Sign In

 

 

Advocacy and support for use of a Surgical Safety Checklist2607Surgical Care SafetyPosition Statements2/5/2019 7:55:32 PMPosition StatementA Surgical Safety Checklist is smart for patients and smart for providers. It's use in Canadian healthcare facilities is endorsed by a Position Statement supported by many surgical interest groups. ​Healthcare professionals must make every reasonable effort to provide safe care to their patients. The purpose of this statement is to express the commitment of the undersigned organizations to prioritize perioperative patient safety by creating an environment conducive to the effective adoption and use of a Surgical Safety Checklist. Download Advocacy and support for use of a Surgical Safety ChecklistPosition Statement A Surgical Safety Checklist is smart for patients and smart for providers. It's use in Canadian healthcare facilities9/24/2020 8:13:01 AM2156https://www.patientsafetyinstitute.ca/en/toolsResourceshtmlTrueaspx
Hand Hygiene Fact Sheets2654Infection Prevention & Control (IPAC)Toolkits & Guides;Tip Sheets4/1/2020 2:15:32 PM ​Hand Hygiene Resources for Healthcare Providers, Patients and Families Cleaning your hands, either with soap and water or with alcohol-based hand rub, is one of the most effective ways to contain the spread of infections. Please read, download, and share these resources to help yourself and others stay safe. Download the following Guidelines and Tip Sheets How to Hand Wash (PDF) How to Hand Rub (PDF)Your 4 Moments (PDF)On-the-Spot Feedback (PDF)Clean Care Conversations (PDF tip sheet for public)Clean Care Conversations (PDF tip sheet for healthcare providers) Browse the following Hand Hygiene Fact Sheets The Need for Better Hand Hygiene in Healthcare If Healthcare Provider Hands Could Talk Proper Hand Hygiene Technique in Healthcare Hand, Skin and Nail Care for Healthcare ProvidersPatient and Family Guide Patient and Family FAQsAdditional Resources Hand Hygiene Fact SheetsHand Hygiene Resources for Healthcare Providers, Patients and Families Cleaning your hands, either with soap and water or with alcohol-based hand9/24/2020 8:13:49 AM14779https://www.patientsafetyinstitute.ca/en/toolsResourceshtmlTrueaspx
Measures: Ventilator-Associated Pneumonia (VAP)10529Infection Prevention & Control (IPAC)Toolkits & Guides7/1/2015 8:57:33 AM Measurement is essential to monitoring success and helps guide your team towards your specific intervention goal. Measurement also tells us what's working and what's not, and provides evidence to inspire other healthcare providers to improve the quality of patient safety. The measurement methodology and recommendations regarding sampling size referenced in this GSK, is based on The Model for Improvement and is designed to accelerate the pace of improvement using the PDSA cycle; a "trial and learn" approach to improvement based on the scientific method. Langley, G., Nolan, K., Nolan, T., Norman, C., Provost, L. The Improvement Guide A Practical Approach to Enhancing Organizational Performance. San Francisco, Second Edition, CA. Jossey-Bass Publishers. 2009. It is not intended to provide the same rigor that might be applied in a research study, but rather offers an efficient way to help a team understand how a system is performing. When choosing a sample size for your intervention, it is important to consider the purposes and uses of the data and to acknowledge when reporting that the findings are based on an "x" sample as determined by the team. The scope or scale (amount of sampling, testing, or time required) of a test should be decided according to The team's degree of belief that the change will result in improvement The risks from a failed test Readiness of those who will have to make the change Provost, Lloyd P; Murray, Sandra (2011-08-26). The Health Care Data Guide Learning from Data for Improvement (Kindle Locations 1906-1909). Wiley. Kindle Edition. Please refer to the Improvement Frameworks GSK (2015) for additional information.VAP Measures Measure Goal Type VAP 1 - VAP Rate in ICU per 1000 Ventilator Days Decrease 50% Outcome VAP 2 - VAP Bundle Compliance 95% Process VAP 3 - Paediatric VAP Bundle Compliance 95% Process Measures and definitions Types of Measures Safer Healthcare Now! (SHN) has two types of measures for each of the interventions process measures and outcome measures. Some interventions also have balancing measures and information measures. Below are examples of each. Outcome measures - answers whether the team is achieving what it is trying to accomplish and articulates the picture of success. For example, if the team wants to reduce falls it should measure the number of falls. Process measures - Processes which directly affect the outcome are measured to ensure that all key changes are being implemented to impact the outcome measure. For example, the delivery of timely prophylactic antibiotics to reduce surgical site infection. Balancing measures - answer the question whether improvements in one part of the system were made at the expense of other processes in other parts of the system. For example, in a project to reduce the average length of stay for a group of patients, the team should also monitor the percent of readmissions within 30 days for the same group. Information measures - collect general details relative to the intervention.VAP: Measurement Worksheets9/24/2020 8:15:22 AM9462https://www.patientsafetyinstitute.ca/en/toolsResources/psm/Pages/Forms/UpdateData.aspxhtmlFalseaspx
Canadian Quality and Patient Safety Framework for Health Services2639General Patient Safety;Policy;Government Relations;Improving Culture;Partnering with Patients;Patient & Family ResourcesFrameworks;Patient and Family Resource;Position Statements;Reports & Publications3/27/2019 7:47:40 PM The need for a national patient safety and quality framework Health services across Canada are comprehensive, complex, and at times complicated. Every person in Canada deserves safe, high-quality healthcare when and where they need it. For the most part, this is our experience. But we don't always get it right. People may be inadvertently harmed by the services intended to help them. The reality is that unintended harm occurs in a Canadian hospital or home care setting every 1 minute and 18 seconds Every 13 minutes and 14 seconds, someone dies Patient safety incidents are the third leading cause of death in Canada Even more, there are significant variations in care by age, gender, race/ethnicity, geography and socio-economic status. Access to quality health services is more challenging for Indigenous peoples, (including First Nations, Inuit and Métis), Black people, LQBTQ2S+ identities (including Lesbian, Gay, Bisexual, Transgender, Queer or Questioning and Two-Spirit), immigrants, visible minorities, and many more diverse peoples that comprise our country. While some jurisdictions have quality and safety plans or frameworks in place, people continue to experience healthcare differently across the country. These considerations, when added to the heightened need for consistency and coordination in healthcare due to the COVID-19 pandemic, prompt us to ask How can we focus and align quality and safety improvement throughout the country, regardless of jurisdiction? The Canadian Quality and Patient Safety Framework for Health Services is the first of its kind in Canada. We can all work together to accelerate quality and patient safety across Canadian health systems by focusing all stakeholders across Canada on five goals for safe, quality care. This people-centred framework defines five goal areas designed to drive improvement and to align Canadian legislation, regulations, standards, organizational policies, and public engagement on patient safety and quality improvement. It includes action guides and resources customized for each stakeholder group to support you in putting the goals into practice. Download the Framework How to use the Framework Be sure to take full advantage of all the communications tools and resources in this package Download the Communication Toolkit Mapping Tool A mapping tool was developed to help you map your organization's current quality and patient safety improvement initiatives to the goals, objectives, and outcomes of the Framework. This exercise will help demonstrate your organization's strengths in aligning with the Framework and uncover opportunities to work toward these key goals for safe, high-quality care. Framework Mapping Tool For any questions, comments or to share your experience using the Framework, please contact qualityservicesforall@healthstandards.org. Contact us Why does Canada need a National Quality and Patient Safety Framework for Health Services?The need for a national patient safety and quality framework Health services across Canada are comprehensive, complex, and at times complicated.1/14/2021 5:58:58 PM17864https://www.patientsafetyinstitute.ca/en/toolsResourceshtmlTrueaspx
About the Framework10413Government Relations;Improving Culture;Partnering with Patients;Patient & Family Resources;PolicyFrameworks;Patient and Family Resource;Position Statements;Reports & Publications10/22/2020 7:26:52 PM Why a Framework?  To truly align Canada's efforts toward better and safer care we must prioritize coordinated action. Collective action across Canadian jurisdictions is needed now more than ever before with the current pandemic. This Framework is the roadmap that can align the country as we work to safely enhance health services. It is already being used in many jurisdictions at different levels. Developed with Broad Consultation, Including Patients and Families  The Framework was developed in consultation with members of the public, health leaders, policy makers, board members, and health teams (including patients and families). The processes also included numerous committee meetings, international and national environmental scans, key stakeholder interviews, a national public consultation, and further targeted consultations with key stakeholder groups. This comprehensive approach was prioritized to ensure the Framework package reflects both current and emerging trends and the realities of health systems across Canada, regardless of jurisdiction. The accompanying action guides, resources, and indicators are curated implementation tools to support all stakeholders with using and implementing the Framework package, regardless of their role or care. Download the Framework Five Goals for Safe, Quality Care   Together, we can create positive change by working towards the Framework’s five overarching goals Goal 1 | People-Centred Care People using health services are equal partners in planning, developing, and monitoring care to make sure it meets their needs and to achieve the best outcomes. Goal 2 | Safe Care Health services are safe and free from preventable harm. Goal 3 | Accessible Care People have timely and equitable access to quality health services. Goal 4 | Appropriate Care Care is evidence-based and people-centred. Goal 5 | Integrated Care Health services are continuous and well-coordinated, promoting smooth transitions. For any questions, comments or to share your experience using the Framework, please contact qualityservicesforall@healthstandards.org. Contact us Wh y a Framework?  To truly align Canada's efforts toward better and safer care we must prioritize coordinated action. Collective11/3/2020 5:12:12 PM1710https://www.patientsafetyinstitute.ca/en/toolsResources/Canadian-Quality-and-Patient-Safety-Framework-for-Health-and-Social-Services/Pages/Forms/AllItems.aspxhtmlFalseaspx
Central Line-Associated Bloodstream Infection (CLABSI): Getting Started Kit6149Infection Prevention & Control (IPAC);Surgical Care SafetyToolkits & Guides7/1/2015 8:51:29 AM ​​​Effective March 14 2019, the Canadian Patient Safety Institute has archived the Central Line-Associated Bloodstream Infection (CLABSI) intervention. Though you may continue to access the Getting Started Kit online, it will no longer be updated. These free resources are designed to help you successfully implement interventions in your organization. Getting Started ​Getting Started Kit The Getting Started Kit contains clinical information, information on the science of improvement, and everything you need to know to start using the intervention. Click here to download the Getting Started Kit. ​One-Pager The One-Pager is a summary of the Getting Started Kit that you can use to promote the intervention to your organization. Click here to download the One-Pager. ​​Icons ​Intervention Icons Use these intervention icons on presentations, reports, flyers, and other material to promote the intervention throughout your organization. Click here to download the full-colour intervention icon. Click here to download the black and white intervention icon. Intervention Icons With Text Click here to download the full-colour intervention icon with text. Click here to download the black and white intervention icon with text. CLI: Getting Started Kit9/24/2020 8:10:31 AM9192https://www.patientsafetyinstitute.ca/en/toolsResources/Pages/Forms/NewDefaultView.aspxhtmlFalseaspx
Tools & Resources25029/18/2020 4:40:20 AMTools & ResourcesTools & Resources9/21/2020 9:19:04 AM68035https://www.patientsafetyinstitute.ca/enhtmlTrueaspx
Hand Hygiene Observation Tools6158Infection Prevention & Control (IPAC)Toolkits & Guides6/3/2015 4:47:24 PMMeasurement is a vital part of the quality improvement process. Auditing hand hygiene compliance by health care providers provides a benchmark for improvement. The results of observation audits will help identify the most appropriate interventions for hand hygiene education, training and promotion. Results should be shared with front-line healthcare providers, management and hospital boards. To support organizations in doing direct observation, CPSI has an observation tool based on the 4 Moments for Hand Hygiene. CPSI has also adapted a Patient Family Observation Tool that will allow patient and family partners to observe and share information about how healthcare workers participate in optimal hand hygiene. Direct observation of hand hygiene practices should be performed by trained observers using a standardized and validated audit tool. Need training on how to conduct Hand Hygiene observations? Here are some training resources to help you. (link to content below) CPSI Hand Hygiene Observation Tool (Paper Tool) This paper tool is for Acute Care only. CPSI Hand Hygiene Observation Tool Instructions for Using the Observation Analysis Tool Observation Analysis Tool - Excel workbook (ZIP) Training on how to conduct Hand Hygiene observations Hand Hygiene Education Module (IPAC Canada) Monitoring and Observation (Auditing) for ACUTE Monitoring and Observation (Auditing) for LTC Measurement is a vital part of the quality improvement process. Auditing hand hygiene compliance by health care providers provides a benchmark for9/24/2020 8:12:25 AM16416https://www.patientsafetyinstitute.ca/en/toolsResources/Pages/Forms/NewDefaultView.aspxhtmlFalseaspx
Surgical Site Infection (SSI): Getting Started Kit6205Surgical Care Safety;Infection Prevention & Control (IPAC)Toolkits & Guides7/1/2015 8:55:00 AMEffective March 14 2019, the Canadian Patient Safety Institute has archived the Surgical Site Infection (SSI) intervention. Though you may continue to access the Getting Started Kit online, it will no longer be updated. ​​​​ Getting Started KitThis free resource is designed to help you successfully implement interventions in your organization. The Getting Started Kit contains clinical information, information on the science of improvement, and everything you need to know to start using the intervention.. Click here to download the Getting Started Kit. Click here to download the summary of changes to the Getting Started Kit ​ ​ One-PagerThe One-Pager is a summary of the Getting Started Kit that you can use to promote the intervention to your organization. Click here to download the One-Pager. ​​ Icons​​ ​Intervention IconsUse these intervention icons on presentations, reports, flyers, and other material to promote the intervention throughout your organization. Click here to download the full-colour intervention icon. Click here to download the black and white intervention icon.​ ​Intervention Icons With Text Click here to download the full-colour intervention icon with text. Click here to download the black and white intervention icon with text.​ SSI: Getting Started Kit9/24/2020 8:12:12 AM11045https://www.patientsafetyinstitute.ca/en/toolsResources/Pages/Forms/NewDefaultView.aspxhtmlFalseaspx
Medication Reconciliation (Med Rec): Getting Started Kit6185Improving Medication Safety;Surgical Care SafetyToolkits & Guides7/1/2015 8:53:35 AM​Effective March 14 2019, the Canadian Patient Safety Institute has archived the Medication Reconciliation (MedRec) intervention. Though you may continue to access the Getting Started Kit online, it will no longer be updated. ​​ Getting Started Kit This free resource is designed to help you successfully implement interventions in your organization. The Getting Started Kit contains clinical information, information on the science of improvement, and everything you need to know to start using the intervention. Click here to download the Acute Care Getting Started Kit. Click here to download the Long Term Care Getting Started Kit. Click here to download the Home Care Getting Started Kit. One-Pager The One-Pager is a summary of the Getting Started Kit that you can use to promote the intervention to your organization. Click here to download the Acute Care One-Pager. Click here to download the Long Term Care One-Pager. Click here to download the Home Care One-Pager. Icons Intervention Icons Use these intervention icons on presentations, reports, flyers, and other material to promote the intervention throughout your organization. Click here to download the full-colour intervention icon. Click here to download the black and white intervention icon. Intervention Icons With Text Click here to download the full-colour Acute Care intervention icon with text. Click here to download the black and white Acute Care intervention icon with text. Click here to download the full-colour Long Term Care intervention icon with text. Click here to download the black and white Long Term Care intervention icon with text. Click here to download the full-colour Home Care intervention icon with text. Click here to download the black and white Home Care intervention icon with text Medication Reconciliation (Med Rec): Getting Started Kit9/24/2020 8:10:39 AM12370https://www.patientsafetyinstitute.ca/en/toolsResources/Pages/Forms/NewDefaultView.aspxhtmlFalseaspx
Surgical Safety Checklist: Download6207Surgical Care Safety;General Patient SafetyToolkits & Guides7/1/2015 8:56:47 AM​​Getting Ready for Implementation Adapt the checklist to your organization using human factors principles Download How-To Guide for implementing the Surgical Safety Checklist A Detailed Explanation of the Checklist Items An Information, Rationale, and Frequently Asked Questions document Surgical Safety Checklist - Canadian Version The checklists below are Word documents with identical content. They are provided in portrait and landscape versions for easier integration into patient files or postings. If your organization is interested in measuring compliance, use the versions with a scorecard. We encourage you to adapt them for use in your organization. Surgical Safety Checklists - Scorecard Portrait Version Landscape Version Surgical Safety Checklists - No Scorecard Portrait version Landscape version LinksWorld Health Organization Safe Surgery Saves Lives WHO Patient Safety Safe Surgery Saves Lives - the second global patient safety challenge Instructional VideosThese videos are intended to teach potential users how to and how not to perform the checklist in a real-world environment. How to use the checklist How NOT to use the checklist How to use the checklist, complex caseReference Articles Impact of using the checklist at the eight WHO pilot sites Haynes AB, Weiser TG, Berry WB, et al. A surgical safety checklist to reduce morbidity and mortality in a global population. New England Journal of Medicine. 2009 Jan 14; [Epub ahead of print]. Retrieved from http//content.nejm.org/cgi/content/full/NEJMsa0810119 The Canadian Adverse Events Study Baker GR, Norton P, Flintoft V, et al. The Canadian adverse events study the incidence of adverse events among hospital patients in Canada. CMAJ. 2004; 170 (11) 1678 - 1686. Retrieved from http//www.cmaj.ca/cgi/content/full/170/11/1678 Team behavior (information sharing during preoperative phases, briefing and information sharing during handoff) impacts the rate of surgical complications and death. Mazzocco K, Petitti D, Fong K, et al. Surgical team behaviors and patient outcomes. The American Journal of Surgery. 2009, Volume 197, Issue 5, Pages 678-685. Preoperative briefings have the potential to increase OR efficiency and thereby improve quality of care and reduce cost. Nundy S, Mukherjee A, Sexton BJ, et al. Impact of preoperative briefings on operating room delays a preliminary report . Arch Surg. 2008 Nov;143(11)1068-72. Team debriefings best practices and tips Salas E, Klein C, King H, et al. Debriefing medical teams 12 evidence-based best practices and tips. The Joint Commission Journal on Quality and Patient Safety. 2008 Sep;34(9)518-27. Adapting the surgical checklist – requirements and implementation tips Verdaasdonk EGG, Stassen LPS, Widhiasmara PP, Dankelman J. Requirements for the design and implementation of checklists for surgical processes. Surg Endosc. 2009, 23 715-726 Prototype surgical checklist development and validation (the Netherlands) De Vries EN, Hollmann MW, Smorenburg SM, et al. Development and validation of the SURgical Patient Safety Sustem (SURPASS) Checklist. Qual Saf Health Care. 2009, 18 121-126 Interprofessional checklist briefings reduce the number of communication failures, promote proactive and collaborative team communication, and identifies patient safety problems. Lingard L, Regehr G, Orser B, et al. Evaluation of a Preoperative Checklist and Team Briefing Among Surgeons, Nurses, and Anesthesiologists to Reduce Failures in Communication. Arch Surg. 2008;143(1)12-17. Large and sustained reduction of the catheter-related infections through an intervention program using a checklist Pronovost P, Needham D, Berenholtz S, et al. An Intervention to Decrease Catheter-Related Bloodstream Infections in the ICU. N Engl J Med 2006 355 2725-2732.​​​​Implementation Resources9/24/2020 8:10:32 AM14851https://www.patientsafetyinstitute.ca/en/toolsResources/Pages/Forms/NewDefaultView.aspxhtmlFalseaspx
Near-fatal medication error leads nurse to make patient safety a priority11016Improving Medication SafetyHealthcare provider stories10/26/2017 7:43:16 PM More than 30 years have passed since the near-fatal medication error but Michael Villeneuve recalls the moment with absolute clarity. The little man on his shoulder was telling him 'wait a second, something is not right here,' but Villeneuve, then a cocky young nurse eager to keep pace with his colleagues in an Ontario intensive care unit, went ahead and administered the medication. The instant he did so, he knew exactly what he'd done right drug, wrong patient. Now the chief executive officer at the Canadian Nurses Association, Villeneuve frequently draws upon that experience in his day-to-day work to promote better care, better health and better nursing across the country. As a youngster, Villeneuve always dreamed of becoming a surgeon. His grandmother was a director of nursing in a small rural hospital and used to take him by the hand and lead him, spellbound, along with her as she did her rounds. His ambitions shifted slightly in high school after a family friend helped him get a job as an orderly at an Ottawa hospital. He was there less than an hour before he realized he was far more fascinated by what the nurses were doing than the doctors. "There was something about the competence of those women," Villeneuve recalls. "If you've been in an emergency department with certain women running the place, there's a kind of swagger and an attitude that's quite intoxicating when you're young. I just thought, 'I want to be like that.' That's where I ended up working in emergency intensive care, neurosurgery and so on, and never looked back. To this day, I would never change a second of it. "Except I wouldn't make the mistake." The mistake happened back in 1985. Two years after graduating nursing school Villeneuve had moved from a ward setting into a neurosurgical intensive care unit. He'd only been there a few weeks. At that time in the profession a male nurse was still something of a novelty and Villeneuve was eager to prove his worth. In that setting, an open ward with 12 beds, the pace is fast. Villeneuve remembers being so impressed by the confident execution and rapid thinking of the nurses around him. "When I think back to what happened, I do think some of it was trying to be better, faster maybe than I was, if you know what I mean." On the day of the incident, Villeneuve had two patients in his care — one with high potassium levels, the other with low potassium. The charge nurse took a call from a doctor, directing potassium be administered to one of his patients. She transcribed the order, called Villeneuve over and holding up the order sheet, instructed him to give medication A to patient B. It is something in that chain of events, a partially obscured order sheet, the utterance of one patient's name rather than the other, that sent Villeneuve to the wrong bedside. "I took the medication, which I had drawn up, potassium, and was about to give it to the patient and — this was a big lesson for me in my entire career — I thought, something was wrong," Villeneuve says. "I thought something was triggering me, something's wrong with this. What I didn't do was stop. I pushed it in, slowly, but pushed it in. It wasn't two seconds after I finished that I thought, oh, it's the wrong patient; it's the guy with the high potassium that I just overdosed with a whole bunch more potassium. Literally I nearly collapsed. I thought, my career's over, I'm going to lose my license, he's going to die." Villeneuve owned up to the error immediately and nurses and doctors swept in to attend to the patient, whose heart went into immediate distress. To make matters even worse, the patient was a senior physician himself. Villeneuve was so upset that his colleagues basically parked him in an adjacent staff lounge for the remainder of the day. "It's 32 or 33 years ago that that happened and it is still cemented in my mind, everything about the lighting in that room that day, the look of people around me, how I felt, what I learned about when the little man on your shoulder says, 'Slow down,' you should slow down before you hurt somebody," Villeneuve says. He views his experience as a perfect example of what is confirmed so often in medicine and nursing, which is that errors most often happen at points of handoff in care. "We see it in handoffs even in home care from registered nurses who provide plans of care and delegate care to a licensed practical nurse who may delegate that to a nursing assistant or a personal support worker and, a point of great error, onto families," Villeneuve says. "Because families provide a lot of care. So it's not just a critical care unit issue or a hospital issue; it's across the healthcare system. Points of handoff, and the more of them there are, the more chances that there are for an error." Villeneuve spent an entire second shift in that staff lounge that fateful day, panic-stricken about his patient, worried about his future, wracked by that "terrible fear of error" that hangs over nursing from graduation day onwards. But as the hours passed it eventually became clear the patient would survive. It was only then that Villeneuve had a chance to talk things over with his head nurse, who was wonderfully supportive. "I was expecting when she came in that I might be disciplined, I might be sent home. Her comment was, 'What did you learn?' " Villeneuve recalls, choking up at the memory. "She said, 'slow down.' One of the nurses I really looked up to was a nurse named Jennifer who was so competent. And she said, 'You're not Jennifer yet. Settle down. Stop. Double check.' All the things I knew I should've done. And it helped me reduce my ego, which was quite constrained after that incident." It was a major life lesson for him. When that little man on your shoulder says stop, it's like encountering the yellow light at the intersection. You shouldn't speed up, you should slow it down. Even now in my administrative roles, my teaching roles, if I sense something's wrong, I just say to people, 'I need a day to think about that.' I try to not make snap decisions and I think my decisions are better."  More than 30 years have passed since the near-fatal medication error but Michael Villeneuve recalls the moment with absolute clarity. The9/24/2020 8:14:04 AM18741https://www.patientsafetyinstitute.ca/en/toolsResources/HealthcareProviderStories/Pages/Forms/AllItems.aspxhtmlFalseaspx
Hand Hygiene Human Factors Toolkit6170Infection Prevention & Control (IPAC);Surgical Care SafetyToolkits & Guides6/3/2015 4:47:25 PM​​​​​Human Factors is the study of how humans interact with the world around them. Studying how people interact with equipment and materials allows us to change the environment in which we work to make the interaction more useful or helpful. A user-friendly hand hygiene environment is one where staff, patients, and visitors are supported in such a way that participating in optimal hand hygiene activities can take place in the right place and at the right time. Developed by the Canadian Patient Safety Institute in conjunction with 3M and the University Health Network, the Hand Hygiene Human Factors Toolkit is designed to help you conduct the assessments necessary to assure that hand hygiene products are located where they are needed, available in the right quantity, visible, within reach, fully stocked and functional, and in the best form. Click here to order the full-colour, spiral-bound toolkit. Extra copies of the assessment forms can be downloaded in PDF format Environment tool Product tool Process tool Ongoing assessment toolsHuman Factors is the study of how humans interact with the world around them. Studying how people interact with equipment and materials allows us to9/24/2020 8:12:26 AM6837https://www.patientsafetyinstitute.ca/en/toolsResources/Pages/Forms/NewDefaultView.aspxhtmlFalseaspx
Hand Hygiene Patient and Family Guide11027Infection Prevention & Control (IPAC)Patient and Family Resource;Toolkits & Guides4/1/2020 7:43:24 PM​ The Canadian Patient Safety Institute has developed a Patient and Family Resource Guide. Download This is in keeping with the World Health Organization's belief that partnerships with patients and families should be encouraged to participate in the promotion of optimal and sustained hand hygiene practices in all healthcare settings. This guide offers basic information to patients and families about hand hygiene, the issue of healthcare associated infections, and how patients, visitors, and family members can actively participate in making healthcare safer. The guide also provides ideas and cues for supporting optimal hand hygiene practices in any setting. Additional guidance on how to engage patients and patient organizations in hand hygiene initiatives can be found on the WHO Website. The Canadian Patient Safety Institute has developed a Patient and Family Resource Guide.  Download This is in keeping9/24/2020 8:13:52 AM2165https://www.patientsafetyinstitute.ca/en/toolsResources/Hand-Hygiene-Fact-Sheets/Pages/Forms/AllItems.aspxhtmlFalseaspx
Breaking down the barriers indigenous people face in Canada’s health-care system10572Patient & Family ResourcesPatient and Family Resource;Patient Stories9/18/2019 8:26:34 PM At the age of 40, Samaria Cardinal found herself homeless and alone, living under a bridge in Calgary, calculating miseries endured and all the hopeless days ahead. Her father had experienced extreme trauma growing up in Alberta’s residential schools and he’d passed that damage on to his daughter in many ways. Samaria had run away from home and lost herself in drug addiction. Years of interaction with the medical and mental health systems had failed her. She’d been diagnosed as bipolar and locked up in mental health wards. She’d been administered shock treatments and overmedicated on so many antipsychotic drugs she wound up with severe tardive dyskinesia, a condition that causes uncontrollable jerky movements of the face and body. On that day, the sum of all those sad experiences brought her to a crossroads. “I was sitting on a mattress, dirty and soaked with urine, and I had no coat, and it was freezing,” Cardinal recalls. “And I thought I’m not living anymore, my life has been destroyed. Nobody can help me so I might as well end it right now.” Cardinal hesitates there, drawing a long ragged breath at the memory. “But something gave me the strength to live. And I chose to live.” Some 20 years later Cardinal seems a world away from that sorrowful half-life. She’s proud of her Metis heritage, happy and confident, back at university, with her own place and her own business. And she’s an outspoken advocate for breaking down the barriers indigenous people face in Canada’s health-care system. “I really feel my indigenous heritage played a big part in how I was treated and misdiagnosed by the health care system,” Cardinal says. “Because we are not understood by mainstream society and we are not understood by many doctors and nurses and people involved in the health care system. They don’t understand what we’ve been through as a people, and they don’t understand how it has affected us. Plus there are judgements.” Cardinal saw that again first-hand recently while riding on the C-train in Calgary when an indigenous man suffered a seizure and slid off his seat onto the floor. All around him the business commuters paid no heed, assuming it was just another drunk Indian. A furious Cardinal had to more or less shame the people in that crowded car into action to get the man the medical help he needed. “I personally believe many people have to connect more with indigenous people. Learn the real history of Canada and North America, learn what these people have gone through, and try and understand where they are at the current time. And as a non-indigenous person, look at the myths out there. Try to educate yourself and try to understand another culture.” Twenty years ago Cardinal picked herself up from beneath that bridge, went to a friend’s house and appealed for help. A man from her past, someone who loved her, re-entered her life and gave her some much-needed support. Her daughter stood by her as well. Gradually, Cardinal came to realize that her long-time pattern of care was simply not working for her. She started resisting the idea of simply taking more and more pills. She found support and improvement with other holistic approaches and counselling. She eventually broke with her old medical team and started up with a new psychiatrist, who was far less quick to prescribe medications. Over two years, she weaned herself off all the drugs and came to see herself as something other than a lifelong victim. “If I had not fired that medical team I would still be living in Calgary housing. I would be taking so many medications that I wouldn’t be able to function. I would be living a life where I was a burden on society, unhappy, a victim, lost, not going anywhere, just basically existing.” Asked what single piece of advice she’d like to give to health-care practitioners, Cardinal draws back on her own early diagnosis as bipolar, one she questions today. “Be very careful with the label that you’re putting on an individual, especially a mental health care diagnosis. Because with that diagnosis, comes a lot. People are judging you wherever you go so be really careful when you’re dispensing that.” Cardinal says she has been encouraged by recent moves toward more culturally appropriate care for indigenous patients in Canadian hospitals, including access to indigenous elders. “Having elders involved in the health care system, working in hospitals in liaison with all the health-care professionals is very important, because they can be an advocate. They dispense wisdom, they dispense experience and they can be the intermediary between the health care system and the indigenous patient involved. It’s very important to have them there and I have started seeing instances of that in Calgary, which is really nice and it’s a real big step from the way things used to be,” Cardinal says. “Also many indigenous people are not urban indigenous, they live on reserves. So they’re coming far away to a place they’re not comfortable in, with a lot of people that don’t know them, so having somebody there like an elder makes them feel better, provides them with a sense of safety…” As part of her healing odyssey, Cardinal has found great satisfaction in working through a difficult reconciliation with her father, Douglas Cardinal, one of Canada’s best-known architects. “He was always very focused on his career and I stayed away from him because of the trauma that I experienced when I was quite young,” she says. “I’ve only got back with my father in the last couple of years when I was off all of the medications and I started doing a lot of personal work on myself to deal with my trauma that was involved." “The reason why I connected back with my father is because many people have seen the growth that I’ve experienced in my life and that I’m actually almost a totally different person off of all of those drugs and now that I’ve found strength in myself. And I’m expecting people to not look at my past and judge me any more, to see me as I am sitting right here now in this moment, and I thought how can I expect people to do that for me when I cannot do that for my father… “Years ago I would not have had the strength to do that. I was still so affected and feeling the victim in my life but now I’m not a victim anymore. I’m an empowered, resilient and strong human being and after I made that connection again I realized he wasn’t the person he was either.” Cardinal joined Patients for Patient Safety Canada because she wanted an opportunity to tell her story. She sees the organization as a place where people can give voice to experiences that many professionals in the health care system need to hear.   At the age of 40, Samaria Cardinal found herself homeless and alone, living under a bridge in Calgary, calculating miseries endured and12/9/2020 8:33:34 PM16683https://www.patientsafetyinstitute.ca/en/toolsResources/Member-Videos-and-Stories/Pages/Forms/AllItems.aspxhtmlFalseaspx
Proper Hand Hygiene Technique in Healthcare11028Infection Prevention & Control (IPAC)Toolkits & Guides4/1/2020 5:10:49 PM Why? Healthcare-associated infections, or infections acquired in healthcare settings, are the most frequent adverse event in healthcare delivery worldwide.1 Hands are the most common means of microbial spread in healthcare. 2 Optimal hand hygiene is one of the most effective measures to reduce the occurrence of healthcare-associated infections (HAIs). When? There are some key moments for hand hygiene Before patient/patient environment contact Before aseptic procedure After body fluid exposure risk After patient/patient environment contact Where? The World Health Organization (WHO) recommends that hand hygiene should be performed at the point of care. How? Clean your hands by rubbing them with an alcohol-based formulation when available. Alcohol-based hand rubs are faster, more effective, and better tolerated by your hands than washing with soap and water.2 Wash your hands with soap and water only when hands are visibly soiled and whenever an alcohol-based formulation if not available.2 Washing hands with soap and water immediately before or after using an alcohol-based hand rub is not recommended as this may predispose the individual to developing contact dermatitis.2 If isolation precautions are in place, always adhere to the hand hygiene directions appropriate to those precautions. Never default to hand rubs where isolation precautions are in place unless the precautions specify that this is acceptable. The act of thorough and vigorous drying is an important measure that helps to eliminate pathogens from your hands. For more information, go to Updated 2009 WHO guidelines full version Updated 2009 WHO guidelines summary version1 World Health Organization (WHO). n.d. Healthcare-Associated Infections Fact Sheet. Retrieved March 20, 2020. 2 WHO Guidelines on Hand Hygiene in Health Care (Updated 2009) Why?    Healthcare-associated infections, or infections acquired in healthcare settings, are the most frequent adverse event in9/24/2020 8:13:51 AM2091https://www.patientsafetyinstitute.ca/en/toolsResources/Hand-Hygiene-Fact-Sheets/Pages/Forms/AllItems.aspxhtmlFalseaspx
S.A.F.E. Toolkit Video Series6202Community Based Care;General Patient Safety;Improving Medication Safety;Surgical Care SafetyReports & Publications;Toolkits & Guides;Social Media/Social Share8/2/2017 3:58:40 PM Understanding that the healthcare system is complex and intimidating, the Manitoba Institute for Patient Safety created the Self Advocacy For Everyone (S. A. F. E) Toolkit to provide tips and resources to ease the minds of those who want to properly speak up about how they feel when it comes to healthcare. To bolster the toolkit, the Manitoba Institute for Patient Safety has created and is pleased to share their new, leading-edge resource. Establishing new ways to encourage people to be more involved in discussions about healthcare is challenging. Therefore, MIPS has come up with the S.A.F.E Toolkit Video series. Based off topics covered in their S.A.F.E Toolkit, the DVD's are made up of eight short three to five minute videos that are supplement the toolkit, and will include the "5 Questions" resource in three of the videos. These videos can be viewed by going to the websites listed below or by accessing YouTube Learn More The S.A.F.E Toolkit Series Playlist We strongly encourage patients, their families and healthcare providers share these resources. Understanding that the healthcare system is complex and intimidating, the Manitoba Institute for Patient Safety created the Self9/24/2020 8:12:42 AM2145https://www.patientsafetyinstitute.ca/en/toolsResources/Pages/Forms/NewDefaultView.aspxhtmlFalseaspx
Infection Prevention and Control (IPAC): Getting Started Kit6188Infection Prevention & Control (IPAC);Surgical Care SafetyToolkits & Guides7/1/2015 8:55:35 AMEffective March 14 2019, the Canadian Patient Safety Institute has archived the Infection Prevention and Control (IPAC) intervention. Though you may continue to access the Getting Started Kit online, it will no longer be updated. ​​​ Getting Started Kit This free resource is designed to help you successfully implement interventions in your organization. The Getting Started Kit contains clinical information, information on the science of improvement, and everything you need to know to start using the intervention. Click here to download the NACS Getting Started Kit. ​ One-Pager The One-Pager is a summary of the Getting Started Kit that you can use to promote the intervention to your organization. Click here to download the One-Pager.​​ Icons​​ Intervention IconsUse these intervention icons on presentations, reports, flyers, and other material to promote the intervention throughout your organization. Click here to download the full-colour intervention icon. Click here to download the black and white intervention icon. NACS: Getting Started Kit9/24/2020 8:10:44 AM7417https://www.patientsafetyinstitute.ca/en/toolsResources/Pages/Forms/NewDefaultView.aspxhtmlFalseaspx
Canada’s Virtual Forum on Patient Safety and Quality Improvement: Looking back, reaching forward – the new Safer Healthcare Now!13986General Patient SafetyNews10/29/2015 1:23:01 PM10/29/2015 2:00:00 PM Day 1 of Canada's Virtual Forum on Patient Safety and Quality Improvement was all about the past, present and future of Safer Healthcare Now! Here's our recap of the day. The day began with Christina Gunther-Murphy from the Institute for Healthcare Improvement (IHI), and Mike Cass from the Canadian Patient Safety Institute (CPSI) talking about the origins of Safer Healthcare Now! (SHN). IHI's mission is to improve health and healthcare worldwide and their goal is to tell the story of various organizations that are working really hard to minimize harm in healthcare. They consider unnecessary harm and adverse events outside of death. SHN was the first organization to bring IHI's 100,000 Lives campaign to an international platform. SHN came forward to IHI and thought about how to bring it to Canada and to share ideas with each other. After that, many campaigns internationally joined to start similar initiatives. Mike Cass talked about how patient safety was a foreign concept at the front line in 2005. Clinical science and improvement science were not considered equally valid by the frontline. Evidence of unnecessary harm continued to accumulate and organizations were compelled to sign up for the new SHN initiative. Pushback was greater than expected but over time the initiative was accepted as a valuable resource. Staff now view it as an essential part of a healthy workplace and part of the hospital's promise to patient safety. Next came two of the more influential voices on patient safety in Canada – Drs. Ross Baker and Peter Norton. They talked about how SHN is the largest quality or patient safety initiative ever launched in this country that engaged a large number of teams, with some notable results. There are definitely 'hot spots' of improvement, however the evidence is mixed as to sustained improvement across the country. The big challenges to move patient safety forward in Canada are Efficient use of collaboratives to reach beyond the local level. How do we sustain improvement once it happens? How can scale up improvements across institutions, regions, provinces and the country? Focus more energy on context and its improvement especially at the microsystem level. The next presenter was Polly Stevens from the Healthcare Insurance Reciprocal of Canada (HIROC), articulating that one of the most significant risks in healthcare is failing to identify and respond to the deteriorating patient condition. HIROC developed a risk ranking process, risk reference sheets on leading practices to address the top risks and pushed out risk assessment checklists to help organizations identify specific opportunities for improvement. Over the past three years, HIROC has seen a steady improvement in the implementation of practices to reduce the risk of failing to identify and respond to the deteriorating patient condition. Polly Stevens was followed by a panel discussing the impact SHN has had on the front line. Dawn Hollohan of the Nova Scotia Health Authority spoke about the role of measurement in SHN interventions. She eloquently expressed that measurement is not the goal, improvement is the goal. Dr. Olavo Fernandes shared his "Top 10 How did SHN support organizations to reduce harm and advance meaningful local and national patient safety improvement?" Rosalie Freund-Heritage spoke about the development of the falls prevention audit tool. Meaningful impact of this work has included a tool that is useful for all sectors, supports organizations to meet Accreditation Canada's Required Organizational Practice requirements and the value in benchmarking. Up next was CPSI CEO Chris Power and CPSI Senior Director of Safety Improvement and Innovation, shedding light on SHN's future direction. They spoke about the comprehensive process that was undertaken to reflect on the success of the first 10 years of SHN and to look forward to what SHN needs to become to help effect transformational change in patient safety across Canada. Through this process, CPSI heard that people wanted a program that is Patient centric and personalized Inclusive Easy to access and act upon Better use of technology Integrated (online and offline) Customized for care teams across the care continuum Credible Supporting everyone in the system (patients, family members, providers, and leaders) The unifying elements across the new SHN program are how do I prevent harm from happening, how do I respond to harm that has already occurred and, how do I learn from harm? CPSI will be ready to launch new SHN next summer. Email info@saferhealthcarenow.com to learn more about how you can get involved in developing the program. Next up was Jody Hales from the Red Cross talking about an increased acuity, frailty, and needs and expectations of patients and families. As an organization, they want to influence and lead change, and not just respond to change by embedding a learning culture in all they do. There are a number of drivers for this organizational strategy, including the Accreditation Canada process which engages all levels of the system, includes clients/families and is continuous and cyclical. Kimbalin Kelly and Cameron McAlpine from the Ontario Chiropractic Association were next on stage. They spoke about key criteria for success in engaging people in change including understanding the audience and their different incentives and changing the approach based on that knowledge. People are mobilized by empowering and give capacity to effect outcome. There is a real difference between instructing and engaging. Programs need to evolve in real time as new opportunities arise. The engagement drivers are purpose, agency (capacity to effect change) and incentive and the enabler is credible leadership. In order to engage people in change you must provide an outstanding experience, understand expectations and aspirations and position the organization to deliver. Our final presenter delivered the French language session for the day. Dr. Claude LaFlamme offered his reflections of SHN, the program's future direction, and SHN 's surgical care safety initiatives. If you missed anything or want to re-watch any of these sessions, all of the recordings can be found online.Day 1 of Canada's Virtual Forum on Patient Safety and Quality Improvement was all about the past, present and future of Safer Healthcare Now! 9/24/2020 8:06:37 AM3959https://www.patientsafetyinstitute.ca/en/NewsAlerts/News/Pages/Forms/AllItems.aspxhtmlFalseaspx
Measures: Venous Thromboembolism (VTE)10530Surgical Care SafetyToolkits & Guides7/1/2015 8:58:09 AM Measurement is essential to monitoring success and helps guide your team towards your specific intervention goal. Measurement also tells us what's working and what's not, and provides evidence to inspire other healthcare providers to improve the quality of patient safety. The measurement methodology and recommendations regarding sampling size referenced in this GSK, is based on The Model for Improvement and is designed to accelerate the pace of improvement using the PDSA cycle; a "trial and learn" approach to improvement based on the scientific method. Langley, G., Nolan, K., Nolan, T., Norman, C., Provost, L. The Improvement Guide A Practical Approach to Enhancing Organizational Performance. San Francisco, Second Edition, CA. Jossey-Bass Publishers. 2009. It is not intended to provide the same rigor that might be applied in a research study, but rather offers an efficient way to help a team understand how a system is performing. When choosing a sample size for your intervention, it is important to consider the purposes and uses of the data and to acknowledge when reporting that the findings are based on an "x" sample as determined by the team. The scope or scale (amount of sampling, testing, or time required) of a test should be decided according to The team's degree of belief that the change will result in improvement The risks from a failed test Readiness of those who will have to make the change Provost, Lloyd P; Murray, Sandra (2011-08-26). The Health Care Data Guide Learning from Data for Improvement (Kindle Locations 1906-1909). Wiley. Kindle Edition. Please refer to the Improvement Frameworks GSK (2015) for additional information.Measurement Worksheets (Measures) and Data Collection Forms (DCF) Measures DCFs Aggregate data (monthly) De-identified Patient-level data (daily) Numerator and Denominator Multiple data elements ​ Roll-up to Measurement Worksheets VTE Audit The tool is designed for use in Acute Care, and was developed to allow organizations to assess the quality of their venous thromboembolism prevention practices and determine the areas requiring quality improvement(s). DCF (Audit) Question Roll-up to Measures A. Preprinted order used on admission or after surgery VTE 4 B. Type of thromboprophylaxis VTE 2 C. Receiving appropriate thromboprophylaxis VTE 1 D. Reason recommended thromboprophylaxis not used VTE 3 VTE Audit DCF VTE Audit Score Template VTE Measures Measure Goal Type VTE 1 - Percent of Patients Receiving Appropriate Venous Thromboembolism Prophylaxis 100% Outcome VTE 2 - Type of Thromboprophylaxis Delivered (Optional Measure) 100% Information VTE 3 - Reasons that Recommended Thromboprophylaxis was NOT Used (Optional Measure) 0% Information VTE 4 - Percent Appropriate Use of Order Sets for Thromboembolism Prophylaxis 100% Process Measures and definitions Types of Measures Safer Healthcare Now! (SHN) has two types of measures for each of the interventions process measures and outcome measures. Some interventions also have balancing measures and information measures. Below are examples of each. Outcome measures - answers whether the team is achieving what it is trying to accomplish and articulates the picture of success. For example, if the team wants to reduce falls it should measure the number of falls. Process measures - Processes which directly affect the outcome are measured to ensure that all key changes are being implemented to impact the outcome measure. For example, the delivery of timely prophylactic antibiotics to reduce surgical site infection. Balancing measures - answer the question whether improvements in one part of the system were made at the expense of other processes in other parts of the system. For example, in a project to reduce the average length of stay for a group of patients, the team should also monitor the percent of readmissions within 30 days for the same group. Information measures - collect general details relative to the intervention. VTE: Measurement Worksheets9/24/2020 8:15:21 AM6278https://www.patientsafetyinstitute.ca/en/toolsResources/psm/Pages/Forms/UpdateData.aspxhtmlFalseaspx
Reducing Falls and Injury from Falls (Falls): Getting Started Kit6155Community Based CareToolkits & Guides7/1/2015 8:52:44 AM​Effective March 14 2019, the Canadian Patient Safety Institute has archived the Reducing Falls and Injury from Falls intervention. Though you may continue to access the Getting Started Kit online, it will no longer be updated. ​ Getting Started Kit This free resource is designed to help you successfully implement interventions in your organization. The Getting Started Kit contains clinical information, information on the science of improvement, and everything you need to know to start using the intervention. Click h​ere to download the Getting Started Kit. ​ ​ ​Falls Prevention GSK Evidence Update! New for 2018 Click here to download. ​ One-Pager ​The One-Pager is a summary of the Getting Started Kit that you can use to promote the intervention to your organization. Click here to download the One-Pager for reducing falls and Injury from falls.​ ​ Framework for Spread (Appendix N from Falls Getting Started Kit) This appendix contains a description of the seven components of a spread framework along with elements of spread readiness. Click here to download the Spread Framework​​ Icons​​ ​ Intervention IconsUse these intervention icons on presentations, reports, flyers, and other material to promote the intervention throughout your organization. Click here to download the full-colour intervention icon. Click here to download the black and white intervention icon.​ ​ Intervention Icons With Text Click here to download the full-colour intervention icon with text. Click here to download the black and white intervention icon with text. Effective March 14 2019, the Canadian Patient Safety Institute has archived the Reducing Falls and Injury from Falls intervention. Though you may9/24/2020 8:10:41 AM10800https://www.patientsafetyinstitute.ca/en/toolsResources/Pages/Forms/NewDefaultView.aspxhtmlFalseaspx
Patient Safety and Incident Management Toolkit2606General Patient Safety;Improving Medication Safety;Healthcare HarmToolkits & Guides12/18/2014 8:28:40 PMPrevent Patient Safety Incidents and Minimize Harm When They Do Occur When a patient's safety is compromised, or even if someone just comes close to having an incident, you need to know you are taking the right measures to address it, now and in the future. CPSI provides you with practical strategies and resources to manage incidents effectively and keep your patients safe. This integrated toolkit considers the needs and concerns of patients and their families, and how to properly engage them throughout the process. Drawn from the best available evidence and expert advice, this newly designed toolkit is for those responsible for managing patient safety, quality improvement, risk management, and staff training in any healthcare setting. Patient Safety Management Incident Management System Factors For more information, contact us at info@cpsi-icsp.ca.Toolkit Focus and Components The toolkit focuses on patient safety and incident management; it touches on ideas and resources for exploring the broader aspects of quality improvement and risk management. There are three sections to the toolkit Incident management—the actions that follow patient safety incidents (including near misses) Patient safety management—the actions that help to proactively anticipate patient safety incidents and prevent them from occurring System factors—the factors that shape and are shaped by patient safety and incident management (legislation, policies, culture, people, processes and resources). Visual representation of the toolkit. Incident management Resources to guide the immediate and ongoing actions following a patient safety incident (including near misses). We emphasize immediate response, disclosure, how to prepare for analysis, the analysis process, follow-through, how to close the loop and share learning. Patient safety management Resources to guide action before the incident (e.g., plan, anticipate, and monitor to respond to expected and unexpected safety issues) so care is safer today and in the future. We promote a patient safety culture and reporting and learning system. System factors Understanding the factors that shape both patient safety and incident management and identify actions to respond, align, and leverage them is crucial to patient safety. The factors come from different system levels (inside and outside the organization) and include legislation, policies, culture, people, processes and resources.Implementing Patient Safety and Incident Management Processes Consider the following guiding principles when applying the practical strategies and resources. Patient- and family-centred care. The patient and family are at the centre of all patient safety and incident management activities. Engage with patients and families throughout their care processes, as they are an equal partner and essential to the design, implementation, and evaluation of care and services. Safety culture. Culture refers to shared values (what is important) and beliefs (what is held to be true) that interact with a system's structures and control mechanisms to produce behavioural norms. An organization with a safety culture avoids, prevents, and mitigates patient safety risks at all levels. This includes a reporting and learning culture. System perspective. Keep patients safe by understanding and addressing the factors that contribute to an incident at all system levels, redesigning systems, and applying human factor principles. Develop the capability and capacity for effectively assessing the complex system to accurately identify weaknesses and strengths for preventing future incidents. Shared responsibilities. Teamwork is necessary for safe patient care, particularly at transitions in care. It is the best defence against system failures and should be actively fostered by all team members, including patients and families. In a functional teamwork environment, everyone is valued, empowered, and responsible for taking action to prevent patient safety incidents, including speaking up when they see practices that endanger safety.Resources to Support Patient Safety and Incident Management CPSI's toolkit resources are practical tools for patient safety and incident management, compiled with input from experts and contributing organizations. You may not require all of them when managing an incident, so please use your discretion in selecting the tools most appropriate for your needs.Toolkit Development and Maintenance CPSI accessed a variety of qualified experts and organizations to compile this practical and evidence-based toolkit. The process included Assigning a CPSI team with support from a writer with experience in the field Seeking advice from an expert faculty that included patient and family representatives Basing the content on the Canadian Incident Analysis Framework Engaging key stakeholders via focus groups and collecting evidence from peer-reviewed journals and publicly available literature The toolkit will be updated every year to keep it relevant. We welcome feedback on what is helpful, what can be improved, and content enhancements at info@cpsi-icsp.ca.Patient Safety and Incident Management ToolkitPrevent Patient Safety Incidents and Minimize Harm When They Do Occur When a patient's safety is compromised, or even if someone just comes close to10/8/2020 7:03:53 PM20424https://www.patientsafetyinstitute.ca/en/toolsResourceshtmlTrueaspx
Enhanced Recovery Canada™ - Enhanced Recovery After Surgery2656Surgical Care Safety;General Patient SafetySocial Media/Social Share7/13/2016 2:57:58 AM What is Enhanced Recovery After Surgery? Enhanced Recovery Canada is a project of the Canadian Patient Safety Institute leading the drive to improve surgical safety across the country and is based on Enhanced Recovery After Surgery – ERAS surgical best practices. These evidence-based principles support better outcomes for surgical patients including an improved patient experience, reduced length of stay, decreased complication rates and fewer hospital readmissions. In partnership with Enhanced Recovery Canada endorses six core ERAS principles to shift the surgical care paradigm Patient and family engagement Nutrition management Perioperative fluid and hydration management Multi-modal opioid sparing analgesia Perioperative best practices Mobilization NEW! Surgical Prehabilitation Workshop & Webinar Series Workshop Saturday, March 27, 2021 Register Webinar Series February – July 2021 Register Anesthetic Challenges to Achieve Same Day Discharge Hip & Knee Arthroplasty Resources for Colorectal Surgeries Industry Partners Enhanced Recovery Canada™ gratefully acknowledges the support from the following industry partners in the development of ERC tools and resources and contributing to the dissemination and implementation of these surgical best practices. The ERC Pathways and other resources have been developed based exclusively on unbiased clinical evidence. Gold Level Silver Level Bronze Level For more information, contact us at info@cpsi-icsp.ca. Enhanced Recovery Canada™What is Enhanced Recovery After Surgery ? Enhanced Recovery Canada is a project of the Canadian Patient Safety Institute leading the drive to2/23/2021 10:14:18 PM25348https://www.patientsafetyinstitute.ca/en/toolsResourceshtmlTrueaspx
Getting ahead of harm before it happens: A guide about proactive analysis for improving surgical care safety6156Surgical Care Safety;Healthcare HarmReports & Publications8/30/2017 6:59:45 PM The Surgical Care Safety Summit brought together over 30 individuals representing professional associations, quality councils, provincial ministries, health authorities and a patients' group. The subsequent Surgical Care Safety Action Plan identified a goal of preventing surgical harm through enhancing the use of both retrospective and proactive analyses. This guide is the culmination of the work of the Proactive Analysis for Surgical Care Safety Action Team. Surgical Safety in Canada A 10-year review of CMPA and HIROC medico-legal data, the retrospective analysis, is also available. In healthcare, when patients are harmed or nearly harmed, reactive investigations are conducted. While these are important, they usually focus only on one patient, although occasionally the care of a group of patients may be reviewed. In a way, these investigations are too late- some patients will have come to harm from hazards in the healthcare system. From a safety point of view, being able to find those hazards before patients are harmed is better for patients, their care providers and the entire healthcare system. This kind of investigation - proactive analysis - is rarely used in healthcare. This guide, although not a 'how to' document, will help you and your colleagues to learn more about proactive analyses and prepare to undertake them. Download The Surgical Care Safety Summit brought together over 30 individuals representing professional associations, quality councils, provincial ministries,9/24/2020 8:12:43 AM1702https://www.patientsafetyinstitute.ca/en/toolsResources/Pages/Forms/NewDefaultView.aspxhtmlFalseaspx
What is Quality and Patient Safety?99122/23/2010 11:02:11 PM Accreditation Canada defines quality as “the degree of excellence; the extent to which an organization meets clients needs and exceeds their expectations”. Key attributes of high quality healthcare systems, as defined by the Institute of Medicine (U.S.) include safety, timeliness, effectiveness, efficiency, equity and patient centeredness. The Health Council of Canada Annual Report (2006) entitled Clearing the Road to Quality found that patient safety, information management, quality councils and performance reporting are four key strategies to improve the quality of healthcare. The Canadian Patient Safety Dictionary (2003) defines patient safety as “the reduction and mitigation of unsafe acts within the healthcare system, as well as through the use of best practices shown to lead to optimal patient outcomes”. International efforts are underway to standardized taxonomy of key patient safety concepts share learning across health systems; thus, the World Health Organization’s (WHO) International Classification for Patient Safety defines patient safety as, “the reduction of risk of unnecessary harm associated with healthcare to an acceptable minimum. An acceptable minimum refers to the collective notions of given current knowledge, resources available and the context in which care was delivered weighed against the risk of non-treatment or other treatment”. Patient safety is often considered a component of quality, thus, practices to improve patient safety improve the overall quality of care.What is Quality and Patient Safety?1/8/2020 7:38:31 PM15403https://www.patientsafetyinstitute.ca/en/toolsResources/GovernancePatientSafety/Pages/Forms/AllItems.aspxhtmlFalseaspx
Measures: Central Line-Associated Bloodstream Infection (CLABSI)10520Infection Prevention & Control (IPAC)Toolkits & Guides7/1/2015 8:51:26 AM Measurement is essential to monitoring success and helps guide your team towards your specific intervention goal. Measurement also tells us what's working and what's not, and provides evidence to inspire other healthcare providers to improve the quality of patient safety. The measurement methodology and recommendations regarding sampling size referenced in this GSK, is based on The Model for Improvement and is designed to accelerate the pace of improvement using the PDSA cycle; a "trial and learn" approach to improvement based on the scientific method. Langley, G., Nolan, K., Nolan, T., Norman, C., Provost, L. The Improvement Guide A Practical Approach to Enhancing Organizational Performance. San Francisco, Second Edition, CA. Jossey-Bass Publishers. 2009. It is not intended to provide the same rigor that might be applied in a research study, but rather offers an efficient way to help a team understand how a system is performing. When choosing a sample size for your intervention, it is important to consider the purposes and uses of the data and to acknowledge when reporting that the findings are based on an "x" sample as determined by the team. The scope or scale (amount of sampling, testing, or time required) of a test should be decided according to The team's degree of belief that the change will result in improvement The risks from a failed test Readiness of those who will have to make the change Provost, Lloyd P; Murray, Sandra (2011-08-26). The Health Care Data Guide Learning from Data for Improvement (Kindle Locations 1906-1909). Wiley. Kindle Edition. Please refer to the Improvement Frameworks GSK (2015) for additional information.CLI Measures Measure Goal Type CLI 1 - Central Line-Associated Primary Bloodstream Infection (BSI) Rate per 1000 Central Line-Days Decrease 50% Outcome CLI 2 - Insertion Bundle Compliance 95% Process CLI 3 - Maintenance Bundle Compliance 95% Process Measures and definitions Types of Measures Safer Healthcare Now! (SHN) has two types of measures for each of the interventions process measures and outcome measures. Some interventions also have balancing measures and information measures. Below are examples of each. Outcome measures - answers whether the team is achieving what it is trying to accomplish and articulates the picture of success. For example, if the team wants to reduce falls it should measure the number of falls. Process measures - Processes which directly affect the outcome are measured to ensure that all key changes are being implemented to impact the outcome measure. For example, the delivery of timely prophylactic antibiotics to reduce surgical site infection. Balancing measures - answer the question whether improvements in one part of the system were made at the expense of other processes in other parts of the system. For example, in a project to reduce the average length of stay for a group of patients, the team should also monitor the percent of readmissions within 30 days for the same group. Information measures - collect general details relative to the intervention.CLI: Measurement Worksheets9/24/2020 8:15:16 AM8168https://www.patientsafetyinstitute.ca/en/toolsResources/psm/Pages/Forms/UpdateData.aspxhtmlFalseaspx
World Patient Safety Day: September 17, 20202588General Patient SafetyEvents8/31/2020 8:43:30 PM Premiere of Building a Safer System Thank you for joining us for World Patient Safety Day! 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. The CPSI Legacy Celebration On September 17th, former staff members, colleagues, and supporters of CPSI gathered to re-connect and celebrate the organization on the Remo conferences platform. 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 below to view the recording of the panel discussion and the closing keynote remarks 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 Theme Health Worker Safety A Priority for Patient Safety Slogan Safe health workers, Safe patients Call for action Speak up for health worker safety! World Patient Safety Day information Sponsored by With special thanks to our generous sponsors – together we are making positive and lasting change. Platinum Gold (in alphabetical order) Watch on Demand: World Patient Safety Day: September 17, 2020 Premiere of Building a Safer System   Thank you for joining us for World Patient Safety Day! Thank you for joining us for the live10/8/2020 7:45:18 PM15364https://www.patientsafetyinstitute.ca/en/EventshtmlTrueaspx
Suicide Risk2610Mental Health;Healthcare HarmToolkits & Guides;Reports & Publications4/21/2011 4:02:20 AMThe Canadian Patient Safety Institute (CPSI) has partnered with the Mental Health Commission of Canada (MHCC) to help healthcare workers and organizations select and compare available suicide risk assessment tools in Canada. For every death by suicide, 15-30 people are profoundly affected - this toolkit can help inform and strengthen the suicide risk assessment process. The Suicide Risk Assessment Toolkit seeks to provide a high-level overview of what to consider when using suicide risk assessment tools, along with a non-exhaustive list of available Canadian and international tools, and their characteristics. It is designed to be a quick, informative guide for healthcare workers and organizations interested in selecting and comparing such tools. The process of assessing suicide risk is complex. While assessment tools play an important role, they should be used to inform, not replace, clinical judgment. Use this toolkit, developed by CPSI and MHCC, to help you select/compare tools to complement the suicide risk assessment process. Download Toolkit (publication January 26, 2021) For a more comprehensive guide to suicide risk assessment, including the role of healthcare workers and organizations, see Suicide Risk Assessment Guide A Resource for Health Care Organizations. Download Guide (publication 2011) We acknowledge the need to have suicide risk assessment tools that are truly inclusive and are based on principles of equity and diversity. We encourage you to seek out opportunities to engage with diverse peoples, including First Nations, Inuit, Métis, people who identify as 2SLQBTQ+, and immigrant, refugee, ethnocultural and racialized groups in order to understand and respond to their specific needs. Sponsored by The Canadian Patient Safety Institute and the Mental Health Commission of Canada. Production of this toolkit has been made possible through a financial contribution from Health Canada. Suicide Risk Assessment - Toolkit and GuideThe Canadian Patient Safety Institute (CPSI) has partnered with the Mental Health Commission of Canada (MHCC) to help healthcare workers and2/4/2021 5:47:10 PM11912https://www.patientsafetyinstitute.ca/en/toolsResourceshtmlTrueaspx
STOP! Clean Your Hands2592Infection Prevention & Control (IPAC)Events6/3/2015 4:46:05 PM #STOPCleanYourHands Thank you to everyone who participated in STOP! Clean Your Hands Day on May 5, 2020. This year we saw the best social media engagement to date! The hashtag #stopcleanyourhands had 7.822 million Twitter impressions. Plus, a tremendous number of people from across Canada took the Clean Hands Self-Assessment, pledged clean hands, and accessed our free hand hygiene resources. Let’s Keep the Momentum Going Although STOP! Clean Your Hands Day has passed, clean hands have never mattered more! Please continue to access and share our free hand hygiene resources. Hand Hygiene Fact Sheets Access and share our free hand hygiene resources to keep yourself and others safe Hand Hygiene Resources Clean Hands Self-Assessments Are you cleaning your hands properly? Are you protecting yourself and your loved ones from infections? Take the Clean Hands Self-Assessments to find out! Learn More Pledge Clean Hands Clean hands have never mattered more. Cleaning your hands, either with soap and water or with alcohol-based hand rub, is one of the best ways to avoid getting sick and spreading infections to others. Hand hygiene is easy and effective. Pledge Clean Hands to tell the world you commit to cleaning your hands. Let’s all work together to flatten the curve! Take the Pledge The Importance of Hand Hygiene 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. It is estimated that over the next 30 years in Canada, infections will be the biggest driver of acute care patient safety incidents, accounting for roughly 70,000 patient safety incidents per year on average – generating an additional $480 million per year on average in healthcare costs.1 Healthcare-associated infections (HAIs), or infections acquired in a healthcare setting, are the most frequently reported adverse events in healthcare delivery worldwide. Each year, hundreds of millions of patients are affected by HAIs, leading to significant morbidity, mortality, and financial cost to healthcare systems.2 World Health Organization SAVE LIVES Clean Your Hands Our STOP! Clean Your Hands campaign is hosted in conjunction with the World Health Organization’s (WHO) SAVE LIVES Clean Your Hands campaign. More information about SAVE LIVES Clean Your Hands and infection prevention is available at the World Health Organization’s website. Sponsored by As a company dedicated to protecting public health, our operating principle is to prioritize healthcare facilities and first responders that are on the front line. We will continue to help safeguard those working so hard to keep us all healthy and safe.​ Partners 1Patient Safety in Canada. Ipsos Public Affairs, 2018. 2 World Health Organization (WHO). n.d. Healthcare-Associated Infections Fact Sheet. Retrieved March 20, 2020. STOP! Clean Your Hands#STOPCleanYourHands Thank you to everyone who participated in STOP! Clean Your Hands Day on May 5, 2020.   9/24/2020 8:05:56 AM88604https://www.patientsafetyinstitute.ca/en/EventshtmlTrueaspx
The Safety Competencies Framework2609General Patient Safety;Healthcare HarmReports & Publications;Frameworks4/14/2009 11:53:32 PMSafety Competencies Framework Educating healthcare providers about patient safety and enabling them to use the tools and knowledge to build and maintain a safe system is fundamental to creating a culture of safety across the spectrum of care. The 2020 Safety Competencies Framework (2nd Edition) is a simple, powerful and flexible framework that includes enabling competencies that can be adopted and adapted by diverse healthcare programs to design curricula to teach safety and quality for any sector or healthcare program. It can also be a valuable resource to policy makers, regulators and accreditors to guide system change. The Six Domains support moving patient safety evidence into action and has strengthened its content with advancements in collective knowledge that include patient/family partnership, leadership, quality improvement and cultural competency concepts. Safety Competencies Framework Domains Domain 1 Patient Safety Culture Patient safety culture improvement involves recognizing the importance of ongoing collaboration and the commitment to advocate for change. Domain 2 Teamwork High-performing interprofessional teams demonstrate capabilities and competencies that are essential to efficient, effective, and safe collaborative practice. Domain 3 Communication Effective communication is beneficial to patients and healthcare providers, builds trust, and is a precondition of obtaining patient consent. Domain 4 Safety, Risk, and Quality Improvement Healthcare providers collect and monitor performance data to assess risk and improve outcomes. Domain 5 Optimize Human and System Factors Optimizing the human and environmental factors that support the achievement of best human performance is an essential safety competency for all healthcare providers. Domain 6 Recognize, Respond to and Disclose Patient Safety Incidents Open, honest, and empathetic disclosure and appropriate apologies benefit patients and families, health providers, and their organizations. The Safety CompetenciesThe Safety Competencies: Message from the CEO12/3/2020 4:19:06 PM39923https://www.patientsafetyinstitute.ca/en/toolsResourceshtmlTrueaspx