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#SuperSHIFTERS Advocating for Patient Safety: Patients for Patient Safety Canada Government Relations Committee689963/15/2019 9:32:30 PMSuper SHIFTERS ​#SuperSHIFTERS Brian Penner, Government Relations Committee Chair, and Linda Huges, Co-Chair of Patients for Patient Safety Canada (PFPSC), shared their insights on advocating for patient safety. The Government Relations Committee is made up of these two individuals, along with PFPSC members Judy Birdsell, Katarina Busija, Allison Kooijman, Maryanne Murray, Sharon Nettleton, and Donna Penner. This group of energetic patient safety advocates work tirelessly to elevate the profile of patient safety in Canada, to raise expectations for improvement among governments, the public and patients themselves. Why did Patients for Patients Safety Canada form a Government Relations Committee? About two years ago, we had an in-person meeting of PFPSC members, where we established our priorities over the next few years. One of those priorities was to increase public awareness of patient safety and patients as partners. A key initiative that came out of that discussion was to increase awareness with federal, provincial and territorial governments. To fully engage with politicians we needed to be organized. From that, the Government Relations Committee was formed; eight PFPSC members volunteered to sit on the Committee. Our mandate is to connect with government officials at the national, provincial and local level. What can you tell us about your Patients at Parliament campaign? On October 30, 2018, in conjunction with Canadian Patient Safety Week (CPSW), 13 patients from across Canada travelled to Ottawa to participate in Patients at Parliament, a unique campaign to raise awareness of patient safety with parliamentarians. Five teams of patient advocates met face-to-face with 31 members of Parliament and Senators in ten buildings across the parliamentary precinct over the course of eight hours. Participants spoke about their personal experience with harm and delivered medication safety messages from the CPSW campaign. Members of the Standing Committee on Health were selected as a priority and we looked for both regional and all-party representation in selecting the parliamentarians to visit. We provided copies of the Five Questions to Ask About Your Medications and asked them to share it widely. We talked about the importance of a national reporting system to report adverse events and a pharmacare program to collect and disseminate information on medication errors. We also asked them to support the Health Canada petition calling for Plain Language labelling on medications. A lot of groundwork happened to make our visits productive. We were armed with an information package prepared by the Government Relations staff at the Canadian Patient Safety Institute that provided us with background data, biographies and talking points to keep our discussions on track, and of course maps so that we did not get lost as we moved from one building to another. We were accompanied by CPSI staff who kept our meetings on track and helped us to move efficiently between the scheduled appointments. Were there any key learnings from the Patients at Parliament meetings? First and foremost, the meetings reinforced the power of the narrative story. For each meeting, one member of the team told a personal story about patient safety and how they were harmed by the healthcare system. That really resonated with the politicians and many of them had personal stories to tell us as well. Second, while we made a fairly big impact with this inaugural campaign, our work does not stop there. Some of the MP offices contacted us in the days following the meetings to ask for more information, but overall the range of awareness and understanding of patient safety as a significant issue varied. It reinforced the value of a personal connection and the importance of following up. Third, an event like this is a great way to build awareness and start to build a relationship with government officials. We took away some dos and don'ts that will provide a template that we can apply for future meetings with MPs and MLAs. What's next for the Government Relations Committee? As a follow-up to our meetings on Parliament Hill, we want to make a presentation to the Standing Committee on Health to reinforce the importance of patient safety. We want to reinforce the need for legislation and regulations on mandatory reporting of adverse events and medication errors. We made a good start in increasing awareness on the widespread and serious problem of harm in healthcare. We will continue our outreach to federal parliamentarians and expand our efforts to include provincial elected officials. We are still at an early stage of planning our provincial campaign, and are looking to hold a number of round table discussions to raise awareness of patient safety across the country. We have developed a draft guide to serve as a template for patient engagement with governments. The guide is currently being tested with PFPSC members and is expected to be made available by mid-2019. The Government Relations Committee will be working closely with the PFPSC Communications Committee to implement a major public awareness campaign. A recent IPSOS survey confirmed that once people know that patient safety incidents are the third leading cause of death in Canada, they become very concerned. We will advocate for the consolidation and dissemination of data on patient safety incidents; and push for legislation and regulations to ensure full disclosure to patients and families when a harmful event occurs. Every patient safety incident should involve the patient and family at the outset and throughout the process. How can we get more information? Direct your questions and comments to More information is available at 3/15/2019 9:00:00 PM #SuperSHIFTERS Brian Penner, Government Relations Committee Chair, and Linda Huges, Co-Chair of Patients for Patient Safety Canada (PFPSC), shared3/15/2019 9:54:19 PM315
Patient Safety Power Play: Will you be joining our Learning Collaboratives?7113/7/2019 10:10:13 PMPatient Safety Power Plays I have no doubt that, if you are a regular reader of my Patient Safety Power Plays, you are aware of our three, brand new, Safety Improvement Projects. These learning collaboratives have been designed by patient safety experts from around the world with CPSI to deliver the most up to date information and techniques to improve patient safety outcomes in your organization. Are you part of a healthcare team that could benefit from medication safety best practices – especially among the frail or elderly – at transitions of care, enhanced recovery outcomes after colorectal surgery, or proven teamwork and communication improvements? We have posted project summaries on this webpage, along with a recording of our one-hour webinar to give details of each project and explain it's Knowledge Translation approach. However, if you prefer to discuss the Safety Improvement Project that interests you with one of the Project Leaders, simply fill out this three-question, one-minute survey and your Lead will get back to you right away. The deadline for Expression of Interest forms is March 15, to give your team time to get the approvals you need. Teams from across Canada are participating in these projects, and I believe they will be of benefit to you and your organization. I am also delighted to mention an initiative that will benefit our nation and the rest of the world. On February 1, 2019 the WHO executive board approved a resolution to advance patient safety. It asks the WHO Director General to provide leadership and support while asking Member Countries to take actions to advance safety. Among many educational and infrastructure recommendations, the resolution endorses a global Patient Safety Day on September 17, 2019 and requests a Global Patient Safety Plan of Action that will commit every nation to reducing the crisis of patient harm. CPSI, as a WHO Collaborating Centre, has contributed to the Ministerial Summits that shaped this work, to requests for data collection, and has participated in collaborative events. We will continue to support this work, while already helping to implement many of the recommendations. Please voice your support online for our Safety Improvement Projects and the WHO resolution, and use the hashtag #PatientSafetyRightNow in any social media you share. If you have a story about preventable patient harm, please share it with your audiences through social media – and use the hashtag. Questions? Comments? My inbox is open to you anytime at, and you can follow me on Twitter @ChrisPowerCPSI. Yours in patient safety, Chris Power 3/7/2019 10:00:00 PMI have no doubt that, if you are a regular reader of my Patient Safety Power Plays, you are aware of our three, brand new, Safety Improvement3/7/2019 10:22:38 PM295
#SHIFTtalks Andrew’s legacy of care6643/5/2019 4:09:03 PMSHIFT Talks My name is Melissa Sheldrick and I am a wife, mom, teacher and patient safety advocate. I came into the role of advocate when our eight-year-old son Andrew was taken from us two and a half years ago due to a substitution error made at our pharmacy. Andrew was a healthy little boy who was diagnosed with parasomnia and was prescribed five tryptophan tablets daily before bed. Parasomnia refers to all the abnormal things that can happen to people while they sleep and in Andrew's case, he went into his REM sleep twice as quickly as he should have which disrupted his whole night's sleep cycle. The large chalky tryptophan tablets were too big for him to swallow at the tender age of six, so I asked the doctor about a different kind of ingestion method. She suggested that we find a compound pharmacy so that they could make it into a liquid for him. We did so for a year and a half, and on Friday March 11, 2016, I called the pharmacy to order a refill. We picked up the bottle Saturday afternoon, put it in our fridge and it stayed there until bedtime. When it was time for bed, I gave Andrew his dose, tucked him in and kissed him goodnight. What unfolded the next morning, is what nightmares are made of. For four months, we did not know why Andrew died and we then learned that the bottle of medication that the police seized from our fridge on Sunday, March 13th, contained no Tryptophan at all, but contained Baclofen, mixed to the same concentration as Andrew's prescription, three times the lethal dose for an adult. Careless errors cost the life of our little boy. When I learned that the pharmacy was not mandated to report their error, I couldn't live with even the idea that nothing would change and another pharmacy could make a mistake that cost a life or caused harm and no one would know about it. I petitioned for change in Ontario, and the College of Pharmacists swiftly created an anonymous error reporting program that is a part of a larger continuous quality improvement program through a company called Pharmapod . Soon, every pharmacy in Ontario will be required to report all medication incidents and near misses so that data can be collected and reports can be compiled to help prevent future errors. Medication errors are common, everyday occurrences that are harming patients of all ages. These errors are avoidable and preventable and we must work harder and have regulations and policies in place that reduce their number, frequency and severity. When examining the errors, there has to be a, "what happened and why?" system instead of a, "who did this?" stance. This system aims to build preventative measures into the pharmacy's processes so that the same errors do not recur. Communication and collaboration are key to maintaining and increasing patient safety, and the learnings must be shared. When incidents are recorded, analyzed and learnings are shared, medication delivery becomes safer. This is Andrew's legacy of care. Melissa Sheldrick is an elementary school teacher and a member of Patients for Patient Safety Canada. She was a member of the Ontario College of Pharmacists' Medication Safety Task Force and provided an invaluable perspective as a patient advocate in the development and implementation of a continuous quality assurance program for medication safety. 3/7/2019 7:00:00 AMMy name is Melissa Sheldrick and I am a wife, mom, teacher and patient safety advocate. I came into the role of advocate when our eight-year-old son3/6/2019 4:08:45 PM780
CAMH and BC Children’s Hospital to Showcase Leading Patient Safety Practices at National Health Leadership Conference7013/7/2019 8:16:10 PMPatient Safety News Two teams from the Centre for Addiction and Mental Health (CAMH) and BC Children's Hospital (an agency of the Provincial Health Services Authority) will present their leading practices in patient engagement for patient safety at the National Health Leadership Conference (NHLC) on June 5th in St. John's NL. The two teams, each formed by a patient partner and a health leader, have been chosen as part of a new recognition program called the Excellence in Patient Engagement for Patient Safety Recognition Program. Developed in partnership by the Canadian Patient Safety Institute (CPSI), HealthCareCAN and Health Standards Organization (HSO) with support from Patients for Patient Safety Canada, the new annual program aims to identify, celebrate and disseminate leading practices in patient engagement for patient safety. A number of additional leading practices, identified through the nomination and scoring process, will also be identified each year and added to HSO's Leading Practices Library. The program provides all travel expenses and full registration to NHLC for members of the selected teams. The team from CAMH will present on its Successful Patient Engagement in Development of Identification Strategies to Improve Medication Safety and the team from BC Children's Hospital will present on its Patient's View Engaging Patients and Families in Patient Safety Incident Reporting. In addition, teams from the following organizations have been formally identified and celebrated as leading practices and added to HSO's Leading Practices Library Alberta Health Services Provincial Health Services Authority (BC Patient Safety & Learning System (BCPSLS)) Health Quality Council, Saskatchewan Kidney Health, Saskatchewan Health Authority BC Children's Hospital (an agency of PHSA) Eastern Health Newfoundland Holland Bloorview Montfort Hospital McMaster Children's Hospital Hamilton Health Sciences BC Autism Assessment Network, Sunny Hill Health Centre for Children, BC Children's Hospital Sunnybrook Health Sciences Centre Health Quality Ontario Fraser Health Descriptions of these initiatives will be available on the HSO website by June 1st. The partners are excited to continue working together to further advance exceptional patient safety work through partnership with patients and families. About HealthCareCAN HealthCareCAN is the national voice of healthcare organizations and hospitals across Canada. We foster informed and continuous, results-oriented discovery and innovation across the continuum of healthcare. We act with others to enhance the health of the people of Canada; to build the capability for high quality care; and to help ensure value for money in publicly financed, healthcare programs. About Canadian Patient Safety Institute The Canadian Patient Safety Institute (CPSI) is a not-for-profit organization that exists to raise awareness and facilitate implementation of ideas and best practices to achieve a transformation in patient safety. Funded by Health Canada, CPSI reflects the desire to close the gap between the healthcare we have and the healthcare we deserve. About HSO Health Standards Organization (HSO) builds world-class standards and innovative assessment programs, new technologies and activation services for accreditation bodies, governments, associations and others. Our standards are designed in partnership with clinicians, policy makers, technical experts and patients to ensure they provide effective health services and overall value. We create global standards that help people in their local jurisdictions save and improve lives. About Patients for Patient Safety Canada Patients for Patient Safety Canada is a patient-led program of the Canadian Patient Safety Institute and the Canadian arm of the World Health Organization's Patients for Patient Safety programme. We are the voice of the patient and bring our safety experiences to help improve patient safety at all levels in the health system. Media contact Christopher Thrall, Communications Officer, CPSI 780-566-8375 3/7/2019 7:00:00 AMTwo teams from the Centre for Addiction and Mental Health (CAMH) and BC Children's Hospital (an agency of the Provincial Health Services Authority)3/7/2019 9:13:34 PM70
#SuperSHIFTER Embracing simulation and its untapped potential706172/14/2019 10:31:32 PMSuper SHIFTERS #SuperSHIFTER Tim Willett is the President and CEO of SIM-one, the Canadian Network for Simulation in Healthcare (CNSH), the member-based network that supports and unites simulation programs across the country. Tim sees simulation as both an educational tool and a change agent to advance healthcare education, patient safety and care quality. What can you tell us about SIM-one/CNSH? We are the non-profit network of healthcare simulation centers and personnel across Canada and beyond. I would estimate there are 200 to 250 simulation centers and programs in Canada, found at university faculties, colleges, hospitals, and other care agencies. Our membership is currently comprised of 52 organizations and close to 300 individuals. Our subscriber base currently sits at 1,950, with 25 per cent of that being international. Our network's vision is exceptional healthcare through simulation. Our mission is to advocate and advance simulation for healthcare education, patient safety and care quality. Our role is to support and expand the scope and quality of simulation, and to help improve the sustainability of simulation programs. We bring people together for knowledge exchange and collaboration, resource sharing, and offer a suite of education programs that teaches people how to use simulation as an educational tool. It requires special skills to facilitate simulations; it is not the same as a traditional teaching paradigm. What makes simulation unique and innovative? Simulation does not just deliver knowledge for individual learning. It has evolved far beyond that. At the team and system level, it provides experience that helps people to understand current practices, challenges to the current culture, ways to make things better, and opportunities to practice new ways so that improvements can be more easily implemented. People working in simulation are powerful change agents. When you are looking to change educational paradigms, improve quality, change an organization's culture, or change the way processes and spaces are designed, you will find that simulationists are very passionate, forward-thinking, open to change and skilled at facilitating change. What opportunities do you see for simulation? There is incredible potential for simulation to improve care in hospitals and other care settings. An important part of our mandate is our advocacy role. We work with other groups, like the Canadian Patient Safety Institute, to help them understand the role that simulation can play to advance their mission. Increasingly, we are seeing that implementation and culture change are bottlenecks to improvement in healthcare. Simulation is a powerful tool for implementation, and can help to change behaviours, improve teamwork and transform a culture. We want to ensure that our stakeholders understand the role simulation can play and find ways through collaboration that we can help to advance their work. In the education world, the evidence of simulation is well-established, and Canada is a world leader in the use of simulation within healthcare education curricula. Simulation is improving how healthcare students learn and develop as professionals. From a patient safety and education perspective, practicing on mannequins and actors is far more desirable than practicing on patients or other healthcare professionals. While simulation has a strong foothold in education, there is a tremendous untapped potential for simulation on the healthcare delivery side. There are only a handful of hospitals and healthcare agencies in Canada who are really embracing simulation to improve safety and quality at the point of care delivery. That is where the opportunity lies and Canada is just at the beginning of taking advantage of the possibilities. This includes using simulation to design healthcare spaces, refining healthcare processes, identifying safety threats before they occur, just-in-time training to ensure staff are refreshed on the skills needed before going into a critical healthcare procedure, improving the quality of continuing professional development, assisting in the implementation of a quality improvement plan, improving teamwork in interprofessional care, and improving safety cultures. Traditionally, simulation has been thought of as an education tool and we are advocating that the use simulation for these system-level opportunities can improve healthcare. How has simulation evolved and what is needed today to advance simulation? Twenty years ago, when simulation was just taking off, the focus was on equipment. After five or 10 years, it became quite apparent that having the human resources to design and implement simulation was paramount. The focus shifted from equipment to personnel and training people to become simulation experts. The next steps to advance simulation in Canada are twofold one is a broader awareness of the opportunities and evidence, especially in the healthcare delivery setting, and the other is to increase the human capacity to implement simulation throughout education and healthcare delivery. In your work in simulation, what have been your major learnings and takeaways? The first is that simulation does not have to be expensive. More thought is needed around simulation programs, rather than simulation laboratories. Creation of a simulation program is not expensive if you invest in people before you invest in equipment. I would be very cautious about treading into simulation without that investment in human resources. Simulation by its nature is immersive and you want to deeply engage people in doing simulations. There is a specific skill set for creating and facilitating simulations. Again, that focus on creating the resource capacity and skill set to implement simulation is both critical and more feasible than many may realize. The other thing that I have learned over the past six years is that as large as Canada is, the simulation community at a national level is not that big. It is a niche area. Collaboration among organizations and professionals is becoming increasingly essential to improve the quality and sustainability of simulation across the country. Finally, there are a lot of aspects of simulation that can be shared – everything from policies within a simulation lab, organizational structures, staffing models, simulation scenarios, and validation tools for assessing simulation. What challenges are you seeing? There is continued skepticism about the value for investment in simulation. The perception of leaders and decision-makers is that it is a nice-to-have program that is expensive. We need to better understand the barriers to overcome this perception, and help our leaders to recognize that it is an investment with demonstrated returns and an essential tool for quality and safety improvement. There is also a perception around the necessary expense of equipment over resources. We need to improve buy-in and investment in simulation at the leadership level. Can others adopt or replicate what SIM-one/CNSH has to offer? I absolutely want to see more engagement across the country in simulation and more organizations involved is this network because the more people contributing to the shared knowledge, resources and insight, the more all benefit and the stronger our collective voice on simulation. There is a lot of value in regional simulation networks as it is not always feasible to travel to national conferences and there is power in establishing regional collaborations. I would encourage groups across Canada to look in their area and build those relationships within their cities and provinces, and build bridges with the national network. I hesitate to say that the model we have developed could be replicated. The history of any group like this is going to be unique. In our case, we grew out of two prior networks SIM-one, which had the luxury of government funding for a number of years to establish programs and an infrastructure. About a year ago, SIM-one integrated with the Canadian Network for Simulation in Healthcare, which had developed national level relationships. Our backgrounds are unique and have provided the foundation to where we are now. What is needed to start the conversation and create a ripple effect to advance simulation? I would like to see two related and parallel conversations at a national level. The first would be a conversation with organizations like the Canadian Patient Safety Institute, the Healthcare Insurance Reciprocal of Canada, the Canadian Foundation for Healthcare Improvement, and other national stakeholders on how to better inform decision makers in government and healthcare delivery settings about the opportunity and value, and to advance the scope and quality of simulation in that setting. The parallel conversation would be among decision-makers and leaders in the educational sphere for healthcare professions. Again, what are the issues that they are grappling with currently and where do they see those issues in five or 10 years from now, and looking at what ways will expanding simulation help to address those issues. Are those issues human resource shortages, education quality, patient safety, and/or increased expectations from the public and employers around highly trained healthcare professionals? Where can I go to learn more? Anyone can look at our website, to get more information and access resources, but I would like people to contact me. My virtual door is always open! Our success will come from community relations and collaboration -- and the best way to establish that is in how we connect with people. Send me an email or give me a call so that we can learn more about your context and discuss how we might support your vision. Tim Willett, President and CEO SIM-one/CNSH Mobile 647-448-7119 Email Learn more about hospital-based simulation at the 2019 National Forum on Simulation for Quality & Safety, May 28, 2019 in Vancouver, BC. Visit for more information. 2/14/2019 10:00:00 PM#SuperSHIFTER Tim Willett is the President and CEO of SIM-one, the Canadian Network for Simulation in Healthcare (CNSH), the member-based network2/14/2019 10:46:27 PM1010

 Latest Alerts



Bed Alarms-Safe use and configuration4714537194/26/2018 6:00:00 AMDeviceAlberta Health ServicesThis alert addresses a patient safety incident of a fall related to bed alarms which may not function properly. The following points are relevant to the incident of a patient fall:  Bed alarms are an alternative strategy for falls prevention.  Alarms may be permanently integrated into the bed or applied as an external device.  Most alarm sensor/pressure pads have a limited life expectancy.  The process for resetting bed alarms varies from brand to brand.  Each brand of alarm has a unique interface with the call bell system Recommendations to prevent similar incidents are provided. As well, specific actions are provided for staff to reduce the likelihood of falls related to bed alarms which do not funcion properly.2/11/2019 10:53:35 PM3
Vaccine storage and cold chain management7050835402/9/2018 7:00:00 AMMedicationNew South Wales Department of Health (Australia)This alert discusses the importance of maintaining a cold chain with the use and distribution of vaccines. Most vaccines used in Australia are temperature-sensitive substances that must be stored between +2ºC and +8ºC at all times to ensure they work effectively. There may be loss of potency if vaccines have been stored at temperatures outside this range. The alert provides reccommendations on necessary education and policies / procedures to ensure that no vaccines are compromised prior to use.2/11/2019 11:02:04 PM
Risk of death and severe harm from failure to obtain and continue flow from oxygen cylinders7039835581/9/2018 7:00:00 AMMedical GasNHS Commissioning BoardThis alert discusses the patient safety incidents that can occur when healthcare staff cannot deliver oxygen from cylinders to patients in a timely manner. The design of oxygen cylinders has changed over recent years. Cylinders with integral valves are now in common use and require several steps (typically removing a plastic cap, turning a valve and adjusting a dial) before oxygen starts to flow. To reduce the risk of fire valves must be closed when cylinders are not in use. Cylinders are often carried in special holders that can be out of the direct line of sight and hearing of staff caring for the patient. An unintended consequence of these changes is that staff may believe oxygen is flowing when it is not, and/or may be unable to turn the oxygen flow on in an emergency. Over a three year period, over 400 incidents involving incorrect operation of oxygen cylinder controls were reported. Six patients died, although most were already critically ill and may not have survived even if their oxygen supply had been maintained. Five patients had a respiratory and/or a cardiac arrest but were resuscitated, and four became unconscious. Incidents involved portable oxygen cylinders of all sizes on trolleys, wheelchairs, resuscitation trolleys and neonatal resuscitaires, and larger cylinders in hospital areas without piped oxygen. A typical incident was as follows: “Patient arrived on coronary care unit with oxygen saturations of 72%. Oxygen in situ and set to correct rate on the flow dial but unfortunately [the valve] was not opened and the patient was not therefore receiving oxygen. Peri-arrest on arrival, [crash team] called …..condition improved …..registered nurse continued to check cylinder was not running out but failed to notice not turned on as indicator green.” Recommendations to prevent similar incidents are provided.2/11/2019 11:01:28 PM
Echoes of Past Disasters4712537031/1/2018 7:00:00 AMMedicationCalifornia Hospital Patient Safety OrganizationThis alert addresses patient safety incidents that result when a chemotherapy medication is given by the wrong route. Wrong medication errors for intrathecal chemotherapy fortunately are rare, but, when they occur, can have severe consequences. The alert provides three cases of wrong route administration or near misses. The alert identifies several challenges associated with intrathecal chemotherapy and highlights the need to learn from near miss events.2/11/2019 10:53:48 PM3
Medication Error – Phenytoin 750 mg infusion was given at faster rate than prescription7003436421/1/2018 7:00:00 AMMedicationHong Kong Hospital AuthorityThis alert briefly describes a medication error where phenytoin was administered faster than the recommended infusion rate. A patient was admitted for tonic convulsions and fast AF. A loading dose was prescribed of phenytoin 750 mg followed by an intermittent infusion to be given over 30 minutes using the inpatient medication order entry (IPMOE) system. The infusion was administered over 10 – 15 minutes. The patient developed cardiac arrest and was successfully resuscitated. It was determined that the cardiac arrest may have been related to the patient’s underlying cardiac conditions or the faster infusion rate of phenytoin. A recommendation is provided to mitigate the risk of recurrence of similar events.2/11/2019 10:56:32 PM