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Creating a Safe Space: Psychological Safety of Healthcare Workers28651/16/2020 9:52:31 PMPatient Safety News ​​Creating a Safe Space Psychological Safety of Healthcare Workers is a comprehensive guide and toolkit that provides Canadian healthcare organizations with the resources they need to develop and sustain a peer-to-peer support program. The Canadian Patient Safety Institute has created a comprehensive guide and toolkit that provides Canadian healthcare organizations with the resources they need to develop and sustain a peer-to-peer support program (PSP). Creating a Safe Space Strategies to Address the Psychological Safety of Healthcare Workers provides a broad overview of what peer support is available in Canada and internationally. The guide outlines best practices, tools, and resources. These help policy makers, accreditation bodies, regulators, and healthcare leaders assess what healthcare workers need in terms of support, and to create PSPs to preserve their emotional well-being. The result enables healthcare organizations to provide the best and safest care to their patients. Some healthcare organizations are unable to provide the support needed to their staff and managers to maintain a healthy and resilient workforce. Albert Wu coined the term "second victim"1 to describe a healthcare worker after a patient safety incident. The "second victim phenomenon"1, 2 describes healthcare providers who are psychologically traumatized by events during the provision of care, resulting in anxiety and depression, decreased performance, high turnover rates, and increased patient safety incidents3. Various studies estimate that the prevalence of the second victim phenomenon ranges from 10.4 per cent up to 43.3 per cent3. Healthcare is a high stress environment. Healthcare providers are expected to work efficiently and safely in often difficult and pressured settings. Over the past decade, research has identified the clear link between a provider's mental health and healthcare outcomes, including patient safety, with the probability of contributing to a preventable incident increased when the provider is suffering from psychological distress4. For example, a healthcare professional may feel emotionally traumatized after a sudden or unexpected bad outcome, a patient safety incident, the loss of a patient with whom they feel close, workplace conflict, or dealing with multiple trauma cases. "While patients and families will always be the first priority in healthcare, workers also need to be supported as a result of what they experience in their profession," says Markirit Armutlu, Senior Program Manager, Canadian Patient Safety Institute. "Peer-to-peer support programs, where health professionals can discuss their emotional distress in a nonjudgmental environment with colleagues who can relate to what they are going through, are now seen as an effective approach to helping health professionals cope and provide a safe space where they can get extra support." Creating a Safe Space is divided into four sections Section 1 provides the results of a pan-Canadian survey of healthcare workers to determine what support they needed and identified gaps in that support. Section 2 includes knowledge from international literature so that we can learn from those who have established or studied healthcare PSPs. Section 3 addresses confidentiality and legal privilege for peer support programs. It provides clear explanations about what is and is not privileged information and how best to strengthen confidentiality. Section 4 provides a step-by-step approach to help healthcare organizations succeed in creating a PSP. It includes recommendations on how to recruit and train peer supporters and how to ensure spread and sustainability of the program. A webinar series has also been created to learn from others who have implemented PSP programs. In partnership with the Mental Health Commission of Canada, the Canadian Patient Safety Institute has compiled the Creating a Safe Space Toolkit with input from experts and contributing organizations. "The Toolkit is an excellent source of information for healthcare workers, leaders, regulators, and policy makers that includes templates, examples, and recommendations for anyone who is embarking on creating a PSP," says Armutlu. "The searchable database provides links to documents and examples from existing peer support programs for healthcare providers." 1 Wu AW. (2000) Medical error the second victim. The doctor who makes the mistake needs help too. BMJ. 320726-727. 2 Scott SD. (2011). The second victim phenomenon A harsh reality of health care professions. Perspectives on Safety. Patient Safety Network. AHRQ. 3 Edrees H, Connors C, Paine L, Norvell M, Taylor H, Wu A. Implementing the RISE second victim support programme at the Johns Hopkins Hospital a case study. BMJ Open. 2016;(6);1-12. doi 10.1136/bmjopen-2016-011708 4 Burlison, JD et al. (2018). The Effects of the second victim phenomenon on work-related outcomes Connecting self-reported caregiver distress to turnover intentions and absenteeism. J Patient Safety. Author manuscript; avail. in PMC. 1/16/2020 10:00:00 PM Creating a Safe Space: Psychological Safety of Healthcare Workers is a comprehensive guide and toolkit that provides Canadian healthcare1/17/2020 6:32:53 PM52
#SHIFTTALKS Building Engagement Capacity in Atlantic Canada9021/15/2020 9:04:34 PMSHIFT Talks by Kelli O'Brien Little did I know, when I volunteered to help with the planning and implementation of the Atlantic Health Quality and Patient Safety Collaborative's Engaging Patients in Patient Safety Collaborative in 2018, that I would be joining forces with such amazing experts with varied backgrounds. The collaborative included a knowledgeable faculty of patient partners and healthcare providers, leaders from the Canadian Patient Safety Institute committed to making healthcare safer, and specialists in science and the art of quality improvement from the Improvement Associates. It was truly a humbling and inspirational experience working with the faculty, the Canadian Patient Safety Institute, Improvement Associates, and the healthcare teams involved. Seventeen teams, representative of all four Atlantic Canadian provinces, were enrolled in the 12-month virtual collaborative, designed to increase the effectiveness of patient engagement in improving patient safety and quality. Building upon the Engaging Patients in Patient Safety A Canadian Guide, the teams accepted the challenge to improve patient engagement within their complex, ever-changing environments. The teams selected change ideas to increase effectiveness of patient engagement at point of care, at the organizational level, and/or to enable effective leadership to support patient engagement. Interestingly, nine teams focused either on strategies to increase effectiveness at the organizational level, and eight focused on strategies to increase effectiveness within specific care processes. The collaborative was unique in that all the learning and collaboration between teams occurred virtually as the teams never came together face-to-face for any of the learning events. The opening and closing events, as well as all the other activities, including the planning for the engagement, occurred remotely. The teams were certainly up to the challenges of working together within a virtual world and the planning group worked diligently to try to create the conditions to support collaboration. An active ingredient contributing to the success of the collaborative was the everyone teaches, everyone learns approach. Although the evaluation results are not yet finalized, informal discussions with team members suggest that the opportunity to learn from each other and from patient partners about successful strategies, as well as to share common struggles, was invaluable for participants. Flexibility and time were key enablers of the collaborative. Congratulations to the participating teams! I am hopeful for the future based on the teams' commitment to "conquer silence" – to hear and listen to the voices of patients and providers and empower and enable patients to be partners in care. This deep belief in engagement will help transform the healthcare system for exceptional care experiences with better outcomes for patients. Sustaining and building on the important work of the collaborative will indeed support the creation of "engagement capable environments" in our provinces.1 The Engaging Patients in Patient Safety Collaborative was co-chaired by Kelli O'Brien, Vice-President of Long Term Care, Rural Health and Quality, Western Health (Newfoundland) and Ioana Popescu, Senior Program Manager, Canadian Patient Safety Institute. 1https// 1/15/2020 9:00:00 PMby Kelli O'Brien Little did I know, when I volunteered to help with the planning and implementation of the Atlantic Health Quality and Patient1/15/2020 10:06:08 PM189
Patient Safety Power Play: A New Decade of Patient Safety590831/9/2020 10:42:57 PMPatient Safety Power Plays In the message I shared with you before the holidays, I spent some time looking back at progress we have made in patient safety over the past year. As we step forward to embrace a new year – indeed, a new decade – I want to cast our gazes forward to what we are doing at CPSI to improve patient safety… and how you can help! First of all, regular readers of Power Play will be familiar with our new public engagement campaign, #ConquerSilence. We asked every person in Canada to share the healthcare message that if something feels wrong, looks wrong or is wrong, speak up—in the moment. We launched the initiative last year during Canadian Patient Safety Week to wonderful response, but that was only the first step. Over the next year, we will ask you to #ConquerSilence within specific issues in healthcare. This month, we continue our focus on medication safety and the Five Questions To Ask About Your Medications. Next month, we will focus on Trauma and Falls – the biggest driver of patient safety incidents in the home care setting, accounting for roughly 115,000 patient safety incidents per year. Among other themes will be infection prevention, surgical errors, and misdiagnosis. We invite you to share your stories and advice on how others can keep themselves safe at This year will be significant for patient safety on another front as well, as our 18-month Safety Improvement Projects wrap up the formal collaborative sections and move into six-month monitored implementation phases. Guided by a Knowledge Translation/Quality Improvement integrated approach, our thirty teams across the country will apply the strategies they learned in our four projects to lead safety improvement in their institutions. We will continue to offer support and guidance as the teams implement their programs. We will also report on their progress and celebrate their successes! Finally, we are in the planning stages for several events that will help shine the spotlight on patient safety in Canada this year. In early May, we will ask you to help us celebrate STOP! Clean Your Hands Day in our effort to reduce preventable infections in healthcare. The second annual World Patient Safety Day arrives in September, only a month before our Canadian Patient Safety Week at the end of October. Each of these events will be opportunities for you to join us in our efforts to confront the third leading cause of death in Canada preventable patient harm. On behalf of the Canadian Patient Safety Institute, I continue to be delighted and empowered by your support in making patient safety a priority for our political leaders, for our healthcare institutions, and for everyone across the country. Watch for information about our new policy framework document next month. Together, we will make this new year count in our ongoing mission to reduce harm and ensure that every patient is safe. Questions? Comments? My inbox is open to you anytime at, and you can follow me on Twitter @ChrisPowerCPSI. Yours in patient safety, Chris Power 1/9/2020 10:00:00 PMIn the message I shared with you before the holidays, I spent some time looking back at progress we have made in patient safety over the past year.1/9/2020 10:52:37 PM220
#SuperSHIFTER Dr. Doug Cochrane: when it comes to patient safety, we can always do better590781/9/2020 4:08:47 PMSuper SHIFTERS #SuperSHIFTER Doug Cochrane, MD is the Board Chair of Interior Health in British Columbia. He served as Board Chair for the British Columbia Patient Safety and Quality Council, from its inception in 2008 until October 2019. He also served as the Provincial Patient Safety and Quality Officer for British Columbia, and is a former Board member and Board Chair of the Canadian Patient Safety Institute. A pediatric neurosurgeon, Cochrane obtained his medical degree at the University of Toronto, and completed a pediatric neurosurgery fellowship at the University of Toronto's Hospital for Sick Children. What professional accomplishment are you most proud of? There are two. The first is having the skills, ability and the opportunity to help as many children as I did who had neurosurgical ailments that could be treated effectively with surgery. This was all about decision-making and technical skill, but more importantly supporting families and their kids. The second is the establishment BC Patient Safety & Quality Council (BCPSQC). This came about because a group of care providers and administrators believed that we, health care professionals, have an obligation to improve care for patients, clients and peers, and that we had the knowledge and tools to do it. Creating an organization that supports this ideal has focused our health system on the "relentless pursuit of quality" so that we can provide the best care we can. Tell us about your work with the British Columbia Patient Safety and Quality Council. The BCPSQC is a facilitator of change. It is an active, vibrant and in my opinion (biased as it is) very influential organization that looks to opportunities worldwide – across Canada, to colleagues in the United States, Great Britain, New Zealand, Australia, and elsewhere to help inform how our health care system can be improved. The Council supports the understanding of issues and provides to partners the support, the best frameworks, and tools to achieve improvement. The Council is singly focused on improving care for patients and, with partners, acts to make health care better. It is also an organization that provides expert advice and confidential reviews for governmental organizations, colleges, and health authorities when requested. Is there a "personal passion" you are working on now? My greatest passion at the moment is trying to understand the world view and life experiences of indigenous peoples in the BC interior. The BC Interior has more indigenous people than in other health authorities elsewhere in British Columbia. The Interior has extraordinarily poor and extremely wealthy populations within our First Nations. Coming to appreciate the indigenous perspective of health has been an eye-opener for me. It has broadened my perspective to health, beyond health care, and certainly beyond the narrow field of neurosurgery. I look forward to this lifelong learning opportunity. What inspired your work in patient safety? While I chaired the BCPSQC, I had a number of frontline administrative roles. I was lead surgery at the Children's Hospital in Vancouver and grew through that organization, and numerous reorganizations, that eventually led to the current BC health authority structure. I provided neurosurgical care and was a senior administrator supporting the care that was being delivered by others. As the Vice-President of Medicine and the Vice-President of Safety and Quality for the Provincial Health Services Authority, I had the unique opportunity to see care being delivered and to be the person responsible for delivering care in the province-wide and diverse health care system that I and others were working to make better. There was an event where British Columbia and the leadership at the Children's Hospital led the country in openness, transparency, honouring of patients and learning from adverse events. This tragedy, a child's death, occurred following an error in the administration of chemotherapy. At the time, Lynda Cranston (President & CEO, Children's and Women's Health Centre), David Matheson (VP of Medicine) and Pat Evans (Head of Communications) were so very instrumental in showing me what my responsibilities were as a manager in care delivery – to undertake a comprehensive and respectful investigation; to provide open and ongoing communication with the patient's family; and to make the event known publicly so that others could learn from this experience. I learned that the cornerstone of the organization's responsibility was respectful, open and transparent communication with the family, the commitment to foster learning amongst other care providers and using our experience to develop system changes that would prevent similar events in the future. What important lesson have you learned about patient safety? We can always make it better. If we have the right mindset and commitment, and if we understand the context and nature of the care we deliver, we can make care better. We will never have everything perfect, yet, if you made a commitment to improve care, you always can. What is the best advice you ever received that helped shape your career? The best things that I have learned in my career – blending both my side of the scalpel and my side of the conversation – have come from families. Families know what is important to them, in comparison to my surgeon's perspective that is focused on the illness or technology. While I had a surgical contribution to make, I also needed to bring realism, in an appropriate and sensitive way, to my discussions with families and my recommendations. What matters to patients and families is the most important question that needs to be asked. If you choose not to ask the question, then the only perspective you will have is your own; too often a perspective that is not relevant to those to whom we are providing care. This philosophy respects the autonomy of the patient supported by respectful and honest realism that defines for care givers, what's important to our patients. For more insights, email Dr. Doug Cochrane at 1/9/2020 4:00:00 PM#SuperSHIFTER Doug Cochrane, MD is the Board Chair of Interior Health in British Columbia. He served as Board Chair for the British Columbia Patient1/9/2020 4:24:44 PM437
Patients Meet with Ministers of Health39012/19/2019 3:08:49 PMPatient Safety News It has been an incredible fall for Patients for Patient Safety Canada (PFPSC), whose efforts have made significant strides to raise awareness with elected officials and senior leaders in governments across Canada. During the months of October and November, PFPSC hosted four Patient Roundtables with Ministers of Health and senior policy makers in Newfoundland and Labrador, Manitoba, Nova Scotia and Prince Edward Island. As volunteers working for more than a decade with providers and health care leaders in Canada, PFPSC members have been and continue to be deeply concerned about what the recent patient safety data is telling us. RiskAnalytica’s 2017 report found that patients are harmed in Canada every minute and 18 seconds, and a patient safety related death occurs every 13 minutes and 14 seconds. For these reasons, PFPSC members felt that it was critical to take this message to elected officials across Canada. Through the creation of the Provincial and Territorial Patient Roundtables, PFPSC’s objective is to promote awareness and understanding about patient safety with Ministers of Health; begin open, honest and frank conversations about what is truly needed to make care safer; and raise concerns about the need for transparency and collaborations that are possible to achieve PFPSC’s vision - ‘Every Patient Safe’.   The first Patient Roundtable was in early October in Newfoundland and Labrador with Minister of Health Dr. John Haggie. Later that month, PFPSC hosted Patient Roundtables in Manitoba with Assistant Deputy Minister Avis Gray, Nova Scotia’s Minister of Health and Wellness, Randy Delorey, and Deputy Minister Mark Spidel on Prince Edward Island. Each roundtable has one overarching goal to strengthen provincial government commitment to safer care. In the 90-minute roundtable conversations, patients share their stories and recommendations for policy action. The conversations centre around three policy requests Do no harm prevention and learning through reporting Prevent further harm disclosure principles Engagement of patients active partners for safer care Each roundtable involves local patient partners from each province. Some are PFPSC members and some are new friends that have been made along the way. Overall, the huge success of these meetings tops off nearly a year of work from our dedicated PFPSC leadership, CPSI team members, and collaborators. The next stage is to focus on the connections made through this initiative with engaged provinces and territories and continue to move the needle on patient safety with more Patient Roundtables to be scheduled in 2020. Learn more about initiatives such as these on the Patients for Patient Safety Canada website. 12/19/2019 3:00:00 PMIt has been an incredible fall for Patients for Patient Safety Canada (PFPSC), whose efforts have made significant strides to raise awareness with12/19/2019 4:28:46 PM512

 Latest Alerts



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.11/7/2019 5:47:11 PM3
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