|Advocacy and support for use of a Surgical Safety Checklist||68992||Position Statements||2/5/2019 7:55:32 PM||Position 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.
||Advocacy and support for use of a Surgical Safety Checklist||Position Statement A Surgical Safety Checklist is smart for patients and smart for providers. It's use in Canadian healthcare facilities||2/5/2019 8:17:32 PM||237||https://www.patientsafetyinstitute.ca/en/toolsResources||html||True||aspx|
|Tools & Resources||35066||3/25/2009 3:33:37 PM|| ||Tools & Resources||Tools & Resources||7/27/2017 8:08:17 PM||3200||https://www.patientsafetyinstitute.ca/en||html||True||aspx|
|Events||35071||Events||6/4/2015 6:09:31 AM|| ||Events||1/20/2019 4:49:45 PM||841||https://www.patientsafetyinstitute.ca/en||html||True||aspx|
|Pressure Ulcer: References||67528||11/17/2015 9:21:31 PM|| Accreditation Canada.
Leading Practices Database. Ottawa, ON Accreditation Canada. Accreditation Canada.
Required Organizational Practices Handbooks. Ottawa, ON Accreditation Canada. Canadian Patient Safety Institute.
Global Patient Safety Alerts. Institute for Healthcare Improvement (IHI).
How-to Guide Prevent pressure ulcers. Cambridge, MA IHI; 2011. Institute for Healthcare Improvement (IHI).
IHI Improvement Map Prevention of pressure ulcers. IHI 2012. Institute for Healthcare Improvement (IHI).
Pressure ulcers. Cambridge, MA IHI. Keast DH, Parslow N, Houghton PE, Norton L, Fraser Cl. Best practice recommendations for the prevention and treatment of pressure ulcers Update 2006.
Wound Care Canada. 2006; 4 (1) 31-43. National Institute for Health and Care Excellence (NICE). Pressure ulcers prevention and management of pressure ulcers. NICE clinical guideline 179. NICE; 2014. NICE. Clinical audit tools.
NICE clinical guideline 179. NICE; 2014. National Pressure Ulcer Advisory Panel, European Pressure Ulcer Advisory Panel and Pan Pacific Pressure Injury Alliance. Emily Haesler (Ed.)
Prevention and treatment of pressure ulcers Quick reference guide. Cambridge Media Perth, Australia; 2014. Registered Nurses' Association of Ontario (RNAO).
Nursing best practice guideline Risk assessment and prevention of pressure ulcers. Toronto, ON RNAO; 2011. Woodbury MG, Houghton PE.
Prevalence of pressure ulcers in Canadian healthcare settings.
Ostomy/Wound Management. 2004; 50 (10) 22-38.
Back to Overview
Leading Practices Database . Ottawa, ON: Accreditation Canada. Accreditation Canada.
Required||10/5/2016 7:26:09 PM||113||https://www.patientsafetyinstitute.ca/en/toolsResources/Hospital-Harm-Measure/Improvement-Resources/HHI-Pressure-Ulcer/Pages/Forms/AllItems.aspx||html||False||aspx|
|UTI: Resources||67353||9/30/2016 6:58:43 PM|| *(Key Resources recommended by Dr. Jerome Leis, **recommend Dr. Shaun Morris)Professional Associations and Helpful Websites
Centers for Disease Control and Prevention
Association for Professional in Infection Control and Epidemiology
Institute for Healthcare Improvement UTI Clinical Practice Guidelines Andreessen L, Wilde MH, Herendeen P. Preventing catheter-associated urinary tract infections in acute care the bundle approach.
J Nurs Care Qual. 2012; 27 (3) 209-217. doi 10.1097/NCQ.0b013e318248b0b1. Association for Professionals in Infection Control and Epidemiology (APIC). APIC
Implementation Guide Guide to preventing catheter-associated urinary tract infections. Washing DC API; 2014. Centers for Disease Control and Prevention (CDC).
Urinary tract infection (catheter-associated urinary tract infection [CAUTI] and non-catheter-associated urinary tract infection [UTI]) and other urinary system infection [USI]) events. CDC; 2016. Clarke K, Tong D, Pan Y, et al.
Reduction in catheter-associated urinary tract infections by bundling interventions.Int J Qual Health Care. 2013; 25 (1) 43-49. Conway LJ, Larson EL.
Guidelines to prevent catheter-associated urinary tract infection 1980 to 2010.
Heart Lung. 2012; 41 (3) 271-283. doi 10.1016/j.hrtlng.2011.08.001. *Epp A, LaRochelle A.
SOGC Clinical Practice Guideline Recurrent urinary tract infection.
J Obstet Gynaecol Can. 2010; 32 (11) 1082–1090. Flodgren G, Conterno LO, Mayhew A, Omar O, Pereira CR, Shepperd S. Interventions to improve professional adherence to guidelines for prevention of device-related infections.
Cochrane Database Syst Rev. 2013; 3 CD006559. doi 10.1002/14651858.CD006559.pub2. Gould CV, Umscheid CA, Agarwal RK, Kuntz G, Pegues DA, Healthcare Infection Control Practices Advisory Committee (HICPAC).
Guideline for prevention of catheter-associated urinary tract infections 2009. Centers for Disease Control and Prevention (CDC); 2010. Hill TC, Baverstock R, Carlson KV, et al.
Best practices for the treatment and prevention of urinary tract infection in the spinal cord injured population The Alberta context. Can
Urol Assoc.J. 2013; 7 (3-4) 122-130. doi 10.5489/cuaj.337. *Hooton TM, Bradley SF, Cardenas DD, et al.
Diagnosis, prevention, and treatment of catheter-associated urinary tract infection in adults 2009 International Clinical Practice Guidelines from the Infectious Diseases Society of America. Clin Infect Dis. 2010; 50 (5) 625-663. Institute for Healthcare Improvement (IHI).
How-to Guide Prevent catheter-associated urinary tract infections. Cambridge, MA IHI; 2011. The Joint Commission. Surgical Care Improvement Project (SCIP). SCIP-Inf-9 Urinary catheter removed on postoperative day 1 (POD 1) or postoperative day 2 (POD 2) with day or surgery being day zero.
Specifications manual for national hospital inpatient quality measures. Joint Commission; 2013. Saskatchewan Infection Prevention and Control Program.
Guidelines for the prevention and treatment of urinary tract infections (UTIs) in continuing care settings. Government of Saskatchewan Ministry of Health; 2013. Toward Optimized Practice (TOP).
Diagnosis and management of urinary tract infection in long term care facilities Clinical practice guideline. Edmonton, AB TOP; 2015. Additional Resources for Prevention of UTI Barnoiu OS, Sequeira-Garcia Del Moral J, Sanchez-Martinez N, Diaz-Molina P, Flores-Sirvent L, Baena-Gonzalez V. American cranberry (proanthocyanidin 120mg) Its value for the prevention of urinary tracts infections after ureteral catheter placement.
Actas Urol Esp. 2015; 39 (2) 112-117. doi 10.1016/j.acuro.2014.07.003. Chenoweth CE, Gould CV, Saint S. Diagnosis, management, and prevention of catheter-associated urinary tract infections.
Infect Dis Clin North Am. 2014; 28 (1) 105-119. doi 10.1016/j.idc.2013.09.002. Chenoweth CE, Saint S. Urinary tract infections.
Infect Dis Clin North Am. 2011; 25 (1) 103-115. doi 10.1016/j.idc.2010.11.005. Dieter AA, Amundsen CL, Edenfield AL, et al. Oral antibiotics to prevent postoperative urinary tract infection a randomized controlled trial. Obstet Gynecol. 2014; 123 (1) 96-103. doi 10.1097/AOG.0000000000000024. [Erratum,
Obstet Gynecol. 2014; 123 (3) 669.] Dumas AM, Girard R, Ayzac L, et al. Effect of intrapartum antibiotic prophylaxis against group B streptococcal infection on comparisons of rates of endometritis and urinary tract infection in multicenter surveillance.
Infect Control Hosp Epidemiol. 2008; 29 (4) 327-332. doi 10.1086/529210. Evron S, Dimitrochenko V, Khazin V, et al. The effect of intermittent versus continuous bladder catheterization on labor duration and postpartum urinary retention and infection a randomized trial.
J Clin Anesth. 2008; 20 (8) 567-572. doi 10.1016/j.jclinane.2008.06.009. *Fakih, MG, George C, Edson BS, Goeschel CA, Saint, S. Implementing a national program to reduce catheter-associated urinary tract infection a quality improvement collaboration of state hospital associations, academic medical centers, professional societies, and governmental agencies. Infect Control Hosp Epidemiol. 2013; 34 (10) 1048-1054. doi 10.1086/673149. Fakih MG, Krein SL, Edson B, Watson SR, Battles JB, Saint S. Engaging health care workers to prevent catheter-associated urinary tract infection and avert patient harm.
Am J Infect Control. 2014; 42 (10 Suppl) S223-S229. doi 10.1016/j.ajic.2014.03.355. Fink R, Gilmartin H, Richard A, Capezuti E, Boltz M, Wald H. Indwelling urinary catheter management and catheter-associated urinary tract infection prevention practices in Nurses Improving Care for Healthsystem Elders hospitals.
Am J Infect Control. 2012; 40 (8) 715-720. doi 10.1016/j.ajic.2011.09.017. Gamage B, Varia M, Litt M, Pugh S, Bryce E. Finding the gaps an assessment of infection control surveillance needs in British Columbia acute care facilities.
Am J Infect Control. 2008; 36 (10) 706-710. doi 10.1016/j.ajic.2008.06.004. Hsu V.
Prevention of health care-associated infections.
Am Fam Physician. 2014; 90 (6) 377-82. Kachare SD, Sanders C, Myatt K, Fitzgerald TL, Zervos EE.
Toward eliminating catheter-associated urinary tract infections in an academic health center. J Surg Res. 2014; 192 (2) 280-285. doi 10.1016/j.jss.2014.07.045 Maharaj D. Puerperal pyrexia a review. Part I.
Obstet Gynecol Surv. 2007; 62 (6) 393-399. Maharaj D. Puerperal Pyrexia a review. Part II.
Obstet Gynecol Surv. 2007; 62 (6) 400-6. Saint S, Fowler KE, Sermak K, et al.
Introducing the No Preventable Harms campaign Creating the safest health care system in the world, starting with catheter-associated urinary tract infection prevention.
Am J Infect Control. 2015; 43 (3) 254-259. doi 10.1016/j.ajic.2014.11.016. Saint S, Gaies E, Fowler KE, Harrod M, Krein SL.
Introducing a catheter-associated urinary tract infection (CAUTI) prevention guide to patient safety (GPS). Am J Infect Control. 2014; 42 (5) 548-50. doi 10.1016/j.ajic.2013.12.019. Salvatore S, Salvatore S, Cattoni E, et al. Urinary tract infections in women.
Eur J Obstet Gynecol Reprod Biol. 2011; 156 (2) 131-136. doi 10.1016/j.ejogrb.2011.01.028. Shuman EK, Chenoweth CE. Recognition and prevention of healthcare-associated urinary tract infections in the intensive care unit.
Crit Care Med. 2010; 38 (8 Suppl) S373-S379. doi 10.1097/CCM.0b013e3181e6ce8f. Wagenlehner FM, Cek M, Naber KG, Kiyota H, Bjerklund-Johansen TE. Epidemiology, treatment and prevention of healthcare-associated urinary tract infections.
World J Urol. 2012; 30 (1) 59-67. doi 10.1007/s00345-011-0757-1.Nursing Interventions for the Prevention of UTI Alexaitis I, Broome B. Implementation of a nurse-driven protocol to prevent catheter-associated urinary tract infections.
J Nurs Care Qual. 2014; 29 (3) 245-252. doi 10.1097/NCQ.0000000000000041. Fuchs MA, Sexton DJ, Thornlow DK, Champagne MT. Evaluation of an evidence-based, nurse-driven checklist to prevent hospital-acquired catheter-associated urinary tract infections in intensive care units.
J Nurs Care Qual. 2011; 26 (2) 101-109. doi 10.1097/NCQ.0b013e3181fb7847. Oman KS, Makic MB, Fink R, et al. Nurse-directed interventions to reduce catheter-associated urinary tract infections.
Am J Infect Control. 2012; 40 (6) 548-553. doi 10.1016/j.ajic.2011.07.018. *Parry MF, Grant B, Sestovic M. Successful reduction in catheter-associated urinary tract infections focus on nurse-directed catheter removal.
Am J Infect Control. 2013; 41 (12) 1178-1181. doi 10.1016/j.ajic.2013.03.296. Willson M, Wilde M, Webb ML, et al. Nursing interventions to reduce the risk of catheter-associated urinary tract infection part 2 staff education, monitoring, and care techniques.
J Wound Ostomy Continence Nurs. 2009; 36 (2) 137-154. doi 10.1097/01.WON.0000347655.56851.04. Wan H, Hu S, Thobaben M, Hou Y, Yin T. Continuous primary nursing care increases satisfaction with nursing care and reduces postpartum problems for hospitalized pregnant women.
Contemp Nurse. 2011; 37 (2) 149-59. doi 10.5172/conu.2011.37.2.149.Catheter Use Baldini G, Bagry H, Aprikian A, Carli F.
Postoperative urinary retention anesthetic and perioperative considerations.
Anesthesiology. 2009; 110 (5) 1139-1157. doi 10.1097/ALN.0b013e31819f7aea. Bernard MS, Hunter KF, Moore KN. A review of strategies to decrease the duration of indwelling urethral catheters and potentially reduce the incidence of catheter-associated urinary tract infections.
Urol Nurs. 2012; 32 (1) 29-37. Chenoweth C, Saint S. Preventing catheter-associated urinary tract infections in the intensive care unit.
Crit Care Clin. 2013; 29 (1) 19-32. doi 10.1016/j.ccc.2012.10.005. Feneley RC, Kunin CM, Stickler DJ.
An indwelling urinary catheter for the 21st century.
BJU Int. 2012; 109 (12) 1746-1749. doi 10.1111/j.1464-410X.2011.10753.x. Healy EF, Walsh CA, Cotter AM, Walsh SR. Suprapubic compared with transurethral bladder catheterization for gynecologic surgery a systematic review and meta-analysis.
Obstet Gynecol. 2012; 120 (3) 678-687. doi 10.1097/AOG.0b013e3182657f0d. *Loeb, M, Hunt D, O'Halloran K, Carusone SC, Dafoe N, Walter SD.
Stop orders to reduce inappropriate urinary catheterization in hospitalized patients a randomized controlled trial.J Gen Intern Med. 2008; 23 (6) 816-820. doi 10.1007/s11606-008-0620-2. Lusardi G, Lipp A, Shaw C. Antibiotic prophylaxis for short-term catheter bladder drainage in adults.
Cochrane Database Syst.Rev. 2013; 7 CD005428. doi 10.1002/14651858.CD005428.pub2. Marschall J, Carpenter CR, Fowler S, Trautner BW, CDC Prevention Epicenters Program.
Antibiotic prophylaxis for urinary tract infections after removal of urinary catheter meta-analysis.
BMJ. 2013; 346 f3147. [Erratum in
BMJ. 2013; 347 f5325]. *Meddings J, Rogers MA, Macy M, Saint S.
Systematic review and meta-analysis reminder systems to reduce catheter-associated urinary tract infections and urinary catheter use in hospitalized patients.
Clin Infect Dis. 2010; 51 (5) 550-560. doi 10.1086/655133. Newman DK, Willson MM. Review of intermittent catheterization and current best practices.
Urol Nurs. 2011; 31 (1) 12-28, 48. Nicolle LE.
Catheter associated urinary tract infections. Antimicrob Resist Infect Control. 2014; 3 23. doi 10.1186/2047-2994-3-23. Nicolle LE.
Catheter-acquired urinary tract infection the once and future guidelines.
Infect Control Hosp Epidemiol. 2010; 31 (4) 327-329. doi 10.1086/651092. Niel-Weise BS, van den Broek PJ, da Silva EM, Silva LA. Urinary catheter policies for long-term bladder drainage.
Cochrane Database Syst Rev. 2012; 8 CD004201. doi 10.1002/14651858.CD004201.pub3. Owen RM, Perez SD, Bornstein WA, Sweeney JF. Impact of surgical care improvement project inf-9 on postoperative urinary tract infections do exemptions interfere with quality patient care?
Arch Surg. 2012; 147 (10) 946-953. doi 10.1001/archsurg.2012.1485. Pickard R, Lam T, Maclennan G, et al. Types of urethral catheter for reducing symptomatic urinary tract infections in hospitalised adults requiring short-term catheterisation multicentre randomised controlled trial and economic evaluation of antimicrobial- and antiseptic-impregnated urethral catheters (the CATHETER trial).
Health Technol Assess. 2012; 16 (47) 1-197. doi 10.3310/hta16470. Pickard R, Lam T, Maclennan G, et al.
Antimicrobial catheters for reduction of symptomatic urinary tract infection in adults requiring short-term catheterisation in hospital a multicentre randomised controlled trial.
Lancet. 2012; 380 (9857) 1927-1935. doi 10.1016/S0140-6736(12)61380-4. Rebmann T, Greene LR. Preventing catheter-associated urinary tract infections An executive summary of the Association for Professionals in Infection Control and Epidemiology, Inc, Elimination Guide.
Am J Infect Control. 2010; 38 (8) 644-646. doi 10.1016/j.ajic.2010.08.003. Regev-Shoshani G, Ko M, Crowe A, Av-Gay Y. Comparative efficacy of commercially available and emerging antimicrobial urinary catheters against bacteriuria caused by E. coli in vitro.
Urology. 2011; 78 (2) 334-339. doi 10.1016/j.urology.2011.02.063. Siddiq DM, Darouiche RO. New strategies to prevent catheter-associated urinary tract infections.
Nat Rev Urol. 2012; 9 (6) 305-314. doi 10.1038/nrurol.2012.68. Tambyah PA, Oon J. Catheter-associated urinary tract infection.
Curr Opin Infect Dis. 2012; 25 (4) 365-370. doi 10.1097/QCO.0b013e32835565cc. Tenke P, Koves B, Johansen TE. An update on prevention and treatment of catheter-associated urinary tract infections.
Curr Opin Infect Dis. 2014; 27 (1) 102-107. doi 10.1097/QCO.0000000000000031. Weber DJ, Kang J, Brown VM, Sickbert-Bennett EE, Rutala WA. Preventing catheter-associated urinary tract infections hospital location of catheter insertion.
Infect Control Hosp Epidemiol. 2012; 33 (10) 1057-1058. doi 10.1086/667771. Wyndaele JJ, Brauner A, Geerlings SE, Bela K, Peter T, Bjerklund-Johanson TE. Clean intermittent catheterization and urinary tract infection review and guide for future research.
BJU Int. 2012; 110 (11 Pt C) E910-E917. doi 10.1111/j.1464-410X.2012.11549.x. Zaouter C, Kaneva P, Carli, F. Less urinary tract infection by earlier removal of bladder catheter in surgical patients receiving thoracic epidural analgesia.
Reg Anesth Pain Med. 2009; 34 (6) 542-548.Newborn References Bizzarro MJ. Health care-associated infections in the neonatal intensive care unit barriers to continued success. Semin Perinatol. 2012; 36 (6) 437-44. doi 10.1053/j.semperi.2012.06.006. **Bonadio W, Maida G. Urinary tract infection in outpatient febrile infants younger than 30 days of age a 10-year evaluation.
Pediatr Infect Dis J. 2014; 33 (4) 342–344. doi 10.1097/INF.0000000000000110. **Braga LH, Farrokhyar F, D'Cruz J, Pemberton J, Lorenzo AJ. Risk factors for febrile urinary tract infection in children with prenatal hydronephrosis A prospective study.
J Urol. 2015; 193 (5 Suppl) 1766–1771. doi 10.1016/j.juro.2014.10.091. Davis KF, Colebaugh AM, Eithun BL, et al.
Reducing catheter-associated urinary tract infections a quality-improvement initiative. Pediatrics. 2014; 134 (3) e857-e864. doi 10.1542/peds.2013-3470. **Goldman M, Lahat E, Strauss S, et al. Imaging after urinary tract infection in male neonates.
Pediatrics. 2000;105 (6) 1232–1235. Graham PL, 3rd. Simple strategies to reduce healthcare associated infections in the neonatal intensive care unit line, tube, and hand hygiene. Clin Perinatol. 2010; 37 (3) 645-653. doi 10.1016/j.clp.2010.06.005. **Herz D, Merguerian P, McQuiston L. Continuous antibiotic prophylaxis reduces the risk of febrile UTI in children with asymptomatic antenatal hydronephrosis with either ureteral dilation, high-grade vesicoureteral reflux, or ureterovesical junction obstruction. J Pediatr Urol. 2014; 10 (4) 650–654. Jagannath VA, Fedorowicz Z, Sud V, Verma AK, Hajebrahimi S. Routine neonatal circumcision for the prevention of urinary tract infections in infancy. Cochrane Database Syst Rev. 2012; 11 CD009129. doi 10.1002/14651858.CD009129.pub2. Kacker S, Frick KD, Gaydos CA, Tobian AA.
Costs and effectiveness of neonatal male circumcision. Arch Pediatr Adolesc Med. 2012; 166 (10) 910-8. **Ismaili K, Lolin K, Damry N, Alexander M, Lepage P, Hall M. Febrile urinary tract infections in 0- to 3-month-old infants a prospective follow-up study.
J Pediatr. 2011; 158 (1) 91–94. doi 10.1016/j.jpeds.2010.06.053. **Levy I, Comarsca J, Davidovits M, Klinger G, Sirota L, Linder N. Urinary tract infection in preterm infants the protective role of breastfeeding.
Pediatr Nephrol. 2009; 24 (3) 527–531. doi 10.1007/s00467-008-1007-7. **Sastre JB, Aparicio AR, Cotallo GD, Colomer BF, Hernández MC, Grupo de Hospitales Castrillo. Urinary tract infection in the newborn clinical and radio imaging studies.
Pediatr Nephrol. 2007; 22 (10)1735–1741. **Tullus K. Vesicoureteric reflux in children.
Lancet. 2015; 385 (9965) 371–379. doi 10.1016/S0140-6736(14)60383-4.
Back to Overview
Download||*(Key Resources recommended by Dr. Jerome Leis, **recommend Dr. Shaun Morris) Professional Associations and Helpful Websites
Centers for||10/7/2016 7:03:05 PM||89||https://www.patientsafetyinstitute.ca/en/toolsResources/Hospital-Harm-Measure/Improvement-Resources/UTI/Pages/Forms/AllItems.aspx||html||False||aspx|
|Near-fatal medication error leads nurse to make patient safety a priority||43300||Healthcare provider stories||10/26/2017 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. The||10/30/2017 10:07:37 PM||940||https://www.patientsafetyinstitute.ca/en/toolsResources/HealthcareProviderStories/Pages/Forms/AllItems.aspx||html||False||aspx|
|Wife’s death left her husband to fight for changes in primary care||43424||Video;Patient Stories||6/14/2015 7:26:58 AM||10/31/2013 6:00:00 AM||
Chris Cox didn't feel her toe nail come off. It was only when she took her sandals off hours later that she saw her nail was gone. That's when she and husband Peter knew something was seriously wrong.
That incident was part of a decades-long journey through health care that convinced Peter the system has to change.
"Chris's story is more common than most want to acknowledge,” says Peter. “It is a story of failure to intervene at the appropriate time, which resulted in personal suffering but also a great deal of cost to the health care system that could have been avoided with good primary care."
He is also concerned Canadian doctors and nurses are working under conditions of stress and burnout with many choosing to leave the profession.
His message to them?
"You have to believe the system can be changed. Both from inside and outside. Keep fighting because without that, we are not going to make it better. Just accepting the situation as it is and trying to struggle on is not enough."
A former Vice-President, Finance and company director, Peter witnessed inefficient organizations struggle for long periods of time. He's also helped them address the root causes of crisis, to become efficient organizations supporting their front line. That's why he's joined Patients for Patient Safety.
Patients for Patient Safety Canada is a patient led program of the Canadian Patient Safety Institute. Patients for Patient Safety Canada works to ensure that healthcare organizations and systems include the patient and family perspective when making decisions and planning safety and quality improvement initiatives.
"Every organization faces a whole raft of different complex issues. I can sit on the side and look at things superficially and snipe, 'These guys didn’t know what they were doing. Look at what happened to Chris.' To understand what really created those situations is far more difficult," says Peter.
What happened to his wife Chris started in the mid-1980s with surgery to remove a cyst on her thyroid. Chris was given medication and told she’d need to take it daily for the rest of her life. Six months later the doctor's office asked Chris to come in for a blood test. She declined, saying she felt fine.
When she tore her toenail off in 1997, doctors discovered she was hyperthyroid, despite taking medication for hypothyroid. She’d developed diabetes and diabetic neuropathy. The nerves in her legs and feet were dead, explaining why she didn’t feel the toenail coming off.
It was then the Cox’s learned that patients with thyroid condition should be tested every six months. The doctor hadn't explained the risk of not taking these tests.
Again, Chris dutifully took her new medication. But in 1999, she developed mild swelling and a prickling sensation in her foot. Her G.P. was no longer in practice, so she consulted an endocrinologist, who described the new symptoms as a secondary condition of diabetic neuropathy. He denied Chris' request for a foot x-ray. Soon after, Chris developed diabetic ulcers, went to the ER and was treated with antibiotics. Still no x-ray. The ulcers returned, along with a prescription for more antibiotics.
A diabetic clinic nurse urged Chris to go the E.R. at a nearby teaching hospital. There, her foot was finally x-rayed. An infectious disease specialist diagnosed Charcot Foot, a degenerative bone disease that can lead to amputation.
Uninformed of the risk, Chris exacerbated the condition by walking on her foot, oblivious to the pain others would feel. Eighteen months later her toe was amputated when infection set in. Then in 2008, Chris' foot was amputated.
Chris adapted to her amputation and remained upbeat and cheerful until mid 2011 when she grew confused. She was even unable to remember where the bathroom was at home. Then she began hallucinating. The G.P. said it was either Alzheimer's, a mini stroke or a urinary tract infection (UTI). She was referred to a neurologist.
"Her endocrinologist, her nephrologist, a walk-in clinic doctor — they all had the same reaction,” said Peter. “Yet I discovered that 80 per cent of women Chris' age who develop sudden dementia-like symptoms have U.T.I."
She was hospitalized, treated with antibiotics and got better. She came home. A few days later Chris had severe abdominal pain, lost coordination and fell. Back to the E.R. More tests. An M.R.I. showed a mini stroke. Chris was admitted. She died ten days later, on the week of her 75th birthday.
It was a European relative of Peter's who pointed out that people of Chris' age with chronic conditions like diabetes are susceptible to UTIs, then to sepsis. Chris had been seen by eight different doctors. No one had tested for, or considered sepsis.
Peter saw Chris' nephrologist, who examined the records. Yes, Chris had likely died of sepsis. There were anomalies in her urine test; her blood pressure dropped about 20 per cent. He talked with Peter for more than an hour, explained how the system works, why this probably fell between the cracks and admitted that he could have done more.
"Saying, 'I’ve learned something from this,' was much better than an apology," says Peter.
Here are the changes Peter would like to see
Involve the patient in care. Help patients understand their condition and how to manage it. Do it one step at a time. Explain the fundamentals. Chris wasn’t properly informed of the importance of six month testing following thyroid surgery, the importance of keeping off of her Charcot Foot, nor the relationship between her chronic condition, U.T.I. and sepsis.
People with chronic conditions need a primary care physician. Once identified with a set of chronic conditions, patients need primary care providers with specific knowledge, who can help avoid the setbacks Chris experienced — hospitalizations for the Charcot foot, the toe amputation, possibly even for the U.T.I.
Protocol to capture and learn from mistakes. Peter asked Chris’s orthopaedic surgeon to call the physicians who missed the Charcot Foot. Not to criticize, but to inform future diagnoses. The surgeon, however, said such a call would be considered professionally unacceptable and regarded as criticism by another doctor.
"Once there's a mistake, the health care system should have a protocol in place to ensure they learn from the mistake and don't repeat it,” says Peter.
“All doctors, no matter how brilliant they are, will make mistakes," says Peter. "In business, people want to be told of mistakes so they can do better. We should be able to do that in the medical profession, too."
Peter’s challenges fuel the importance of the Canadian Patient Safety Weeks message, ASK.LISTEN.TALK. “Good healthcare starts with good communication”. Learn more about Canadian Patient Safety, October 28 to November 1, 2013 at www.asklistentalk.ca.||Chris Cox didn't feel her toe nail come off. It was only when she took her sandals off hours later that she saw her nail was gone. That's when she||8/23/2016 7:34:34 PM||262||https://www.patientsafetyinstitute.ca/en/toolsResources/Member-Videos-and-Stories/Pages/Forms/AllItems.aspx||html||False||aspx|
|Step up your teamwork and communication with TeamSTEPPS Canada™||49387||News||3/13/2018 5:32:26 PM||3/14/2018 6:00:00 AM|| The Canadian Patient Safety Institute is now offering an exciting new program to enhance patient safety through improved teamwork and communication. TeamSTEPPS® is the acronym for Team Strategies and Tools to Enhance Performance and Patient Safety. It is a teamwork system originally developed jointly by the Department of Defense (DoD) and the Agency for Healthcare Research and Quality (AHRQ) to improve institutional collaboration and communication relating to patient safety. As part of its efforts to enhance a patient safety culture under the SHIFT to Safety platform, the Canadian Patient Safety Institute has adopted and adapted the program and is now making TeamSTEPPS Canada™ available to the Canadian healthcare field. TeamSTEPPS® has been shown to improve safety and transform culture in healthcare through the promotion of teachable, learnable skills that lead to better teamwork, communication, leadership, situation monitoring, and mutual support within and among teams. These core skills lead to important team outcomes, such as enabling the team to adapt to changing situations, achieve compatible shared mental models among team members, and maintain a stronger orientation toward teamwork. The Canadian Patient Safety Institute has been working with Canadian and international partners to cultivate the growing network of TeamSTEPPS® early adopters, and to develop capacity across the country in support of better teamwork and communication for patient safety. The TeamSTEPPS Canada™ program is delivered in a train-the-trainer model, where Master Trainers are certified to teach the program to others. The program is designed for providers, leaders and patients alike, from a variety of healthcare settings, including acute, primary, long-term and ambulatory care fields. The Canadian Patient Safety Institute has partnered with the Health Quality Council of Alberta (HQCA), as a TeamSTEPPS Canada™ Regional Training Centre, to deliver the TeamSTEPPS Canada™ Master Trainer program. The Master Trainer program includes a comprehensive set of ready-to-use materials and a training curriculum to integrate teamwork principles into a variety of healthcare settings. The inaugural two-day TeamSTEPPS Master Trainer program will be offered in Calgary, May 8 and 9, 2018. The HQCA plans to deliver programs at various locations throughout Alberta quarterly. To register, visit www.hqca.ca "TeamSTEPPS is a good conduit for standardization, sharing, and creating a common vision for safe care between all organizations," says Rhonda Pouliet, Lead, Collaborative Learning & Education, HQCA and a TeamSTEPPS Master Trainer. "The Health Quality Council of Alberta is pleased to collaborate with the Canadian Patient Safety Institute and come on board as a Regional Training Centre for the TeamSTEPPS Canada™ program. It is an exciting opportunity and we have people throughout the province chomping at the bit to get started on their TeamSTEPPS training!" The Canadian Patient Safety Institute has also partnered with the Atlantic Health Quality and Patient Safety Council to offer a TeamSTEPPS Canada™ training session in Halifax, in April 2018. The TeamSTEPPS Canada™ program consists of 12 modules. The TeamSTEPPS Essentials course is a brief (1-2 hours) introduction to the TeamSTEPPS framework, and the tools and strategies contained in the TeamSTEPPS Pocket Guide. The TeamSTEPPS Fundamentals course teaches the core teamwork skills in seven modules, which are represented in the elements of the TeamSTEPPS Framework Triangle model. Completion of the Fundamentals course is prerequisite to the Master Trainer course (modules 8-12). The Master Trainer course focuses on topics related to the implementation and sustainment of TeamSTEPPS. Content for the 12 modules focus on these topics Module 1 Introduction—provides an overview of Master Training, TeamSTEPPS, and the science of team performance. Module 2 Team Structure—defines a team and its members, including patients and their families, and describes a multi-team system, which is important in planning a TeamSTEPPS implementation. Module 3 Communication—provides tools and strategies for communicating effectively through standardized information exchange strategies such as SBAR, check-back, call-out, and handoff. Module 4 Leading Teams—identifies the activities conducted to effectively lead teams and the tools that support these activities, such as briefs, huddles, and debriefs. Module 5 Situation Monitoring—describes the importance of team members gaining or maintaining an accurate awareness or understanding of the situation in which the team is functioning, and outcomes of situation monitoring, including a shared mental model among team members. Module 6 Mutual Support— describes approaches for providing mutual support, or "backup behavior," that allows teams to become self-correcting, distribute workload effectively, provide effective feedback, and manage conflict. Module 7 Summary Pulling It All Together— provides an opportunity for participants to review and apply the TeamSTEPPS tools and strategies learned through the course. Module 8 Change Management—provides information about organizational change through Kotter's Eight Steps of Change. Module 9 Coaching—describes coaching, how to coach, and the role of coaching in implementing TeamSTEPPS. Module 10 Measurement—provides information about evaluating the success of your TeamSTEPPS implementation, including available assessment tools and resources. Module 11 Implementation Workshop—serves as a capstone to the course by allowing you and your team members to think through your implementation plans and strategies. Module 12 Teachback opportunity—provides participants an opportunity to plan and teach a module from the Fundamentals course. For more information on TeamSTEPPS Canada™, visit www.teamstepps-canada.ca||The Canadian Patient Safety Institute is now offering an exciting new program to enhance patient safety through improved teamwork and communication.||3/14/2018 2:32:55 AM||236||https://www.patientsafetyinstitute.ca/en/NewsAlerts/News/Pages/Forms/AllItems.aspx||html||False||aspx|
|Introduction of the Measuring and Monitoring of Safety (Vincent) Framework to Canada||38928||Events;Presentation;Metrics||1/4/2017 4:11:25 PM||
Archive Monday, January 30, 2017 at 1000 am MST / 1200 pm EST
Purpose of the Call
"…if I apply
this [framework] conceptually to any problem I've got in safety I can make it work, and it orders my thinking" – Neil Prentice, Assistant Medical Director Mental Health, Tayside Trust, Scotland In Canada, as in the UK and US the focus of governments on assessing both quality and safety has increased over the past 10 years., A very large number of quality outcomes have been specified but the approach to safety has been much narrower, leaving many aspects of safety unexplored. The measurement of harm, so important in the evolution of patient safety, has been largely neglected and there have been prominent calls for improved measures. There is a critical need for patient safety measurement at the front lines, so that clinical teams can focus on key problems. Don Berwick has stated that 'most health care organisations at present have very little capacity to analyse, monitor, or learn from safety and quality information. This gap is costly and should be closed. Early warning signals can be valued and should be maintained and heeded'.5, In 2013 Professors Charles Vincent, Susan Burnett and Jane Carthey published their report
The Measuring and Monitoring of Safety which describes their framework to be implemented in practice to close the gap identified by Berwick. The framework provides a broader view of the information needed to create and sustain safer care.
Objectives Introduce the Measuring and Monitoring of Safety Framework to a Canadian healthcare audience Describe how the framework would work in Canada
Presentation A framework for measuring and monitoring safety A practical guide to using a new framework for measuring and monitoring safety in the NHS (2014) -
Download the guide from The Health Foundation The measurement and monitoring of safety Drawing together academic evidence and practical experience to produce a framework for safety measurement and monitoring (2013) –
Download the full report from The Health Foundation Speaker Biographies
Professor Charles Vincent Professor Charles Vincent is trained as a clinical psychologist and has worked in the British NHS for several years. Since 1985 he has focused on conducting research on the causes of harm to patients, the consequences for patients and staff and methods of improving the safety of healthcare. He established the Clinical Risk Unit at the Department of Psychology, University College London where he was Professor of Psychology. In 2002 he moved to become Professor of Clinical Safety Research in the Department of Surgery and Cancer at Imperial College in 2002. From 1999 to 2003 he was a Commissioner on the UK Commission for Health Improvement. He has acted as an advisor on patient safety in many inquiries and committees including the Bristol Inquiry, the Parliamentary Health Select Committee, the Francis Inquiry and the Berwick Review. From 2007 to 2013 he was the Director of the National Institute of Health Research Centre for Patient Safety & Service Quality at Imperial College. He moved to the Department of Experimental Psychology in January 2014 with the support of the Health Foundation to continue his work on safety in healthcare.
G. Ross Baker, Ph.D. G. Ross Baker, Ph.D., is a professor in the Institute of Health Policy, Management and Evaluation at the University of Toronto and Director of the MSc. Program in Quality Improvement and Patient Safety. Ross is co-lead for a large quality improvement-training program in Ontario, IDEAS (improving and Driving Excellence Across Sectors). Recent research projects include a review and synthesis of evidence on factors linked to high performing healthcare systems, an analysis of why progress on patient safety has been slower than expected and an edited book of case studies on patient engagement strategies.
Chris Power What began as a desire to help those in need 30 years ago has evolved into a mission to improve the quality of healthcare for all Canadians. Chris Power's journey in healthcare began at the bedside as a front-line nurse. Since then, she has grown into one of the preeminent healthcare executives in Canada. Her experiences, her success, and her values have led her to the position of CEO of the Canadian Patient Safety Institute. Previously, Chris served for eight years as president and CEO of Capital Health, Nova Scotia, with an annual operating budget of approximately $900 million, and 12,000 staff. Under Chris’s leadership Capital Health achieved Accreditation with Exemplary Status in 2014 with recognition for 10 Leading Practices.
SHIFT to Safety Ensuring patients are safe remains a major challenge for Canadian healthcare organisations and systems. The Canadian Patient Safety Institute's (CPSI) new initiative,
SHIFT to Safety, has been launched to address these challenges, including helping providers and leaders improve their measurement efforts.
References  Baker, G Ross,
Beyond the quick fix – Strategies for improving patient safety. Institute of Health Policy Management and Evaluation. Nov.9.2015  Darzi A. High quality care for all. London Department of Health, 2009.  Quality and Outcomes Framework 2013/14. London Department of Health, 2013.  Vincent CA, Aylin P, Franklin BD, et al.
Is health care getting safer? BMJ 2008;3371205–07.  Francis R.
Independent Inquiry into care provided by Mid Staffordshire NHS Foundation Trust January 2005–March 2009. London Department of Health, 2013.  Jha A, Pronovost P.
Toward a safer health care system The critical need to improve measurement. JAMA. 2016.  Berwick DM.
A promise to learn—a commitment to act. Improving the safety of patients in England. London Department of Health, 2013  Vincent CA, Burnett S, Carthey C.
The measurement and monitoring of safety in healthcare. London Health Foundation, 2013||Archive: Monday, January 30, 2017 at 10:00 am MST / 12:00 pm EST
Purpose of the Call:
"…if I apply
this||4/5/2017 7:29:00 PM||290||https://www.patientsafetyinstitute.ca/en/toolsResources/Pages/Forms/NewDefaultView.aspx||html||False||aspx|
|Hand Hygiene Toolkit||38911||Guide;Toolkits||6/3/2015 4:47:25 PM||This comprehensive Hand Hygiene Toolkit allows you to start improving hand hygiene in your organization. You can buy this toolkit here. Additional copies of some of the tools available in the Hand Hygiene Toolkit can be found below.
Hand Hygiene Toolkit resource links to scholarly literature and fact sheets can also be found in the Resources section.
Copies of the hand hygiene education PowerPoint presentations can be found in Hand Hygiene Education.
Looking for the Patient and Family Guide? You can find it plus other resources in the Patients & Their Families section.
Hand Hygiene Observation Tool
WRHA Hand Hygiene Observation Tool
WRHA Hand Hygiene Audit Instructions
On-the-Spot Feedback Tool
Hand Hygiene Surveillance Instrument
Guidebook for Use of Hand Hygiene Surveillance Instrument
Instructions for Using the Hand Hygiene Surveillance Instrument
A Simple Framework and tools for Establishing Accountability in Hand Hygiene Programs
How to Handrub
How to Handwash
4 Moments for Hand Hygiene (poster)
WHO Facility-Level Situation Analysis
WHO Template Action Plan
||This comprehensive Hand Hygiene Toolkit allows you to start improving hand hygiene in your organization. You can buy this toolkit here .||7/19/2017 8:04:47 PM||391||https://www.patientsafetyinstitute.ca/en/toolsResources/Pages/Forms/NewDefaultView.aspx||html||False||aspx|
|STOP! Clean Your Hands Day||36689||Events||6/3/2015 4:46:05 PM||
May 6, 2019 Register today to receive updates, tools and resources to promote hand hygiene.
Sponsored by Partners
||STOP! Clean Your Hands Day||May 6, 2019 Register today to receive updates, tools and resources to promote hand hygiene.
||2/15/2019 9:29:28 PM||1459||https://www.patientsafetyinstitute.ca/en/Events||html||True||aspx|
|Safety Improvement Projects||36609||Framework||9/14/2018 2:50:29 PM||
Canadian Patient Safety Institute (CPSI) is offering new Safety Improvement Projects designed with a Quality Improvement/Knowledge Translation integrated learning design for accelerating Patient Safety in Canada.
CPSI is working with committed partners to implement and evaluate measurable and sustainable Safety Improvement Projects that align with pan-Canadian priorities. The new Safety Improvement Projects are as follows Please email SafetyImprovementProjects@cpsi-icsp.ca
for a Word version of the Expression of Interest. The deadline to submit
applications is March 1, 2019. Successful applicants will be notified by March
Teamwork and Communication leads to improved patient safety culture and positive patient outcomes.
Expression of Interest
Medication Safety at Care Transitions improves medication safety at discharge for frail, elderly patients with poly-morbidity in your organization.
Expression of Interest
Enhanced Recovery Canada leads to improved outcomes and system efficiencies for colorectal surgery patients.
Expression of Interest
Measurement and Monitoring of Safety creates a culture of safety and reduces harm in your organization. (already in progress) Each Safety Improvement Project lasts 18 months and uses principles from the Institute for Healthcare Improvement Breakthrough Series and the Knowledge to Action Framework. The learning design is unique in that it is guided by a Quality Improvement/Knowledge Translation integrated learning design. By adopting these projects, you and your organization will step in to a leading role in healthcare delivery. Please
sign up to subscribe to our Safety Improvement Project mailing list for updates and to learn more about each of these projects. Consider introducing them in your organization with a goal of supporting higher patient safety standards within your organization and across the country.
Sign up Benefits to participating organizations Support of expert faculty and coaches who are knowledgeable about the best-known evidence as well as practical ideas, tips and tools for application.
Use of a collaborative virtual space for networking with other participating teams and faculty, and continual and ongoing support provided through in-person and virtual contact opportunities with coaches. Opportunity to demonstrate, showcase and share the practices that support meeting strategic and operational objectives at a congress event. If you have any questions, please email
SafetyImprovementProjects@cpsi-icsp.ca ||Safety Improvement Projects ||Canadian Patient Safety Institute (CPSI) is offering new Safety Improvement Projects designed with a Quality Improvement/Knowledge Translation||2/7/2019 6:42:02 PM||1114||https://www.patientsafetyinstitute.ca/en/toolsResources||html||True||aspx|
|Teamwork and Communication: Safety Improvement Project||36648||Events;Toolkits||1/11/2019 10:32:45 PM||Teamwork and Communication Safety Improvement Project – An 18-month learning collaborative
What is happening? The Canadian Patient Safety Institute will launch a new Safety Improvement Project in January 2019, focused on teamwork and communication. This collaborative learning approach will be delivered by expert faculty and coaches, and mentoring provided over 18 months. Participating teams will be empowered to actively solve local level teamwork and communication issues that are impacting patient safety outcomes. Please email firstname.lastname@example.org for a Word version of the Expression of Interest. The
deadline to submit applications is March 1, 2019. Successful applicants will be
notified by March 15, 2019.
Expression of Interest Teams enrolled in the Teamwork and Communication Safety Improvement Project will test and implement evidence-informed change ideas to improve patient safety using a quality improvement and knowledge translation/implementation science approach for implementation of TeamSTEPPS Canada™ tools and resources.
Participating teams will Learn how to think differently about teamwork and communication. Identify local level patient safety and quality outcome(s) and processes to be improved. Test and implement evidence-informed change ideas to improve patient safety using TeamSTEPPS Canada™ tools and resources. Access, share and adapt advanced patient safety knowledge, tools, and resources within a learning network. Improve your team's approach to patient safety while taking action to deliver safer care.
What is TeamSTEPPS?
TeamSTEPPS is a teamwork system program developed jointly by the Department of Defense (DoD) and the Agency for Healthcare Research and Quality (AHRQ) to improve institutional collaboration and communication relating to patient safety. TeamSTEPPS Canada™ has been adopted and adapted by the Canadian Patient Safety Institute (CPSI) and made available to the Canadian healthcare field. The following image illustrates the TeamSTEPPS Framework. A properly structured patient care team is an enabler for and the result of effective communication, leadership, situation monitoring, and mutual support. Proper team structure can promote teamwork by including a clear leader, involving the patient, and ensuring that all team members commit to their roles in effective teamwork. Communication is the lifeline of a well-functioning team and serves as a coordinating mechanism for teamwork.
How to learn more? You can learn more about the three new Safety Improvement Projects launching in early 2019 at two information webinars held on
February 5 and again on
February 12, 2019. These webinars will have the same content and are a great opportunity for your team members to learn more about the learning collaborative and get answers to any questions.
Tuesday, February 5, 2019 at 1200 ET
Tuesday, February 12, 2019 at 1200 ET
How to apply to the Teamwork and Communication Safety Improvement Project? Please email email@example.com for a Word version of the Expression of Interest. The
deadline to submit applications is March 1, 2019. Successful applicants will be
notified by March 15, 2019.
Expression of Interest
Need additional information? For additional information about the upcoming learning collaborative, please contact the planning team at
Important Dates & Fees
Faculty and Project Team
Testimonials ||Teamwork and Communication: Safety Improvement Project||Teamwork and Communication: Safety Improvement Project – An 18-month learning collaborative
What is happening? The Canadian Patient||2/15/2019 3:42:20 PM||1876||https://www.patientsafetyinstitute.ca/en/toolsResources||html||True||aspx|
|Tips for patient engagement in patient safety and quality committees||38947||Events;Patient and Family Resource;Presentation||1/29/2016 9:43:27 PM|| The tips below summarize the learning and best practices shared by patients/ families and providers/ organizations during a webinar, hosted by Patients for Patient Safety Canada and the World Health Organization, and on two discussion boards (the World Health Organization Patients for Patient Safety community and the Institute for Patient and Safety Centred Care community). One of the goals of engaging patients in patient safety and quality committees is to help ensure that the care delivered at the front line is patient centred. As part of patient safety and quality committees, patient representatives (known as champions, advisors or partners) possess a valuable and unique perspective which represents the sum of their personal experience as a user of the healthcare system, as a member of a patient group, and as a member of the community. Patients can point to gaps between what is supposed to happen and what actually happens, highlight imbalances of power and safety across the healthcare system, identify gaps in knowledge and evidence that could lead to new research and initiatives, shape discussions and decisions about programs, policies, practices, identify and evaluate outcomes that matter to the patient, family and community, and contribute to staff and organizational learning, growth and development. Organizations, regions and systems are encouraged to set-up patient groups (often referred to as patient advisory groups) where clients/residents/patients/families/citizens with a desire to make care safer Can get involved. Members are provided with orientation, training and support throughout their journey as partners in patient safety and quality improvement efforts. The commitment to partner with patients and successes achieved should be made public to inspire and sustain engagement.
Tips for patients/families Consider your interest, skill and readiness to participate in such a committee as patient safety incidents that can trigger strong emotions or reactions. Get answers to all your questions and be clear on what is expected of you before making the decision to participate. Meaningful and fruitful collaboration is the result of a good understanding of why and how you can contribute. Ask that at least one other patient representative is part of this work (if not already confirmed) so that you can support each other in this process. Participate in training, orientation and smaller projects before participating in patient safety and quality committees. Ensure you understand the confidentiality and privacy aspects related to this work. Ask questions and provide feedback throughout the collaboration especially related to what you believe is the impact of your contribution on patient safety outcomes. Be polite but assertive when you contribute the patient perspective. Let the chair of the committee or liaison know if what, and how you contribute is different than what you expected. Provide feedback to ensure your experience and the experience of other advisors is the best it can be.
Tips for providers/organizations Recruit experienced patients who have been members of a patient council/ group for a number of years. Organizations where patient participation is already the norm before engaging patients in patient safety committees have a better experience. If the committee has concerns, begin by having patients join a task force, a smaller project, or just observe. Also consider choosing patients who would be seen as peers by committee members (e.g. same demographic, education level) especially in cases patient engagement at this level is new. Offer an opportunity for the patient(s) and committee chair to meet before they make the decision to join a patient safety committee (it is recommended to have two patient advisors participate). The chair of the committee or staff liaison should meet with patients prior to their participation to welcome, orient them to the committee members and the work, and to be their contact person. Provide a glossary of terms and background documents at this meeting. A staff liaison (e.g. lead of the patient group) should meet with the committee ahead of time to explain why and how the patient representatives were selected, oriented (e.g. confidentiality, privacy legislation) and ways they can contribute. This is an opportunity to provide examples of successful engagement and point to supports available to the committee and advisors including regular check-in to ensure all are going well. The committee chair should formally introduce the patients and encourage dialogue and collaboration throughout. Identify and offer committee members and patients opportunities to update and/or report back about their work and its impact to others. Testimonials from patients and committee members, especially when the partnership resulted in improvement, are powerful tools to educate about patient engagement, celebrate of successes and potentially recruit new members. Expect that a successful partnership results in more opportunities for patients to partner either in other patient safety areas or at higher organizational levels (e.g. board). Strong leadership together with patient/family engagement is an integral part in sustainable change.
Resources Canadian Foundation for Healthcare Improvement.
Patient Engagement Resource Hub.
Better together campaign (Families are more than visitors. They're partners in care.) Accreditation Canada.
Required Organizational Practices Handbook 2016. Ontario Hospital Association.
Governance Toolkit. Section 1.4. Quality Committee Terms of Reference. Section 1.5. Recommendations for an Effective Quality Committee. Health Quality Council Saskatchewan
Safety Alert/Stop the Line strategy Agency for Healthcare Research and Quality.
Guide to Patient and Family Engagement in Hospital Quality and Safety. Proceedings from past webinars
Tips for Partnering with Patients and Families on Committees.
How can we make the partnership with patients and families more impactful?
Learning from the best A webinar with the Patient Safety Champion Awards Finalists Archive February 24, 2016
Patient engagement in safety committeesObjective At the end of the session patient/family champions as well as health authorities will understand different approaches to patient engagement in patient safety and quality committees (e.g. dealing with incident reporting, root cause analysis, developing policies and procedures) and how patient engagement impacted patient safety and quality outcomes. The participants and presenters are invited to present examples, tools, and leading practices so the participants will leave with at least one practical idea to implement. Resources
Speakers and moderatorAlethse De la Torre Rosas
Infectious diseases specialist at the hospital epidemiology and quality of care division,
National Institute of Medical Sciences and Nutrition Salvador Zubiran,
Ciudad de México, MexicoMalori Keller Kaizen (Continuous Improvement) Specialist – Patient Engagement Saskatchewan Health Quality Council Saskatoon, SK, CanadaModerator Theresa Malloy-Miller
Patient Champion, Patients for Patient Safety Canada London, ON, 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
here. For more information contact
firstname.lastname@example.org.||The tips below summarize the learning and best practices shared by patients/ families and providers/ organizations during a webinar, hosted by||11/28/2016 5:44:45 PM||280||https://www.patientsafetyinstitute.ca/en/toolsResources/Pages/Forms/NewDefaultView.aspx||html||False||aspx|
|Enhanced Recovery After Surgery||36646||Video||7/13/2016 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.
Position Statement Application Deadline (March 1, 2019) Enhanced Recovery Canada Safety Improvement Project The Canadian Patient Safety Institute is set to launch a new Safety Improvement Project focused on surgical best practices for colorectal surgeries in January 2019.
Safety Improvement Project Video Series We trust this 6 part interview with international ERAS expert Dr. Henrik Kehlet will whet your appetite. Stay tuned for additional information regarding Enhanced Recovery Canada.
Use the YouTube playlist below to play all, or any of the six videos in the series.
Where can you learn more about ERAS in the interim?
BC's ERAS Collaborative has developed a website providing a variety of resources to support the implementation of Enhanced Surgical Recovery programs. See
Enhanced Recovery BC
The McGill University Health Center has developed a number of ERAS related
Surgery Patient Guides you may find helpful as well.
Connect with an experienced ERAS coordinatorIndustry Partners
For more information, contact us at
email@example.com.||Enhanced Recovery Canada||What is Enhanced Recovery After Surgery ? Enhanced Recovery After Surgery - ERAS is a program highlighting surgical best practices and consists of a||1/17/2019 8:59:46 PM||842||https://www.patientsafetyinstitute.ca/en/toolsResources||html||True||aspx|
|A Framework for Establishing a Patient Safety Culture||36622||Framework||2/14/2018 4:54:19 PM||Patient Safety Culture "Bundle" for CEOs/Senior Leaders What is the Patient Safety Culture "Bundle"? Strengthening a safety culture necessitates interventions that simultaneously
enable, enact and elaborate in a way that is attuned to the existing culture. Through a literature review of more than 60 resources, a Patient Safety Culture Bundle has been created and validated through interviews with Canadian thought leaders. The Bundle is based on a set of evidence-based practices that must all be applied in order to deliver good care. All components are required to improve the patient safety culture. The
Patient Safety Culture "Bundle" for CEOs and Senior Leaders encompasses key concepts of safety science, implementation science, just culture, psychological safety, staff safety/health, patient and family engagement, disruptive behavior, high reliability/resilience, patient safety measurement, frontline leadership, physician leadership, staff engagement, teamwork/communication, and industry-wide standardization/alignment. Download a one-pager of the Patient Safety Culture Bundle for CEOs/Senior Leaders
Why was this Bundle created? A patient safety culture is difficult to operationalize. Improving safety requires an organizational culture that enables and prioritizes patient safety. The importance of culture change needs to be brought to the forefront, rather than taking a backseat to other safety activities. The National Patient Safety Consortium Education Working Group verified the critical role senior leadership plays in ensuring patient safety is an organizational priority. A Working group of partners, led by the Canadian Patient Safety Institute, Canadian College of Health Leaders (CCHL), HealthCareCAN and the Healthcare Insurance Reciprocal of Canada (HIROC) were brought together to establish a framework and advance this work. How can I use the Patient Safety Culture Bundle? The key components required for a Patient Safety Culture are identified under three pillars
LEARNING Within each pillar you will find links to valuable tools and resources to help your efforts in establishing and sustaining a patient safety culture. (coming soon)Are you looking to establish and sustain a culture of safety? We are committed to providing a robust framework to advance a safety culture. The Bundle is a dynamic tool that will be continually updated. We invite you to check back often for more links and resources. We also need your participation and input to ensure the Bundle is current and relevant. Please forward any links or comments to firstname.lastname@example.org. Testimonials
"Patient safety and healthcare quality are advanced when boards and senior leaders are committed to it and are able to show evidence of that commitment. Missing until now is a concise "how to" guide. The Patient Safety bundle for Leaders fills that gap." Catherine Gaulton, CEO, HIROC
"Leadership is critical to developing a patient safety culture and building leadership capacity requires a vision of the knowledge, skills and behaviours necessary to achieve this. The Patient Safety Leadership Bundle provides this and will be a practical tool for health leaders across the healthcare continuum to assess their personal capabilities. It will also provide both organizations and the system, as a whole, a checklist for what's missing from our collective leadership education toolkits so that we can strategically respond to these needs. HealthCareCAN is committed to the spread of this tool across the country as part of a cultural shift to safety and a drive towards high-reliability culture."
Dale Schierbeck, Vice-President, Learning & Development, HealthCareCAN and Co-Chair, Patient Safety Education for Leaders Working
||A Framework for Establishing a Patient Safety Culture||Patient Safety Culture "Bundle" for CEOs/Senior Leaders What is the Patient Safety Culture "Bundle"? Strengthening a safety||11/7/2018 4:58:32 PM||402||https://www.patientsafetyinstitute.ca/en/toolsResources||html||True||aspx|
|Pressure Ulcer: Measures||67527||9/28/2016 5:40:03 PM|| Vital to quality improvement is measurement, and this applies specifically to implementation of interventions. The chosen measures will help to determine whether an impact is being made (primary outcome), whether the intervention is actually being carried out (process measures), and whether any unintended consequences ensue (balancing measures). Below are some recommended measures to use, as appropriate, to track your progress. In selecting your measures, consider the following Whenever possible, use measures you are already collecting for other programs. Evaluate your choice of measures in terms of the usefulness of the final results and the resources required to obtain them; try to maximize the former while minimizing the latter. Try to include both process and outcome measures in your measurement scheme. You may use different measures or modify the measures described below to make them more appropriate and/or useful to your particular setting. However, be aware that modifying measures may limit the comparability of your results to others. Posting your measure results within your hospital is a great way to keep your teams motivated and aware of progress. Try to include measures that your team will find meaningful and exciting (IHI, 2011). For more information on measuring for improvement, contact the Canadian Patient Safety Institute Central Measurement Team at
email@example.comOutcome Measure Incidence of Pressure UlcersProcess Improvement Measures Percentage with Pressure Ulcer Risk Assessment Completed on Admission Percentage of At-Risk Patients Receiving Full Pressure Ulcer Preventive Care Admission Percentage of Patients Receiving Daily Pressure Ulcer Risk Reassessment Percentage of Patients with Pressure Ulcer Risk Reassessed Following Change in Clinical Status (NICE Audit Tool, 2014) Percentage of At-Risk Patients Repositioned Every Six Hours (Self or With Assistance) (NICE Audit Tool, 2014) Percentage of At-Risk Patients with High-Specification Foam Mattress (NICE Audit Tool, 2014) Percentage of At-Risk Patients who Received an Individualized Care Plan (NICE Audit Tool, 2014)
Back to Overview
Download||Vital to quality improvement is measurement, and this applies specifically to implementation of interventions. The chosen measures will help to||10/5/2016 7:25:32 PM||73||https://www.patientsafetyinstitute.ca/en/toolsResources/Hospital-Harm-Measure/Improvement-Resources/HHI-Pressure-Ulcer/Pages/Forms/AllItems.aspx||html||False||aspx|
|Canadian Patient Engagement Network||36637||Guide;News;Patient and Family Resource;Publication||7/12/2016 10:02:15 PM||
Share, learn and help others about patient engagement Achieving safe healthcare for all Canadians requires everyone's involvement. CPSI offers patients and families, patient advisors, healthcare providers, leaders, and organizations a place to connect in real time so they can share, learn and help others.
The Canadian Patient Engagement Network
Engaging Patients in Patient
Safety – a Canadian Guide. This extensive
helps patients and
partners, providers, and leaders
Patient and Family
Centred Care (PFCC)
Facebook Group PFCC
Connect The Canadian Patient Engagement Network
result of a partnership
Institute for Patient and Family
Centred Care (who hosts the platform) and the Canadian Patient
Safety Institute (moderates the
community). Follow the instructions to
create a login and profile (can
then explore the
resources to help
Facebook Group The Canadian Patient Engagement Network
hosted on Facebook
is a public group
moderated by the Canadian Patient
community to engage in conversation. The Canadian Patient Engagement Network emerged when several partners and patient advisors from across Canada began to discuss the needs and opportunities around a comprehensive guide for patient engagement based on evidence and best practices, as part of the
National Patient Safety Consortium's
Integrated Patient Safety Action Plan. For more information, contact us at
firstname.lastname@example.org.||Canadian Patient Engagement Network||Share, learn and help others about patient engagement Achieving safe healthcare for all Canadians requires everyone's involvement. CPSI offers||1/25/2019 9:42:10 PM||4444||https://www.patientsafetyinstitute.ca/en/toolsResources||html||True||aspx|
|Patient Safety and Incident Management Toolkit||36596||Toolkits||12/18/2014 8:28:40 PM||Prevent Patient Safety Incidents and Minimize Harm When They Do Occur When a patient's safety is compromised, or even if someone just comes close to having an incident, you need to know you are taking the right measures to address it, now and in the future. CPSI provides you with practical strategies and resources to manage incidents effectively and keep your patients safe. This integrated toolkit considers the needs and concerns of patients and their families, and how to properly engage them throughout the process. Drawn from the best available evidence and expert advice, this newly designed toolkit is for those responsible for managing patient safety, quality improvement, risk management, and staff training in any healthcare setting.
Patient Safety Management
System Factors For more information, contact us at
email@example.com.Toolkit Focus and Components The toolkit focuses on patient safety and incident management; it touches on ideas and resources for exploring the broader aspects of quality improvement and risk management. There are three sections to the toolkit Incident management—the actions that follow patient safety incidents (including near misses) Patient safety management—the actions that help to proactively anticipate patient safety incidents and prevent them from occurring System factors—the factors that shape and are shaped by patient safety and incident management (legislation, policies, culture, people, processes and resources).
Visual representation of the toolkit.
Incident management Resources to guide the immediate and ongoing actions following a patient safety incident (including near misses). We emphasize immediate response, disclosure, how to prepare for analysis, the analysis process, follow-through, how to close the loop and share learning.
Patient safety management Resources to guide action before the incident (e.g., plan, anticipate, and monitor to respond to expected and unexpected safety issues) so care is safer today and in the future. We promote a patient safety culture and reporting and learning system.
System factors Understanding the factors that shape both patient safety and incident management and identify actions to respond, align, and leverage them is crucial to patient safety. The factors come from different system levels (inside and outside the organization) and include legislation, policies, culture, people, processes and resources.Implementing Patient Safety and Incident Management Processes Consider the following guiding principles when applying the practical strategies and resources.
Patient- and family-centred care. The patient and family are at the centre of all patient safety and incident management activities. Engage with patients and families throughout their care processes, as they are an equal partner and essential to the design, implementation, and evaluation of care and services.
Safety culture. Culture refers to shared values (what is important) and beliefs (what is held to be true) that interact with a system's structures and control mechanisms to produce behavioural norms. An organization with a safety culture avoids, prevents, and mitigates patient safety risks at all levels. This includes a reporting and learning culture.
System perspective. Keep patients safe by understanding and addressing the factors that contribute to an incident at all system levels, redesigning systems, and applying human factor principles. Develop the capability and capacity for effectively assessing the complex system to accurately identify weaknesses and strengths for preventing future incidents.
Shared responsibilities. Teamwork is necessary for safe patient care, particularly at transitions in care. It is the best defence against system failures and should be actively fostered by all team members, including patients and families. In a functional teamwork environment, everyone is valued, empowered, and responsible for taking action to prevent patient safety incidents, including speaking up when they see practices that endanger safety.Resources to Support Patient Safety and Incident Management CPSI's
toolkit resources are practical tools for patient safety and incident management, compiled with input from experts and contributing organizations. You may not require all of them when managing an incident, so please use your discretion in selecting the tools most appropriate for your needs.Toolkit Development and Maintenance CPSI accessed a variety of qualified experts and organizations to compile this practical and evidence-based toolkit. The process included Assigning a CPSI team with support from a writer with experience in the field Seeking advice from an expert faculty that included patient and family representatives Basing the content on the Canadian Incident Analysis Framework Engaging key stakeholders via focus groups and collecting evidence from peer-reviewed journals and publicly available literature The toolkit will be updated every year to keep it relevant. We welcome feedback on what is helpful, what can be improved, and content enhancements at firstname.lastname@example.org.||Patient Safety and Incident Management Toolkit||Prevent Patient Safety Incidents and Minimize Harm When They Do Occur When a patient's safety is compromised, or even if someone just comes close to||6/19/2017 4:19:43 PM||763||https://www.patientsafetyinstitute.ca/en/toolsResources||html||True||aspx|
|Patient Stories||36635||7/27/2015 12:39:48 PM|| ||Patient Stories||5/19/2016 4:22:33 AM||1206||https://www.patientsafetyinstitute.ca/en/toolsResources||html||True||aspx|
|Atlantic Learning Exchange||36691||Events||9/20/2016 6:01:00 PM||
Get Updates ||Atlantic Quality and Patient Safety Learning Exchange||Get Updates||2/11/2019 5:00:16 PM||317||https://www.patientsafetyinstitute.ca/en/Events||html||True||aspx|
|Medication Safety at Care Transitions Safety Improvement Project Learning Collaborative||36608||1/15/2019 9:35:30 PM||Medication Safety at Care Transitions Safety Improvement Project – An 18 month learning collaborative
What is happening? The Canadian Patient Safety Institute will launch a new Safety Improvement Project in January 2019, focusing on medication safety. This learning collaborative approach will be delivered by expert faculty and coaches, and mentoring with be provided over 18 months. Participating teams will learn and apply strategies to decrease readmissions related to medication safety issues at discharge among frail patients. Please email email@example.com
a Word version of the Expression of Interest. The deadline to submit
applications is March 1, 2019. Successful applicants will be notified by March
Expression of Interest
Teams enrolled in the Medication Safety at Care Transitions Safety Improvement Project will test and implement evidence-informed change ideas to improve patient safety using a quality improvement and knowledge translation/implementation science approach for implementation of medication reconciliation processes at discharge. According to the We Can't Address What We Don't Measure Consistently Building Consensus on Frailty in Canada report produced for the National Institute on Aging, while an individual's health conditions contribute to his or her level of frailty, the number of medications an individual is taking in order to manage those conditions can also contribute to frailty. Polypharmacy - defined as being prescribed five or more medications - is also considered a risk factor for frailty."
Participating teams willLearn to identify Frail clients who are at risk for medication safety issues,Learn and apply new processes for medication management at discharge,Learn and utilize Knowledge Translation and Implementation Science techniques to successfully implement and sustain new evidence-based practices for medication safety at transitions,Share key learnings and challenges, and network with colleagues across Canada,Access, share and adopt advanced patient safety knowledge, tools, and resources within a learning network,Improve your team's approach to patient safety while taking action to deliver safer care. What is Medication Safety? Medications are the most common treatment intervention used in healthcare around the world. When used safely and appropriately, they contribute to significant improvements in the health and well-being of patients. Medication safety is defined as freedom from preventable harm with medication use (ISMP Canada, 2007). Medication safety issues can impact health outcomes, length of stay in a healthcare facility, readmission rates, and overall costs to Canada's healthcare system.How to learn more? You can learn more about the three new Safety Improvement Projects launching in early 2019 at two information webinars held on February 5 and again on February 12, 2019. These two webinars will have the same content and are a great opportunity for you and your team members to learn more about the learning collaborative and get answers to any questions.
Tuesday, February 5, 2019 at 1200 ET
Tuesday, February 12, 2019 at 1200 ET
How to apply to the Medication Safety at Care Transitions Safety Improvement Project? Please email firstname.lastname@example.org for
a Word version of the Expression of Interest. The deadline to submit
applications is March 1, 2019. Successful applicants will be notified by March
Expression of Interest
Need additional information? For additional information about the upcoming learning collaborative, please contact the planning team at
Important Dates & Fees
Faculty and Project Team ||Medication Safety at Care Transitions: Safety Improvement Project||Medication Safety at Care Transitions: Safety Improvement Project – An 18 month learning collaborative
What is happening? The Canadian||2/7/2019 6:17:51 PM||1347||https://www.patientsafetyinstitute.ca/en/toolsResources||html||True||aspx|
|Improvement Frameworks Getting Started Kit||36595||Toolkits;Getting Started Kit;Framework||11/24/2011 4:21:24 PM||12/2/2015 7:00:00 AM||The Improvement Frameworks Getting Started Kit is intended to serve as a common document appended to the Safer Healthcare Now! Getting Started Kits. The goal is to help provide a consistent way for teams and individuals to approach the challenge of making changes that result in improvements.
Download ||Improvement Frameworks Getting Started Kit||The Improvement Frameworks Getting Started Kit is intended to serve as a common document appended to the Safer Healthcare Now! Getting Started||1/5/2016 6:18:07 PM||367||https://www.patientsafetyinstitute.ca/en/toolsResources||html||True||aspx|
|Teamwork and Communication||36597||Publication;Framework||7/22/2009 8:44:35 PM||
Effective teamwork and communication are critical for ensuring high reliability and the safe delivery of care. Teamwork and communication techniques can improve quality and safety, decrease patient harm, promote cross-professional collaboration and the development of common goals, decrease workload issues, and improve staff and patient satisfaction.
Building effective teams and improving communication through standardized tools will move effective teamwork forward in Canada and contribute to a culture of patient safety. CPSI is developing a Canadian Framework for Teamwork and Communication to help healthcare providers and organizations integrate tools and resources into practice.
Canadian Framework for Teamwork and Communication Appendix A
Teamwork and Communication in Healthcare A Literature Review Appendix B
Consultation with Health Professionals and Administrators Regarding Teamwork and Communication Appendix C Report on Summary of Team Training Programs
||Canadian Framework for Teamwork and Communication||Effective Teamwork and Communication to Enhance Patient Safety||11/9/2016 8:44:39 PM||466||https://www.patientsafetyinstitute.ca/en/toolsResources||html||True||aspx|
|The Safety Competencies Framework||36599||Publication;Framework||4/14/2009 11:53:32 PM|| Achieve safe patient care by incorporating our framework The Safety Competencies into your healthcare organization’s educational programs and professional development activities. Patient safety, defined as the reduction and mitigation of unsafe acts within the healthcare system, and the use of best practices shown to lead to optimal patient outcomes, is a critical aspect of quality healthcare.
Educating healthcare providers about patient safety and enabling them to use the tools and knowledge to build and maintain a safe system is critical to creating one of the safest health systems in the world. The Safety Competencies is a highly relevant, clear, and practical framework designed for all healthcare professionals. Created by the Canadian Patient Safety Institute (CPSI), The Safety Competencies has six core competency domains
Domain 1 Contribute to a Culture of Patient Safety – A commitment to applying core patient safety knowledge, skills, and attitudes to everyday work.
Domain 2 Work in Teams for Patient Safety – Working within interprofessional teams to optimize patient safety and quality of care..
Domain 3 Communicate Effectively for Patient Safety – Promoting patient safety through effective healthcare communication..
Domain 4 Manage Safety Risks – Anticipating, recognizing, and managing situations that place patients at risk..
Domain 5 Optimize Human and Environmental Factors – Managing the relationship between individual and environmental characteristics in order to optimize patient safety..
Domain 6 Recognize, Respond to, and Disclose Adverse Events – Recognizing the occurrence of an adverse event or close call and responding effectively to mitigate harm to the patient, ensure disclosure, and prevent recurrence.. This valuable framework includes 20 key competencies, 140 enabling competencies, 37 knowledge elements, 34 practical skills, and 23 essential attitudes that can lead to safer patient care and quality improvement. CPSI encourages its stakeholders, national, provincial, and territorial health organizations, associations, and governments; and universities and colleges to play a role in engaging stakeholders and spreading the word about this program so that healthcare professionals recognize the knowledge, skills, and attitudes needed to enhance patient safety across the spectrum of care. For further information, please email
email@example.com.||The Safety Competencies||The Safety Competencies: Message from the CEO||9/12/2017 8:43:40 PM||1708||https://www.patientsafetyinstitute.ca/en/toolsResources||html||True||aspx|
|Suicide Risk||36602||Guide;Publication||4/21/2011 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.
||Inventory and Resource Guide Development for the Assessment and Prevention of Suicide Risk||We are pleased to announce that Dr. Chris Perlman, associate director, Homewood Research Institute, and his team are the successful recipients of||11/9/2016 5:59:18 PM||367||https://www.patientsafetyinstitute.ca/en/toolsResources||html||True||aspx|
|Engaging Patients in Patient Safety – a Canadian Guide||36605||Guide||4/25/2017 3:01:50 PM|| During the past decade, we have seen evidence that when healthcare providers work closely with patients and their families, we can achieve great things. The healthcare system will be safer, and patients will have better experiences and health outcomes when patients, families, and the public are fully engaged in program and service design and delivery. Patient involvement is also important in monitoring, evaluating, setting policy and priorities, and governance. This work is not easy and may even be uncomfortable at first. Providers may need to let go of control, change behaviours to listen and understand patients more effectively, brainstorm ideas together, build trust, and incorporate many different perspectives. Patients may need to participate more actively in decisions about their care. Leaders must support all this work by revising practices to embed patient engagement in their procedures, policies, and structures. But finding different and innovative ways to work together, even when it's challenging, benefits everyone. When patients and healthcare providers partner effectively, the results are powerful. We invite you to join us in advancing this work. We welcome diverse perspectives and beliefs to challenge the status quo. Let's explore ways to shape new behaviours, using everyone's unique perspectives and courage to make healthcare a safe and positive experience. A deep belief in the power of partnership inspired the Engaging Patients in Patient Safety - a Canadian Guide. Written by patients and providers
for patients and providers, the information demonstrates our joint commitment to achieving safe and quality healthcare in Canada.
Download Better yet, bookmark this page. This resource is updated regularly. To ensure you are accessing the most up-to-date version, we recommend that you bookmark this page for future reference. Who is this guide for? The guide is for anyone involved with patient engagement, including Patients and families interested in how to partner in their own care to ensure safety Patient partners interested in how to help improve patient safety Providers interested in creating collaborative care relationships with patients and families Managers and leaders responsible for patient engagement, patient safety, and/or quality improvement Anyone else interested in partnering with patients to develop care programs and systems While the guide focuses primarily on patient safety, many engagement practices apply to other areas, including quality, research, and education. The guide is designed to support patient engagement in any healthcare sector. What is the purpose of the guide? This extensive resource, based on evidence and leading practices, helps patients and families, patient partners, providers, and leaders work together more effectively to improve patient safety. Working collaboratively, we can more proactively identify risks, better support those involved in an incident, and help prevent similar incidents from occurring in the future. Together we can shape safe, high-quality care delivery, co-design safer care systems, and continuously improve to keep patients safe.What is included in the guide? Evidence-based guidance Practical patient engagement practices Consolidated information, resources, and tools Supporting evidence and examples from across Canada Experiences from patients and families, providers, and leaders Outstanding questions about how to strengthen current approaches Strategies and policies to meet standards and organizational practice requirementsChapter summariesEngaging patients as partners Why partner on patient safety and quality Current state of patient engagement across Canada Evidence of patient engagement benefits and impact Challenges and enablers to patient engagement Embedding and sustaining patient engagement
Read More Partners at the point of care Partnering in patient safety Partnering in incident management
Read More Partners at organizational and system levels Preparing to partner Partnering in patient safety Partnering in incident management
Read More Evaluating patient engagement Introduction to evaluating patient engagement Evaluating patient engagement at the point of care Evaluating patient engagement at the organizational level Evaluating patient engagement integration
Click here to learn how and why was the guide developed.
Citation Patient Engagement Action Team. 2017. Engaging Patients in Patient Safety – a Canadian Guide. Canadian Patient Safety Institute. Last modified February 2018. Available at www.patientsafetyinstitute.ca/engagingpatients ||Engaging Patients in Patient Safety – a Canadian Guide||During the past decade, we have seen evidence that when healthcare providers work closely with patients and their families, we can achieve great||7/24/2018 7:34:54 PM||930||https://www.patientsafetyinstitute.ca/en/toolsResources||html||True||aspx|
|Questions Are the Answer||36606||Checklists;Patient and Family Resource||7/14/2016 9:07:34 PM||Tips and Tools for Talking to Your Healthcare Team Empower yourself with information and tools to help you ask good questions, connect with the right people, and learn as much as you can to keep you or a family member safe while receiving healthcare. Questions Are the Answer helps you effectively prepare for making decisions about medical treatment options by asking the right questions of your healthcare team. It considers topics for before, during, and after appointments, using past, present, and future medicines, medical tests, and surgeries. Always use these resources before you attend any healthcare appointment Questions to ask before an appointment Questions to ask during an appointment Questions to ask after an appointment Overall question checklist SHIFT to Safety helps you advocate for your healthcare safety. Shift your focus to what really matters—the patient. Are you a provider? Please share this valuable resource with your patients! For more information, contact us at firstname.lastname@example.org. Internet Citation Be More Involved in Your Health Care. September 2012. Agency for Healthcare Research and Quality, Rockville, MD.||Questions Are the Answer||Tips and Tools for Talking to Your Healthcare Team Empower yourself with information and tools to help you ask good questions, connect with the||4/5/2017 7:20:44 PM||443||https://www.patientsafetyinstitute.ca/en/toolsResources||html||True||aspx|
|Effective Governance for Quality and Patient Safety||36615||Toolkits||2/23/2010 10:49:46 PM||
Effective Governance for Quality and Patient Safety A Toolkit for Healthcare Board Members and Senior Leaders Safe patient care happens when healthcare service delivery organizations are functioning at the highest levels. Governing boards and senior leaders of healthcare organizations can ensure effective governance and meet their legal responsibilities with the Effective Governance for Quality and Patient Safety Toolkit.
This toolkit teaches healthcare board members, senior executives, and physician leaders across Canada about the tools available to support organizational efforts in improving quality and patient safety. Commissioned research led by Dr. G. Ross Baker (2010), Effective Governance for Quality and Patient Safety in Canadian Healthcare Organizations, identified a number of interdependent drivers that enable boards to fulfill their responsibilities for quality and patient safety.
The resources in this toolkit are organized around each of the key drivers and include Principles of each driver Tools and recommended reading Stories and examples from healthcare organizations
Use this toolkit to strengthen your organization’s performance and to promote and advance safer care.
This symbol, used throughout the toolkit, denotes Canadian references and examples.||Effective Governance for Quality and Patient Safety||Effective Governance for Quality and Patient Safety: A Toolkit for Healthcare Board Members and Senior Leaders||4/24/2018 5:35:19 PM||584||https://www.patientsafetyinstitute.ca/en/toolsResources||html||True||aspx|
|Incident Analysis||36617||Framework;Publication||4/19/2011 9:12:41 PM||
Analyze, manage, and learn from patient safety incidents in any healthcare setting with the Canadian Incident Analysis Framework.
Incident analysis is a structured process for identifying what happened, how and why it happened, what can be done to reduce the risk of recurrence and make care safer, and what was learned. It is an integral activity in the incident management continuum, which represents the activities and processes that surround a patient safety incident.
The framework was developed collaboratively by CPSI, the
Institute for Safe Medication Practices Canada,
Patients for Patient Safety Canada (a patient-led program of CPSI), Paula Beard, Carolyn Hoffman, and Micheline Ste-Marie and is based on the 2006 Canadian Root Cause Analysis Framework.
To learn more about the framework and the resources available, you can
click here to watch the information webinars recorded.
following resources have been carefully selected to support you in implementing the Canadian Incident Analysis Framework.
To contribute a resource or to provide feedback, please email
To learn more about the framework and the learning opportunities available
||Incident Analysis||Root Cause Analysis (RCA)||6/20/2016 3:47:55 PM||966||https://www.patientsafetyinstitute.ca/en/toolsResources||html||True||aspx|