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Canadian Quality and Patient Safety Framework for Health Services3030General 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 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.10/30/2020 6:43:22 PM8142https://www.patientsafetyinstitute.ca/en/toolsResourceshtmlTrueaspx
Measures: Ventilator-Associated Pneumonia (VAP)26504Infection 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 AM6968https://www.patientsafetyinstitute.ca/en/toolsResources/psm/Pages/Forms/UpdateData.aspxhtmlFalseaspx
Creating a Safe Space: Addressing the Psychological Safety of Healthcare Workers3014General Patient Safety;Psychological Safety for Healthcare WorkersToolkits & Guides;Healthcare provider stories;Reports & Publications1/6/2020 4:59:11 PM Cumulative stress, compassion fatigue and trauma due to experiences with patient safety incidents impact the mental wellness of our healthcare providers. These factors contribute to inadvertent patient care errors, mental health issues and attrition which compromise patient safety. A peer support program and other support models not only simply helps healthcare workers with their experiences with patient safety incidents but also improves the system and help make patient care safe. The Creating a Safe Space Addressing the Psychological Safety of Healthcare Workers manuscript and the Canadian Peer Support Network are intended to assist healthcare organizations support healthcare workers by creating peer-to-peer support programs (PSPs) or other models of supports to improve the emotional well-being of healthcare workers and allow them to provide the best and safest care to their patients. The Creating a Safe Space Addressing the Psychological Safety of Healthcare Workers manuscript provides a comprehensive overview of what healthcare worker support models are available in Canada and internationally. The Manuscript outlines best practice guidelines, tools, and resources that policy makers, accreditation bodies, regulators and healthcare leaders can use to assess the support needs of healthcare workers. The Canadian Peer Support Network is intended as a forum for healthcare organizations seeking guidance in the development of their Peer Support Programs to assist providers who have experienced a patient safety incident. Disclaimer The Canadian Peer Support Network is not intended as therapeutic support between, or amongst, members It is for informational purposes only.Creating a Safe Space: Psychological Safety of Healthcare Workers (Peer to Peer Support and Other Support Models)Cumulative stress, compassion fatigue and trauma due to experiences with patient safety incidents impact the mental wellness of our healthcare10/14/2020 6:58:52 PM7074https://www.patientsafetyinstitute.ca/en/toolsResourceshtmlTrueaspx
Surgical Site Infection (SSI): Getting Started Kit6848Surgical 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 AM9303https://www.patientsafetyinstitute.ca/en/toolsResources/Pages/Forms/NewDefaultView.aspxhtmlFalseaspx
Advocacy and support for use of a Surgical Safety Checklist2999Surgical 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 AM1880https://www.patientsafetyinstitute.ca/en/toolsResourceshtmlTrueaspx
Tools & Resources28639/18/2020 4:40:20 AMTools & ResourcesTools & Resources9/21/2020 9:19:04 AM59234https://www.patientsafetyinstitute.ca/enhtmlTrueaspx
Hand Hygiene Fact Sheets3045Infection 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 AM11250https://www.patientsafetyinstitute.ca/en/toolsResourceshtmlTrueaspx
TeamSTEPPS Canada(TM) Essentials microlearning course launched through Canada’s Patient Safety Online Learning Centre12616Education;General Patient SafetyNews9/14/2020 3:34:10 PM9/14/2020 6:00:00 AM Are you looking for tools to instil a culture of safety among your teams? A free micro-learning course, TeamSTEPPS Canada™ Essentials, is now available to optimize team performance across the healthcare system. The course consists of six interactive microlearning sessions that demonstrate teamwork and communication tools that can be used to equip your team for improved team functioning. "Initially, the material was designed to support the Safety Improvement Project Collaborative participants," says Maureen Sullivan-Bentz, Senior Program Manager at the Canadian Patient Safety Institute. "TeamSTEPPS Essentials has since been adapted and designed to accommodate the changing needs of today's learners in an interactive and engaging format. Teams can now easily access the course online and learn at their own pace." The Essentials course is based on the five key principles encompassed in the evidence-based TeamSTEPPS CanadaTM framework. These principles are designed to optimize team performance Team Structure, Communication, Leading Teams, Situation Monitoring, and Mutual Support. Each session is five minutes long; at the end of the program teams are familiarized with the tools to use in different situations. Each of the sessions has been enhanced with simulation videos and has been contextualized for Canadian audiences. The Centre for Innovative Education and Simulation in Nursing at the University of Ottawa generously provided their simulation lab as the backdrop for filming; props were provided by the University of Ottawa; and the contributions of Ben Hrkach, both as Director and one of the actors, were invaluable in creating a fun and creative portrayal of the teamwork and communication tools. Canada's Patient Safety Online Learning Centre Canada's Patient Safety Online Learning Centre takes learning anywhere, anytime, at your own pace, on any electronic device. This free, open source learning centre will house a repository of e-courses from the Canadian Patient Safety Institute. It was designed to provide open access to healthcare leaders, managers, educators, and point-of-care providers to learn as efficiently as possible in a self-paced environment. "The world of technology has advanced, and learning needs have evolved," says Gina de Souza, Senior Program Manager at the Canadian Patient Safety Institute. "People want on-demand learning in short snippets. Canada's Patient Safety Online Learning Centre is learner-centric and accommodates the increasing demands and diversity of learners using new tools, technologies, and design strategies." Learners must register to gain access, and once registered, they can explore all of the available e-courses for free. There are no learning pre-requisites required. A certificate of completion is available to print after each course is completed. Click here to learn more about Canada's Patient Safety Online Learning Centre and register for the TeamSTEPPS Essentials course. Watch for the quick-start microlearning version of the Guide to Patient Safety Improvement publication, to be added this fall. Are you looking for tools to instil a culture of safety among your teams? A free micro-learning course, TeamSTEPPS Canada™ Essentials , is now9/24/2020 8:10:14 AM728https://www.patientsafetyinstitute.ca/en/NewsAlerts/News/Pages/Forms/AllItems.aspxhtmlFalseaspx
“How Safe is Your Care?” Measurement and Monitoring of Safety Through the Eyes of Patients and their Caregivers - Research Project15487Research;Partnering with PatientsFrameworks9/23/2020 3:00:22 PM The research study, "'How Safe is Your Care?' Measurement and Monitoring of Safety Through the Eyes of Patients and their Caregivers," is being conducted by a team from the Canadian Patient Safety Institute, Sinai Health, and the Institute of Health Policy Management and Evaluation at the University of Toronto. It is being led by Drs. Lianne Jeffs, Kerry Kuluski, and G. Ross Baker, as well as Anne MacLaurin and Virginia Flintoft. The Canadian Patient Safety Institute and its partners aim to use a new approach to patient safety that is grounded in the 5 dimensions of the Measurement and Monitoring Safety Framework (MMSF) and include the voice of patients, families and caregivers by answering the following questions How do patients, caregivers and providers experience safety in the health care system? What role can patients, caregivers and providers play in helping us understand safety? How can we create environments that support safer care experiences? The Measurement and Monitoring of Safety Framework (MMSF) provides a broader view of safety. It is not just about the reduction of physical harm or managing risk. The framework challenges our assumptions in terms of patient safety and helps to shift our thinking away from what has happened in the past, to a new approach that moves us from the absence of harm to the presence of safety. The MMSF includes the following five dimensions of safety with key questions Past harm - Has patient care been safe in the past? Reliability - Are our clinical systems and processes reliable? Sensitivity to operations - Is care safe today? Anticipation and preparedness - Will care be safe in the future? Integration and learning - Are we responding and improving?Advisory Committee The Canadian Patient Safety Institute and the research co-leads brought together leaders in the fields of patient safety, patient partnership, and the Measurement and Monitoring of Safety Framework to participate in an Advisory Committee. The Committee will advise the Research Team on processes, methodology and outputs associated with this work. Committee Membership Co-Chairs Dr. G. Ross Baker, University of Toronto Maaike Asselbergs, Patients for Patient Safety Canada Members Susan Burnett, Co-Author of the Measurement and Monitoring Safety Framework Jane Carthey Co-Author of the Measurement and Monitoring Safety Framework Sarah Garrett, Co-Facilitator of the CPSI Measurement and Monitoring Safety Demonstration Project and Safety Improvement Project Kathy Kovacs Burns, Patients for Patient Safety Canada Susan Brien, Health Quality Ontario Markus Lahtinen, Health Quality Council Alberta Jenny Lacroix, Canadian Institute of Health Information Lena Cuthbertson, British Columbia Ministry of Health Rachel Martens, IMAGINE Anne MacLaurin, Canadian Patient Safety Institute Virginia Flintoft, Canadian Patient Safety Institute Wayne Miller, Canadian Patient Safety Institute Researchers Dr. Lianne Jeffs, Sinai Health System Dr. Kerry Kuluski, Institute for Better Health, Trillium Health Partners Recruitment Please consider participating in either a face-to-face / telephone/ videoconference interview or a focus group. During the interview (or focus group), you will be asked to answer questions about how you currently define and experience safety in the healthcare system. A single interview should take 45-60 minutes, while a focus group is 90 minutes. If you are interested in participating in the study, either in an interview or a focus group, please contact Frances Bruno, Research Coordinator at Frances.Bruno@sinaihealth.ca or 416-461-8252, ext. 2953. For further questions about the study, you can contact the Principal Investigator, Dr. Lianne Jeffs at Lianne.Jeffs@sinaihealth.ca or 416-522-1052. The research study, " 'How Safe is Your Care?' Measurement and Monitoring of Safety Through the Eyes of Patients and their Caregivers ," is10/16/2020 7:59:09 PM1260https://www.patientsafetyinstitute.ca/en/toolsResources/Measure-Patient-Safety/Pages/Forms/AllItems.aspxhtmlFalseaspx
Get involved in Canadian Patient Safety Week!12373General Patient SafetyNews9/27/2018 7:51:16 PM9/27/2018 6:00:00 AM Canadian Patient Safety Week (CPSW) is a national, annual campaign to inspire extraordinary improvement in patient safety and quality. Working together, thousands of healthcare professionals, patients and families spread the message to Ask. Listen. Talk. to create a safer healthcare system. Canadian Patient Safety Week runs October 29 to November 2, 2018. This year, CPSW will focus on medication safety with the goal of reducing medication errors across Canada. Not All Meds Get Along encourages an open dialogue between patients and healthcare professionals by promoting each to seek medication reviews for at-risk populations and promoting the use of the 5 Questions to Ask About Your Medications. Medication errors should be taken seriously. Consider these facts An estimated 37 per cent of seniors in nine provinces received a prescription for a drug that should not be taken by this population. Two out of three Canadians over the age of 65 take at least five different prescription medications. One out of four Canadians over the age of 65 take at least 10 different prescription medications. In 2016, one in 143 Canadian seniors was hospitalized due to harmful effects of their medication. Preventable medication hospitalizations cost over $140 million CDN in direct and indirect healthcare expenditures, with lost productivity, including time off work, adding $12 million CDN in costs. Globally, the cost associated with medication errors has been estimated at over $55 billion. To reduce the risk of medication errors, medication reviews are specifically recommended for anyone on five or more medications; those over 65 years of age; individuals with multiple caregivers, or using multiple pharmacies; people at risk of falls; individuals with chronic medical issues; and during transitions of care. Ask your healthcare professional or pharmacist for a medication review when you are having a new or existing prescription filled or if you are considering adding, removing or changing any non-prescription medications or supplements. The goal of Canadian Patient Safety Week is to reduce medication errors by 50 per cent over the next five years. The Canadian Patient Safety Institute is coordinating the World Health Organization's Medication Without Harm campaign in Canada; Canadian Patient Safety Week supports this initiative. Much of the promotion of Canadian Patient Safety Week takes place digitally and on social media. Some activities planned for the week include online quizzes to test medication safety knowledge for both patients and providers; a medication safety webinar; a "caption this" comic challenge; a virtual screening and Twitter Talk event of "Falling Through the Cracks Greg's Story"; and new episodes of the award-winning PATIENT podcast. Join the CPSW Medication Safety webinar on Monday, October 29th at 1200 Noon EST. Details on the presentations and speakers are available on www.asklistentalk.ca and will be emailed to CPSW registered participants. The "Caption This" Comic Challenge is a fun way to get involved. Use the Not All Meds Get Along image and write a caption for the illustration. Post your entry on social media and tag the message with #AskListenTalk for the chance to win great prizes! On Friday, November 2, at 1200 Noon EST, a Twitter Talk event will take place learn about Greg Price's journey through the healthcare system that ended in his unexpected and tragic death, followed by a discussion moderated by the Price family. The film and discussion are intended to inspire positive change and improvement in the healthcare system, sure to resonate with healthcare providers and leaders, and will help create a platform for future dialogue. Follow @Patient_Safety and @GregsWings to learn more. The second season of the PATIENT podcast series explores patient safety through a non-fiction medical drama from the perspective of the patient. Three new episodes will be added to this series, focusing on medication safety. Listen to the first season of PATIENT podcasts at www.patientpodcastcanada.ca Free digital downloads and promotional packages are available to help you promote Canadian Patient Safety Week at your organization. Printable posters, social media images and slides for point of sale and TV screens are available at www.asklistentalk.ca. You can also order promotional tools such as pens, stickers, buttons, large-scale posters and medications lists and much more from the CPSW online store. How will your organization celebrate Canadian Patient Safety Week? For ideas, take a look at the Communications Toolkit and don't forget to share your messages and pictures on social media using the hashtag #AskListenTalk. To register for Canadian Patient Safety Week, visit www.asklistentalk.ca Canadian Patient Safety Week (CPSW) is a national, annual campaign to inspire extraordinary improvement in patient safety and quality. Working9/24/2020 8:09:07 AM1138https://www.patientsafetyinstitute.ca/en/NewsAlerts/News/Pages/Forms/AllItems.aspxhtmlFalseaspx
Home Care Safety Falls Prevention Virtual Improvement Collaborative12393Community Based CareNews11/4/2015 10:29:59 PM11/4/2015 11:00:00 PM ​The Canadian Patient Safety Institute, Canadian Home Care Association and Canadian Foundation for Healthcare Improvement have launched a new pan-Canadian initiative to prevent falls in the home. More than one third of Canadians aged 65 or older experience a fall, with half of these falls resulting in hospitalization taking place in or around the home. Fall-related injuries are the leading cause of injury for seniors across all Canadian provinces and territories and account for over 85 percent of all injury-related hospitalizations. Direct health care costs from falls among seniors are estimated to be $1 billion every year. Teams from Winnipeg Regional Health Authority (MB), St. Elizabeth Health Care (ON), Canadian Red Cross, VHA Home HealthCare (ON) and Eastern Health (NL) have been accepted into the first wave of the Home Care Safety Falls Prevention Virtual Improvement Collaborative focused on fall prevention and injury reduction. Working with the three partner organizations, the teams from will work from November 2015 to mid-2016 to Identify client outcomes for home care clients at risk for falls; Adapt quality improvement approaches to the home care environment; Build quality improvement capacity - including measurement capacity - in the home care sector; Identify evidence, tools and resources for spread across Canada; and Engage patients and families in falls risk assessment and prevention. The work by the partner organizations and teams in the first wave of the collaborative could lead to an expanded collaborative - open to more organizations that provide home care services - later in 2016.The Canadian Patient Safety Institute, Canadian Home Care Association and Canadian Foundation for Healthcare Improvement have launched a new9/24/2020 8:06:43 AM3156https://www.patientsafetyinstitute.ca/en/NewsAlerts/News/Pages/Forms/AllItems.aspxhtmlFalseaspx
Central Line-Associated Bloodstream Infection (CLABSI): Getting Started Kit6794Infection 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 AM7500https://www.patientsafetyinstitute.ca/en/toolsResources/Pages/Forms/NewDefaultView.aspxhtmlFalseaspx
Patient engagement in medication safety at the point of care – roles, responsibilities6835Improving Medication Safety;General Patient SafetyEvents;Patient and Family Resource;Webinars;Social Media/Social Share8/26/2016 6:43:53 PM ​​​ ​Archive September 15, 2016 Objective At the end of the session patient/ family/ advisors/ champions as well as health providers/ leaders/ authorities will leave with at least one practical idea to advance patient engagement in medication safety as a result of their increased understanding of the role and responsibilities of patients/ families in medication safety different approaches to patient engagement in medication safety influencing factors (e.g. health literacy, culture, organizational and public policy) supporting resources and leading practices Resources Download (Available in English only) Speakers and moderator Helen Haskell – President, Mothers Against Medical Error and Consumers Advancing Patient Safety; Steering Group, World Health Organization Global Patient Safety Challenge on Medication Safety Johanna Trimble – Patient Champion, Patients for Patient Safety Canada and Patient Voices Network British Columbia Maryann Murray –Patient Champion, Patients for Patient Safety Canada; Patients and Public Workgroup, WHO Global Patient Safety Challenge on Medication Safety ​Theresa Malloy-Miller (moderator) - Patient Champion, Patients for Patient Safety Canada Designed by patient/family champions for champions this interactive webinar is offered by the World Health Organization Patients for Patient Safety Programme in partnership with Patients for Patient Safety Canada. For this session the term patient safety champion includes any individual that volunteers as a patient/family representative in programs, groups, networks and/or organizations working to improve quality and safety in healthcare. The session is designed to allow for conversation among participants, so be prepared to contribute to the dialogue verbally or via chat. The slides, recording and a summary of ideas presented will be publicly available after the session he​re. For more information contact patients@cpsi-icsp.ca.   Archive: September 15, 2016 Objective: At the end of the session patient/ family/ advisors/ champions as well as9/24/2020 8:12:32 AM2448https://www.patientsafetyinstitute.ca/en/toolsResources/Pages/Forms/NewDefaultView.aspxhtmlFalseaspx
Preventing Falls: From Evidence to Improvement in Canadian Health Care6840Community Based CareReports & Publications7/27/2015 8:13:41 PM ​​​Falls among seniors (individuals 65 years and older) have become a significant health concern in Canada. Falls are experienced by more than one third of seniors and can have a devastating physical and psychological impact resulting in disability, chronic pain, loss of independence, reduced quality of life, and even death. Falls are the leading cause of injury for seniors and also contribute to a significant burden on the health care system. Direct health care costs for falls in Canada are estimated at $2 billion annually. The negative impact of falls highlights a need to understand the burden of falls on Canadians and the health system. How are Canadian health care organizations progressing with falls prevention programs? Which populations are at greatest risk of falls? What tools are available to support organizations? In the report Preventing Falls From Evidence to Improvement in Canadian Health Care, Accreditation Canada, the Canadian Institute for Health Information (CIHI), and the Canadian Patient Safety Institute (CPSI) take a closer look at these questions and share information about falls and falls prevention in acute care, long-term care, and home care settings. Download Falls among seniors (individuals 65 years and older) have become a significant health concern in Canada. Falls are experienced by more than one third9/24/2020 8:10:38 AM5483https://www.patientsafetyinstitute.ca/en/toolsResources/Pages/Forms/NewDefaultView.aspxhtmlFalseaspx
New Patient Safety Improvement Guide Integrates Knowledge Translation and Quality Improvement12449Improving Culture;General Patient Safety;PolicyNews9/14/2020 3:59:47 PM9/14/2020 6:00:00 AM The best way to improve patient safety outcomes is to apply the best research in the most effective way. A Guide to Patient Safety Improvement is a new resource that integrates knowledge translation and quality improvement approaches to guide you through the improvement process. Are there gaps in your patient safety performance? This Guide offers a simplified process to select strategies to effectively implement patient safety practices. Although originally designed to support National Canadian Safety Improvement Projects, it can be adapted to fit any healthcare context. "The Guide to Patient Safety Improvement is an integrated approach to practice change – change that can have a sustainable impact on patient safety outcomes," says Gina De Souza, Senior Program Manager at the Canadian Patient Safety Institute. "It shows how two bodies of knowledge, quality improvement and knowledge translation, can be used synergistically." Several models, theories, and frameworks contributed to the Guide, including the Knowledge Translation and Quality Improvement Integrated Learning Design, Model for Improvement, Knowledge to Action Cycle, and COM-B theory. It includes ideal practice changes ("the what") and strategies ("the how") that creates the evidence-based intervention as well as a section on engaging patients at all levels, not just the point-of-care. "Understanding context and what supports behaviour change is so important when choosing a strategy," adds Gina De Souza. "Knowledge translation goes beyond looking only at what the evidence says, to getting people to be a part of the change and selecting the right strategy to support and sustain the change." A five-minute, 'Quick Start' microlearning course has been designed to complement the Guide to Patient Safety Improvement publication and is now available through Canada's Patient Safety Online Learning Centre at https//learning.patientsafetyinstitute.ca/ The best way to improve patient safety outcomes is to apply the best research in the most effective way. A Guide to Patient Safety Improvement is9/24/2020 8:10:15 AM220https://www.patientsafetyinstitute.ca/en/NewsAlerts/News/Pages/Forms/AllItems.aspxhtmlFalseaspx
Education to support mandatory ADR and MDI reporting (Vanessa’s Law)3036General Patient Safety;Government Relations;Healthcare HarmReports & Publications;Patient and Family Resource;Toolkits & Guides3/4/2019 9:27:01 PM The Protecting Canadians from Unsafe Drugs Act, also known as Vanessa's Law, is intended to increase drug and medical device safety in Canada by strengthening Health Canada's ability to collect information and to take quick and appropriate action when a serious health risk is identified. As of December 16, 2019, it became mandatory for hospitals to report serious adverse drug reactions (serious ADRs) and medical device incidents (MDIs) to Health Canada. Downloadable from this webpage are 4 PowerPoint modules developed in collaboration with Health Canada. These modules contain core content intended for use by hospitals, health care professionals, patients and their families, and educators, to explain, describe, or promote the reporting of serious ADRs and MDIs. Module 1 – Overview of Vanessa's Law and Reporting Requirements PowerPoint - Module 1 Module 2 – Reporting Processes to Health Canada PowerPoint - Module 2 Module 3 – Strategies to Promote and Support Mandatory Reporting PowerPoint - Module 3 Module 4 – Health Canada's Review and Communication of Safety Findings PowerPoint - Module 4 These materials (as entire modules or as individual slides or selected content) can be used for individual learning or incorporated into presentations, orientation, continuing education, and other information-sharing activities. The materials can be used in the following ways to support and raise awareness of mandatory reporting requirements Hospitals can include some or all of the content in their local, regional, and/or provincial information-sharing activities (e.g., "Lunch and Learn" sessions, presentations, orientation programs for new staff). Educators in the health care sector can use the content in presentations or as part of a curriculum. Professional associations, societies, and regulatory colleges, as well as other training institutions for health care workers, may incorporate the content of the modules into accredited courses or continuing education certification programs. Patient and consumer organizations can help disseminate some or all of the information in the modules to increase awareness and knowledge among their members. If you have questions about how to use these educational materials for your specific audience (e.g., selecting slides or content from several modules to create a customized presentation), please contact ISMP Canada info@ismpcanada.ca HSO https//healthstandards.org/ CPSI info@cpsi-icsp.ca ​If you have questions about Vanessa's Law and the mandatory reporting requirements, please contact hc.canada.vigilance.sc@canada.ca. This conceptual model of serious ADR and MDI reporting by hospitals depicts the information provided in the 4 PowerPoint modules mandatory reporting requirements, reporting processes to Health Canada, strategies to promote and support reporting, and Health Canada’s review and communication of safety findings. ACKNOWLEDGEMENTS Health Canada, ISMP Canada, HSO, and CPSI gratefully acknowledge input received from the Advisory Panel (listed in alphabetical order) Glenn Cox, Senior Director Pharmacy Services NSHA, Director Pharmacy Services, Cape Breton/Antigonish/Guysborough, Cape Breton Regional Hospital, Sydney, NS ; Michael Gaucher, Director Pharmaceuticals & Health Workforce Information Services, Canadian Institute for Health Information, Ottawa, ON ; Andrew Ibey – Clinical Engineer, Children's Hospital of Eastern Ontario, Ottawa, ON ; Denis Lebel – Pharmacien, adjoint aux soins, enseignement et recherche, Département de pharmacie, CHU Sainte-Justine, QC ; Dr. Joel Lexchin, Professor Emeritus, School of Health Policy & Management, York University, Toronto, ON ; Faith Louis, Regional Manager, Quality Improvement & Support Services, Pharmacy Services, Horizon Health Network, NB; Holly Meyer, Provincial Director, Product Quality & Safety, Alberta Health Services, AB ; Maryann V. Murray, Patients for Patient Safety Canada; Tolu Oyebode, Government of Saskatchewan, Senior Project Manager, Patient Safety Unit, Strategic Priorities Branch, Ministry of Health, SK ; Sheryl Peterson, Associate Director, Lecturer, Faculty of Pharmaceutical Sciences, The University of British Columbia (Vancouver Campus); Michelle Rossi, Director, Policy and Strategy, Health Quality Ontario, Toronto, ON ; Myrella Roy, Executive Director, and Cathy Lyder, Director Professional Practice, Canadian Society of Hospital Pharmacists, Ottawa, ON ; Christelle Sessua, Quality Assurance-Risk Management Coordinator, Iqaluit Health Services, Department of Health, Government of Nunavut ; Robyn Tamblyn, James McGill Chair, Professor, Department of Medicine, Department of Epidemiology & Biostatistics, McGill University, Scientific Director, Institute of Health Services and Policy Research, Canadian Institutes of Health Research, Montreal, QC ; Annemarie Taylor, Executive Director, Patient Safety & Learning System, Vancouver, British Columbia ; Terence Young, Chair of Drug Safety Canada and father of Vanessa Young. Educational Support for Mandatory Reporting of Serious ADRs and MDIs by HospitalsThe Protecting Canadians from Unsafe Drugs Act, also known as Vanessa's Law, is intended to9/24/2020 8:13:31 AM60125https://www.patientsafetyinstitute.ca/en/toolsResourceshtmlTrueaspx
Medication Reconciliation (Med Rec): Getting Started Kit6828Improving 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 AM10357https://www.patientsafetyinstitute.ca/en/toolsResources/Pages/Forms/NewDefaultView.aspxhtmlFalseaspx
Canadian Patient Safety Week (CPSW)2951General Patient SafetyEvents12/8/2009 9:50:43 PM Welcome to your home for Canadian Patient Safety Week! #ConquerSilence Canadian Patient Safety Week runs October 26 to 30, 2020. The Canadian Patient Safety Institute invites all Canadians – the public, providers and leaders – to become involved in making patient safety a priority. Register for updates and to receive resource information. Register Virtual Care is New to Most of Us The theme of Canadian Patient Safety Week 2020 is Virtual Care is New to Us. Only 10% of Canadians have experience with virtual care1, but 41% would like to have virtual visits with their healthcare providers2. The way to ensure that healthcare providers and patients make the most of virtual appointments is to use tried and true basics – encourage patients to ask questions and to bring an advocate with them to appointments. During Canadian Patient Safety Week, join us in the following activities to conquer silence. Let's work together for better healthcare for all. Be sure to take full advantage of all the activities during Canadian Patient Safety Week Visit ConquerSilence.ca for tips and tools for both healthcare providers and patients on how to make the most of virtual care appointments. Listen to three new episodes of our award-winning PATIENT podcasts Register for the Virtual Care webinar Register for a webinar on the Canadian Quality and Patient Safety framework Join in our "Virtual Care is New to Us social media campaign" #ConquerSilence Share our Virtual Care Quiz with your patients Please explore the Canadian Patient Safety Week's Tools & Resources, including our Communications Toolkit. Remember to sign up for updates for Canadian Patient Safety Week HERE. Virtual Care Resources – ConquerSilence.ca Access valuable resources for you, your colleagues, and your patients to improve virtual care appointments. We worked with the Canadian Medical Association to develop a WEBside manner infographic for healthcare providers, plus two virtual care checklists and a how to make the most of your virtual visit infographic for patients. Access Now About Canadian Patient Safety Week is a national, annual campaign that started in 2005 to inspire extraordinary improvement in patient safety and quality. As the momentum for promoting best practices in patient safety has grown, so has the participation in Canadian Patient Safety Week. Canadian Patient Safety week is relevant to anyone who engages with our healthcare system providers, patients, and citizens. Working together, thousands help spread the message to Conquer Silence. Partners Sponsorship If your organization is interested in sponsoring a portion of CPSW 2020, please contact sponsorshipsmail@cpsi-icsp.ca. We have many opportunities available. Virtual Care Definition Virtual care has been defined as any interaction between patients and/or members of their circle of care, occurring remotely, using any forms of communication or information technologies with the aim of facilitating or maximizing the quality and effectiveness of patient care. (CMA definition) Do you have any questions or suggestions? Contact CPSI Communications Email CPSW@cpsi-icsp.ca Join the conversation at #ConquerSilence 1https//www.cma.ca/sites/default/files/pdf/virtual-care/ReportoftheVirtualCareTaskForce.pdf 2https//www.cma.ca/sites/default/files/pdf/virtual-care/ReportoftheVirtualCareTaskForce.pdf; https//actt.albertadoctors.org/file/VirtualVisitsLitSummary2020.pdf Canadian Patient Safety WeekCanadian Patient Safety Week (CPSW)10/26/2020 1:26:03 PM95012https://www.patientsafetyinstitute.ca/en/EventshtmlTrueaspx
Prevent healthcare-acquired infections: Share how to have Clean Care Conversations during STOP! Clean Your Hands Day12565Infection Prevention & Control (IPAC)News5/6/2019 2:50:36 PM5/6/2019 6:00:00 AM 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. Every year, 220,000 Canadian patients (approximately one in nine) develop a hospital-acquired infection during their stay in hospital, and an9/24/2020 8:09:31 AM1955https://www.patientsafetyinstitute.ca/en/NewsAlerts/News/Pages/Forms/AllItems.aspxhtmlFalseaspx
Surgical Safety Checklist: Download6850Surgical 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 AM11843https://www.patientsafetyinstitute.ca/en/toolsResources/Pages/Forms/NewDefaultView.aspxhtmlFalseaspx
Conquer Silence – Encourage your patients to ask the right questions about their medications26737Improving Medication SafetyToolkits & Guides10/25/2019 4:33:20 PM Thank you for listening to stories and advice on reducing healthcare harm from real people at ConquerSilence.ca. When you or another healthcare provider make changes to patient’s medications (starting, stopping or changing doses) - especially when the patient is on multiple medications - there may be a risk of adverse drug reactions or errors. The Canadian Patient Safety Institute has teamed up with the Institute for Safe Medications Practices Canada, Patients for Patient Safety Canada, the Canadian Pharmacists Association, and the Canadian Society for Hospital Pharmacists to create this list of questions to help your patients have conversations about medications with you. Engaging patients in the healthcare journey reduces the chances of preventable harm. Please encourage your patients to ask you and other healthcare providers these 5 Questions. Download Sign up to for the Conquer Silence mailing list to be notified when we feature different patient safety issues, add new resources, and ask you to help us evaluate the effectiveness of this campaign.Thank you for listening to stories and advice on reducing healthcare harm from real people at ConquerSilence.ca . When you or another9/24/2020 8:13:49 AM2141https://www.patientsafetyinstitute.ca/en/toolsResources/5-Questions-to-Ask-about-your-Medications/Pages/Forms/AllItems.aspxhtmlFalseaspx
November is Fall Prevention Month12454General Patient Safety;Community Based CareEvents;News;Patient and Family Resource;Toolkits & Guides;Reports & Publications9/25/2015 9:51:34 PM9/25/2015 10:00:00 PMNovember is Fall Prevention Month "It takes a community to prevent a fall; we all have a role to play" Falls are the leading cause of injury among older Canadians 20 to 30 per cent of seniors experience one or more falls each year. Falls are the cause of 85 per cent of hospitalizations for Canadian seniors. The average Canadian senior stays in hospital 10 days longer for falls than for any other cause. The cost to treat injuries from falls, is over $2 billion annually in direct healthcare costs. The Fall Prevention Month partners have put together a plethora of resources to help promote Fall Prevention Month. The toolkit includes suggestions for quick and simple activities; promotional materials (logo, sample media releases, social media guide, etc.); the most-up-to-date fall statistics and infographics; information such as handouts, links and self-assessments for clients and caregivers; practitioner resources; evidence-informed and evaluated programs and interventions; and simple surveys to evaluate and track fall initiatives in your organization. Click here to download the toolkit free-of-charge. The toolkit also includes links to publications available in French, Chinese, Korean, Polish, Russian, Serbian-Croatian, Spanish, Urdu, Vietnamese, and for First Nations communities. Visit www.oninjuryresources.ca for more information on Fall Prevention Month. Check back often, as additional resources will be added in the coming weeks.November is Fall Prevention Month "It takes a community to prevent a fall; we all have a role to play" Falls are the leading cause9/24/2020 8:06:28 AM4857https://www.patientsafetyinstitute.ca/en/NewsAlerts/News/Pages/Forms/AllItems.aspxhtmlFalseaspx
STOP! Clean Your Hands2953Infection 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 AM77563https://www.patientsafetyinstitute.ca/en/EventshtmlTrueaspx
Near-fatal medication error leads nurse to make patient safety a priority26795Improving 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 AM15327https://www.patientsafetyinstitute.ca/en/toolsResources/HealthcareProviderStories/Pages/Forms/AllItems.aspxhtmlFalseaspx
How do you spell better teamwork and communication? TeamSTEPPS®! 6811General Patient SafetyEvents;Webinars10/31/2017 4:38:44 PM Archive November 30, 2017Improving teamwork and communication skills in healthcare in Canada and around the world What do the Canadian Patient Safety Institute (CPSI), the Agency for Healthcare Research & Quality (AHRQ) in the United States, and the Michael Garron Hospital in Toronto have in common? All three organizations have seen the benefits to patient safety when implementing the evidence-based teamwork and communication framework, TeamSTEPPS (Team Strategies and Tools for Effective Performance and Patient Safety). Join us for a one-hour webinar to learn more about the experience of each organization on their TeamSTEPPS journey. Discover how each organization has been working to implement TeamSTEPPS, and learn how you can use TeamSTEPPS to improve teamwork, communication and patient safety in your practice and organization. Presentation Speakers include Christopher Hund, MFA Chris is Director of Quality at the Health Research and Educational Trust of the American Hospital Association. He directs the AHA's national work in TeamSTEPPS (Team Strategies and Tools to Enhance Performance and Patient Safety) and has also worked in a variety of projects to improve culture and drive innovation amongst teams across the health care spectrum. Before his decade of working in teaming, quality improvement and patient safety for the AHA, Chris worked in both the health care publishing and education sectors. Jennifer Braun, MPH Jen Braun is a Senior Program Manager at the Health Research & Educational Trust of the American Hospital Association (AHA). She manages the AHA's national work in TeamSTEPPS (Team Strategies and Tools to Enhance Performance and Patient Safety) and other team training and quality improvement initiatives. Prior, under a federal contract with the Agency for Healthcare Research and Quality, she managed the National Implementation of TeamSTEPPS for over four years. Jen completed her Master of Public Health from the University of Iowa. Braun also holds a BA in Health Promotion from the University of Iowa. Debbie Gillis, BScN MEd Debbie is the Clinical Resource Leader for Organizational Learning at Michael Garron Hospital (MGH), and Adjunct Lecturer at University of Toronto Bloomberg School of Nursing. Debbie's career has spanned 30 years, working in a variety of Critical Care areas at MGH (Formerly Toronto East General Hospital) and Sunnybrook Hospital. Over the last 15 years, Debbie has completed undergraduate and graduate degrees in Nursing and Education, concurrently gaining expertise in simulation, instructional design and competency evaluation. As part of her role teaching healthcare professionals team resuscitation in the critical care setting, Debbie understood the importance of ensuring the development of high performing teams. Having identified the importance of team dynamics to improving team performance, Debbie became interested in what the TeamSTEPPS program had to offer, completing the Master Trainer Program in 2015. In 2016 she worked with the Intensive Care Leadership at MGH to initiate a pilot using the TeamSTEPPS communication techniques, and is continuing to champion further implementation throughout the organization. Karen L. Chapman, RN BScN MScQ&PS Karen is passionate about quality patient care and patient safety. A Registered Nurse for over 30 years, her clinical work has included Nursing in medicine, critical care, cardiology and emergency. A self-identified lifelong learner, Karen returned to university after Nursing for 20 years, earning a BScN at Ryerson University, subsequently attending post-graduate studies, completing a Master of Science degree in Quality and Patient Safety at the University of Toronto in 2014. Karen currently works at Michael Garron Hospital in Toronto, full time, as a Quality and Patient Safety Specialist. She is co-chair of the hospital's Safe Medication Practice committee, also participating on the Medical Quality and Patient Safety Committee and Falls Prevention Action Team. Karen has also been a member on the Ontario Hospital Association's working group on Critical Incidents, and in the Patient Safety Networking group.Archive: November 30, 2017 Improving teamwork and communication skills in healthcare in Canada and around the world What do the Canadian9/24/2020 8:12:24 AM1780https://www.patientsafetyinstitute.ca/en/toolsResources/Pages/Forms/NewDefaultView.aspxhtmlFalseaspx
Atlantic Learning Exchange2956General Patient SafetyEvents9/20/2016 6:01:00 PM Discover innovative and emerging trends in patient safety & quality improvement October 8 – 9, 2019 St. John's, NL, The Atlantic Health Quality and Patient Safety Collaborative (AHQPSC), through partnership support of the Canadian Patient Safety Institute (CPSI), welcomes you to attend this year's Atlantic Health Quality & Patient Safety Learning Exchange (ALE 2019) which will take place at the Sheraton Hotel Newfoundland, St. John's, NL, October 8 – 9, 2019. Program Who should attend? We look forward to welcoming innovative and engaged care providers, managers, health leaders, academics and students from university and college setting, as well as government representatives from the four Atlantic Provinces in attendance this year. Tickets are limited! Through this conference, you will be given an opportunity to Mobilize energy and enthusiasm for a new era of patient safety and quality improvement; Understand the role innovation and technology play in healthcare improvement; Stimulate change through the power of the patient voice; and Develop the skills for leading transformational change! Program Partners Sponsors Do you want to support this event? Do you want exclusive access to the front line of healthcare in the Atlantic provinces? We are looking for Sponsors and Exhibitors contact Gina Peck at 902-481-5034 or gpeck@cpsi-icsp.ca to receive more information on sponsorship and exhibiting at the conference. Atlantic Quality and Patient Safety Learning ExchangeDiscover innovative and emerging trends in patient safety & quality improvement October 8 – 9, 2019 St. John's, NL, The Atlantic Health10/29/2020 9:25:42 PM11393https://www.patientsafetyinstitute.ca/en/EventshtmlTrueaspx
The Safety Competencies Framework3001General 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 CEO9/24/2020 8:16:49 AM28948https://www.patientsafetyinstitute.ca/en/toolsResourceshtmlTrueaspx
Webinar Series - Creating a Safe Space: Psychological Health and Safety of Healthcare Workers 15493General Patient SafetyEvents;Webinars4/10/2019 8:02:20 PM Watch on DemandWebinar 1 Creating a Safe Space Confidentiality and Legal Privilege for Peer Support Programs Download Webinar 2 Results of the Pan Canadian survey of Healthcare Workers' Views on the Second Victim Phenomenon Download Webinar 3 Global environmental scan of Peer-to-Peer Support Programs Download Webinar #4 Canadian Best Practices Guidelines for Peer-to-Peer Support Programs in Healthcare Download Webinar #5 Creating a Safe Space Launch of the Toolkit for Peer-to-Peer Support Programs in Healthcare, the Expert Advisory Committee and Canadian Peer Support Network Download   Watch on Demand Webinar 1: Creating a Safe Space: Confidentiality and Legal Privilege for Peer Support Programs  9/24/2020 8:13:24 AM3081https://www.patientsafetyinstitute.ca/en/toolsResources/Creating-a-Safe-Space-Psychological-Safety-of-Healthcare-Workers/Pages/Forms/AllItems.aspxhtmlFalseaspx
MedError.ca38521Partnering with Patients;Patient & Family Resources;Improving Medication Safety;General Patient SafetyPatient and Family Resource10/26/2020 4:10:45 PM Medication errors cause harm to Canadians. Preventing such harm requires an understanding of where and why the medication safety system has failed, and the perspective of consumers is needed to advance this understanding. By sharing the learning from medication errors, consumers and providers can meaningfully work together to improve medication safety in Canada. Developed by the Institute for Safe Medication Practices Canada (ISMP Canada) and CPSI, www.mederror.ca is a new website for the public to submit reports of medication errors for analysis, learning, and action. It builds on the work and success of SafeMedicationUse.ca , to create a more user-friendly portal to share their medication error experiences with the goal to improve the quality and quantity of incident reporting in Canada. Anyone can report and with the growing numbers of Canadians who take prescription and non-prescription medications in the community, it is important to understand and learn from the public. Whether it is a suspected medication error or medication reaction, the website provides a quick and easy way to provide valuable insight that contributes to patient safety improvement. Access Now Mederror.caMedication errors cause harm to Canadians. Preventing such harm requires an understanding of where and why the medication safety system has failed,10/26/2020 4:23:42 PM83https://www.patientsafetyinstitute.ca/en/toolsResourceshtmlTrueaspx
Measures: Reducing Falls and Injury from Falls (Falls)26498Community Based CareToolkits & Guides7/1/2015 8:52:38 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 Falls Prevention Audit The tool is designed for use in Acute, Long-Term, and Home Care, Supportive Living and Rehab and was developed to allow organizations to assess the quality of their falls prevention and injury reduction practices and determine the areas requiring quality improvement(s). DCF (Audit) Question Roll-up to Measures A. Type of Falls Risk Assessment performed on Admission Falls-Acute/LTC 3 B. Was patient/resident/client designated "at risk" for Fall and was risk status communicated? Falls-Acute/LTC 10 C. Medication review completed? Falls-Acute/LTC 11 D. Pt. has documented Falls Prevention/Injury Reduction Plan Falls-Acute/LTC 5 E. Completed Falls Risk Assessment following a significant change in medical status Falls-Acute/LTC 12 F. Patient/Resident/Client is restrained at any time in this reporting period Falls-Acute/LTC 6 G. How many times did the patient/resident/client fall in this reporting period Falls-Acute/LTC 13 H. Was patient/resident/clients assessed for harm on discovery of fall? Falls-Acute/LTC 14 I. Harm from Fall? Falls-Acute/LTC 2 J. Completed Falls Risk Assessment following fall? Falls-Acute/LTC 15 K. Monitored for 24-48 hours after fall? Falls-Acute/LTC 16 L. Falls Prevention/Injury Reduction Plan Reviewed/Revised after Fall? Falls-Acute/LTC 17 Falls Prevention Audit Tools Acute Care Long Term Care Falls-Acute DCF - [PDF] Falls-LTC DCF - [PDF] Falls-Acute Instructions - [PDF] Falls-LTC Instructions - [PDF] Falls-Acute Score Template - [Excel] Falls-LTC Score Template - [Excel] Falls (Acute Care) Measures Measure Goal Type Falls-Acute 1 - Falls Rate per 1000 Patient Days Reduce 40% Outcome Falls-Acute 2 - Percentage of Falls Causing Injury Reduce 40% Outcome Falls-Acute 3 - Percentage of Patients with Completed Falls Risk Assessment on Admission 100% Process Falls-Acute 4 - Percentage of Patients with Completed Falls Risk Assessment Following a Fall or Change in Medical Status 100% Process Falls-Acute 5 - Percentage of "At Risk" Patients with a Documented Falls Prevention/Injury Reduction Plan 100% Process Falls-Acute 6 - Percentage of Patients with Restraints Reduce baseline Process Falls-Acute 7 - Fall Related INJURY Rate per 1000 Patient/Resident Days Annual reduction of 40% or annual rate <= 0.3 Outcome Falls-Acute 9 - Percent of patients designated "at risk" Does Not apply Process Falls-Acute 10 - Percent of Patient designated 'at risk' and risk status communicated 100% Process Falls-Acute 11 - Percentage of patients with a medication review was completed 100% Process Falls-Acute 12 - Percentage of patients with Completed Fall Risk Assessment following Significant change in Medical Status 100% Process Falls-Acute 13 - Percentage of Patients with 2 or more falls 0% Outcome Falls-Acute 14 -Percentage of Patients Assessed for harm on discovery of fall 100% Process Falls-Acute 15 - Percentage of Patients with Completed Fall Risk Assessment following a fall 100% Process Falls-Acute 16 - Percentage of "Fallers" with monitoring in place for 24-48 hours after the fall 100% Process Falls-Acute 17 - Fallers with review or revision of Falls Prevention / Injury Plan after fall 100% Process Falls-Acute 18 - Fall Prevention Score 100% Outcome Falls-Acute 19 - Fall Management Score (after fall) 100% Outcome Measures and definitions Falls (Long Term Care) Measures Measure Goal Type Falls-LTC - Prevention of Falls in Long-Term Care Monthly Report N/A Information Falls-LTC 1 - Falls Rate per 1000 Resident Days Reduce 40% Outcome Falls-LTC 2 - Percentage of Falls Causing Injury Reduce 40% Outcome Falls-LTC 3 - Percentage of Residents with Completed Falls Risk Assessment on Admission 100% Process Falls-LTC 4 - Percentage of Residents with Completed Falls Risk Assessment Following a Fall or Change in Medical Status 100% Process Falls-LTC 5 - Percentage of "At Risk" Residents with a Documented Falls Prevention/Injury Reduction Plan 100% Process Falls-LTC 6 - Percentage of Residents with Restraints Reduce baseline Process Falls-LTC 7 - Percentage of residents physically restrained daily on the most recent RAI assessment At a minimum, to maintain at or below baseline Outcome Falls-LTC 8 - Injury Rate Due to Falls (Fall-Related INJURY) per 1000 Resident Day Annual reduction of 40% or annual rate <= 0.3 Process Falls-LTC 9 - Percentage of Residents Designated "At Risk" Does Not Apply Process Falls-LTC 10 - Percentage of Residents Designated "At Risk" and Risk Status Communicated 100% Process Falls-LTC 11 - Percent of Residents With a Medication Review Completed 100% Process Falls-LTC 12 - Percent of Residents With Completed Fall Risk Assessment Following a Significant Change in Medical Status 100% Outcome Falls-LTC 13 - Percent of Residents With Two or More Falls 0% Process Falls-LTC 14 - Percent of Long-Term Care Residents Assessed for Harm on Discovery of Fall 100% Process Falls-LTC 15 - Percent of residents With Completed Fall Risk Assessment Following a Fall 100% Process Falls-LTC 16 - Percent of "Fallers" in Long-TermCare With Monitoring in Place for 24-48 Hours After Fall 100% Process Falls-LTC 17 - Percent of "Fallers" in Long-Term Care With Review or Revision of Falls Prevention/Injury Reduction Plan After Fall– 100% Outcome Falls-LTC 18 - Fall Prevention Score (Long-Term Care) 100% Outcome Falls-LTC 19 - Fall Management Score After a Fall (Long-Term Care) 100% Outcome 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.Falls: Measurement Worksheets9/24/2020 8:15:18 AM9648https://www.patientsafetyinstitute.ca/en/toolsResources/psm/Pages/Forms/UpdateData.aspxhtmlFalseaspx