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Creating a Safe Space: Addressing the Psychological Safety of Healthcare Workers2623General 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. Download 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 healthcare12/1/2020 4:47:37 PM7932https://www.patientsafetyinstitute.ca/en/toolsResourceshtmlTrueaspx
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 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.11/10/2020 4:34:09 PM12226https://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 AM7619https://www.patientsafetyinstitute.ca/en/toolsResources/psm/Pages/Forms/UpdateData.aspxhtmlFalseaspx
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 PM549https://www.patientsafetyinstitute.ca/en/toolsResources/Canadian-Quality-and-Patient-Safety-Framework-for-Health-and-Social-Services/Pages/Forms/AllItems.aspxhtmlFalseaspx
Tools & Resources25029/18/2020 4:40:20 AMTools & ResourcesTools & Resources9/21/2020 9:19:04 AM61207https://www.patientsafetyinstitute.ca/enhtmlTrueaspx
Atlantic Learning Exchange mobilizes energy and enthusiasm for patient safety and quality37702General Patient SafetyNews12/1/2020 5:08:35 PM12/1/2020 7:00:00 AM #SuperSHIFTER Leslie Ann Rowsell was Chair of the Atlantic Learning Exchange held in St. John's, Newfoundland and Labrador, in October 2019. The Atlantic Learning Exchange brings together healthcare professionals from the four Atlantic provinces to discover innovative and emerging trends in patient safety and quality improvement. What can you tell us about the Atlantic Learning Exchange? The Atlantic Learning Exchange (ALE) is a wonderful opportunity for people in Atlantic Canada to come together to discuss their work in patient safety and quality. We offer the opportunity for people to showcase their work and what they are doing in their respective regions. To engage ALE delegates, our presenters go through a rapid-fire process to talk about their projects for about five minutes as well as display poster and story boards. It also opens doors for people who are in this line of work to meet with various vendors and sponsors. It provides conversation time and exposure to things that our delegates may not necessarily see every day. In a nutshell, the ALE is a great networking opportunity for like-minded individuals to connect, broaden their knowledge, and take that knowledge translation back to their workplace. Tell us about your experience as Chair of the event? It was great fun to be the Chair of such a phenomenal event. I haven't been on the planning side of many healthcare conferences, so I was a newbie when it comes to this level of work. In 2015, I was approached by our Vice-President Clinical Supports and the Director of Quality Risk and Patient Safety, who were responsible for Quality at Eastern Health to be the provincial representative on the planning committee for these conferences. I attended the 2015 and 2017 conferences before taking on the Chair role for the Conference here in Newfoundland and Labrador in 2019. Everyone on the planning committee works full-time and the conference planning is in addition to our regular work. It requires the help of everyone in all the Atlantic provinces to help ensure there is adequate representation from each province attending the event, and for the storyboards and rapid-fire presentations. But the ALE also needs a commitment of organizations to send people to the Conference. It's definitely a team effort to pull an event like this together. In the beginning days, we thought it may have been difficult to attract delegates because air travel is expensive and it's not easy to drive to our province at that time of the year. The response was overwhelming and in the end we maximized the room capacity and had to turn people away. What makes the Atlantic Learning Exchange unique? The ALE is designed by Atlantic Canadians, for Atlantic Canada. Because the geography of Atlantic Canada is somewhat small, we bring a grassroots perspective with people on the planning committee representing all four provinces. As a group, we pick the theme and design the agenda. We have a lot of flexibility when it comes to our speakers and how we spend the money entrusted to us to run the ALE. Because there is so much input from all provinces, the agenda is very relevant and applicable for everyone in the room. The Atlantic Learning Exchange has been successful because we have been able to work together and network together. We have been able to help keep the costs down so that people can afford to come. And, we have made the event something meaningful that happens every second year. What were some of the highlights of the 2019 ALE for you? Jeffrey Braithwaite was one of our keynote speakers and he wowed the audience with his knowledge on patient safety. There was so much rich content in his presentation, and I have become quite interested in his work in systems improvement and now follow him on Twitter. To encourage resilience, Braithwaite suggests Look at what goes right, not just what goes wrong; When something goes wrong, begin by understanding how it (otherwise) usually goes right. Look at frequent events, not just severe ones; Be proactive about safety - try to anticipate developments and events; and Be thorough, as well as efficient (the ETTO principle – efficiency-thoroughness trade-off). Marlies van Dijk from Alberta Health Services Design Lab delivered a powerful presentation demonstrating how the biggest opportunities to transform health care lie not within strategies or processes, but within mindsets. Marlies reinforced the importance of knowing your team, and networking within work to build your own resources and strengths. When you connect with people who build you up and you find those people to trust, brainstorm and work with, you will find your supporters! There was also an interesting presentation from the Hacking Health team at Eastern Health and their work to hack no-show rates. Hacking Health fosters collaborative innovation by engaging key groups of stakeholders to create solutions to healthcare challenges as a mindset, not a skill-set. Where can we go for more information? Copies of the presentations from the 2019 ALE are available on the Canadian Patient Safety Institute's website. Click here to access the presentations. If you have questions about the ALE, contact me at LeslieAnnRowsell@EasternHealth.ca. #SuperSHIFTER Leslie Ann Rowsell was Chair of the Atlantic Learning Exchange held in St. John's, Newfoundland and Labrador, in October 2019. The12/1/2020 5:15:29 PMhttps://www.patientsafetyinstitute.ca/en/NewsAlerts/News/Pages/Forms/AllItems.aspxhtmlFalseaspx
CFHI and CPSI welcome Government of Canada’s $6.4 million investment in pandemic preparedness and response long-term care and retirement homes37708General Patient SafetyNews12/1/2020 11:06:09 PM12/1/2020 7:00:00 AM Yesterday, the Honourable Chrystia Freeland, Deputy Prime Minister and Minister of Finance, tabled Supporting Canadians and Fighting COVID-19 Fall Economic Statement 2020. We welcome the $6.4 million investment the Government of Canada is making to expand the LTC+ Acting on Pandemic Learning Together initiative which is helping long-term care and retirement homes strengthen their pandemic preparedness and response. This additional funding is part of their commitment to help provinces and territories protect long-term care and other supportive care facilities. The funding will allow LTC+ to support up to 1000 teams delivering care for adults in congregate living settings across Canada. Through LTC+, teams are able to rapidly share with and learn from each other, prepare for possible future outbreaks, and work to mitigate the pandemic's effects through coaching, funding, virtual learning opportunities and peer-to-peer support. We owe it to those affected by early outbreaks of COVID-19 in long-term care and retirement homes to learn from their experiences and hard-won lessons. These homes all have the common goal of protecting their residents and staff and LTC+ is helping them to come together quickly and efficiently. Teams are focusing on six promising practices to strengthen pandemic preparedness and response preparation; prevention; people in the workforce; pandemic response and surge capacity; planning for COVID-19 and non-COVID-19 care; and presence of family. LTC+ is being delivered by the newly amalgamated organization that brings together the Canadian Foundation for Healthcare Improvement and Canadian Patient Safety Institute. LTC+ is supported by our partners the BC Patient Safety and Quality Council, New Brunswick Association of Nursing Homes and CADTH and with funding support from the CMA Foundation. If your team is delivering care to older adults in congregate care settings and interested in LTC+, you can find out more details here or reach out to the team via LTC-SLD@cfhi-fcass.ca. Jennifer Zelmer President and CEO Yesterday, the Honourable Chrystia Freeland, Deputy Prime Minister and Minister of Finance, tabled Supporting Canadians and Fighting COVID-19:12/1/2020 11:10:17 PMhttps://www.patientsafetyinstitute.ca/en/NewsAlerts/News/Pages/Forms/AllItems.aspxhtmlFalseaspx
Glossary of Terms97585/22/2018 7:52:41 PM This Glossary defines and describes the terms used in the Engaging Patients in Patient Safety – a Canadian Guide. When appropriate, use your organization's preferred or commonly used terms. Accreditation A self-assessment and external peer assessment process used by health and social service organizations to accurately assess performance levels against established standards, and to implement ways to continuously improve. Culture of safety Culture is "the way we do things around here." Culture refers to people's shared values (what is important) and beliefs (what is held to be true), which interact with an organization's structure or system to produce behavioural norms (what people do). Positive safety culture Communication is open and honest, there is mutual respect and trust among providers and patients, people are comfortable reporting safety concerns, and there are fair and just processes in place to examine, address, and learn from failures. Disclosure A formal process to openly discuss a patient safety incident with the patient, their family, and members of the healthcare organization. Engagement An approach to encourage the people most impacted to participate actively in defining their issues of concern, and help decide, plan, deliver, implement, evaluate, and improve initiatives, processes, and/or policies. Ongoing engagement involves developing and sustaining constructive relationships, building strong, active partnerships at various levels across the healthcare system, and holding a meaningful dialogue with partners. Types of engagement include surveys, consultations, and shared decision making, as described in the spectrum of engagement. Effective engagement is goal-focused, decision-oriented and values-based. Patient engagement An approach to involve patients, families, and/or patient partners in Their own healthcare The design, delivery, evaluation of health services A way that fits their circumstances Patients' experiential knowledge is recognized; and power is shared in ongoing, meaningful, constructive relationships at all system levels Direct care Healthcare organization (service design, governance) Health system (setting priorities and policies) Public engagement involving the public/ citizens before or after they access the healthcare system (e.g. make healthy and informed decisions regarding care) Spectrum (continuum, levels) of engagement The range of ways patient engagement takes place. It can span from input and consultation to shared leadership, accountability, and decision making. Evaluation Collecting, analyzing, and using data and information to understand how a project, program, or policy is progressing and/or what is its impact on individuals, organizations, and/or society. Evaluation often measures success or importance in relation to goals, objectives, and needs. Incident analysis (or root cause analysis) Structured, rigorous, often legally-protected and confidential process to review a patient safety incident. It identifies what happened, how, why it happened, what can be done to reduce the risk of recurrence and make care safer, and what was learned. It examines the whole system of care to identify the factors that contributed to the patient safety incident. Incident management Various actions and processes required immediately and on an ongoing basis following a patient safety incident. It includes immediate response, disclosure, incident analysis, sharing and learning. Patient and family Patient Person who is receiving, has received, or has requested health services. It refers to all other terms for patient, including client, resident, person, and individual. Family Person(s) whom the patient wishes to be involved in their care, and act on their behalf or interests. Family is defined by the patient. This person speaks up on behalf of the patient with the patient's input. Note because of the inconsistent terminology some use the term "those most impacted" instead of patient. Patient partner (or advisor) An individual who experienced care in the healthcare system (as a patient, family member or caregiver) and who, as part of a patient group (e.g., patient/family council), engages in shaping decisions, policies, and/or practices at all system levels. Patient representative An employee working in a healthcare setting who helps patients and families with their specific concerns, and answers their questions while in a healthcare facility. This person is the link between patients/ families, and providers/ organization. Person (Patient, family) Centred Care An approach to care where patients and healthcare professionals partner to Give patients a voice in the design and delivery of the care and services they receive Allow patients to be proactive in their healthcare journey for better health outcome; and Improve the experience of patients People-centred care An approach to care that consciously adopts individuals', carers', families' and communities' perspectives as participants in, and beneficiaries of, trusted health systems that are organized around the comprehensive needs of people rather than individual diseases, and respects their preferences. People-centred care is broader than patient and person-centred care, encompassing not only clinical encounters, but also including attention to the health of people in their communities and their crucial role in shaping health policy and health services. Patient empowerment (or activation) Helping patients gain control over their own lives and increase their capacity to act on issues that they themselves define as important. Aspects of empowerment include self-efficacy, self-awareness, confidence, coping skills, and health literacy. Patient experience The sum of all interactions, shaped by an organization's culture, that influence patient perceptions, across the continuum of care. Patient safety The pursuit of the reduction and mitigation of unsafe acts within the health care system, as well as the use of best practices shown to lead to optimal patient outcomes. Patient safety is one of the dimensions of quality. Patient safety incident An event or circumstance which could have resulted, or did result, in unnecessary harm to a patient. It includes Near miss A patient safety incident that did not reach the patient. Replaces "close call." No harm incident A patient safety incident that reached a patient, but no discernible harm resulted. Harmful incident A patient safety incident that resulted in harm to the patient. Other terms sometimes still used to describe a harmful incident are adverse event or critical incident. Patient safety science Methods to acquire and apply safety knowledge to create highly reliable systems that approach "fail-safe" conditions (i.e., those in which the operator cannot perform the function improperly). Past effort has been directed toward developing defences, which are barriers that prevent an unsafe act from resulting in harm. Over the years, healthcare has developed many of these barriers, and usually several must be breached for patient harm to occur Measurement A process essential to monitoring success. It indicates what's working and what's not, and can provide evidence for others to improve the quality of patient safety. Measures (metrics) Standard for determining an organization or initiative's activities and performance. Performance measures Monitors, evaluates, and communicates the extent to which various activities of the organization or the healthcare system meet their key objectives. Process measures Assesses what is being done and how (e.g., engagement activities, strategies or methods which directly affect the outcome), what is working well, and what needs to be changed or improved (e.g., the delivery of timely prophylactic antibiotics to reduce surgical site infection). Outcome measures Determines what effects the engagement had, what it did or did not accomplish, and what success looks like (e.g., to reduce falls, teams should measure the number of falls). Balancing measures Determines if improvements in one part of the system were made at the expense of other processes in other parts of the system (e.g., 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). Providers (or clinicians) Includes physicians, nurses, and allied health care professionals who directly provide healthcare services to patients. The term does not include the family members providing care (family caregivers or care partners). Quality of care The degree to which healthcare services produce the desired health outcomes and measure up to current evidence and knowledge. The attributes most often used to describe quality care are safe, patient-centred, accessible, appropriate, effective, efficient, and equitable. Each province or organization may have their own quality frameworks. Quality Improvement A systematic approach to making changes that lead to better patient outcomes and stronger health system performance. It involves applying quality improvement science, which provides a robust structure, tools, and processes to assess and accelerate efforts for testing, implementing, and spreading good practices. Information Qualitative information Descriptive information, such as patient stories, notes from interviews or focus group discussions, and observation notes. Qualitative information can be systematically analyzed to identify issues of interest. Quantitative information Information that measures characteristics using a numeric value (e.g., gender, income, marital status, etc.). The numeric values can be statistically analyzed to identify issues of interest. Stakeholder A person who has a vested interest in engagement outcomes and who could be affected by any decisions taken or changes made. Stakeholders could include patients, families, caregivers, providers, administrative staff, suppliers, organizational partners, the community, the public and others. System levels The healthcare system is comprised of many sub-systems operating at different levels (e.g., outside of the organization, within the organization and/or program level, at point of care) each with specific goals, resources (e.g., human, financial, equipment), and formal or informal processes. Point of care direct care (patient and family receiving care and providers and others who deliver care and services) Organization program/ unit/service and facility/organization/ health region (service design and delivery, strategy, system planning, organizational design, governance) System the sum of all the organizations, institutions, and resources that deliver health care services to meet the health needs of a target population (policy, planning, resourcing, research, education, accreditation) Validated tool/survey/questionnaire A measurement tool that has been tested for reliability (produces consistent results) and validity (produces true results).References Canadian Patient Safety Institute. Patient Safety and Incident Management Toolkit. Glossary. 2015. Carman KL, Dardess P, Maurer M, Sofaer S, Adams K, Bechtel C, Sweeney J. Patient and family engagement a framework for understanding the elements and developing interventions and policies. Health Aff (Millwood). 2013 Feb;32(2)223-31 Charles Vincent, René Amalberti. Safer Healthcare. Strategies for the Real World. Springer, Cham. 2016. Emanuel LL, Taylor L, Hain A, Combes JR, Hatlie MJ, Karsh B, Lau DT, Shalowitz J, Shaw T, Walton M, eds. The Patient Safety Education Program – Canada (PSEP – Canada) Curriculum. © PSEP – Canada, 2016. European Patients Forum. Patient Empowerment http//www.eu-patient.eu/campaign/PatientsprescribE/ Health Quality Council of Alberta. The Alberta Quality Matrix for Health. Health Quality Ontario. Quality Matters Realizing Excellent Care for All. 2015. Institute for Patient- and Family-Centered Care. What is patient and family centred care. Safer Healthcare Now! Improvement Frameworks Getting Started Kit. 2015 The Beryl Institute. Defining Patient Experience. World Health Organization Secretariat. Framework on Integrated, People-Centred Health Services. World Health Organization; 2016. https//www.who.int/servicedeliverysafety/areas/people-centred-care/framework/en/. This Glossary defines and describes the terms used in the Engaging Patients in Patient Safety – a Canadian Guide . When appropriate, use your6/19/2020 9:15:50 PM1020https://www.patientsafetyinstitute.ca/en/toolsResources/Patient-Engagement-in-Patient-Safety-Guide/Pages/Forms/AllItems.aspxhtmlFalseaspx
November is Fall Prevention Month14016General 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 AM5272https://www.patientsafetyinstitute.ca/en/NewsAlerts/News/Pages/Forms/AllItems.aspxhtmlFalseaspx
Education to support mandatory ADR and MDI reporting (Vanessa’s Law)2645General 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 AM102704https://www.patientsafetyinstitute.ca/en/toolsResourceshtmlTrueaspx
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 AM15964https://www.patientsafetyinstitute.ca/en/toolsResources/HealthcareProviderStories/Pages/Forms/AllItems.aspxhtmlFalseaspx
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 AM1945https://www.patientsafetyinstitute.ca/en/toolsResourceshtmlTrueaspx
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 AM9657https://www.patientsafetyinstitute.ca/en/toolsResources/Pages/Forms/NewDefaultView.aspxhtmlFalseaspx
TeamSTEPPS Canada(TM) Essentials microlearning course launched through Canada’s Patient Safety Online Learning Centre14177Education;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 AM905https://www.patientsafetyinstitute.ca/en/NewsAlerts/News/Pages/Forms/AllItems.aspxhtmlFalseaspx
Suicide Risk2610Mental Health;Healthcare HarmToolkits & Guides;Reports & Publications4/21/2011 4:02:20 AM ​​​We are pleased to announce that Dr. Chris Perlman, associate director, Homewood Research Institute, and his team are the successful recipients of Ontario Hospital Association (OHA) and Canadian Patient Safety Institute (CPSI) funding to develop an inventory and resource guide for assessing and preventing suicide risk. Among its many accomplishments, Homewood Research Institute, located in Guelph, Ontario, was a lead organization in the development of mental health assessment systems, such as the Resident Assessment Instrument – Mental Health (RAI-MH), the interRAI Community Mental Health, and the interRAI Emergency Screener for Psychiatry. The five-member team—Dr. Chris Perlman, Dr. John Hirdes, Dr. Lynn Martin, Dr. Eva Neufeld, and Ms. Mary Goy—includes researchers, policy analysts, and clinicians with more than 20 years of experience conducting health and policy research at the regional, provincial, national, and international levels. All team members have tremendous expertise in mental health research. Dr. Perlman and his team will be working closely with the Advisory Group and with members of the OHA and CPSI to develop the inventory and resource guide. The innovative guide will be available by fall 2011. Download Inventory and Resource Guide Development for the Assessment and Prevention of Suicide RiskWe are pleased to announce that Dr. Chris Perlman, associate director, Homewood Research Institute, and his team are the successful recipients of9/24/2020 8:16:27 AM7095https://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 AM11978https://www.patientsafetyinstitute.ca/en/toolsResourceshtmlTrueaspx
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 AM1728https://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 AM10756https://www.patientsafetyinstitute.ca/en/toolsResources/Pages/Forms/NewDefaultView.aspxhtmlFalseaspx
Home Care Safety Falls Prevention Virtual Improvement Collaborative13953Community 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 AM3442https://www.patientsafetyinstitute.ca/en/NewsAlerts/News/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 AM7845https://www.patientsafetyinstitute.ca/en/toolsResources/Pages/Forms/NewDefaultView.aspxhtmlFalseaspx
Patient engagement in medication safety at the point of care – roles, responsibilities6192Improving 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 AM2608https://www.patientsafetyinstitute.ca/en/toolsResources/Pages/Forms/NewDefaultView.aspxhtmlFalseaspx
Resources10417General Patient Safety;Government Relations;Improving Culture;Partnering with Patients;Patient & Family Resources;ResearchFrameworks;Patient and Family Resource;Position Statements;Reports & Publications;Toolkits & Guides10/29/2020 6:57:56 PM ​ We have compiled a curated list of resources to support you in taking action to improve quality and patient safety. While these resources can be used by any group, your stakeholder group's recommended resources are colour coded in the table below. Each resource is numbered to allow for easy reference between this list and the recommended areas for action. Framework Resources About the Framework 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 For any questions, comments or to share your experience using the Framework, please contact qualityservicesforall@healthstandards.org. Contact us We have compiled a curated list of resources to support you in taking action to improve quality and patient safety. While these resources can be11/3/2020 4:46:43 PM206https://www.patientsafetyinstitute.ca/en/toolsResources/Canadian-Quality-and-Patient-Safety-Framework-for-Health-and-Social-Services/Pages/Forms/AllItems.aspxhtmlFalseaspx
Evaluation Research of Measurement and Monitoring of Safety Framework Collaborative9983General Patient SafetyReports & Publications10/15/2020 4:11:19 PM ​Executive Summary The Measurement and Monitoring of Safety Framework consists of five dimensions, and a series of prompting key questions, that guide users to comprehensively and conceptually view safety. These five dimensions and related questions address past harm, reliability, sensitivity to operations, anticipation and preparedness and integration and learning. In October 2018, The Canadian Patient Safety Institute (CPSI) launched a patient safety improvement project under the leadership of Maryanne D'Arpino of CPSI (Executive Lead) and Dr. G. Ross Baker at the University of Toronto (Academic Lead). This program, a learning collaborative with expert faculty and mentorship, aimed to enable the implementation of the MMSF amongst 11 teams from seven provinces across Canada over an 18-month period with the aim of each team developing a more comprehensive approach to safety and the delivery of safer care. This report presents findings from an evaluation study funded by CPSI that aimed to examine the effectiveness of this Collaborative. Download the evaluation report Methods This study used a qualitative approach based on interview, observation and documentary data collection methods. In-depth semi-structured interviews were conducted with team members, one-day site visit observations were conducted at five sites, observations of learning sessions were conducted and relevant documents were collected. Thirty-six team members participated in interviews. A total of 29 hours was spent at site visits; in addition to approximately 33 hours at learning session 3, closing congress and all-team virtual meetings. Key Findings Overall participants provided positive feedback about the in-person learning sessions. They particularly valued the expert presenters, multifaceted approaches used to teach the MMSF, and the structure created for learning within and between participating teams. While some participants felt 'overwhelmed' at the amount of information in the first learning session, the majority felt positive about the Framework from the outset. The first learning session set in place the need for a shift in thinking about safety from an absence of harm to presence of safety, to thinking about changing culture, and that it would take time to understand and implement the MMSF. The coaching by CPSI Senior Program Managers played key roles in participants' understanding and implementation of the MMSF. The coaches were responsive and accessible in between site visits. They provided ongoing education and support, and were instrumental in providing the feedback necessary for ongoing implementation of the MMSF. Some participants would have wanted more coaching and more clarity about coaching and team accountability expectations. Team members used a range of teaching strategies and methods to support the implementation of MMSF into practice. These included teaching about the Framework to groups of stakeholders (e.g. front line providers, senior leadership, QI consultants, physicians, Boards) and teaching about the Framework by integrating its language into day to day communication and using it to discuss specific safety or patient care issues. Team members made decisions about how to teach the Framework to the stakeholder groups, taking into consideration issues such as availability, numbers of people involved, professional roles, and interest. There were different perceptions about the effectiveness of teaching the MMSF, and whether it is necessary to teach the Framework itself or it is sufficient to teach and implement tools/ processes informed by the Framework. Teams were encouraged to focus on MMSF implementation strategies that were context specific and allowed for the integration of the Framework into the daily clinical and administrative work of the units or targeted areas. Teams consequently used a variety of strategies. These included the use of the MMSF to inform the following processes and activities safety huddles, health care processes, safety incidents/reports; meetings; communication; patient and family focused initiatives; and board and senior leadership level activities. Each strategy had success in targeting different stakeholders and effecting change in different ways. The MMSF teams consisted of individuals with varied professional backgrounds and roles at local, regional and provincial levels. This variability allowed for sharing of diverse perspectives and multiple avenues to teach, implement and spread the MMSF. However, variability in engagement with the Collaborative and movement out and into the teams over the 18 months were challenges. A small number of teams had patient/family and board representation who were seen to bring valuable perspectives to the team and its work. Physicians were a more difficult group to engage. The majority of participants were supportive of wider spread of the MMSF yet there was variability in their opportunities for spread beyond their implementation site(s). While a small number remained focused at the original site of implementation, the other teams demonstrated varying levels of spread unplanned spread; planned individual or team efforts which led to pockets of uptake in the organization or region; planned and coordinated widespread efforts to spread the MMSF across an organization and region. Challenges to spread included limited dedicated resources, uncertain authority to influence spread, the need for alignment with wider-level processes and frameworks and healthcare organizational and regional restructuring. The majority of participants reported positive impacts from MMSF implementation. These included changes in thinking about safety which impacted on behaviours and practices; healthcare staff engagement in prevention, identification and management of safety issues; patient/resident and family engagement in safety; and improvements in healthcare processes and patient care. Conclusions and Implications The MMSF Collaborative was successful in teaching the teams about the MMSF and coaching them to implement the Framework in their local settings. Participants perceived the MMSF work to be having positive impacts on stakeholder groups' knowledge and behaviours, and on healthcare processes and patient outcomes. These findings support further education and implementation of the MMSF; however, these efforts would need to address the facilitators and challenges identified in this report to ensure a more systematic and comprehensive spread throughout healthcare organizations and regions. Download the evaluation report Executive Summary The Measurement and Monitoring of Safety Framework consists of five dimensions, and a series of prompting key questions, that10/16/2020 9:17:02 PM175https://www.patientsafetyinstitute.ca/en/toolsResources/Measure-Patient-Safety/Pages/Forms/AllItems.aspxhtmlFalseaspx
Canadian Patient Safety Week (CPSW)2590General Patient SafetyEvents12/8/2009 9:50:43 PM Virtual Care is New to Us #ConquerSilence Thank you to everyone who participated in Canadian Patient Safety Week from October 26 to 30, 2020. Let’s Keep the Momentum Going The theme of Canadian Patient Safety Week 2020 was 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. Although Canadian Patient Safety Week 2020 has passed, virtual care is here to stay! Please continue to access and share the virtual care resources below.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 PATIENT Podcast Series Listen to season 4 of our award-winning PATIENT podcast! Listen Here Are your patients ready for Virtual care? Share our free online quiz with your patients Virtual care Quiz 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)11/16/2020 6:18:23 PM98393https://www.patientsafetyinstitute.ca/en/EventshtmlTrueaspx
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 AM80258https://www.patientsafetyinstitute.ca/en/EventshtmlTrueaspx
Measures: Infection Prevention and Control (IPAC)10524Infection Prevention & Control (IPAC)Toolkits & Guides7/1/2015 8:55:33 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.Hand Hygiene MeasuresMeas​ure​Goal​Type​ HH 1 - Volume of Alcohol Based Hand Rub Used for the Area being Monitored Increase baseline Process​ HH 2 - Volume of Hand Hygiene Soap Used for the Area being Monitored Increase baseline ​Process HH 3 - Percent Appropriate Hand Hygiene Practice by Health Care Workers (HCW) 80% Process​ HH 4 - Percent Availability of Hand Hygiene Products at Bed Spaces or Patient Areas being Monitored - Bundle Compliance 95%​ Process​ Infection Prevention and Control Measures​Measure​Goal​Type​ IPAC 1 - Number of Gowns Used for the Area being Monitored Increase 50% Process IPAC 2 - Number of Boxes of Gloves Used for the Area being Monitored Increase 50% Process IPAC 3 - Percentage of Eligible Patient Admissions Screened for MRSA per Month 90% Process​ IPAC 4 - Percentage of Eligible Patient Admissions Screened for VRE per Month 90%​ Process IPAC ​​ 5 - Percent Appropriate Environmental Cleaning Practice​ 100%​ Process​ IPAC ​​6 - Reduction in Mean Time to Placement on Contact Precautions​ Decrease 50%​ Process​ IPAC ​7 - Reduction in Mean Time from Lab Notification to Placement on Contact Precautions​ Decrease 50%​ Process​ IPAC ​​ 8 - Incidence of HAI-MRSA Clinical Isolates per 1000 Patient Days​ Reduce 50%​ Outcome​ IPAC ​​ 9 - Incidence of HAI-VRE Clinical Isolates per 1000 Patient Days​ Reduce 50%​ Outcome​ IPAC ​10 - Incidence of HAI-CDAD Positive Toxin Assay per 1000 Patient Days​ Decrease 30%​ Outcome​ ​IPAC 11 – Surveillance for new healthcare-associated CRE clinical isolates​ Reduce 50%​​ ​Outcome​ Measures and definitions Safer Healthcare Now! has two types of measures for each of the interventions process measures and outcome measures. Some interventions also have balancing and information measures. Below are examples of each. Outcome measures – These answer whether the team is achieving what it is trying to accomplish and articulate the picture of success. For example, if the team wants to reduce falls, it should measure the number of falls. Process measures – Processes that directly affect the outcome are measured to ensure that all key changes are being implemented to impact the outcome measure. The timely delivery of prophylactic antibiotics to reduce surgical site infection is one example. Balancing measures – These determine 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 percentage of readmissions within 30 days for the same group. Information measures – These collect general details relative to the intervention. Please note that the Patient Safety Metrics system is no longer accepting data. Click here or email us at metrics@saferhealthcarenow.ca for more information. NACS: Measurement Worksheets9/24/2020 8:15:17 AM10744https://www.patientsafetyinstitute.ca/en/toolsResources/psm/Pages/Forms/UpdateData.aspxhtmlFalseaspx
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 After Surgery - ERAS is a program highlighting surgical best practices and consists of a number of evidence-based principles that support better outcomes for surgical patients including an improved patient experience, reduced length of stay, decreased complication rates and fewer hospital readmissions. As part of CPSI's Integrated Patient Safety Action Plan for Surgical Care Safety and with support from 24 partner organizations from across the country, Enhanced Recovery Canada™ is leading the drive to improve surgical safety across the country and help disseminate these ERAS principles. A number of Canadian surgical care teams have already embraced the ERAS principles Alberta Health Services, Eastern Health, McGill University Health Centre, University of Toronto's Best Practices in Surgery, the Winnipeg Regional Health Authority as well as BC's Patient Safety & Quality Council and the Doctors of British Columbia. Additional Information Position Statement NEW Discover best practices with Enhanced Recovery After Surgery (ERAS) in the latest accredited online module. This 30-minute interactive learning case assessing fluid management for better patient recovery outcomes was developed in partnership with the Royal College of Physician and Surgeons of Canada and is available to all healthcare professionals. All learning modules qualify for MOC Section 3 credits. Access Now Resources for Colorectal Surgeries Patient Story Video 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 After Surgery - ERAS is a program highlighting surgical best practices and consists of a11/13/2020 5:07:07 PM21326https://www.patientsafetyinstitute.ca/en/toolsResourceshtmlTrueaspx
Measures: Surgical Site Infections (SSI)10528Surgical Care SafetyToolkits & Guides7/1/2015 8:54:58 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 SSI Prevention Audit The tool is designed for use in Acute Care, and was developed to allow organizations to assess the quality of their surgical site infection prevention practices and determine the areas requiring quality improvement(s). DCF (Audit) Question Roll-up to Measures A. Type of Surgery N/A B. Surgical Class N/A C. Pre-Op Shower or bath with soap or antiseptic agent SSI 9, 14, 17 D. Solution used for intra-operative intact skin cleansing SSI 10, 14, 17 E. Prophylactic antibiotic administration SSI 8, 15, 17 F. Dose of Cefazolin used as prophylactic antibiotic SSI 11, 15, 17 G. Appropriate prophylactic antibiotic redosing according to guidelines SSI 12, 15, 17 H. Discontinuation of prophylactic antibiotic SSI 2, 16, 17 I. Hair removal method SSI 4, 14, 17 J. Glucose was below 11.1 mmol/L on each of POD 0, 1, & 2 SSI 5, 16, 17 K. Temperature at end of surgery or on arrival in PACU was within range of 36.0-38.0 degrees C SSI 6, 15, 17 SSI Prevention Audit DCF SSI Prevention Audit Instructions SSI Prevention Audit Score Template SSI Measures Measure Goal Type SSI 1 - Percent of clean and clean-contaminated patients with timely prophylactic antibiotic administration 95% Process SSI 2 - Percent of clean and clean-contaminated patients with appropriate prophylactic antibiotic discontinuation 95% Process SSI 3 - Percent of clean and clean contaminated surgery patients with surgical infection Reduce by 50% Outcome SSI 4 - Percent of surgical patients with appropriate hair removal 95% Process SSI 5 - Percent of all diabetic or surgical patients at risk of high blood glucose with controlled post-operative serum glucose POD 0, 1, and 2 95% Process SSI 6 - Percent of all clean or clean-contaminated surgical Patients with normothermia within 15 minutes of end of surgery or on arrival in PACU 95% Process SSI 7 - Percentage of clean or clean-contaminated surgical patients with appropriate selection of prophylactic antibiotic 95% Process SSI 8 - Percent of clean and clean-contaminated caesarean section patients with timely prophylactic antibiotic administration for C-Section 95% Process SSI 9 - Percent of clean and clean-contaminated surgical patients with pre-op wash with soap or antiseptic agent 95% Process SSI 10 - Percent of clean and clean-contaminated surgical patients with appropriate intra-op skin cleansing on intact skin 95% Process SSI 11 - Percent of clean and clean-contaminated adult surgical patients receiving 2 grams of Cefazolin as prophylactic antibiotic 95% Process SSI 12 - Percent of clean and clean-contaminated surgical patients receiving appropriate prophylactic antibiotic re- dosing 95% Process SSI 13 - Percent of clean and clean contaminated surgery patients with evidence of surgical site infection at the time of, or prior to discharge Reduce by 50% Outcome SSI 14 - Surgical Site Infection Pre-operative (Pre-op) Score 95% or higher Outcome SSI 15 - Surgical Site Infection Perioperative Score 95% or higher Outcome SSI 16 - Surgical Site Infection Postoperative (Post-op) Score 95% or higher Outcome SSI 17 - Surgical Site Infection Score 95% or higher 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. SSI: Measurement Worksheets9/24/2020 8:15:19 AM8712https://www.patientsafetyinstitute.ca/en/toolsResources/psm/Pages/Forms/UpdateData.aspxhtmlFalseaspx
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 AM1383https://www.patientsafetyinstitute.ca/en/toolsResources/Pages/Forms/NewDefaultView.aspxhtmlFalseaspx
Atlantic Learning Exchange2595General 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 PM11712https://www.patientsafetyinstitute.ca/en/EventshtmlTrueaspx