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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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 CPSI Latest News

 

 

#SuperSHIFTER Betty Scharf: Reflections on nursing then and now8762Super SHIFTERS A graduate of the Misericordia Hospital School of Nursing, Betty Scharf recently celebrated 60 years as a nurse. Of the 24 students in the class of 1959, six graduates attended the reunion to reminisce and brought their daughters along to hear their stories. The 84-year old Edmontonian shares her thoughts on what is was like to be a nurse and provides some sage advice for patients today. Tell us about your nursing career. When I graduated from a two-year nursing program in 1959, I initially worked as an Emergency Room (ER) nurse, and was occasionally called on to be a ward nurse at the Misericorida Hospital in Edmonton. I then worked at a doctor's office, where I did blood pressure tests, gave allergy shots and the like. After that, I worked at the old Sturgeon Hospital in St. Albert, again as both an ER and ward nurse. When the hospital moved to 12-hour shifts, I had to leave as I had a young family and it was difficult working those long hours. I moved to the Medi-Center walk-in clinics and was the Head Nurse there for almost 20 years. What challenges did you face in your early years of nursing? When working on wards and even in emergency, the nurse was responsible for the sole care of the patient. We provided more of what I call total care. From daily changing of bedding; three backrubs per patient per day; bathing patients daily, or as called for; distributing and assisting with all meals and medications; and moving patients to the operating room, or from room to room. There were orderlies in those days, but they were mostly assigned to the men's wards to assist with bathing or the occasional bed move. (Betty Scharf (left) with her daughter Charlene at the reunion) Nurses did two rounds per day, assessing their patients and recording the results on paper after each round – there were no computers then. Checks were frequent to ensure patients were doing okay and that the equipment was functioning – we did not have the bells and whistles to alert you to any problems or if the patient was in distress. During the day you could call on another nurse to help if they were available, but at night, there was only one nurse assigned to a ward of 30 to 35 patients. Needless to say, some nights were a bit crazy, especially when you had wanderers or patients with special needs. I remember one gentleman who possibly had PTSD from the Second World War. He would hide under his bed and you had to figure out how to get him back to bed. When I worked in Emergency in the 60s and early 70s, there were two to three nurses per shift during the day, and only one or two at night. During the night shift, the doctors were on call. This meant the nurses had to triage and keep the patient stable until the doctor arrived. If the injuries were really serious, you could try and grab a doctor from the floor. Mostly, you had to rely on your training, past experience, and gut instinct. How would you compare your days of nursing to the nursing today? There are more teams now. I like how the role of the Licensed Practical Nurse (LPN) has evolved and their connection with the patient. The equipment is amazing and that makes it much easier to keep a watch on patients and monitor their progress. There seems to be a different kind of busyness today. There are so many different people coming and going. The staff are doing more with less. There is no real time to establish a patient/caregiver relationship, or have real communication or face time with any of the team. The relationship element is vital for the patient, both physically and mentally. Chats and time for real observation of a patient can tell a caregiver far more than what a machine will tell you. What did you learn from nursing that you are most proud of? I would say my ability to engage with people. I was able to truly communicate and empathize with people from all walks of life – you never knew who would come through the ER door – from biker gangs who had been in a knife fight, to a family with a sick child, etc. When I worked in ER, there was no doctor at your elbow and I am proud of the triage skills that I developed. When you become a nurse, you never stop caring about people. Once I retired, I kept on working with people, serving tea to patients in the hospital and listening to them; driving and caring for those with Meals on Wheels; and doing foot care and taking blood pressure readings at the Senior Centre. What advice would you give to others about being a partner in their care? Ask questions and don't stop until you get clearly explained answers. For example, if you need a surgical procedure, ask why it is being done, what can be expected, and what you must do as the patient after the surgery. Always bring an advocate with you to an appointment. It is always better to have two sets of ears. The same goes for medications. Ask why am I being prescribed this drug; how will it help me; are there any side effects; and what do I do if I think there is an issue. 2/7/2020 9:00:00 PMA graduate of the Misericordia Hospital School of Nursing, Betty Scharf recently celebrated 60 years as a nurse. Of the 24 students in the class of2/10/2020 4:54:02 PM459https://www.patientsafetyinstitute.ca/en/NewsAlerts/News/Pages/Forms/AllItems.aspxhtmlFalseaspx
Conquer Silence: Speak Up to Prevent Falls115380Patient Safety News ​ There was an elderly woman in the bed. Her face was badly swollen and bruised. Her lip was stitched and her knee gashed. She looked like an assault victim. "I looked at her and could hardly believe it was my mom," says Anne Findlay. "She was that badly bruised. She looked awful." Her mom was conscious, but terrified, says Anne. She couldn't speak much, because her tongue was swollen. How could this happen? Falls are the leading cause of injury among older Canadians. Consider these facts Falls account for up to 40% of inpatient incidents 30% of falls result in physical injury, with 2-5% resulting in moderate to serious injury including hip fractures or even death Falls can result in longer lengths of stay, increased health care cost and staff workload, and staff and family distress Approximately 50% of patients sustaining a in-hospital hip fracture die within one year of the fracture.One in three Canadians has suffered from preventable healthcare harm, including falls, and yet collectively most people are unaware that the problem exists. That is the silent epidemic. If we do nothing, 1.2 million Canadians will die from preventable patient harm in the next 30 years. You can help battle this systemic silence in our collective efforts to reduce patient harm. Anne's mother had been sent for a third X-ray in 24 hours, which was very taxing for the fragile old woman. During the procedure, for reasons still not clear, she rolled off the gurney and dropped to the floor. Paramedics were called and transferred her to the emergency department where she was treated for her injuries. The emergency room doctor said he'd been told the wheels on Beth's gurney were not properly locked down. The nurses looking after Beth, though clearly upset, couldn't provide any answers. No one seemed to know the exact reason why the gurney had moved, resulting in Beth's fall. How can falls be prevented? Small changes in the environment can help to address potential harms. You can identify threats and take simple actions to mitigate them, by asking yourself Is care safe today? #ConquerSilence aims to prevent patient harm before it happens. The campaign focuses on topical themes to encourage patients, providers and the public to speak up for safe care, so others can learn from their experiences. If something looks wrong, feels wrong, or is wrong – you need to speak up! One tool that can help you to communicate and get the attention to a problem before a fall happens is called CUS. These are three assertive statements to communicate with your healthcare provider. They begin with "I'm Concerned that…", "I'm Uncomfortable with…", and "This is a Safety issue…". This acronym – and these conversations – are ways that patients and advocates can help providers identify safety concerns, then take action to fix them. "When somebody is injured in the hospital," says Anne, "if you don't feel that the people involved are being honest with you about what happened, you lose trust. You're this individual, or this family, and you feel like you're up against a huge system. Trust is all you've got to go on." Anne decided to #ConquerSilence and get involved as a volunteer. She sits on Alberta Health Service's Patient/Family Advisory Group, the Health Quality Council of Alberta's Patient/Family Safety Advisory Panel, and is a member of Patients for Patient Safety Canada. For more information on strategies to reduce falls, visit www.patientsafetyinstitute.ca. To speak up about falls and trauma, visit www.conquersilence.ca 2/5/2020 10:00:00 PM There was an elderly woman in the bed. Her face was badly swollen and bruised. Her lip was stitched and her knee gashed. She looked like an2/7/2020 9:49:51 PM402https://www.patientsafetyinstitute.ca/en/NewsAlerts/News/Pages/Forms/AllItems.aspxhtmlFalseaspx
CPSI at the National Health Leadership Conference, June 15-16115378Patient Safety News Presented by HealthCareCAN and the Canadian College of Health Leaders, the National Health Leadership Conference will be held June 15-16 in Edmonton, Alberta. This patient-included conference is the largest national gathering of health system decision-makers in Canada. Attendees include trustees, chief executive officers, directors, managers, department heads and other health leaders representing various sectors and professions in health regions, authorities and alliances, hospitals, long-term care organizations, public health agencies, community care, mental health and social services. As well, the conference draws participants from government, education and research organizations, professional associations, consulting firms and industry. (CEO of the Canadian Patient Safety Institute, Chris Power.) This year’s theme is “Adaptive leadership in complex times.” The program features health reporter Andre Picard from the Globe and Mail, McMaster professor of strategic management Dr. Nick Bontis, and advocate for student mental health Donovan Taplin. However, of particular interest, is a breakfast session to be held at 715 am on the morning of Tuesday, June 16. 5 goals, 13 objectives & 28 outcomes that will save lives! Breakfast Session Serves Up Actions to Guide Quality and Patient Safety Improvement Unintended patient harm occurs every 1 minute and 18 seconds throughout our healthcare system, resulting in a death every 13 minutes and 14 seconds. Come and hear how two of Canada’s most powerful heath leaders are driving change through collective action. The Canadian Patient Safety Institute and Health Standards Organization CEOs, Chris Power and Leslee Thompson, have spearheaded the development of the Canadian Quality and Patient Safety Framework. Join us to learn how the #qualitypatientsafety Framework will improve care for ALL people in Canada. Don’t miss this opportunity to hear these two national health leaders discuss the future of healthcare in Canada. Register today for the National Health Leaders Conference, and then register for the complimentary breakfast session with CPSI and HSO! 2/5/2020 9:00:00 PMPresented by HealthCareCAN and the Canadian College of Health Leaders, the National Health Leadership Conference will be held June 15-16 in Edmonton,2/6/2020 9:09:29 PM350https://www.patientsafetyinstitute.ca/en/NewsAlerts/News/Pages/Forms/AllItems.aspxhtmlFalseaspx
Patient Safety Power Play: How do the new Frameworks, that frame our work, work?69474Patient Safety Power Plays Two major projects are in the final stages of development here at the Canadian Patient Safety Institute, with significant help from several partner organizations. We are launching two framework documents this year, "Strengthening Commitment for Improvement Together A Policy Framework for Patient Safety" and the "Canadian Quality and Patient Safety Framework", and we couldn't be more excited to use these tools to further our mission to ensure Canada has the safest care in the world! However, I had to stop myself before I got too carried away. We have been talking about these tools for years, but what if you – our partners and supporters – don't know what they are? What if you don't know the differences between them and their goals? We decided it was time for a little walk-through.Strengthening Commitment for Improvement Together A Policy Framework for Patient Safety Our new Policy Framework is intended to be a roadmap for patient safety among federal, provincial and territorial policymakers in Canada. These include healthcare ministers and their deputies, of course, but also political analysts, regulatory bodies, accreditation groups, and healthcare organizations themselves. The document sets out guiding principles for patient safety, outlines measures of success, and specifies the knowledge to action system that we use to deliver the highest quality, current research to the people who can best apply it. The Policy Framework identifies five policy levers that can be used by any given policymaker Legislation Regulation Standards Organizational policies Public engagement In partnership with CPSI staff, this Framework helps a given policymaker identify the most appropriate policy actions required to deliver safer care in Canada. Our role is to disseminate this knowledge, assist in advancing the work identified, and help evaluate the outcomes.You can read about Strengthening Commitment for Improvement Together A Policy Framework for Patient Safety here.Canadian Quality and Patient Safety (CQPS) FrameworkThe CQPS Framework, on the other hand, is a guidance document. It is intended to help align efforts and actions to improve key quality and safety areas across Canada. This framework describes overarching principles and goals for safe, high-quality health services in Canada, focusing on policy, action and resources that improve experience and outcome from healthcare systems across the country. Ultimately, this effort will reduce care variations across different communities. While the CQPS Framework team is currently identifying key interventions, indicators, and evaluation methodologies, their activities are focused on five goals People-Centered Care Safe Care Accessible Care Appropriate Care Integrated CareThis framework and these goals will inform standards development and accreditation programs for HSO and Accreditation Canada, targeting healthcare teams (including patients), as well as Boards, leaders, policymakers and the public – each with roles to play in meeting or exceeding high standards of care to be set in Canada.CPSI partnered with the HSO to develop the CQPS Framework, guided by a broad pan-Canadian steering committee made up of diverse stakeholders. It is also intended to be broadened to include social services in future iterations, since most developed countries consider social determinants of health in achieving optimal health outcomes.You can read about the Canadian Quality and Patient Safety Framework here.Next Steps Our Policy Framework has a dissemination strategy in place, ensuring that the document lands in the appropriate hands across Canada within the next six weeks. We invite policymakers interested in the work to reach out to us for a special introduction to the five levers and how we can help you use them in your organization. The CQPS Framework team is currently developing five action guides to help audiences use the framework to increase patient safety and healthcare quality in their particular locations. We look forward to the publication of the full framework and action guides by the fall.As delighted as we are in the progress we are making with these projects, we know that they could not have happened without your support – and won't result in affecting patient safety in Canada without you. Please reach out to us with any questions or comments you have about either framework.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 2/5/2020 8:00:00 PMTwo major projects are in the final stages of development here at the Canadian Patient Safety Institute, with significant help from several partner2/5/2020 8:34:49 PM214https://www.patientsafetyinstitute.ca/en/NewsAlerts/News/Pages/Forms/AllItems.aspxhtmlFalseaspx
Have you heard about CPSI in the media?115370Patient Safety News Only a few short months ago, the Canadian Patient Safety Institute launched a major public engagement campaign called #ConquerSilence. We are shining the light on patient harm in Canada. We are asking the one in three people who have suffered from this harm to share their stories on www.conquersilence.ca. And we are telling people that they can expect better of their healthcare system we don't have to accept that patient harm is the third leading cause of death in the country. CPSI’s Senior Director of Strategic Partnerships & Priorities, Sandi Kossey The results have been outstanding we have collected more than 180 stories of healthcare harm on the website. Our social media posts have led to hundreds of other stories shared, led to conversations, and identified supporters across Canada. People are listening. Even more exciting has been the success of our media outreach. During Canadian Patient Safety Week, CPSI and the #ConquerSilence campaign were mentioned in over 200 articles – print and online – with a reach of over 75 million views across Canada and the United States. These ranged from individual hospitals and partner organizations announcing their support for #ConquerSilence to blog posts, Letters to the Editors, and our own #ConquerSilence announcement. In response to this widespread interest, CBC Radio invited CEO Chris Power and Patients for Patient Safety Canada (PFPSC) member Theresa Malloy-Miller to speak on radio programs across the country. Our #ConquerSilence discussions reached over 5 million people throughout 25 different radio stations! This unprecedented profile for patient safety didn't stop there. The following week, the Canadian Institute for Health Information published a report on the rate of patient harm in Canada compared to 25 other nations around the world. Since CPSI was named in the report and we were top of mind in the media, we were invited to bring the patient perspective on the statistics that were shared. Over the course of 36 hours, CPSI was mentioned in print, online and broadcast media 589 times for a combined total reach of 145 million impressions! CPSI's Senior Director of Strategic Partnerships & Priorities, Sandi Kossey, gave several interviews a day in order to respond to media requests. Radio stations in Toronto and Kingston invited CPSI's Anne MacLaurin, as well as PFPSC co-chair Linda Hughes, to discuss patient harm in our healthcare system. CTV National News - Alarming slip-ups (featuring Sandi Kossey) Global News - More than 500 objects forgotten in surgery patients over 2 years (featuring Sandi Kossey) Zoomer Radio, Toronto - Canada's track record when it comes to patient safety (featuring Sandi Kossey and Linda Hughes) CBC News - Medical device used during labour falls out of patient 10 weeks later (featuring Sandi Kossey) As new stories drew away media interest, CPSI sent out a series of three Public Service Announcements, in English and French, to radio stations across the country in order to keep the public attention firmly on the patient safety crisis. Since Canadian Patient Safety Week, these 30-second radio spots have been broadcast over 1000 times across the country, including over 100 times in French markets. French PSAs have run on two Montreal stations and one in Quebec City. The English PSAs have run everywhere from Toronto, Ottawa and Edmonton to Corner Brook, NL, and La Ronge, SK. If we total every certified listener from each time a PSA was aired, these PSAs have reached over 125 million impressions!Listen to our Public Service Announcements here. CPSI's first long-term public engagement campaign continues to attract attention. Through social, print, and broadcast media, we are committed to warning people across Canada about the crisis of patient harm – and what they can do to keep themselves safer in our healthcare system.Visit www.conquersilence.ca to hear stories of harm in our healthcare system and how you can help #ConquerSilence. 2/5/2020 8:00:00 PMOnly a few short months ago, the Canadian Patient Safety Institute launched a major public engagement campaign called #ConquerSilence . We are2/10/2020 3:45:23 PM295https://www.patientsafetyinstitute.ca/en/NewsAlerts/News/Pages/Forms/AllItems.aspxhtmlFalseaspx

 Upcoming Events

 

 

2020 HQCA Patient Experience Awards 680https://www.hqca.ca/health-care-provider-resources/patient-experience-awards/2/21/2020 12:00:00 AM2/21/2020 11:59:00 PMNOW ACCEPTING SUBMISSIONS – APPLY BY FEBRUARY 21, 2020! For the fifth year, the HQCA, in partnership with our Patient and Family Advisory Committee (PFAC), will be hosting the Patient Experience Awards program to recognize and help spread knowledge about initiatives that improve the patient experience in accessing and receiving healthcare services. Who can apply? These awards are for any individual or team of healthcare workers in Alberta involved in designing and implementing an initiative that made a positive impact on patients’ experiences in accessing or receiving healthcare services.1/10/2020 7:01:14 PM8https://www.patientsafetyinstitute.ca/en/Events/Lists/Events/calendar.aspxFalseSpecial EventTrue
Human Factors in Healthcare Course68639Calgary, ABhttps://www.w21c.org/portfolio/human-factors-in-healthcare/2/25/2020 12:00:00 AM2/25/2020 11:59:00 PMThe Canadian Patient Safety Institute is proud to support this event. This event is hosted by Health Quality Council of Alberta 1/27/2020 4:25:36 PMhttps://www.patientsafetyinstitute.ca/en/Events/Lists/Events/calendar.aspxFalseWorkshopTrue
TeamSTEPPS Canada™ Master Trainer Training Course 34440https://www.patientsafetyinstitute.ca/en/education/teamstepps/pages/teamstepps-master-trainer-training-course---2018-12-04.aspx3/17/2020 12:00:00 AM3/18/2020 11:59:00 PMThe Health Quality Council of Alberta (HQCA) is proud to partner with the Canadian Patient Safety Institute (CPSI) to offer a foundational course for developing high-functioning teams. Organizations often try team-building exercises, which are energizing and valuable, but are quite different than investing in team training. TeamSTEPPS Canada offers participants the knowledge, skills, and tools they need to build and promote sustainable teamwork strategies.1/17/2020 11:08:49 PM9https://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 PM9https://www.patientsafetyinstitute.ca/en/Events/Lists/Events/calendar.aspxFalseCollaborativeTrue
Medication Safety Self-Assessment: Focus on Never Events 46205https://www.patientsafetyinstitute.ca/en/toolsResources/Pages/Medication-Safety-Self-Assessment-Focus-on-Never-Events.aspx3/31/2020 12:00:00 AM3/31/2020 11:59:00 PMJoin your colleagues in improving patient safety by understanding and preventing medication-related never events! We’re looking for at least 100 teams (60 acute care and 40 long-term care) to complete the MSSA-Never Events for their practice site between January and March 2020.1/21/2020 5:52:34 PM6https://www.patientsafetyinstitute.ca/en/Events/Lists/Events/calendar.aspxFalseNational Audits;CollaborativeTrue