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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

 

 

Learning from Greg’s story: inspiring change and improvement in the healthcare system69438SHIFT Talks ​Falling Through the Cracks Greg's Story is a short film that gives a glimpse into the life of Greg Price and the healthcare journey that resulted in his unexpected and tragic death. The film premiered to a sold-out audience on May 17, 2018. In spite of Greg's sad story, the film is intended to inspire positive change and improvement in the healthcare system. In the last year the film has been screened more than 200 times, in every Canadian province, and at two international conferences. During post-film discussions, we have learned that the cracks that Greg fell through are not unique to him, to his diagnosis, or to the Alberta healthcare system. The film clearly portrays that, while everyone who was involved in Greg's care did their "job", they didn't work as a team – and Greg was not included as a member of his own team. The University of Calgary's Team Scheme framework and the use of the film with TeamSTEPPS training has provided the tools to reinforce "good teamwork", spelling out elements that are required to function as a high-performing team. The framework is a tool which outlines tangible behaviours that contribute to good teamwork. We need health systems that are structured and incentivized to enable and value teamwork. Our current "system" (including our information systems) is not set up to enable teamwork that would lead to improved safety and quality care. We need true partnerships with patients (and families) and recognition that they are critical members of the team. Patients have valuable insights and a unique understanding of the system. They are the only consistent member of a team and often have to overcome obstacles to be able to find the care that they need. Patient involvement is an incredibly important (and often untapped) resource that needs to be appreciated and utilized. When given the opportunity, we believe that many patients, families or caregivers can and will step up to contribute in a meaningful way as valuable members of the team. For those patients who can't, we need the time and resources to build a team around them that will recognize their vulnerabilities and fill any potential gaps. We need everyone on the team to know that they have a critical role to play and their unique perspective should be invited, respected and valued. In the film, the fax machine is depicted and referred to (appropriately) as the villain. There are alternative tools for transmitting information that are secure and compliant, that could effectively eliminate the fax machine. Swapping fax machines for another technology and expecting the cracks in the system to be filled will not work. We need to do more than just "Axe the Fax" – we need to look for tools that will enable sharing information with the team. We need the acknowledgement and shift in mindset that recognize information is critical and all members of the team should have access – including patients and their families. Decisions that are made about what technology to invest in should be made with this fundamental value guiding us. As a family, we are grateful for the interest in the film and for all of the people we have met in the last year. We continue to encourage positive discussion, the sharing of ideas and learning from successes. Greg loved a challenge. He believed in people, that we should aim high and always be ready to learn. With that in mind, we are (re) launching an online community called the Co-Pilot Collective. Co-Pilot will be the place to request access to the film, additional teaching scenes, and the curriculum and training materials that have been developed. It will also be a place to interact with and learn from others who have hosted screenings of the film or used it for training and education. We will also help others to share the projects that they are working on to build a network of champions, and ideally speed up the spread and scale of some of the good things that are happening. Teri Price is co-founder and a director of Greg's Wings Projects, a not-for-profit organization established in honour of her brother, Greg Price. The Co-Pilot Collective was created as a means to involve the public in enacting change in the healthcare system.5/21/2019 9:00:00 PM Falling Through the Cracks: Greg's Story is a short film that gives a glimpse into the life of Greg Price and the healthcare journey that5/21/2019 10:08:56 PM22https://www.patientsafetyinstitute.ca/en/NewsAlerts/News/Pages/Forms/AllItems.aspxhtmlFalseaspx
#SuperSHIFTER Saegis: advancing patient safety and practice management68572Super SHIFTERS ​Margaret Hanlon-Bell is the Chief Executive Officer of Saegis, a wholly-owned subsidiary of the Canadian Medical Protective Association (CMPA); Dr. Tom Lloyd is Director of the Saegis Safety Institute, responsible for the planning and direction of programs for physicians, healthcare professionals and institutions. Saegis was established by the CMPA in 2017. Margaret Hanlon-Bell Dr. Tom Lloyd Why was Saegis created? Margaret Through research and data gathered by the CMPA, it was determined that there was a greater need in the healthcare space to reach out to multidisciplinary healthcare teams and to hospitals and institutions with programs that focus on reducing risk and improving outcomes for both patients and healthcare professionals. Saegis was formed to meet that need. The mission of Saegis is to make a difference in healthcare provider and patient experience through professional development, quality improvement and practice management solutions. What is unique about the programs and services you offer? Margaret We have been able to leverage some of the work that the CMPA has done with physicians over the years and provide additional, complementary programs to multidisciplinary teams. We have looked at the medical-legal risks and applied what we have learned from their outcomes to both the system and the culture, from a team perspective. Knowledge and communication are key in improving patient safety across the country. From a broad view, the core areas we focus on include teamwork and communication, changing culture, and disclosure. Our SafeOR program is unique in that it is an educational and quality improvement program designed to generate lasting improvements to the safety, efficiency and culture of hospital operating rooms (ORs). The program leverages intra-operative data and insights from the OR Black Box, developed by Dr. Teodor Grantcharov from St. Michael's Hospital. The program delivers customized and evidence-based education, coaching and other safety initiatives for operating room teams. Another area we focus on is practice management. We are helping clinics that are not within institutions, both large and small, to improve their safety for both patients and healthcare professionals. One of the first products we are launching is a cybersecurity program, as many clinics do not have the necessary infrastructure in place to deal with these types of issues. How do you determine what patient safety programs Saegis will provide? Tom What is important is that we are not trying to reinvent the wheel here. There are some great courses and interventions from around the world and also within Canada that we are leveraging. For example, we partnered with the University of Toronto on an opioid-prescribing educational session that we are moving across the country. We partnered with Outcome Engenuity, who have decades of experience in just culture, to bring that program to Canada. There is a communication program that has been running for many years in Australia, the United Kingdom (UK) and many other jurisdictions with some great results, so we partnered with the Cognitive Institute and Medical Protection Society to bring the Clinical Communication Program to Canada to fill that need. In terms of engagement, we look at trends from CMPA data, review the literature, and have thoughtful discussions with colleges and hospitals to identify the gaps. Then we put together meaningful interventions that are going to drive change. When we can get many people from different disciplines within the same organizations talking the same language, looking at barriers, and doing things together along the lines of a program, we have a much better chance of driving the cultural change. With the experience you bring to the table, can you share any key learnings or "Aha!" moments? Margaret It is very important that the focus in healthcare is on improving culture within institutions. There is a realization that this will lead to improved outcomes for all. When I look at the Saegis product offering, I see programs specifically designed to help improve communication and culture and to help reduce risk. It is very exciting. Tom I trained in surgery in the UK and have worked in the medical-legal field for about 12 years and I have seen many medical-legal and patient safety events. Whether it is here in Canada, across the UK, Ireland, South Africa or the Far East, it is basically the same issues that are causing trouble. Communications in all forms and the impact of culture are the drivers I have frequently experienced. You have an individual responsibility, but the environment that you work in also has a big impact. When I think about just culture, if you can institute that, you can make quite a difference in the way that a unit, a department, or even an organization operates. The surrounding culture is so important if you're really going to push a healthy attitude toward patient safety and make things right for both staff and patients. Where can we go to learn more and what call to action would you like to leave with us? Tom The message I would like to leave with physicians and healthcare providers is the value of teamwork, communication and culture and how that can have a significant impact on their ability to practice safely. If you can develop skills and knowledge in these areas, you can make a difference for patient safety. Margaret I would encourage people to visit our website and engage with us. Let's see what we can do to partner with you and help you achieve your goals in professional development, quality improvement and practice management. I encourage you to subscribe to our e-newsletter and sign-up to receive program updates on a regular basis. For more information, visit https//saegis.solutions 5/15/2019 7:00:00 PM Margaret Hanlon-Bell is the Chief Executive Officer of Saegis, a wholly-owned subsidiary of the Canadian Medical Protective Association (CMPA); Dr.5/15/2019 8:28:39 PM483https://www.patientsafetyinstitute.ca/en/NewsAlerts/News/Pages/Forms/AllItems.aspxhtmlFalseaspx
Patient Safety Power Play: Awareness of the Patient Safety Crisis in Canada66142Patient Safety Power Plays In September 2017, Patients for Patient Safety Canada members set an objective to increase the public and elected official awareness about patient safety and patients as partners. CPSI contracted an IPSOS Public Affairs survey to discover Canadians' understanding of patient safety, as well as how they prioritize the issue. We also asked for their experience with patient safety incidents (PSIs), which we defined as preventable harm to patients resulting in prolonged healthcare, disability or death. We discovered that one in three Canadians have either personally experienced a PSI or have a loved one who did. However, as for patient safety, only three in ten Canadians say they know it very well or a fair amount. Five percent say they've never heard of it. When we asked Canadians to rank healthcare issues, only one third of Canadians rank patient safety in their top three priorities, with fewer than one in ten ranking it first. The next section of the survey was telling we asked about knowledge about the actual impact of patient safety on Canadians. We know that patient safety incidents are the third leading cause of death in Canada – but only one in ten knew that. Only one in ten thought that patient mortality from PSIs was anywhere close to the reality of once every 13 minutes. Finally, the 2.75-billion-dollar cost of PSIs per year was higher than expected for 60 per cent of respondents, while one in three say it was much higher. After we shared this information, we asked if that knowledge changed our respondents' healthcare priorities. After they received the facts about PSIs, there was a very significant change. Suddenly, three quarters of Canadians ranked patient safety in their top three priorities and one quarter named it the number one issue in healthcare. Three quarters were concerned about experiencing a patient safety incident, for themselves or a loved one. So, in conclusion, we know that overall awareness of patient safety and patient safety incidents is low. Even among the one third who have experienced a PSI, few Canadians are aware of the significance of the issue or how much it costs us – both financially and in human lives. However, when they are presented with the facts, Canadians overwhelmingly place a higher priority on patient safety. Increasing awareness of patient safety is key, not only the toll PSIs take both in terms of increased costs and lives lost, but how Canadians can stay safe. Canadians are not aware how serious of an issue patient safety is, and education is needed to close the gap. Together, and armed with this information, we can make a difference. You can read more about the report here, including conclusions from the report and next steps, as well as read the full report in detail. You can watch the Patients for Patient Safety Canada webinar on the subject here. I invite you to share your thoughts about the report online. Please use the hashtag #PatientSafetyRightNow in any social media you share. If you have a story about preventable patient harm, please share it with your audiences through social media – and use the hashtag. 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 5/8/2019 6:00:00 AMIn September 2017, Patients for Patient Safety Canada members set an objective to increase the public and elected official awareness about patient5/8/2019 8:06:47 PM160https://www.patientsafetyinstitute.ca/en/NewsAlerts/News/Pages/Forms/AllItems.aspxhtmlFalseaspx
Prevent healthcare-acquired infections: Share how to have Clean Care Conversations during STOP! Clean Your Hands Day43023Patient Safety News Every year, 220,000 Canadian patients (approximately one in nine) develop a hospital-acquired infection during their stay in hospital, and an estimated 8,000 of those patients will lose their lives. Whether you're a patient, visitor, provider, or worker in a healthcare setting – cleaning your hands is one of the best ways to prevent infection. Clean care saves lives. The Canadian Patient Safety Institute (CPSI), in partnership with the World Health Organization's SAVE LIVES Clean Your Hands campaign, is directing the annual STOP! Clean Your Hands Day on May 6, 2019, to bring attention to healthcare-acquired infections. This year, CPSI is teaching the public and healthcare providers how to have Clean Care Conversations and stop the infection crisis. We want to encourage compassionate conversations, where healthcare providers, patients and families work hand in hand to create a clean care culture. We are asking you to share the attached infographic through your social media accounts. If you wish, you can also publicize the events happening today. Clean Care Conversations Webinar, 1000 am MDT 1200 EDT The Germ Guy, Jason Tetro, will discuss Clean Care Conversations with Prince Edward Island's medical microbiologist and infectious disease consultant, Dr. Greg German, and Saskatchewan Patients for Patient Safety Canada patient partner, Carmen Stephens. Download a special new episode of our award-winning PATIENT Podcast and learn how to start a clean care conversation. Download tip sheets for public and healthcare providers on how to start Clean Care Conversations. Do you know how to have a conversation about clean care? Take the quiz, one for the public or one for healthcare providers, and see for yourself! Show us on social media how you're starting #CleanCareConversations. Share photos of #STOPCleanYourHandsDay events and activities and of you cleaning your hands. There will be a giveaway of GOJO products based on social media activity. All of these tools and resources are available at www.handhygiene.ca. 5/6/2019 6:00:00 AMEvery year, 220,000 Canadian patients (approximately one in nine) develop a hospital-acquired infection during their stay in hospital, and an5/6/2019 3:00:51 PM118https://www.patientsafetyinstitute.ca/en/NewsAlerts/News/Pages/Forms/AllItems.aspxhtmlFalseaspx
#SuperSHIFTER - Encourage conversations between patients and providers: 5 Questions to Ask About Your Medications11Super SHIFTERS SuperSHIFTERS Alice Watt, Medication Safety Specialist at the Institute for Safe Medication Practices Canada (ISMP Canada) and Mike Cass, Senior Project Manager at the Canadian Patient Safety Institute, were instrumental in the development and widespread dissemination of the 5 Questions to Ask About Your Medications. The 5 Questions creates a platform for patient engagement and promotes safe medication practices. What are the 5 Questions to Ask About Your Medications? The 5 Questions are a launching pad to encourage conversations between patients and healthcare providers. Patient Advocate Jill Adophe has been quoted as saying, "Patients want a dialogue, not a monologue. They want a choice and a voice." The 5 Questions tool gives patients something to think about in preparing for these conversations. ​ ​ ​ Alice Watt ​ Mike Cass How did you land on these particular questions for the 5 Questions tool? In 2014, a Medication Safety Summit concluded that a checklist would engage patients in medication safety. ISMP Canada was asked by the Canadian Patient Safety Institute to lead this opportunity, working with patients and a number of patient safety and medication specialists. Co-designed with representatives from Patients for Patient Safety Canada (PFPSC), the working group took a collaborative approach, ensuring that the patient voice guided the questions. An initial environmental scan of medication safety literature and tools produced questions for consideration. Safety tools reviewed included medication reconciliation materials that had been developed following analyses of medication incidents at transitions of care (and shared with the Canadian Medication Incident Reporting and Prevention System). Those questions were narrowed down to create the final 5 Questions that would resonate most with the target audience. What we ended up with went beyond our expectations! What do patients and providers have to say about the 5 Questions? In a recent Canadian Patient Safety Week survey, 63 per cent of healthcare providers said that patients are asking more questions about their medications, and 60 per cent of patients said they are asking more questions about their medications. Healthcare providers say they are distributing the 5 Questions to patients, posting them in examination rooms and clinics, and using the tool as a guide for conversations between patients and providers. What is being done to spread the use of the 5 Questions? We conducted several surveys with patients and healthcare providers to validate the 5 Questions and people told us to make it available in multiple languages. This has been another fascinating element of the project. Today, the 5 Questions tool is available in 25 languages from Albanian to Korean and Ukrainian. Organizations are still asking us to make the 5 Questions available in more languages and we're working on that! Another feature of the 5 Questions is that healthcare organizations can add their logo to the tool, and it has been customized by more than 200 organizations to date. More than five million patients are learning about the 5 Questions through an eye-catching digital poster campaign in doctors' offices and hospital waiting rooms in Ontario, Alberta, British Columbia and Quebec. The 5 Questions tool has also been shared with organizations in other sectors through initiatives like the Home Care Collaborative and the Medications Safety at Transitions of Care Safety Improvement Project. Were there any surprises or key learnings that you can share in developing the 5 Questions? The enthusiasm of patients to promote the 5 Questions in their communities has been so rewarding. They have asked for copies and distributed them locally in grassroots efforts. There has been interest from sectors outside of acute care, including long term care, home care, primary care, and the 5 Questions have proven useful at transitions of care. We've been delighted by the international interest in the tool and the fact that it's now available in so many languages around the world. We know that working with patients and having them participate in the co-design was crucial and will continue to be important as we develop new tools. There's always room for modification, but as they were created, the 5 Questions have become a successful platform for starting a conversation. We tapped into an unmet need and the pick-up has snowballed. Have you expanded on the initial 5 Questions tool? A new 5 Questions handout has been developed with the Canadian Deprescribing Network and Choosing Wisely Canada, with the goal of reducing the use of opioids for pain after surgery. Key messages in the handout focus on safe storage and disposal of opioids. We are now looking at developing a 5 Questions tool to address the use of opioids for short-term pain and dental pain. Where can our readers go for a copy of the 5 Questions, or learn more? Click on the link to download the 5 Questions to Ask About Your Medications poster. For more information, contact alice.watt@ismpcanada.ca or mcass@cpsi-icsp.ca 4/11/2019 6:00:00 AMSuperSHIFTERS Alice Watt, Medication Safety Specialist at the Institute for Safe Medication Practices Canada (ISMP Canada) and Mike Cass, Senior4/10/2019 7:38:04 PM872https://www.patientsafetyinstitute.ca/en/NewsAlerts/News/Pages/Forms/AllItems.aspxhtmlFalseaspx

 Upcoming Events

 

 

National Forum on Simulation for Quality and Safety70632Vancouver, BChttp://www.sim-one.ca/simexpo/forum5/28/2019 12:00:00 AM5/28/2019 11:59:00 PMThe Canadian Patient Safety Institute is a proud sponsor of this event.2/15/2019 4:00:15 PM3https://www.patientsafetyinstitute.ca/en/Events/Lists/Events/calendar.aspxFalseConferenceTrue
Advancing Safety for Patients in Residency Education (ASPIRE) workshop 6468Ottawa, ONhttps://www.patientsafetyinstitute.ca/en/education/advancing-safety-for-patients-in-residency-education/Pages/default.aspx5/28/2019 8:00:00 PM5/31/2019 9:00:00 PMThe Canadian Patient Safety Institute in collaboration with the Royal College of Physicians and Surgeons of Canada are offering an Advancing Safety for Patients in Residency Education (ASPIRE) workshop from May 28 - 31, 2019 in Ottawa ON. Registration closes on May 21, 20192/8/2019 8:34:50 PM8https://www.patientsafetyinstitute.ca/en/Events/Lists/Events/calendar.aspxFalseWorkshopFalse
A TeamSTEPPS Canada™ Master Training course842Edmonton, ABhttps://www.patientsafetyinstitute.ca/en/education/TeamSTEPPS/Pages/TeamSTEPPS-Master-Trainer-Training-Course---2018-12-04.aspx6/3/2019 2:00:00 PM6/4/2019 10:30:00 PMA TeamSTEPPS Canada™ Master Training course is coming to the Edmonton area in June 2019! This course will help you to improve team collaboration, clinical outcomes and patient safety at your organization. Learn about the TeamSTEPPS® tools – what they are and how to use them – so that you can make a difference in your workplace.4/4/2019 4:24:29 PMhttps://www.patientsafetyinstitute.ca/en/Events/Lists/Events/calendar.aspxFalseWorkshopFalse
Canadian Patient Safety Officer Course39900Ottawahttps://www.patientsafetyinstitute.ca/en/education/psoc/Pages/default.aspx6/3/2019 2:00:00 PM6/6/2019 10:00:00 PMThe Canadian Patient Safety Officer Course is jointly developed and delivered by the Canadian Patient Safety Institute and HealthCareCAN, supported by experts from across Canada and internationally.8/22/2018 9:49:14 PMhttps://www.patientsafetyinstitute.ca/en/Events/Lists/Events/calendar.aspxFalseWorkshopFalse
Human Patient Simulation Network (HPSN) Canada 20193435911763 106 St NW Edmonton, AB T5G 1Y5http://www.hpsn.com/event/hpsn-canada6/4/2019 11:00:00 PM6/5/2019 11:30:00 PMThis conference will address how we can achieve making healthcare a high-reliability environment by improving competency, teamwork, and safety during healthcare simulations. Focusing on how to design deliberate healthcare simulations that practice both technical skills and interprofessional communication. Human Patient Simulation Network (HPSN) Canada, will provide interactive workshops with hands-on simulation training and techniques, opportunities to network with other sim users, a chance to gather and learn from enthusiastic experts, and hear from eager innovators expanding the world of healthcare simulation. Experience, contribute, and learn together at HPSN Canada; a joint initiative of the Northern Alberta Institute of Technology (NAIT) and CAE.5/16/2019 2:50:50 PMhttps://www.patientsafetyinstitute.ca/en/Events/Lists/Events/calendar.aspxFalseConferenceFalse