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What’s in a name382502/3/2021 9:42:29 PMPatient Safety News​ ​Jennifer Zelmer In our case, a lot. On March 2, 2021 it will be my great pleasure to introduce you to the new organization that brings together the Canadian Foundation for Healthcare Improvement and the Canadian Patient Safety Institute. (And not just because we are all very tired of calling ourselves "the newly amalgamated organization that brings together CFHI and CPSI"!). Working with you as CPSI and CFHI, we achieved a LOT. But we know there is much more to do. And so, we teamed up and together will bring a greater capacity to support you to turn proven innovations into widespread and lasting improvement in patient safety and all the dimensions of healthcare excellence. This new organization will have a relentless focus on improving healthcare, with – and for – everyone in Canada. When we launch, you will be able to read our story, see the new logo and tagline and hear our new name. Why is the name the most important? Well, in this case, it's not just how you can identify us. It's how you will know who we are, what we believe in and what we are determined to do – together with people like you. Would an organization by any other name be the same? We don't think so. Because the journey that brought us to this name is at the core of what that name is. It's a journey that was completed during a global pandemic that reinforced the need for the amalgamation of our two organizations into something greater than the sum of our parts. And it's a journey that was completed together, with you. It includes many (many) people, from across the country, who participated in in-depth interviews, discussion groups, conversations and testing. Patient partners, essential caregivers, Indigenous partners and many other people committed to healthcare quality and safety were extremely generous with their time and provided unparalleled insight and expertise. And staff, Board and working group members were tireless in their commitment to getting this right. The conversations were not always easy. The passion and dedication that drove input was beyond what we would have hoped for. In engaging with stakeholders across the country to explore their priorities and how the amalgamated organization can support them, many common themes emerged Be bold in actions to change the system Be clear and focused about our purpose Look to the future Strengthen diversity and inclusivity Share expertise and guide others Be agile and move quickly And in the end, it all boils down to finding a name that reflects and honours all of this. True, a name that does not make you who you are, but when brought to life with partners, it definitely sets you in the right direction to begin to make a name for this organization that includes all of us. Because of who we are, what we will do – and mostly, how we will do it. Together, we have found that name. And together, we will live up to that name. Want to hear more about the journey, the new name and what the new organization will do? Join us March 3, 2021 for a webinar panel discussion, Shaping the future of quality and safety. Together. Register 2/3/2021 7:00:00 AM Jennifer Zelmer In our case, a lot. On March 2, 2021 it will be my great pleasure to introduce you to the new organization that2/9/2021 5:08:36 PM1348https://www.patientsafetyinstitute.ca/en/NewsAlerts/News/Pages/Forms/AllItems.aspxhtmlFalseaspx
In Jennifer Zelmer’s Words: Holiday Greetings and a Year in Review 3822212/11/2020 3:51:40 PMPatient Safety News ​The Canadian Patient Safety Institute and the Canadian Foundation for Healthcare Improvement recently amalgamated. CEO of CPSI Chris Power retired, and CFHI CEO Jennifer Zelmer was named President and CEO for the newly amalgamated organization. In this monthly blog, Jennifer shares her thoughts about this month's Digital Magazine topic. Without question, this has been a tough, challenging year. The global pandemic has dominated the news and our personal lives, and it has reinforced the commitment we share to supporting and improving healthcare. I want to offer my most sincere thanks to all healthcare providers and essential care partners across the country. We value your tireless efforts to heal each patient, manage each crisis, support your well-being and that of your colleagues, and find the strength to carry on – and we pledge to continue to work with you to ensure care is better and safer for everyone. This issue of the Digital Magazine highlights just a few ways that we are doing so. It includes progress made on our Policy Framework for Patient Safety, for instance. Our Senior Program Manager, Jan Byrd, spoke to the Executive Director of the Manitoba Institute for Patient Safety, Laurie Thompson, to discuss how that organization has applied the five policy levers to improve the effectiveness of their outreach programs. We also hear from long-time partners at the Atlantic Learning Exchange about their unique opportunities for like-minded individuals across the Atlantic provinces to connect, broaden their knowledge, and take that knowledge translation back to their workplaces. And we are expanding efforts across the country to support pandemic preparedness and response in long-term care and retirement homes, with the Government of Canada's latest $6.4 million investment doubling the number of homes we can support with seed funding, coaching, connections with peers, and other elements of the LTC+ Acting on Pandemic Learning Together Program. As 2020 draws to a close, in addition to reflecting on the tough times that we have seen, we can also celebrate how we have come together. STOP! Clean Your Hands Day, World Patient Safety Day, and Canadian Patient Safety Week are just three examples that have joined patient safety proponents across the country together. And I am glad to also look back on all the work we have done this year to amalgamate the Canadian Foundation for Healthcare Improvement and the Canadian Patient Safety Institute. We are looking forward to introducing our new organization to you in the upcoming months, along with exploring with you the ways that we can continue to partner to accelerate improvements in healthcare quality and patient safety. As you too reflect on the turning of the year, I hope that you take a break if you are able and share special moments with loved ones in any way you can. Take care, be well, and stay safe, Jennifer Zelmer Follow @jenzelmer12/11/2020 3:00:00 PM The Canadian Patient Safety Institute and the Canadian Foundation for Healthcare Improvement recently amalgamated. CEO of CPSI Chris Power retired,1/7/2021 6:33:35 PM745https://www.patientsafetyinstitute.ca/en/NewsAlerts/News/Pages/Forms/AllItems.aspxhtmlFalseaspx
Introducing the heART of Healthcare: Safety, Healing and Partnership - an online art gallery 3774912/10/2020 3:18:08 PMPatient Safety News In 2021 we are celebrating Patients for Patient Safety Canada's 15-year anniversary. As part of this celebration, we will build an online, virtual art gallery of paintings, quilts or yarnwork, poetry and stories, sculpture, dance and song from people across Canada. These works will celebrate art as a way to express patient safety, prevent harm, heal after harm, and engage patients and families as partners. It will feature work from patients, healthcare workers, leaders, and our partners from every walk of life. Our ultimate objective is to increase awareness and strive for the improvements in our healthcare system to keep every patient safe. So, please if you create art in any form, at any level, inspired by this theme, we invite you to sign up for our heART of Healthcare mailing list. We will inform you as we progress in building our online gallery, and let you know how to share your artwork with us so we can feature it. Sign up "Too Soon" by Kim Neudorf, Patients for Patient Safety Canada If you have any questions, we invite you to contact patients@cpsi-icsp.ca. 12/10/2020 3:00:00 PMIn 2021 we are celebrating Patients for Patient Safety Canada 's 15-year anniversary. As part of this celebration, we will build an online, virtual2/12/2021 7:28:04 PM2300https://www.patientsafetyinstitute.ca/en/NewsAlerts/News/Pages/Forms/AllItems.aspxhtmlFalseaspx
Taking Action: Five Policy Levers to Improve Patient Safety3775512/10/2020 3:30:44 PMPatient Safety News​A Conversation between the Manitoba Institute for Patient Safety and CPSI The longstanding relationship between the Manitoba Institute for Patient Safety (MIPS) and the Canadian Patient Safety Institute (CPSI) is a mutually beneficial, dynamic, and supportive one. When CPSI sought out a partner to test out a new policy framework through which patient safety could be introduced to government decision-makers, MIPS was among the first to sign on! CPSI's strategic plan for 2018-2023 promises to lead health system-level strategies to ensure safe healthcare by demonstrating what works and by strengthening commitment. Patient safety incidents in total (acute care and home care combined) are the third leading cause of death, behind cancer and heart disease with just under 28,000 deaths across Canada (in 2013). This is equivalent to such harm events occurring in Canada every one minute and 18 seconds, resulting in a death every 13 minutes and 14 seconds. This rate and scale of harm is unacceptable. Strengthening Commitment for Improvement Together A Policy Framework for Patient Safety focuses on key policy levers available to influence system changes. As the national thought leader in patient safety, CPSI supports provincial/territorial governments, health system leaders, and other policy actors to develop and enhance legislation, regulations, standards and organizational policies to improve patient safety. CPSI also engages with the public to raise awareness about patient safety. ​ Jan Byrd and Laurie Thompson MIPS was thrilled to consult on the development of the policy framework. Laurie Thompson, Executive Director of MIPS, believes "it would have been invaluable to our early work, when the landscape was very different. For us, and organizations starting out on or refreshing their patient safety agenda, the framework will serve as an excellent guide." Laurie Thompson, Jan Byrd and Renee Misfeldt (co-authors of CPSI's Policy Framework), worked together to offer examples of MIPS initiatives that illustrate the framework's five policy levers in action! 1 Legislation Government leadership is essential for putting into place protections to address and reduce patient safety incidents in healthcare. MIPS assesses legislation with a patient safety lens. During the latest review of the Personal Health Information Act, MIPS posed questions about disclosure of information to patients/families such as "Is there enough emphasis on the balance of privacy, with the needs of patients and families to have information in order to make decisions?" and "Are there positive messages being conveyed in the educational materials about patient and family centred care principles as they relate to provision of information in a timely way?" 2 Regulation Embedding patient safety within professional self-regulation sets out clear expectations for safe patient care by healthcare providers. MIPS has worked on a number of projects over the years with regulators to strengthen patient safety such as The Importance And Impact of An Apology An Information Sheet, to support regulators in promoting apology as an essential component of disclosure of patient harm. Since 2016, MIPS has partnered with the Manitoba Alliance of Health Regulatory Colleges on a new provincial patient safety reporting and learning system to extend opportunities for creating safety, learning and improvement across disciplines and sites of care. 3 Standards Accreditation is an important driver for patient safety and quality improvement. MIPS creates tools and resources for use by service delivery organizations that meet accreditation standards. Examples include a tool to support policies in eliminating the use of dangerous abbreviations, dose designations and symbols; a tool to provide clear messaging to patients, families and healthcare providers about the critical incident process; and a family of resources entitled "It's Safe to Ask" supporting patient/client engagement, self-advocacy, and health literacy. The It's Safe to Ask suite of resources – initially led by CPSI's own Jan Byrd in 2005! - was a specific request from regional health authorities during the early years to support accreditation. 4 Organizational Policies Improving safety requires an organizational culture that enables and prioritizes patient safety. MIPS initiated governance education in 2006, working with provincial leaders. Boards assessed their governance education needs against leading practices in governance for patient safety and quality. MIPS worked with CPSI to test governance education and continued to offer tailored programs for several years, with evaluations noting a positive impact in governance practices. 5 Public Engagement MIPS has been committed to engaging the public since early in their existence. In addition to a collection of self-advocacy tools and resources, extensive social media, volunteer-led public presentations and information sessions, MIPS hosted nine public forums in a series, "We listen, We learn, We evolve". These forums are opportunities for patients/families and the public to meet and talk about patient safety issues and concerns. Can you see your work within the 5 Policy Levers we have outlined? Please reach out and let us know at jbyrd@cpsi-icsp.ca 12/10/2020 3:00:00 PMA Conversation between the Manitoba Institute for Patient Safety and CPSI The longstanding relationship between the Manitoba Institute for Patient12/10/2020 5:29:48 PM681https://www.patientsafetyinstitute.ca/en/NewsAlerts/News/Pages/Forms/AllItems.aspxhtmlFalseaspx
Atlantic Learning Exchange mobilizes energy and enthusiasm for patient safety and quality3770212/1/2020 5:08:35 PMSuper SHIFTERS #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. 12/1/2020 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. The12/2/2020 8:25:30 PM1329https://www.patientsafetyinstitute.ca/en/NewsAlerts/News/Pages/Forms/AllItems.aspxhtmlFalseaspx

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Necessity to check sterilization of sterile medical materials37713391411/27/2020 7:00:00 AMInfection Prevention and ControlKorea Patient Safety Reporting & Learning SystemThis alert describes an incident where a non-sterile compression bandage was used on a patient. Non-sterile medical materials can cause severe harm due an increased risk of infection with their use. Caution and steps to verify the sterility of medical materials is required prior to providing patient care. 4/28/2021 7:05:18 PM3https://www.patientsafetyinstitute.ca/en/NewsAlerts/Alerts/Lists/Alerts/AllItems.aspxFalse
Errors in administering antithrombotic agents in the period of pre and post surgery/procedure15740391311/12/2020 7:00:00 AMMedicationKorea Patient Safety Reporting & Learning SystemThis alert describes a medication incident involving a patient following a change in the medication regimen during an outpatient clinic visit prior to a scheduled surgery for an artificial joint replacement. Recommendations are provided to prevent recurrence when temporarily discontinuing an antithrombotic agent for more than a necessary period for patients with antithrombotic agent adaptation.12/11/2020 4:43:35 PMhttps://www.patientsafetyinstitute.ca/en/NewsAlerts/Alerts/Lists/Alerts/AllItems.aspxFalse
Delay or Omission of Critical Value Report (CVR)15738391110/6/2020 6:00:00 AMDiagnostic ImagingKorea Patient Safety Reporting & Learning SystemFollowing a biopsy of a mass on the left elbow, a patient was discharged from hospital and was to be contacted following a pathological test of the sample. The biopsy result was confirmed as a malignant tumor two weeks later but was not classified as a critical value report (CVR). As a result, the diagnosis was omitted from the report to the physician and not discovered until six months later causing a significant delay in treatment for the patient. Recommendations and examples of related preventive activities are included to prevent patient safety incidents that cause disturbance of precise diagnosis and delay of treatment due to a lack of action taken immediately on the result of CVR.12/11/2020 4:43:36 PM3https://www.patientsafetyinstitute.ca/en/NewsAlerts/Alerts/Lists/Alerts/AllItems.aspxFalse
Errors in management of tissue and cell pathology samples1573939129/27/2020 6:00:00 AMCare ManagementKorea Patient Safety Reporting & Learning SystemThis alert describes three cases of mismanagement of tissue and cell pathology samples (switched samples, lost samples, errors in barcodes) that led to suboptimal and potentially harmful care management. The alert includes recommendations to prevent recurrence, precautions to take before/during/after sample collection, and precautions for receiving and labelling samples. 12/11/2020 4:43:36 PM6https://www.patientsafetyinstitute.ca/en/NewsAlerts/Alerts/Lists/Alerts/AllItems.aspxFalse
A fatal risk caused by carelessness in the use of an automatic contrast media injector1573739109/18/2020 6:00:00 AMCare ManagementKorea Patient Safety Reporting & Learning SystemA patient was prescribed a chest and abdomen computer tomography (CT) following a diagnosis of non-small cell lung cancer. On the day of the examination, a health care worker discovered that about 10cc of air was introduced into the syringe connected to the patient prior to injecting contrast medium. While sitting on the waiting chair after the examination, the patient lost consciousness fell due to cardiac arrest. The patient recovered consciousness after CPR was performed but died the next day in the intensive care unit. The chest and abdomen computed tomography images taken just before the incident suggest a cardiac arrest caused by air embolism. Recommendations and examples of related preventive activities are included to prevent patient safety incidents that cause air ingress into veins due to careless use of automatic contrast media injectors.10/16/2020 9:45:11 PMhttps://www.patientsafetyinstitute.ca/en/NewsAlerts/Alerts/Lists/Alerts/AllItems.aspxFalse