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Canadian Patient Safety Institute

Safe care....accepting no less​

The Canadian Patient Safety Institute (CPSI) has over 10-years of experience in safety leadership and implementing programs to enhance safety in every part of the healthcare continuum.​

SHIFT to Safety

 

Improving patient care safety and quality in Canada requires everyone’s involvement—SHIFT to Safety gives you the tools and resources you need to keep patients safe, whether you are a member of the public, a provider, or a leader.


 

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Our Programs​

 CPSI Latest News

 

 

Cecilia Bloxom named to CPRS College of Fellows68565Patient Safety News ​The Canadian Patient Safety Institute’s Cecilia Bloxom, Senior Director of Strategic Communications, has been named to the Canadian Public Relations Society College of Fellows, a pinnacle of achievement for members of the Society. An induction ceremony will be held in Quebec City on May 24, 2020, during the Canadian Public Relations Society (CPRS) National Conference. College of Fellow members have at least 20 years of professional experience and at least 10 years of Society involvement. They have demonstrated that they are leaders in the public relations profession, but also have demonstrated outstanding leadership in CPRS. Fellows devote their time and undertake tasks that advance the state of public relations in Canada, including mentoring others, speaking and writing about the value of effective public relations and being involved in other College initiatives. Cecilia is a dynamic communications professional with boundless energy and creativity; she is known to raise the bar and quick to approach every task with the same drive and commitment. She truly upholds the status of leadership in public relations. “Cecilia’s career has flourished over the last two decades as she has consistently challenged herself to grow her skills to become a dynamic and well-respected communications professional,” says Chris Power, CEO, Canadian Patient Safety Institute. “She is constantly looking toward the next big challenge and accomplishment, while providing inspiration to her team and peers. Her unwavering commitment to improve patient safety is evident in the campaigns she has spearheaded and the issues she has tackled. She has the unique ability to bring together diverging opinions and ensure people feel heard, respected and valued, leading to successful outcomes for everyone involved.” An award winning Senior Communications Professional with 20 years of experience in regional, provincial and national organizations, Cecilia is highly skilled in developing and landing memorable strategic plans, creating lasting brands, and routinely building awareness on a national level. She is one of a few hundred communicators in Canada with dual accreditation from both the International Association of Business Communicators and the Canadian Public Relations Society. Cecilia is a true leader in the Communications industry with a solid background in leadership development, including a Masters of Arts in Leadership from Royal Roads University. Cecilia has a solid understanding of Governance, supporting the Canadian Patient Safety Institute’s national Board of Directors, serving as the current Past President of the Canadian Public Relations Society (Edmonton), current Director on the CPRS Foundation Board (formerly Communications + Public Relations Foundation), and past Director with the Nina Haggerty Centre for the Arts. Over the past ten years, Cecilia has shared advice, experience and guidance as a mentor to protégés in the CPRS mentorship program. Cecilia also chaired the Local Advisory Committee for the Canadian Public Relations Society National Conference, Evolving Expectations, welcoming over 300 delegates to Edmonton in June 2019. Cecilia has made a mark in healthcare communications, locally, nationally and internationally. The knowledge, passion and energy that Cecilia brings to her position with the Canadian Patient Safety is evident through the branding and the development of numerous initiatives including the development of a Strategic Communication Plan for a national strategy on patient safety. In addition to her professional accomplishments, Cecilia cherishes being a mother to her beautiful daughter Cyr and lives in the heart of Edmonton’s Little Italy with her husband Jesse and standard poodle, Walker. Cecilia loves all things active including skiing and yoga and is very involved in transforming her community. Congratulations, Cecilia! 12/5/2019 9:00:00 PM The Canadian Patient Safety Institute’s Cecilia Bloxom, Senior Director of Strategic Communications, has been named to the Canadian Public Relations12/5/2019 9:42:09 PM17https://www.patientsafetyinstitute.ca/en/NewsAlerts/News/Pages/Forms/AllItems.aspxhtmlFalseaspx
How safe is our care?46143Patient Safety News By Anne MacLaurin, Virginia Flintoft, Wayne Miller and Alex Titeu All healthcare leaders, providers, patients, and the public should wrestle with a fundamental question How safe is our care? The typical approach has been to measure harm as an indicator of safety, implying that the absence of harm, is equivalent to the presence of safety. But, are we safe, or just lucky? Jim Reinertsen, MD, a past CEO of complex health systems and a leader in healthcare improvement, suggests that past harm does not say how safe you are; rather it says how lucky you have been. After learning about the Measurement and Monitoring of Safety (MMS) Framework, Reinertsen found the answer to his question, "Are we safe or just lucky?" "The Measurement and Monitoring of Safety Framework challenges our assumptions in terms of patient safety," says Virginia Flintoft, Senior Project Manager, Canadian Patient Safety Institute. "The Framework helps to shift our thinking away from what has happened in the past, to a new lens and language that moves you from the absence of harm to the presence of safety." Professor Charles Vincent, Professor of Psychology at Oxford University, advocates that assessing safety is not the same as counting harm. As the first author of the Measurement and Monitoring of Safety framework, he believe it is critical for us to ask five questions, each related to a specific dimension of safety, in order to determine whether an organization is safe. This approach is one often used by industry that looks at leading and lagging indicators, and relies on soft intelligence. A holistic view of safety prompts leaders and providers to be inquisitive and empowers everyone to take a proactive role in safety. The five critical questions are Has patient care been safe in the past? Systematically reviewing existing measurement and monitoring of past harm can increase your understanding and help you to respond appropriately to harm when it occurs. Are our clinical systems and processes reliable? This dimension gauges the probability that a task, process, intervention or pathway will be carried out or followed as specified. Is care safe today? Sensitivity to operations focuses on the day-to-day, hour-by-hour and even minute-by-minute management of safety, bringing together a mix of intelligence to help staff, clinicians, managers and leaders assess and act upon safety in real time. Will care be safe in the future? By focusing on the identification of possible sources of future harm, you can work to become more resilient to them. Don't wait for things to go wrong before trying to improve safety. Are we responding and improving? The development of systems to promote a cycle of learning and sharing from safety incidents, multiple sources of safety intelligence and insights developed through the other domains. Integration and learning is the glue that holds a rounded safety picture together. "The Framework changes the nature of the conversation to being more mindful and forward-thinking," says Wayne Miller, Senior Project Manager, Canadian Patient Safety Institute and MMS coach. In 2017, the Canadian Patient Safety Institute launched a measurement and monitoring of safety demonstration project, led by Dr. Ross Baker at the University of Toronto. An 18-month Safety Improvement Project was subsequently launched in 2018, to support healthcare teams in rewiring their thinking on patient safety and to work within their organizations to foster and promote this new approach to safety. The coaches supporting the MMS collaboratives have learned that this expanded view, helps to provide a shared and consistent understanding of safety. It empowers everyone to take a proactive role and promotes a culture of collective responsibility for safety. MMS promotes the importance of the contribution that patients and carers make to safer care. Most importantly, it reinforces the message that safety is more than counting harm. "It is exciting to see the transformation within the teams and their understanding and focus on patient safety," says Anne MacLaurin, Senior Program Manager, Canadian Patient Safety Institute and MMS coach. Danielle Bellamy, Director of Continuing Care, Yorkton & District Nursing Home (Saskatchewan Health Authority) participated in the MMS collaborative. She says that the value of this work is how it empowers team members to focus on the presence of safety. "We often speak about how safety is everyone's responsibility, but team members have historically told us that they don't feel they have the tools to take action," says Bellamy. "This Framework has given us the opportunity to co-create a tool to empower our frontline team to not only identify the potential for harm, but to work towards reducing or eliminating the harm. As a result, we are witnessing a shift in the culture of safety within our care home, and providing a safer environment for both our residents and team." Crystal Browne, Director Clinical Operations, Alberta Health Services – Area 4 (North Zone) says, "I think the biggest takeaway I have gained from this learning collaborative is that safety is not a 'project' with a defined beginning, middle and end. It's an ethos of constant inquiry at all levels of the organization as we try to answer the questions of is care safe today? and will it be safe tomorrow?" Virginia Flintoft, Anne MacLaurin, Wayne Miller and Alex Titeu are coaching the 11 teams from across the country participating in the MMS Safety Improvement Project, helping them to implement this new approach to measuring and monitoring of safety. For more information, visit www.patientsafetyinstitute.ca. 12/2/2019 7:00:00 AMBy Anne MacLaurin, Virginia Flintoft, Wayne Miller and Alex Titeu All healthcare leaders, providers, patients, and the public should12/2/2019 8:53:28 PM58https://www.patientsafetyinstitute.ca/en/NewsAlerts/News/Pages/Forms/AllItems.aspxhtmlFalseaspx
Educational modules available for hospitals and the public to support new mandatory reporting requirements46158Patient Safety News Effective December 16, 2019, reporting of adverse drug reactions (ADRs) and medical device incidents (MDIs) within 30 calendar days of first documentation will be mandatory for all Canadian hospitals. The Protecting Canadians from Unsafe Drugs Act, also known as Vanessa's Law, is intended to increase drug and medical device safety in Canada by strengthening Health Canada's ability to collect information and to take quick and appropriate action when a serious health risk is identified. Four educational modules have been developed to support and raise awareness of mandatory reporting requirements. Available in PowerPoint and PDF formats, these presentations were developed collaboratively by Health Canada, Institute for Safe Medication Practices Canada (ISMP Canada), Health Standards Organization (HSO), and the Canadian Patient Safety Institute. The materials can be used as entire modules, individual slides or selected content for individual learning, or incorporated into presentations for information-sharing. The modules include Module 1 – Overview of Vanessa's Law and Reporting Requirements explains the purpose of Vanessa's law, describes the regulations for mandatory reporting of serious ADRs and MDIs by hospitals, and outlines the required data elements for mandatory reporting. Module 2 – Reporting Processes to Health Canada describes the expectations for mandatory reporting, provides samples of the forms for reporting and how to submit reports to Health Canada, and includes a number of case studies as examples. The module also includes a Guidance document for reporting and options for voluntary reporting. Module 3 - Strategies to Promote and Support Mandatory Reporting identifies potential barriers to serious ADR and MDI reporting, how to facilitate documentation and reporting, and outlines strategies to support implementation. Examples of various reporting systems in place are also included. Module 4 – Health Canada's Review and Communication of Safety Findings summarizes the importance of health product vigilance, the process that will be used to share information on ADR and MDI reporting, and how data will be secured and shared. All four modules can be accessed on the Canadian Patient Safety Institute website at https//www.patientsafetyinstitute.ca/mandatoryreporting Patients for Patient Safety Canada have also created a presentation to help patients and the public understand and promote the reporting of serious adverse drug reactions and medical device incidents. Click here Click here to download the presentation. For the purposes of mandatory reporting, a serious adverse drug reaction is defined as a noxious and unintended response to a drug that occurs at any dose and that requires in-patient hospitalization or prolongation of existing hospitalization, causes congenial malformation, results in persistent or significant disability or incapacity, is life threatening, or results in death. The mandatory reporting requirements for hospitals apply to therapeutic products, including Pharmaceuticals (prescription and non-prescription drugs), Biologic drugs (biotechnology products, fractionated blood products, plasma proteins and vaccines (excluding vaccines administered under a routine immunization program of a province or territory), Radiopharmaceutical drugs, Disinfectants, Medical devices, and Drugs for an urgent public health need. Mandatory reporting does not apply to natural health products, however reporting is encouraged. A medical device incident is an incident related to a failure of a medical device or a deterioration in its effectiveness, or any inadequacy in its labelling or its directions for use that has led to the death or a serious deterioration in the state of health or a patient, user, or other person, or could do so were it to recur. All classes of medical devises are included in mandatory reporting by hospitals, including those classified as Class I (lowest risk) to Class IV (highest risk). Examples are Class I – Hospital beds, wheelchairs, leg prostheses, Class II – infusion sets, syringes, tracheostomy tubes, urethral catheters, Class III – infusion pumps anesthesia gas machines, intrauterine devices, and Class IV – pacemakers, defibrillators, breast implants, bone grafts. More information on mandatory reporting is available on the Health Canada website. 12/2/2019 7:00:00 AMEffective December 16, 2019, reporting of adverse drug reactions (ADRs) and medical device incidents (MDIs) within 30 calendar days of first12/2/2019 9:48:05 PM61https://www.patientsafetyinstitute.ca/en/NewsAlerts/News/Pages/Forms/AllItems.aspxhtmlFalseaspx
Patient Safety Power Play: Thank you for helping us #ConquerSilence70845Patient Safety Power Plays This year, I have discussed our new public engagement campaigns several times since our mandate at the Canadian Patient Safety Institute is evolving. We continue to research and supply healthcare organizations with effective patient safety tools; we still encourage strong patient safety policy for leaders; and now we also focus on connecting with the public and patients about this silent epidemic – and what we can all do to keep ourselves safe. We have had some wonderful successes in our efforts to connect. Over the past few months, we have organized four round table meetings with provincial Ministers and Deputy Ministers of Health. Hosted by members of Patients for Patient Safety Canada, we have meet in Winnipeg, St. John’s, Halifax and Fredericton to give local patient partners the opportunity to tell their stories of harm and to ask that provincial governments commit to making care safer. Safer care has certainly caught the public’s attention. On November 6, the Canadian Institute for Health Information released a biannual comparison of healthcare performance among over 30 first-world nations. Compared with other countries, Canada does a good job of documenting, reporting, and acting on patient safety issues. However, we still have much room for improvement, since the report stated that not only are patients twice as likely to experience tears during childbirth and develop lung clots after hip and knee surgery, but that Canada also reported the highest number of items left behind inside patients after surgery. In response to media requests, CPSI highlighted that the public doesn’t know much about patient safety incidents. We called for a higher commitment to safer care, not by placing blame, but instead by inviting everyone concerned to learn about healthcare harm and make it a priority. We have to work together to identify the patient safety gaps, share ways to resolve them, and establish a patient safety culture in Canada. The messages we shared in response to the report were similar to those declared during this year’s Canadian Patient Safety Week. We launched our #ConquerSilence campaign to improve communication in the healthcare system to help reduce preventable patient harm in Canada. We engaged both new and existing audiences, built partnerships founded on patient safety, and heard from many people about the popularity of #ConquerSilence. This popularity assured us that we are headed in the right direction, as #ConquerSilence did not end with Canadian Patient Safety Week it is also our first long-term public engagement campaign. We built a platform that will stand against silence and build momentum over time. We will continue to encourage members of the public, healthcare providers, and healthcare leaders to anonymously record and listen to stories and advice about preventable harm at www.conquersilence.ca. #ConquerSilence will feature different patient safety issues throughout the year, plus offer resources to help the public and healthcare providers battle systemic silence. The first issue we are tackling is medication safety, featuring materials on how to speak up when issues arise with medications. Other issues we will tackle through the campaign will include misdiagnoses and miscommunication, traumas, infections, pressure wounds, and deteriorating patient condition. I am thrilled that you have joined us to keep making safe healthcare a priority. Questions? Comments? My inbox is open to you anytime at cpower@cpsi-icsp.ca, and you can follow me on Twitter @ChrisPowerCPSI. Yours in patient safety, Chris Power 11/25/2019 7:00:00 AMThis year, I have discussed our new public engagement campaigns several times since our mandate at the Canadian Patient Safety Institute is evolving.11/25/2019 8:52:20 PM185https://www.patientsafetyinstitute.ca/en/NewsAlerts/News/Pages/Forms/AllItems.aspxhtmlFalseaspx
#SuperSHIFTER Janet Bradshaw helps to ensure the patient voice is heard70660Super SHIFTERS #SuperSHIFTER Janet Bradshaw is the Project Coordinator supporting the work of Patients for Patient Safety Canada, a patient-led program of the Canadian Patient Safety Institute. Respectfully referred to as Mama Bear by her colleagues, Janet's passion, empathy, and creativity is what drives her to ensure the patient voice is heard in healthcare. What can you tell us about your role at the Canadian Patient Safety Institute? ​ ​Janet Bradshaw (right) with Abisaac Saraga at a Patients for Patient Safety Canada meeting As a Project Coordinator, I have the privilege of supporting the Patients for Patient Safety Canada program; that is the major part of my job. When a request comes in for patient involvement, I match the patient members with the engagement opportunities to advance patient safety. Last year, there were over 100 requests for patient volunteers to support patient safety and quality work. I support the Patients for Patient Safety Canada co-chairs and build relationships with all the volunteers. I am also fortunate to coordinate the in-person meetings for Patients for Patient Safety Canada. What does a typical day look like for you? Generally, there is no typical day. At the moment, a lot of my time is spent on planning and arranging logistics for the next Patients for Patient Safety Canada in-person meeting taking place in November. I try and go above and beyond to bring a little extra to the table to let the patient members know how much they are appreciated. In my spare time, I am always busy creating something. I do a lot of crafts and enjoy knitting and crocheting. In the past, I have made flower and maple leaf lapel pins as a way to give a little piece of myself to the patient members to take home with them. This year, I am making poppies for everyone as I feel it is an important way to honour the hours of volunteer time that the patient members have given to us. What do you like most about working at the Canadian Patient Safety Institute? The organization is so supportive and a great place to work. They ensure we have the skills that we need to do our job and that we are comfortable in our position. I enjoy the people that I work with. We are a small team that does very important work and I feel we are making a difference. There is always a lot happening and everyone is so passionate about what they do. We are not here solely for the job; we are here because we believe in what we do. Everyone cares so much and wants to make the healthcare system safer. What I enjoy most about my job is the interaction with patients and hearing their stories. Their stories are so touching and truly help to spread the word about the importance of patient involvement to advance safe care. Those stories inspire me too. What are your hidden talents? I am positive and look for the good in every situation. I like to bring people together and am always looking for ways to help people work together. There is the Mama Bear side of me that is nurturing, and shows a lot of empathy and patience. What is your proudest moment with the Canadian Patient Safety Institute? I get a lot of fulfillment in doing a good job, keeping that spark alive and igniting the passion of the patient members in telling their stories. Every time I watch one of the patient videos, I am proud of the role that I played behind the scenes to help patients to share their experiences and make a difference to other patients and to the healthcare system. With the launch of #ConquerSilence, the patient voice is one of the most important voices of this campaign. I have been working with the patients that are so brave in sharing their stories. Those stories are so powerful and help to get the message out. I am proud that I have been able to lift them up and help them to find their voice and do their part in making the campaign successful. What are your hopes for patient safety? Family is very important to me. I have a large family, five children and seven grandchildren. I do the job that I do to ensure that they are safe too. In the next five years, I would like to see the healthcare system get safer and the public become more aware of the magnitude of the problem so that they can be vigilant and keep themselves safe. Janet is celebrating her 5th Anniversary with the Canadian Patient Safety Institute. To learn more about her work with Patients for Patient Safety Canada, email Janet at jbradshaw@cpsi-icsp.ca. 11/19/2019 9:00:00 PM#SuperSHIFTER Janet Bradshaw is the Project Coordinator supporting the work of Patients for Patient Safety Canada, a patient-led program of the11/25/2019 3:47:11 PM695https://www.patientsafetyinstitute.ca/en/NewsAlerts/News/Pages/Forms/AllItems.aspxhtmlFalseaspx

 Upcoming Events

 

 

2nd Saudi Patient Safety Center International Patient Safety Conference 2019.64597Riyadh, Saudi Arabiahttps://spsc.gov.sa/English/2nd-Conference/Pages/default.aspx12/7/2019 12:00:00 AM12/7/2019 11:59:00 PMThe Canadian Patient Safety Institute is proud to support this event. This event is hosted by Saudi Patient Safety Center7/8/2019 7:56:12 PM3https://www.patientsafetyinstitute.ca/en/Events/Lists/Events/calendar.aspxFalseConferenceTrue
The Future of Patient Safety: Status Quo or Innovate?34360Webinarhttps://www.cchl-ccls.ca/viewEvent.html?no_header=true&productId=802212/9/2019 7:00:00 PM12/9/2019 8:00:00 PMThe Canadian Patient Safety Institute is proud to support this event. This event is hosted by Canadian College of Health Leaders 11/29/2019 9:46:54 PM6https://www.patientsafetyinstitute.ca/en/Events/Lists/Events/calendar.aspxFalseWebcastFalse
Human Factors in Healthcare Course70870Calgary, ABhttps://www.w21c.org/portfolio/human-factors-in-healthcare/2/11/2020 12:00:00 AM2/11/2020 11:59:00 PM The Canadian Patient Safety Institute is proud to support this event. This event is hosted by Health Quality Council of Alberta 11/27/2019 4:47:48 PM8https://www.patientsafetyinstitute.ca/en/Events/Lists/Events/calendar.aspxFalseWorkshopTrue
Closing Congress: Measurement and Monitoring of Safety in Canada SIP Learning Collaborative 1388Torontohttps://www.patientsafetyinstitute.ca/en/toolsresources/measure-patient-safety/mms-collaborative/pages/default.aspx3/24/2020 12:00:00 AM3/25/2020 11:59:00 PMOn October 23, 2018 CPSI launched a new safety improvement project. A learning collaborative approach with expert faculty and mentoring over 18 months. Based upon the Measurement and Monitoring of Safety Framework (2013). This follows on the success of a 12-month demonstration project that was led by Dr. Ross Baker at the University of Toronto. During this new Safety Improvement Project, participating teams will be supported in rewiring their thinking on patient safety and work within their organization to foster and promote a new approach to safety. 7/10/2019 5:44:06 PM3https://www.patientsafetyinstitute.ca/en/Events/Lists/Events/calendar.aspxFalseCollaborativeTrue
Vision 2020: Partnering to Enhance the Care Experience / Vision1435Moncton, NB http://www.HorizonNB.ca/PFCCExperience5/26/2020 12:00:00 AM5/27/2020 11:59:00 PMThe Experience Conference is a National Conference hosted by Horizon Health Network. The two-day conference provides an opportunity for participants to actively learn from and collaborate with health care experts and patient advocates focused on enhancing the care experience. 10/31/2019 4:37:49 PM3https://www.patientsafetyinstitute.ca/en/Events/Lists/Events/calendar.aspxFalseConferenceTrue