the best information to keep people safe. I thank you so much for your help in our efforts. My inbox is open to you anytime at, and you can follow me on Twitter @ChrisPowerCPSI. Yours in patient safety, Chris Power 1 Health Canada, Coronavirus disease (COVID-19) Being prepared https// 3/5/2020 7:00:00 PMSince the beginning of the COVID-19 outbreak, more and more countries – including Canada – are reporting cases. Localized and even internationally3/5/2020 8:39:20 PM608
CPSI and PFPSC shine in global expert meeting28753/5/2020 6:25:11 PMPatient Safety News In May 2019, the 72nd World Health Assembly adopted resolution WHA72.6 “Global Action on Patient Safety” recognizing patient safety as a key global health priority. This was a watershed moment for patient safety around the world… It is truly time for Patient Safety Right Now! The resolution established World Patient Safety Day to be observed annually on September 17th and Canada rose to the challenge with our celebration! Amongst several key actions, the resolution requests that the WHO Director-General to formulate a global patient safety action plan by May 2021 and report on its progress every two years at the World Health Assembly. ​ ​Sandi Kossey and Ioana Popescu at the World Health Organization headquarters in Geneva To begin formulating this Global Patient Safety Action Plan, WHO brought together global experts, stakeholders and partners for three days in Geneva, Switzerland. As a revered national and global authority on patient safety improvement and as a WHO Collaborating Centre on Patient Safety and Patient Engagement, the Canadian Patient Safety Institute (CPSI) was a critical contributor to the meeting. Sandi Kossey, Senior Director of Strategic Partnerships & Priorities, and Ioana Popescu, Senior Program Manager, joined other experts, advisors, researchers, academicians and representatives from all WHO Regions and Headquarters. More than 45 countries, 20 international organizations and associations, economic organizations, foundations and patient groups were represented, including members of the Patients for Patient Safety Advisory Group and Global Network which CPSI supports through its WHO Collaborating Centre Terms of Reference. During the meeting, which was chaired by Sir Liam Donaldson with support from Ed Kelly and Neelam Dhingra, CPSI’s longstanding global leadership on patient partnership through its support to Patients for Patient Safety Canada was regarded as a gold standard which should be emulated and spread around the world via the action plan. Our successes with the Integrated Action Plan, the Conquer Silence Campaign, the Patient Alliance for Patient Safety, and the many foundational patient safety and patient engagement frameworks and resources were highlighted as potential contributors to the plan. The Global Patient Safety Action Plan is a commitment of WHO, international health agencies and Member States to definitive action to reduce the overall burden of patient harm due to unsafe care and will be based on the guiding principles of equity, sustainability and accountability. The action plan will seek inspiration from and coherence with other global priorities and patient safety challenges. It will be strategically positioned to advance WHO’s work to achieve Universal Health Coverage and is aligned with the United Nations’ Sustainable Developmental Goals. The plan will be a roadmap for “A Decade of Patient Safety 2020-2030” as a WHO Flagship Initiative. ​ ​ In the Executive Board Room of the World Health Organization headquarters in Geneva, experts from 40 countries set the foundation for “A Decade of Patient Safety 2020-2030 Formulating the Global Patient Safety Action Plan”. Patient safety is finally being given the attention and priority it deserves. Canada should be proud of our commitment and successes so far, and of our global leadership in patient safety and patient engagement, and we should be inspired to join the global community in making care as safe as possible, as soon as possible. By the end of the decade, in 2030, we believe Canada and the world will have much to celebrate. A PFPSC patient partner noted once that “the knowledge and energy within those who have experienced harm is like Niagara Falls before they were harnessed to produce the great social benefits that they have for so many years. There exists no more powerful experience than this to provide motivation to have something good come of something tragic – to honour the loved one that we have lost and to prevent others from suffering similar harm”. The global patient safety action plan, “A Decade of Patient Safety 2020-2030” is set to harness the power of patients, providers and leaders from around the world to create visible and sustained patient safety improvement. We can only do this with you. Reach out to Patients for Patient Safety Canada at 3/5/2020 6:00:00 PMIn May 2019, the 72nd World Health Assembly adopted resolution WHA72.6 “Global Action on Patient Safety ” recognizing patient safety as a key3/5/2020 10:03:12 PM370

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Handicare/Prism Medical C series Ceiling Lift -Potential of Sling Straps Not Remaining on Carry Bar869381010/7/2019 6:00:00 AMDeviceAlberta Health ServicesThis alert discusses the potential patient safety incidents involving the use of the Handicare/Prism Medical C series ceiling lift. The open design of the bull horn hooks on the device carry bar may increase the risk of the sling loops coming off the carry bar. Any unloading of tension on the sling straps during sling application or patient repositioning while in the sling may result in the sling loops coming off the carry bar hooks and harm to the patient. The alert provides recommendations to staff and managers to ensure safe patient lifting with this device.2/6/2020 8:38:28 AM3
Electronic Prescribing in Primary Care: Effects on Medication Safety1976374212/18/2018 7:00:00 AMMedicationInstitute for Safe Medication Practices CanadaThis Safety Bulletin discusses the support for medication safety as well as some hazards of electronic prescribing (e-prescribing). E-prescribing in primary care is defined as “the secure electronic creation and transmission of a prescription between an authorized prescriber and a patient’s pharmacy of choice, using clinical electronic medical record (EMR) and pharmacy management software.” This bulletin focuses on select findings from an environmental scan and literature search conducted by ISMP Canada examining the effects of e-prescribing on medication safety (both benefits and unintended introduction of risk) as well as lessons learned from some early-adopting jurisdictions. The key medication safety benefits identified were: • Improvement in prescription communication between pharmacists and prescribers • Support for opioid safety strategies. E.g. providing alerts when doses exceed recommended guidelines • Support for better medication adherence ensuring that all prescriptions are received by the pharmacy • Patient engagement through online patient-facing applications where patients can view their own medication profile and e.g. add otc medications for a more complete profile. The unintended introduction of risks included: • Prescription modifications missed by the system as when e.g. a change is made to a prescription which has already been transmitted. • Loss of prescription bundling where all prescriptions for the same patient are not transmitted at the same time and may be missed at the pharmacy. • Confusing free-text entries where supplementary information may be e.g. contrary to the prescription instructions • Reduced patient engagement since the prescription is sent directly to the pharmacy without a chance for the patient to review it.9/17/2019 4:00:41 PM
Medication Reviews in Long-Term Care Homes1858376111/24/2018 7:00:00 AMMedicationInstitute for Safe Medication Practices CanadaThis newsletter discusses the value of medication reviews in long-term care facilities and/or nursing homes. A medication review with the pharmacist is a good time for residents, family members, and other caregivers to ask questions about medications or talk about any concerns. A specific incident is described. A resident in a long-term care home was mistakenly started on a medication called trazodone. This sleep medication should have been given to someone else with a similar name. The mistake was discovered a year later when a medication review took place. Because of the review, the error was noticed, and the medication was stopped. Afterwards, family members commented that their loved one had seemed more tired than usual over the past year, but they did not know to mention it. Suggestions regarding medication reviews are provided for families with loved ones living in a long-term care home.9/17/2019 3:59:59 PM
Do Not Use a Syringe for a Topical Product – A Focus on Chlorhexidine Disinfectant Solutions1979374111/21/2018 7:00:00 AMMedicationInstitute for Safe Medication Practices CanadaThis Safety Bulletin discusses the patient safety incidents which may occur when topical solutions such as chlorhexidine are administered via a syringe. The practice of drawing a medication intended for topical use into a syringe is unacceptable. The bulletin stresses that the risk for inadvertent wrong route injection exists for any topical solution that is used in an environment where syringes are present and reminds the reader that previous recommendations from ISMP Canada have warned against the use of open containers to hold medications intended for injection. Recommendations aimed at hospital procurement as well as clinical management and staff are provided to prevent administration of topical solutions by the wrong route.9/17/2019 4:00:42 PM6
Alarm Default Settings-LIFEPAK Monitor/Defibrillator2496380910/25/2018 6:00:00 AMDeviceAlberta Health ServicesThis alert discusses potential patient safety incidents for patients being monitored by the LIFEPAK 12, 15 or 20 device when the audible alarm function has been disabled. The alarm function may default to the “off” setting to avoid disruption during a code. When “off” the alarm function may not alert users to a sudden change in a patient’s vital signs. The alert provides recommendations to health care providers and managers to ensure reduced risk of adverse events occurring with this device.11/7/2019 5:47:14 PM3