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Board and leadership announced for new Pan-Canadian Healthcare Quality and Safety Organization3851610/23/2020 9:17:30 PMPatient Safety News​Ottawa (ON) and Edmonton (AB) – Today, the leadership of the new organization formed through the amalgamation of the Canadian Patient Safety Institute (CPSI) and Canadian Foundation for Healthcare Improvement (CFHI) was announced. Ronald Guse and Dr. Lynn Stevenson are Co-Chairs of the Board of Directors, Jennifer Zelmer is President and CEO, and the senior leadership team was also unveiled. "As health systems across the country and around the world grapple with the COVID-19 pandemic, forming this new organization with an expanded capacity to support safe, high-quality healthcare and a more coordinated and patient-partnered care comes at a critical time," says Board Co-Chair Ronald Guse. "Under the thoughtful and strategic leadership of Jennifer Zelmer and her team, I have no doubt this organization will rise to the challenge." "We have a tremendous opportunity to achieve a shared vision of safe, high quality healthcare for all," agrees Board Co-Chair Dr. Lynn Stevenson. "I can think of no better time than the start of Canadian Patient Safety Week to introduce our new team who will harness the strengths of both organizations to improve healthcare with, and for, more people." The new organization will be fully introduced in the coming months, along with opportunities for stakeholders to partner to improve quality and safety. Until the organization completes the next steps in the amalgamation journey, it will continue to operate as CPSI and CFHI. "I am honoured and excited to be chosen to lead this new pan-Canadian organization with an expanded capacity and uncompromising focus on raising the bar for quality and safety in healthcare," says Jennifer Zelmer. "At this pivotal time, my promise to everyone committed to better healthcare is to work with you to deliver measurable, widespread and lasting improvement." A transition Board of Directors for the amalgamated organization has been named – with equal representation from both CPSI and CFHI boards – and the senior leadership team has also been selected (see backgrounder for biographies). In engaging with stakeholders across the country to explore their priorities and how the amalgamated organization can support them, some common themes have begun to emerge Be bold in actions to change the system Be clear and focused about our purpose Look to the future Strengthen diversity and inclusivity Share expertise and guide others Be agile and move quickly Over the next year, the new organization will continue to engage with stakeholders across the country to develop its strategy and chart a course for the organization. The newly amalgamated organization that brings together CFHI and CPSI works with partners to share proven healthcare innovations and best practices in patient safety and healthcare quality. Working together with patients and other partners, we can deliver lasting improvement in patient experience, work life of healthcare providers, value for money and the health of everyone in Canada. The organization is a not-for-profit charity funded by Health Canada. Visit cfhi-fcass.ca and patientsafetyinstitute.ca for more information. 10/26/2020 10:00:00 AM Ottawa (ON) and Edmonton (AB) – Today, the leadership of the new organization formed through the amalgamation of the Canadian Patient Safety10/25/2020 9:46:40 PM552https://www.patientsafetyinstitute.ca/en/NewsAlerts/News/Pages/Forms/AllItems.aspxhtmlFalseaspx
In Jennifer Zelmer’s Words: Virtual Care is new to most of us3841710/19/2020 8:17:24 PMPatient Safety News ​The Canadian Patient Safety Institute and the Canadian Foundation for Healthcare Improvement recently amalgamated. CEO of CPSI Chris Power retired, and CFHI CEO Jennifer Zelmer was named President and CEO for the newly amalgamated organization. In this monthly blog, Jennifer shares her thoughts about this month’s Digital Magazine topic. My first experience of virtual care was when I was living in Denmark. I had an eye infection and days after a visit to my ophthalmologist, my symptoms hadn't resolved. When I called her office to follow-up, I learned that she was away for several weeks so I sent a secure email to my GP asking if he could help. Less than an hour later, the reply came in. Don't worry, he said. He had looked up the medication that I had received in my electronic record and seen the lab results from a swab that my ophthalmologist had done. My GP told me that he had now prescribed a different antibiotic based on those results. No need to come to his office, he said, I could go directly to the pharmacy of my choice to have the prescription filled. Getting care without having to go to the clinic while my vision was blurry was priceless, as was being able to take my time to translate my GP's message to make sure that I understood it fully. Of course, today, in the middle of a pandemic, virtual care isn't just a nice-to-have option. That said, as it was for me when I had my eye infection, it is new for many patients and healthcare providers. In the past few months, more than half of Canadian adults who needed advice from a doctor connected with them by phone, video, or other types of virtual care. (source) Going forward, more than a third of us would choose virtual care as the first way we seek a doctor's advice. So virtual care is here to stay. But how do we make sure it is safe? Can we improve on what we have? Virtual care can improve timely access to care, quality and safety, and healthcare costs, but these benefits are neither automatic nor guaranteed. And the ways that it is designed and used can improve or threaten equity. Thinking safety, here are some practical ideas to think about While virtual care might be new, asking someone to join you for a healthcare visit shouldn't be and may be easier when visits are virtual. Whether it's a phone call, videoconference, or email, remember that you are allowed, and encouraged, to ask questions about your care. Patients who take an active role in their care tend to see greater improvements in their health. Finally, continuity of care is important. If possible, connect with your regular providers. If not, ensure that any new information is communicated to your circle of care. You can find more tips on navigating virtual care at ConquerSilence.ca. While you're there, sign up for Canadian Patient Safety Week and our team will tell you when the new series of PATIENT podcasts is released. Each episode will feature a different discussion about patient experiences with virtual care. What does safe, ideal virtual care look like for you? Let's continue to learn together. Take care, be well, and stay safe, Jennifer Zelmer Follow @jenzelmer 10/19/2020 8:00:00 PMThe Canadian Patient Safety Institute and the Canadian Foundation for Healthcare Improvement recently amalgamated. CEO of CPSI Chris Power retired,10/19/2020 10:06:32 PM231https://www.patientsafetyinstitute.ca/en/NewsAlerts/News/Pages/Forms/AllItems.aspxhtmlFalseaspx
The Final Patient Safety Power Play126219/27/2020 1:08:18 AMPatient Safety Power Plays ​As you may know, I am retiring at the end of this month. Six years ago, I was invited to lead an organization that was founded on one guiding principle we will not accept one more case of a patient being harmed. I saw a history of national leadership on developing evidence-based tools, of resources intended to educate and inspire safe care… most importantly, in partnership with patients themselves. I saw a groundwork laid for concerted and coordinated patient safety improvement in Canada. This inspired me. Every patient experience should be safe. However, patient safety incidents are the third leading cause of death in Canada. Most people – though fewer today than there were last year – are unaware that the problem exists. I am incredibly proud of what we have achieved at CPSI. Together, we built a new strategy on the ideas of demonstrating what works and strengthening commitment to harm prevention. We have extended those ideas by engaging both the public and policymakers into making Canadian healthcare safe, while making sure there is a patient voice at every table. Reflected right in the name of our strategy, we emphasized PATIENT SAFETY RIGHT NOW. Every day, we worked to implement and spread sustainable patient safety improvements. We requested a higher priority for patient safety in our healthcare systems. We committed to influencing policy, regulations, and standards to ensure evidence-based patient safety practices are requirements, not afterthoughts. I know that our achievements would not have been attainable if it were not for the exceptional staff, leaders, partners and the patient voice working along side us to inspire safer care. When I reflect upon my time with this wonderful organization, I firmly believe that our legacy is the success we have achieved in building the foundational elements for patient safety. The pending amalgamation of CPSI and CFHI will create the scale, breadth, and capabilities to more effectively improve healthcare for everyone in Canada. This amalgamation – along with the momentum we have built together – presents an opportunity like no other for the future. Without question, we all still have work to do, and we can do it far more effectively together. I have enjoyed an incredible journey with CPSI and will forever be a champion of patient safety. I have learned so much from you, my team at CPSI, and so many others around the world. I hope that the work that we have accomplished together will forge safer healthcare for all in the future. Without a doubt, the Canadian Patient Safety Institute has achieved what it set out to do. By trying new approaches, focusing on our strengths, and working together, the new organization can and will make the Canadian healthcare system safer for all health workers and patients. Push hard, be bold, and know that I am cheering you on. My inbox is open to you until October 1 at cpower@cpsi-icsp.ca, and you can follow me on Twitter @ChrisPowerCPSI – though I can't promise I will be updating it regularly. As I take on this new adventure, I simply want to say thank you to each and every one of you so much for your support, for being part of my journey. I remain… Yours in patient safety, Chris Power 9/26/2020 6:00:00 PM As you may know, I am retiring at the end of this month. Six years ago, I was invited to lead an organization that was founded on one guiding9/27/2020 1:21:13 AM635https://www.patientsafetyinstitute.ca/en/NewsAlerts/News/Pages/Forms/AllItems.aspxhtmlFalseaspx
CPSI, PFPSC and WHO: World Patient Safety Day 2020 Successes123519/25/2020 9:04:57 PMPatient Safety News ​Thank you so much for joining us in supporting the second annual World Patient Safety Day on September 17, 2020! In May 2019, all 194 World Health Organization Member States endorsed the establishment of World Patient Safety Day to be marked annually on September 17. Globally, 134 million adverse events contribute to 2.6 million deaths each year because of unsafe care. At 28,000 deaths per year in Canada, patient harm ranks third in mortality after cancer and heart disease. Building on the success of last year's World Patient Safety Day, we once again came together in a global commitment to recognize patient safety as a key health priority. To make patient safety a priority, we were proud to offer the following Canadian Patient Safety Institute Thank you for joining us for the live streaming of Building a Safer System, the documentary celebrating Canadian Patient Safety Institute's 17-year impact on Canada's healthcare system. #BuildingaSaferSystem In case you missed it, the documentary is available on our Youtube channel. Following the documentary screening and lively panel discussion on healthcare worker safety, former staff members, colleagues, and supporters of CPSI gathered online to re-connect and celebrate the organization. A panel of CEOs discussed the future of patient safety, and Donna Davis of Patients for Patient Safety Canada powerfully represented the patient voice. Click here to view the recording of the panel discussion and the closing keynote remarks. Patients for Patient Safety Canada Due to the diligent work and outreach of several of our Patients for Patient Safety Canada members, the 2020 World Patient Safety Day was recognized in Canada like never before! Not only did we see the CN Tower in Toronto lit up in orange to commemorate patient safety, but municipal buildings in Saint-Laurent Montreal, Mississauga, Calgary and Sylvan Lake, Alberta beamed our message into the night. Not only that, but by reaching out to political figures across the country, PFPSC members encouraged declarations of support for World Patient Safety Day from Conseiller Francesco Miele, on behalf of the Council of Saint-Laurent Montreal, Quebec Mayor Ed Holder, on behalf of the City of London, Ontario Mayor Greg Dionne, on behalf of the City of Prince Albert, Saskatchewan Mayor Don Iveson, on behalf of the City of Edmonton, Alberta Mayor Naheed Nenshi, on behalf of the City of Calgary, Alberta Hon. Cameron Friesen, Minister of Health, Seniors and Active Living, on behalf of the Province of Manitoba Hon. Tyler Shandro, Minister of Health, on behalf of the Province of Alberta Hon. Janet Austin, Lieutenant Governor, on behalf of the Province of British Columbia Finally, an opinion-editorial written by PFPSC member Kathy Kovacs-Burns was distributed across the country for newspapers to consider running on the special day and members hosted a lively Tweet Chat using the #BuildingASaferSystem hashtag before the CPSI documentary screening! World Health Organization The COVID-19 pandemic has unveiled the huge challenges and risks health workers are facing globally including health care associated infections, violence, stigma, psychological and emotional disturbances, illness and even death. Furthermore, working in stressful environments makes health workers more prone to errors which can lead to patient harm. Therefore, on World Patient Safety Day 2020, the WHO selected the theme of Health Worker Safety A Priority for Patient Safety. The World Health Organization published a call for action on health worker safety that you can read here. We offer our special thanks to our World Patient Safety Day Platinum Sponsor, BD, as well as our two Gold Sponsors, HealthPro Procurement Services and Gojo Industries, makers of PURELL Hand Sanitizer, for their invaluable support. 9/25/2020 9:00:00 PM Thank you so much for joining us in supporting the second annual World Patient Safety Day on September 17, 2020! In May 2019, all 194 World Health10/6/2020 9:56:50 PM291https://www.patientsafetyinstitute.ca/en/NewsAlerts/News/Pages/Forms/AllItems.aspxhtmlFalseaspx
Special Notes for Chris Power upon her Retirement125809/25/2020 8:45:19 PM ​We invited colleagues of Chris Power to share their thoughts with her for her retirement. Please feel free to share your thoughts with Chris as well. Here are a very few of the kind words. "Chris, you are recognized as one of the preeminent healthcare executives in Canada," says Ron Guse, Board Chair for the Canadian Patient Safety Institute. "For the past six years, you have shared your experiences, initiative, and values to lead the Canadian Patient Safety Institute. The patient safety movement owes a debt of gratitude to you for your leadership and dedication." "Thank you for your commitment to patient safety improvement and to involving patients and families," says Katarina Busija, Founding Director, Inaugural Co-Chair and Member of Patients for Patient Safety Canada. "Your demonstrated leadership and championing of Patients for Patient Safety Canada has been instrumental to our ongoing credibility and impact. I hope you enjoy your well-deserved retirement and wish you well as you embark upon a new path." "Your qualities of calm presence, confidence and compassion are something I will strive to emulate," says Alain Doucet, CEO of the Canadian College of Health Leaders. "I am writing to you on behalf of all who work at CPAC - and our many shared partners - but mostly I am writing to you for myself," says Cindy Morton, CEO of Canadian Partnership Against Cancer. "Even before we met, I had the privilege to know of your work for many years, as your reputation as a stellar and steady healthcare leader is well known across Canada and internationally. If I could clone you and place you at the helm of every part of this country's federated and complex healthcare system, we would be golden!" "Thank you for your dedication and hard work in your leadership role with CPSI in keeping our patients and healthcare environments safe," says President of Infection Prevention and Control Canada, Barbara Catt. "On behalf of IPAC Canada, wishing you a wonderful retirement and all the best." "I will always remember when I first met you at an in-person meeting with Patients for Patient Safety Canada," says member Eileen Chang. "I immediately felt your passion and knew that your wisdom would strengthen our vision and mission. Thank you for doing just that, and I wish you all the best of health, happiness and peace in your next chapter." "I'm delighted to add my voice to the chorus of supporters and fans wishing you love and light as you place new steps of change on your journey!" says Mike Villeneuve, CEO of the Canadian Nurses Association. "You have been such a great role model for so many of us, and the nursing community has been especially proud of your executive leadership in role in Halifax over so many years - and of course, most recently, so ably leading the CPSI." "It has been such a pleasure working with you over many years. Your leadership in patient safety was inspirational," says Laurie Thompson, Executive Director of the Manitoba Institute for Patient Safety. "You have opened up the conversation about patient safety and moved it to be inclusive of patients, families, healthcare providers, regulators, industry - truly reflecting the need for patient safety to be everyone's responsibility. Thank you for your significant contribution to improving patient safety in Canada. All the very best in your next chapter." "Chris is a phenomenal person, a role model for all women leaders and quite frankly, for all leaders," says Catherine Gaulton, CEO of the Healthcare Insurance Reciprocal of Canada. "However, her most shining moment was when she became and excelled at being CEO of CPSI. She was in her element. This was where her heart is and always had been and it showed. Chris's work with CPSI leaves a wonderful legacy for patient safety and for how we value and respond to the needs of those we serve. Thank you, Chris, for not only being an agent of change, but for truly caring and for also being a mentor for so many." "I have always been impressed and learned from the way you approach your dealings with others - with empathy and compassion, open ears and an open mind, and great poise and thoughtfulness in your words and actions," says Lindy VanAmburg, Assistant Director at Health Canada. "Thank you for all of the tremendous work you have done for Canadians and for being such a great partner with us at Health Canada over the years. I wish you the healthiest and happiest of retirements." "How absolutely fortunate I am to have had the opportunity to work with you, most recently, of course, at CFHI and CPSI but also at other organizations in the past," says Jennifer Zelmer, CEO of the Canadian Foundation for Healthcare Improvement and the upcoming amalgamated organization. "Your commitment to better health and better care has shone brightly throughout. Your heart is large; your counsel wise. Always generous with your time, your dedication to patient safety and to the health of health workers is crystal clear. We will never know the names of all those whose lives your efforts have made better, but know that they are many and the results of your work very long-lasting. We'll miss you very much but wish you all the best with the new adventures ahead of you." 9/25/2020 8:00:00 PMWe invited colleagues of Chris Power to share their thoughts with her for her retirement. Please feel free to share your thoughts with Chris as9/25/2020 10:04:59 PM373https://www.patientsafetyinstitute.ca/en/NewsAlerts/News/Pages/Forms/AllItems.aspxhtmlFalseaspx

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Preventable Tragedies: Two Pediatric Deaths Due to Intravenous Administration of Concentrated Electrolytes1431938151/16/2029 7:00:00 AMMedicationInstitute for Safe Medication Practices CanadaThis alert discusses two fatal medication incidents involving high alert drugs of concentrated electrolytes. IV administration of concentrated electrolytes has been identified as a “never event” where patient safety incidents result in serious patient harm or death, and can be prevented by using organizational checks and balances. In these cases concentrated potassium phosphates and potassium chloride were administered under separate circumstances. Each incident is described: Incident No. 1: Concentrated potassium phosphates solution for injection, available in a patient care area, was mistakenly used to flush a child’s IV line; a flush solution of normal saline (0.9% sodium chloride) was intended. The child immediately became pulseless and later died, despite intensive resuscitation efforts. The error was recognized when blood tests revealed severe hyperkalemia and hyperphosphatemia. Incident No. 2: An infant required IV replacement of potassium during a hospital stay. The medical resident contacted the staff pediatrician by phone for direction. The resident subsequently gave a verbal order to the nurse to administer IV potassium chloride (KCl) to the infant. The prescribed dose was not available in a premixed format, so the nurse used a vial of concentrated KCl solution for injection (stocked on the ward) to prepare the IV infusion for administration. However, the verbal order was misinterpreted, and 10 times the amount of KCl required was added to the IV bag. The IV solution was administered overnight, and the infant went into cardiac arrest and subsequently died. Several identifying contributing factors were identified: • Availability of concentrated injectable potassium solution in patient care areas • Non-standardized processes for the prescription and preparation of IV electrolyte solutions • Lack of independent double checks • Similar physical appearance of the electrolyte solutions and vials due to a product shortage Recommendations directed at health care facilities and health care practitioners are provided in the alert to reduce the likelihood of recurrence of such never events.7/9/2020 3:37:01 PMhttps://www.patientsafetyinstitute.ca/en/NewsAlerts/Alerts/Lists/Alerts/AllItems.aspxFalse
Delay or Omission of Critical Value Report (CVR)37931391110/6/2020 6:00:00 AMDiagnostic ImagingKorea Patient Safety Reporting & Learning SystemFollowing a biopsy of a mass on the left elbow, a patient was discharged from hospital and was to be contacted following a pathological test of the sample. The biopsy result was confirmed as a malignant tumor two weeks later but was not classified as a critical value report (CVR). As a result, the diagnosis was omitted from the report to the physician and not discovered until six months later causing a significant delay in treatment for the patient. Recommendations and examples of related preventive activities are included to prevent patient safety incidents that cause disturbance of precise diagnosis and delay of treatment due to a lack of action taken immediately on the result of CVR.10/16/2020 9:57:42 PMhttps://www.patientsafetyinstitute.ca/en/NewsAlerts/Alerts/Lists/Alerts/AllItems.aspxFalse
A fatal risk caused by carelessness in the use of an automatic contrast media injector1432539109/18/2020 6:00:00 AMCare ManagementKorea Patient Safety Reporting & Learning SystemA patient was prescribed a chest and abdomen computer tomography (CT) following a diagnosis of non-small cell lung cancer. On the day of the examination, a health care worker discovered that about 10cc of air was introduced into the syringe connected to the patient prior to injecting contrast medium. While sitting on the waiting chair after the examination, the patient lost consciousness fell due to cardiac arrest. The patient recovered consciousness after CPR was performed but died the next day in the intensive care unit. The chest and abdomen computed tomography images taken just before the incident suggest a cardiac arrest caused by air embolism. Recommendations and examples of related preventive activities are included to prevent patient safety incidents that cause air ingress into veins due to careless use of automatic contrast media injectors.10/16/2020 9:45:11 PMhttps://www.patientsafetyinstitute.ca/en/NewsAlerts/Alerts/Lists/Alerts/AllItems.aspxFalse
Pediatric fall incidents in hospitals1432439096/9/2020 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 PMhttps://www.patientsafetyinstitute.ca/en/NewsAlerts/Alerts/Lists/Alerts/AllItems.aspxFalse
Managing Mild COVID-19 Symptoms at Home1421939085/14/2020 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 PMhttps://www.patientsafetyinstitute.ca/en/NewsAlerts/Alerts/Lists/Alerts/AllItems.aspxFalse