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untilThis virtual workshop will provide participants with background theory and hands-on practice in using a multi-incident analysis to analyse a group of medication incidents that share a common topic on day 1 and introduce a novel tool called the Medication Safety Culture Indicator Matrix (MedSCIM) on day 2. Register- Posted
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untilThis virtual workshop will provide health care professionals with background theory and hands-on practice in incident analysis using Root Cause Analysis (RCA) and in proactive risk assessment using Failure Mode and Effects Analysis (FMEA). Register- Posted
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- Patient safety incident
- Risk assessment
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untilThis virtual workshop will provide health care professionals with background theory and hands-on practice in incident analysis using Root Cause Analysis (RCA) and in proactive risk assessment using Failure Mode and Effects Analysis (FMEA). Register- Posted
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untilThis virtual workshop from the Institute for Safe Medication Practices Canada will provide healthcare professionals with background theory and hands-on practice in incident analysis using Root Cause Analysis (RCA) and in proactive risk assessment using Failure Mode and Effects Analysis (FMEA). Register- Posted
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untilThis virtual workshop from the Institute for Safe Medication Practices Canada will provide healthcare professionals with background theory and hands-on practice in incident analysis using Root Cause Analysis (RCA) and in proactive risk assessment using Failure Mode and Effects Analysis (FMEA). Register- Posted
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untilThis virtual workshop from the Institute for Safe Medication Practices Canada will provide healthcare professionals with background theory and hands-on practice in incident analysis using Root Cause Analysis (RCA) and in proactive risk assessment using Failure Mode and Effects Analysis (FMEA). Register- Posted
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Just Culture and incident investigation
Patient Safety Learning posted an event in Community Calendar
untilThis virtual seminar from the Clinical Human Factors Group will be looking at Just Culture and incident investigation and will feature two of the authors, Jan Davies and Carmella Steinke, of the new book 'Fatal Solution' , a book which describes "how a healthcare system used tragedy to transform itself and redefine Just Culture". In this provocative true story of tragedy, the authors recount the journey travelled and what was learned by, at the time, Canada’s largest fully integrated health region. They weave this story together with the theory about why things fall apart and how to put them back together again. Building on the writings and wisdom of James Reason and other experts, the book explores new ways of thinking about Just Culture, and what this would mean for patients and family members, in addition to healthcare providers. With afterwords by two of the major players in this story, the authors make a compelling case that Just Culture is as much about fairness and healing as it is about supporting a safety culture." To accompany this story Ken Catchpole, Professor of Human Factors at Medical University of South Carolina will discuss a variety of enablers and barriers to learning from clinical safety incidents, based on his perspective within the US health system. This will illustrate the format of incident analysis and response at MUSC; legal and regulatory issues; and the role and impact of human factors and systems engineering. He will also comment on the recent RaDonda Vaught case, and what that tells us about how far we still have to go. Jane O’Hara, Professor of Healthcare Quality and Safety in Leeds will adds a UK perspective to this worldwide issue, together with a session focusing on the view from a pharmacy perspective. Register- Posted
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Content Article
This bulletin from the Canadian Institute for Health Information (CIHI) describes two new in-hospital infections indicators for Clostridium difficile (C. difficile) and Methicillin-Resistant Staphylococcus aureus (MRSA). It includes a table listing CIHI’s selected patient safety performance indicators and definitions.- Posted
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- Healthcare associated infection
- Infection control
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Historically, patient safety efforts have focused mostly on measuring and responding to harm. However, safety is much more than the absence of harm. Instead, patient safety includes looking at the whole system: its past, present and future in all its complexity. Healthcare Excellence Canada and Patients for Patient Safety Canada held many conversations with users of the health system, people who work in healthcare and safety scientists. The ideas collected suggest a new way of approaching patient safety – where everyone can contribute to creating safe conditions and where harm is more than physical. This discussion guide summarises what has been learned so far and captured in this key statement: Everyone contributes to patient safety. Together we must learn and act to create safer care and reduce all forms of healthcare harm.- Posted
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- Canada
- Patient safety strategy
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In this blog, Sling the Mesh founder Kath Sansom highlights the variation in medical treatment depending on where you live in the world. Describing patient safety advocacy as "like a giant game of chess—but a hideous version where innocent people get hurt," she describes recent developments in the use of pelvic mesh globally. New Zealand recently suspended the use of a particular type of pelvic mesh at the same time as a Canadian study recommended its use for stress urinary incontinence (SUI). Kath gives a brief history of mesh sling suspension and argues that patient safety needs joined up thinking to protect women around the world.- Posted
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- Medical device
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News Article
Canada: 6 Saskatchewan ICU patients with COVID-19 being transferred to Ontario
Patient Safety Learning posted a news article in News
Saskatchewan will be transferring six COVID-19 patients to Ontario over the next 72 hours as the Prairie province struggles to deal with a record number of intensive care patients. One patient will be transferred Monday, with the other five expected by end of day Wednesday, according to the Saskatchewan Health Authority (SHA). Premier Scott Moe said planning for transferring patients has been going on for "a number of days" and that patients will be transferred to ensure they receive "the very best possible care that they can." Additional out-of-province support that may be required beyond Wednesday is being finalized, according to the SHA. "We recognize the stress this will cause the families affected," SHA CEO Scott Livingstone said in a news release Monday morning. "We continue to work every day to maximize capacity to provide care as close to home as possible, but this decision is necessary to maintain the quality of critical care services our patients need." Read full story Source: CBC News, 18 October 2021- Posted
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News Article
Toronto, Canada, will launch a pilot programme that will see civilians, not police officers, dispatched to 911 calls involving mental health crises — as long as violence is not being threatened. Council also approved a motion by Mayor John Tory to fast-track parts of the plan and review 911 call services in 2021 to determine how best to dispatch help through the proposed new service. The plan calls for four crisis support teams in different parts of the city, to respond to some of the roughly 30,000 calls for people in crisis that go through 911 each year. Pilot programmes are to be launched in early 2022, and were scheduled to be fully implemented in 2026 if proven successful. Tory’s motion called for full implementation by 2025. “Putting something else in place is not a simple task. It is necessary that we do it properly,” said Tory, in bringing forward the motion. Nonetheless, the mayor said, he believes it can be done more quickly. Asante Haughton, a mental health advocate and co-founder of the Reach Out Response Network, focused on transformational change in mental-health crisis response, said the move is another rung on the ladder to a more equitable society. “I really see this as an opportunity to transform the way that we think about mental health and transform the way that we think about social service and community building in general,” he said. Read full story Source: Toronto Star, 2 February 2021 -
News Article
Logan Giesbrecht left his dream job as an emergency room nurse when the mental health strain of an understaffed department became unbearable, even before the pandemic's fourth wave hit and anti-vaccination protesters began gathering outside hospitals. “The biggest frustration, and what I'm taking home from work, was basically doing the job of more than one nurse,” said Giesbrecht, who feared low staffing levels would risk patient safety. He quit working at Royal Inland Hospital in Kamloops, Canada, last April. Representatives for nurses around the country are calling on the federal government to come up with a national plan to attract and retain nurses during a “crisis” they say needed action long before the uptick in cases from the Delta variant. Statistics Canada released data this week from the second quarter of 2021 showing a steep rise in job vacancies for both registered nurses and registered psychiatric nurses, which are part of a single category in its analysis. Those professions had the largest increase in vacancies of all occupations over a two-year period, up by 10,400 to 22,400 - a hike of nearly 86 per cent, the agency said, adding nearly half of the vacancies had been open for 90 days or more, compared with 24 days across all occupations. Linda Silas, president of the Canadian Federation of Nurses Unions, said it's not uncommon for some registered nursing positions to be vacant for a couple of weeks, as workers switch jobs within a hospital or health region, but having vacancies unfilled for 90 days or longer is unsustainable. Read full story Source: CP24 News, 24 September 2021- Posted
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Think back to 2006 and recall what you knew about patient safety, and patients as partners in safety. Now, pause for a second to reflect on where we are now, in 2021. Then, imagine what you want patient safety to look like in 15 years – 2036 to be specific. Join the Canadian Patient Safety Insitute in exploring how patients, families and communities have helped shape patient safety in the past 15 years, and contribute your thoughts on how we can accelerate safety efforts together in the next 15 years. In celebration of Patients for Patient Safety Canada's 15th anniversary, we will share our journey so far, our successes, and our dream: "EVERY PATIENT SAFE". Register- Posted
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- Patient
- Patient / family involvement
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Content Article
This article in the Journal of Interprofessional Care highlights the challenges experienced by programme leaders and healthcare professionals as they work to improve patient safety. It discusses the complexities of translating organisation-wide speaking-up policies to local practices and settings.- Posted
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- Speaking up
- Whistleblowing
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Content Article
This study in BMC Health Services Research aimed to evaluate the impact of an Internet of Things intervention in a hospital unit. The Internet of Things refers to a network of physical objects that are connected by sensors, software and other technologies in order to transfer data and interact with one another. This study demonstrates the effects of smart technologies on patient falls, hand hygiene compliance rate and staff experiences. The authors reported some positive changes that were also reflected in interviews with staff. They identified behavioural and environmental issues as being particularly important to ensure the success of Internet of Things innovations in a hospital setting.- Posted
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- Technology
- Hospital ward
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Content Article
Falling through the cracks: Greg’s story
Patient Safety Learning posted an article in Patient stories
Falling Through the Cracks: Greg’s Story is a short film on Greg Price’s journey through the healthcare system. The film gives a glimpse of who Greg was and focuses on the events of his healthcare journey that ended in his unexpected and tragic death. In spite of the sadness of Greg’s Story, the message of the film is intended to inspire positive change and improvement in the healthcare system. Greg's family believe the film will resonate with the audience and create a platform for further dialogue. They hope people will feel empowered and challenge the status quo of the current healthcare system so we all end up with better care and outcomes.- Posted
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- Organisation / service factors
- Patient death
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Content Article
One box of chemicals mistaken for another. Ingredients intended to be life-sustaining are instead life-taking. Families in shock, healthcare providers reeling and fingers starting to point. A large healthcare system’s reputation hangs in the balance while decisions need to be made, quickly. More questions than answers. People have to be held accountable – does this mean they get fired? Should the media and therefore the public be informed? What are family members and the providers involved feeling? When the dust settles, will remaining patients be more safe or less safe? In this provocative true story of tragedy, the authors recount the journey travelled and what was learned by, at the time, Canada’s largest fully integrated health region. They weave this story together with the theory about why things fall apart and how to put them back together again. Building on the writings and wisdom of James Reason and other experts, the book explores new ways of thinking about Just Culture, and what this would mean for patients and family members, in addition to healthcare providers. With afterwords by two of the major players in this story, the authors make a compelling case that Just Culture is as much about fairness and healing as it is about supporting a safety culture.- Posted
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- Just Culture
- Safety culture
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Content Article
The purposes of the Canadian Medication Incident Reporting and Prevention System (CMIRPS) programme are to:Coordinate the capture, analysis and dissemination of information on medication incidents;Enhance the safety of the medication use system for Canadians.Support the effective use of resources through the reduction of potential or actual harm caused by preventable medication incidents.The goals of the CMIRPS information system are to:Collect data on medication incidents.Facilitate the implementation of reporting of medication incidents.Facilitate the development and dissemination of timely, targeted information designed to reduce the risk of medication incidents (e.g. ISMP Canada Safety Bulletins).Facilitate the development and dissemination of information on best practices in safe medication use systems.- Posted
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Canadian Institute for Health Information
Patient Safety Learning posted an article in International patient safety
The Canadian Institute for Health Information (CIHI) provides comparable and actionable data and information that are used to accelerate improvements in health care, health system performance and population health across Canada. Stakeholders use the broad range of health system databases, measurements and standards, together with the evidence-based reports and analyses, in their decision-making processes.- Posted
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- Canada
- Information sharing
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Content Article
The Culture Change Toolbox is a collection of tools and interventions for changing culture. It’s full of ideas, examples, and exercises. For each tool there are tips on how to apply it and a description of which components of culture it helps to improve. This latest version includes: the latest evidence on culture change a refreshed format with an improved flow for learning new activities and resources for teams examples from across the continuum of care.- Posted
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- Organisational culture
- Staff safety
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Content Article
Patients, families, and care providers affected by patient safety incidents expect there will be learning and improvement so that others will not suffer. For that, countries need mature data systems and a culture of safety that includes improving by learning from reporting hazards, harm, and near misses, as well as learning from situations and organisations where safe care is delivered consistently over time, which is in most cases. In this article, Ioana Popescu discusses patient safety in Canada. While systems are in place to support incident reporting, sharing, and learning from a variety of sources, in Canada truly national incident reporting is limited to medications, adverse drug reactions, and device failures. However, there are other pan-Canadian and grassroots efforts to advance reporting and learning from patient safety incidents that are complementary.- Posted
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- Canada
- System safety
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Content Article
This article discusses how medication safety can be improved in Canada. It explores the complexities of aging, what can go wrong with medication, 'Best Possible Medication Histories', the role of pharmacists and paramedics, engaging with patients and their families, and improving communication across the healthcare system.- Posted
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- Medication
- Adminstering medication
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Content Article
This editorial in BMJ Quality & Safety looks at the need for urgent improvement in the test result management and communication process in primary care. The authors highlight the inconsistency in tracking and communicating test results and look at potential solutions to reduce the patient safety risks associated with test results. They look at the evidence surrounding automated alerts built into provider IT systems and giving patient direct access to test results through apps, highlighting the growing importance of patients in safeguarding their own care through actively pursuing test results.- Posted
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- Diagnosis
- Communication
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Content Article
Safety conversations are an important step in building a proactive patient safety culture. They’re a respectful discussion about safety between two or more people involved in organising, delivering, and seeking or receiving care. This collection of tools and resources, from quick tip sheets to comprehensive reports and frameworks, aims to help healthcare professionals to have effective safety conversations and support safer care of older adults.- Posted
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- Canada
- Communication
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