Patient Safety on Longwoods.com

On the Journey to a Culture of Patient Safety

Tue, 23 Sep 2008 13:05:51 -0400

In 2005, our hospital participated in a Canadian Council on Health Services Accreditation (CCHSA) Patient Safety Cultural Assessment project. Online survey results collected and analyzed by CCHSA demonstrated numerous opportunities for our organization to improve its patient safety culture. An eight-point Patient Safety Plan was created, and over the following two years, numerous patient safety initiatives were implemented. In 2007, the Patient Safety Cultural Assessment was repeated using the same survey instrument and an online survey response method. Results showed only very minor positive improvements in our culture.

Indicator Madness: A Cautionary Reflection on the Use of Indicators in Healthcare

Fri, 20 Jun 2008 09:51:10 -0400

Indicators are increasingly being used to monitor and evaluate health system performance. However, although indicators can provide valuable information, they also have limitations. The benefits of indicators are vitiated when they are seriously flawed (unreliable, invalid or easily "gamed"), selected before the right question has been posed or used to the exclusion of other sources of information. This critical assessment of the use and misuse of indicators employs practical examples from a Canadian health authority to illustrate common pitfalls. It concludes with some solutions to optimize the benefits of indicator use.

Commentary: Indicators with a Purpose - Meaningful Performance Measurement and the Importance of Strategy

Fri, 20 Jun 2008 09:51:32 -0400

Sarah Bowen and Sara Kreindler argue that indicators can be valuable, but are also often flawed. They suggest that performance indicators should at best serve as a flag for policy makers but should not drive decisions. We would argue that there is growing evidence of the positive impact of performance indicators. When performance indicators are selected based on sound strategies - and used as part of a clear performance management cycle that balances policy instruments (e.g., accountability agreements) and performance improvement processes (e.g., process redesign) - they can drive valuable performance improvements and help align strategies across all health system partners.

The Authors Respond

Fri, 20 Jun 2008 09:52:08 -0400

Adalsteinn Brown and Jeremy Veillard have done an excellent job of outlining the gains that may be achieved from performance measurement, and the context for increased focus on this area. We do not suggest that indicators should not be used, or cannot be useful. We believe, however, that it is important to differentiate between the efficacy of indicators (their potential in ideal situations) and their effectiveness (what we see happening in actuality). The observation that the Veterans' Administration and Institute for Healthcare Improvement are using indicators in appropriate and helpful ways does not imply that every local health authority or hospital is doing the same. There remains a need for caution - not about the fact that indicators are used, but about the way they are used.

Toward a Model of Successful Electronic Health Record Adoption

Fri, 6 Jun 2008 10:01:21 -0400

The Canadian healthcare landscape abounds with pressures to address wait times, chronic disease management, aging at home, information and service integration, health human resource shortages, pandemic planning and most importantly health outcomes of individuals receiving care in our system. Investment in clinical information technologies is often touted as significant to the successful resolution of most if not all of these issues. For example, Baker and Norton (2001) uncovered an alarming rate of preventable adverse events occurring within Canadian hospitals. A particularly high error rate associated with the administration of fluids and medications suggests that there is a dire need to introduce processes and tools to reduce human error in healthcare facilities. The implementation of clinical applications such as computerized physician order entry (CPOE) with integrated electronic medication administration records (MAR) has been identified as a key step to safer care (Bates and Gawande 2003; Leape et al. 2002; Leatt et al. 2006). It has been suggested that the full value of electronic health records (EHR) will only be realized with the implementation of CPOE and that its use (by physicians) is a reasonable proxy for adoption (Ash and Bates 2005). Considering recent surveys of Canadian and American hospitals, those that have fully implemented CPOE remain in the minority (Ash et al. 2004; Davis 2007; Gudbranson 2007); most have yet to tackle the challenges of the change imperative and adoption issues associated with the use of a complete EHR.

Practice Changes to Improve Delivery of Surgical Antibiotic Prophylaxis

Tue, 15 Apr 2008 11:52:51 -0400

Timely administration of appropriate antibiotics preoperatively can decrease the incidence of surgical site infection. We evaluated compliance with quality indicators in the delivery of antimicrobial surgical prophylaxis at The Ottawa Hospital and assessed the impact of a change to the hospital's Surgical Prophylaxis Policy.

An Evaluation of a Fall Management Program in a Personal Care Home Population

Tue, 15 Apr 2008 11:52:38 -0400

Falls are a common problem among institutionalized adults, often resulting in serious negative consequences (Tideiksaar 2002). Fortunately, many of these falls are preventable (Tideiksaar 2002). However, there has been a recent shift from a fall "prevention" approach to one of fall "management," which aims at preventing injuries rather than falls. Falling is regarded as indicative of activity, which strengthens muscles, improves balance, and ultimately reduces the risk of falling (North Eastman Health Association Inc. 2005). For this research, the effectiveness of a fall "management" program that has been implemented in five provincial personal care homes (PCHs) in a Manitoba rural regional health authority will be evaluated. Fall-related administrative data will be analyzed to determine if there are differences (i) within the study sites over time (from pre- to post-intervention) and (ii) between the study and comparison sites. Qualitative information from staff interviews and chart audits will supplement the quantitative information.

Prevention of Ventilator-Associated Pneumonia in the Calgary Health Region: A Canadian Success Story!

Tue, 15 Apr 2008 11:52:29 -0400

This article describes the experiences of a Canadian multidisciplinary critical care team striving to reduce the incidence of ventilator-associated pneumonia (VAP). Several interventions, including a VAP bundle, were used and applied across a health region. Our regional VAP rate has seen a steady decline over the past 12 months and has been largely under our goal of 9.8 cases per 1,000 ventilator-days. The team's success in lowering VAP has provided the momentum for sustained improvement, which has spread to other areas.

Using Human Factors Methods to Evaluate the Labelling of Injectable Drugs

Tue, 15 Apr 2008 11:51:59 -0400

Adverse drug events, including in-hospital medication errors, are a well-documented world-wide problem. This interdisciplinary team set out to examine the issues related to the labelling of injectable drugs. We sought answers to the following two questions: (1) To what extent do injectable drug labels adhere to existing Canadian design practice recommendations and regulations for labelling and (2) is there a need to make changes to the recommendations or regulations for labelling of injectable drugs in Canada? The project contained three phases. The first phase involved taking a sample of vials and ampoules from a hospital pharmacy and identifying adherence to the 1999 Canadian Standards Association standard for the labelling of drug ampoules, vials and prefilled syringes, as well as with the Canadian (Health Canada) Food and Drug Regulations for labelling. The second phase involved a failure mode and effects analysis of the label-reading process in order to identify information on the label considered critical for safe medication use. The third phase involved a preliminary human factors experiment addressing one problem identified with existing labels. Our finding is that existing injectable drug labels do not adhere sufficiently to available best design standards for labels and also do not adhere to all Canadian Food and Drug Regulations. Recommendations are made to inform future enhancements to labelling standards, guidelines and regulations.

An Intervention Program to Reduce Falls for Adult In-Patients Following Major Lower Limb Amputation

Tue, 15 Apr 2008 11:51:46 -0400

A qualitative and quantitative assessment was conducted regarding falls sustained by in-patients receiving rehabilitation therapy following major lower limb amputation at the Glenrose Rehabilitation Hospital. During the nine-month assessment period, 18 of 58 patients in the amputee unit experienced a fall, of which 17% resulted in a moderate injury. The majority of falls occurred during patients' use of a wheelchair (14 of 18) and involved poor balance (nine of 14). Patient wheelchair self-transfers accounted for 71% (10 of 14) of the falls, while sitting in the wheelchair and reaching represented 29% (four of 14). The hospital's rehabilitation program teaches patient safety including using assistive devices such as wheelchairs but did not include a comprehensive graded learning path to monitor patients' ongoing risk for falls.

Safe Medication Swallowing in Dysphagia: A Collaborative Improvement Project

Tue, 15 Apr 2008 11:51:31 -0400

Episodes of choking during medication administration to patients with dysphagia prompted a chart audit and caregiver interview to identify system problems that allowed inappropriate drug administration to occur. Sixty elderly patients residing on two patient care areas in a 500-bed complex continuing care facility were studied. The audit explored the actual nursing medication administration methods and compared this to the information obtained from various communication tools including instructions that appeared on the medication administration record (MAR), the current diet order, the recommendations of the speech-language pathologist (SLP) and comments on the nursing care plan. The audit yielded a number of discrepancies between nursing actions and the instructions obtain from these sources.

Improving Patient Safety through a Multi-faceted Internal Surveillance Program

Tue, 15 Apr 2008 11:51:08 -0400

Surveillance, a method used in epidemiology to study the incidence, distribution and control of disease, is an important means of gathering and analyzing information that can be used as needed to effect change. Surveillance has been an important component of the Blueprint for Patient Safety at the Hospital for Sick Children to identify potential and existing vulnerabilities and failures and put measures in place to avoid and mitigate any harm. Reviewing internal reports and actively seeking vulnerabilities has allowed us to make important changes to improve patient safety at the hospital. In this article, we review four internal surveillance strategies that have been particularly successful in driving change - safety reports, morbidity and mortality reviews, patient safety walkarounds and shoe leather infection control rounds - and discuss the successes and challenges we have experienced.

Canadian Patient Safety Champions: Collaborating on Improving Patient Safety

Tue, 15 Apr 2008 11:50:53 -0400

Patients for Patient Safety Canada champions have grown in numbers and purpose since their initiation into the World Health and Pan-American Health Organizations' Patients for Patient Safety initiative in May 2006. The 25 Canadian patients and family members not only share their adverse event experiences but are actively engaged in collaboration with health professionals, administrators and decision-makers to initiate proactive patient safety strategies. Their intention is to have their stories heard as tools for learning. They also wish to raise local, regional and national awareness of patient safety problems. The different patient and family stories and experiences share some common issues and suggested solutions that might make a difference in patient safety. One key solution is involving patients and families not only in discussions of treatment and follow-up when adverse events occur but also proactively on patient safety advisory committees. These actions would acknowledge a common interest in seeing that the right things are done. Patients and families share the common interest of all those advocating for patient safety, namely, First do no harm (attributed to Hippocrates, circa 470-360 B.C.). The patients and families of Patients for Patient Safety Canada are a group of committed, dedicated individuals who should be acknowledged for sharing their experiences and trying to make a difference in patient safety.

"It's Safe to Ask": Promoting Patient Safety through Health Literacy

Tue, 15 Apr 2008 11:50:40 -0400

The Manitoba Institute for Patient Safety launched "It's Safe to Ask" in January 2007. The communication and health literacy initiative is aimed at Manitoba's vulnerable populations and their primary care providers. Phase 1 includes a poster and brochure for patients and a toolkit for providers/organizations, pilot tested in six sites in Manitoba. Posters will serve as a symbol that dialogue is encouraged. Tools, available in 15 languages, provide patients and family members with three key questions to ask in healthcare interactions, tips on how to ask questions, and room for notes and listing of medications. The initiative will promote involvement in healthcare by patients, stronger communication between patient and provider, and reduction of risk for adverse events. "It's Safe to Ask" has been implemented in over 65 sites across Manitoba. A formal evaluation is underway. Phase 2 and 3 will enhance key tools and include interventions with specific populations.

Giving Back the Pen: Disclosure, Apology and Early Compensation Discussions after Harm in the Healthcare Setting

Tue, 15 Apr 2008 11:50:20 -0400

In her recently published book After Harm, Nancy Berlinger shares a story about Bishop Desmond Tutu as he comments on the importance of restitution or compensation after an event that has led to harm. Transparency and disclosure are very much on the healthcare agenda in Canada. The increased interest in training providers for difficult conversations and disclosure is a positive sign. Using honest disclosure and apology as important interventions, organizations are beginning to adopt a more open approach to the concept of rebuilding trust after a patient has been harmed. But there continues to be significant reluctance to take the next logical step to solidify the fiduciary relationship between provider and patient - the willingness to enter into early discussions about compensation, non-monetary and otherwise.

Communities of Practice: Creating Opportunities to Enhance Quality of Care and Safe Practices

Tue, 15 Apr 2008 11:49:58 -0400

A Communities of Practice (CoPs) approach was used to enhance interprofessional practice in seven clinical sites across Alberta. Participating staff were free to decide the area of practice to focus on and the actions to be implemented. All practice changes implemented by the CoPs related to either improving communications (e.g., introduction of joint care meetings) or information transfer (e.g., streamlining of admission and discharge processes). The practice changes contributed to more effective communication of information and more effective transitions of patients between providers, hence potentially reducing errors.

Effectiveness of an Adapted SBAR Communication Tool for a Rehabilitation Setting

Tue, 15 Apr 2008 11:49:34 -0400

Effective communication and teamwork have been identified in the literature as key enablers of patient safety. The SBAR (Situation-Background-Assessment-Recommendation) process has proven to be an effective communication tool in acute care settings to structure high-urgency communications, particularly between physicians and nurses; however, little is known of its effectiveness in other settings. This study evaluated the effectiveness of an adapted SBAR tool for both urgent and non-urgent situations within a rehabilitation setting.

Communication and Relationship Skills for Rapid Response Teams at Hamilton Health Sciences

Tue, 15 Apr 2008 11:49:15 -0400

Rapid response teams (RRT) are an important safety strategy in the prevention of deaths in patients who are progressively failing outside of the intensive care unit. The goal is to intervene before a critical event occurs. Effective teamwork and communication skills are frequently cited as critical success factors in the implementation of these teams. However, there is very little literature that clearly provides an education strategy for the development of these skills. Training in simulation labs offers an opportunity to assess and build on current team skills; however, this approach does not address how to meet the gaps in team communication and relationship skill management. At Hamilton Health Sciences (HHS) a two-day program was developed in collaboration with the RRT Team Leads, Organizational Effectiveness and Patient Safety Leaders. Participants reflected on their conflict management styles and considered how their personality traits may contribute to team function. Communication and relationship theories were reviewed and applied in simulated sessions in the relative safety of off-site team sessions. The overwhelming positive response to this training has been demonstrated in the incredible success of these teams from the perspective of the satisfaction surveys of the care units that call the team, and in the multi-phased team evaluation of their application to practice. These sessions offer a useful approach to the development of the soft skills required for successful RRT implementation.

Survey of Nursing Perceptions of Medication Administration Practices, Perceived Sources of Errors and Reporting Behaviours

Tue, 15 Apr 2008 11:48:59 -0400

In January 2003, St. Mary's Hospital Center in Montreal, Quebec, established an interdisciplinary Committee on the Systematic Approach to Medication Error Control to review the whole process of medication administration within the hospital and to develop a systematic approach to medication error control. A cross-sectional survey on medication administration practices, perceived sources of errors and medication error reporting of nurses, adapted from a nursing practice survey and medication variance report (Sim and Joyner 2002), was conducted over a two-week period in February 2004. The results were analyzed by years of experience (greater or less than five years) and patient care unit of practice. The perceived source of error most often cited was transcription (processing), and the second most frequently cited source was the legibility of handwritten medication orders (prescribing).

Medication Safety in the Operating Room: Teaming Up to Improve Patient Safety

Tue, 15 Apr 2008 11:48:20 -0400

A medication safety project for operating rooms (ORs) was initiated under the leadership of the Departments of Anesthesia and Nursing with a representative from the Canadian Anesthesiologists' Society and the Institute for Safe Medication Practices Canada. The aims of the collaborative project were twofold: (1) to identify areas of exposure to risk and make recommendations to enhance medication safety within the hospital and (2) to inform the development of a medication safety checklist specific to the OR setting. The strategies developed and implemented during this project were aimed at reducing the risk of injury induced by medications. Attempts were made to use feasible best practices and managerial support systems for defined areas - in this case, medication-use systems for the ORs and associated patient care areas. The learning from this project will also inform the development of a medication safety checklist for use by other hospitals and OR settings.

Development of Canadian Safety Indicators for Medication Use

Tue, 15 Apr 2008 11:48:00 -0400

Reports of preventable illness due to medication errors are widespread in Canada. However, quantifying the magnitude of the problem has been hampered by a lack of measurement tools. Canadian-specific indicators, or performance measures, of safe medication use do not exist. The objective of this study was to develop a set of Canadian consensus-based indicators for the safe use of medication for both in-patient and outpatient settings.

Using ISMP Canada's Framework for Failure Mode and Effects Analysis: A Tale of Two FMEAs

Tue, 15 Apr 2008 11:47:46 -0400

Patient safety concerns in healthcare are not new or unexpected, and one goal of all healthcare organizations is to provide the safest possible care for patients and their families. With that goal in mind, Annapolis Valley Health, a rural district health authority in Nova Scotia, identified the need to develop expertise in the use of failure mode and effects analysis (FMEA) as a tool to promote quality processes within the organization. Staff members were aware of the value of this type of analysis but also recognized that real learning would best be achieved through completing an FMEA of an existing process or situation, rather than through a simulation or staff training. Annapolis Valley Health identified two high-risk situations requiring attention: transcription of medication orders for in-patients and overcrowding in the emergency department. The Institute for Safe Medication Practices Canada provided training and support to two staff teams and visited the organization eight months later for an update on progress. This article chronicles the journey of Annapolis Valley Health to improve patient safety through the application of FMEA to two high-risk processes for one of its hospital sites.

Nursing Education: A Catalyst for the Patient Safety Movement

Tue, 15 Apr 2008 11:47:29 -0400

Creating a culture of safety in healthcare systems is a goal of leaders in the patient safety movement. Commitment of leadership to safety in the Saskatchewan Institute of Applied Science and Technology (SIAST) Nursing Division has resulted in the development of the Patient Safety Project Team (PSPT) and a steady shift in the culture of the organization toward a systems approach to patient safety. Graduates prepared with the competencies necessary to be diligent about their practice and skilled in determining the root causes of system error in healthcare will become leaders in shifting the healthcare culture to strengthen patient safety. The PSPT believes this cultural shift begins with the education system. It involves modifications to curricula content, facilitation of multidisciplinary processes, and inclusion of theory and practice that reflect critical inquiry into healthcare and nursing education systems to ensure patient safety.

Broadening the Patient Safety Agenda to Include Safety in Long-Term Care

Tue, 15 Apr 2008 11:47:03 -0400

The recent patient safety literature has included less of an emphasis on long-term settings than on research in the acute care sector. Recognizing this knowledge gap in our understanding of safety in the long-term care sector, the Canadian Patient Safety Institute, Capital Health (Edmonton) and CapitalCare (Edmonton) have collaborated to create a research and action agenda for improving resident safety in Canadian long-term care settings. This collaboration resulted in the development of a background paper highlighting the current state of the science and 14 key-informant interviews with stakeholders across Canada. The background paper subsequently informed an invitational round-table discussion. Key findings from the key-informant interviews as well as implications for research are described in this article.

Developing a Patient Safety Plan

Tue, 15 Apr 2008 11:46:44 -0400

Many healthcare organizations are focused on the development of a strategic plan to enhance patient safety. The challenge is creating a plan that focuses on patient safety outcomes, integrating the multitude of internal and external drivers of patient safety, aligning improvement initiatives to create synergy and providing a framework for meaningful measurement of intermediate and long-term results while remaining consistent with an organizational mission, vision and strategic goals. This strategy-focused approach recognizes that patient safety initiatives completed in isolation will not provide consistent progress toward a goal, and that a balanced approach is required that includes the development and systematic execution of bundles of related initiatives.

Implementation of a Safety Framework in a Rehabilitation Hospital

Tue, 15 Apr 2008 11:46:29 -0400

This patient safety initiative was implemented at the Toronto Rehabilitation Institute, a fully affiliated hospital of the University of Toronto that operates in-patient and outpatient facilities on five sites. A working group was created to engage the leaders and employees in defining and implementing our "ideal" safety culture.

An Evaluation of Patient Safety Leadership Walkarounds

Tue, 15 Apr 2008 11:46:06 -0400

Patient safety leadership walkarounds (PSLWA) have been identified as an effective tool to improve patient safety culture. At Hamilton Health Sciences, after one year of monthly PSLWA in all clinical and service programs, 1,351 patient safety issues were identified, of which 64-80% have been resolved or have active improvement work in progress. Five hundred staff were invited to complete a process evaluation regarding the effectiveness of the current process of PSLWA.

Patient Safety Papers: Perspectives

Tue, 15 Apr 2008 11:45:35 -0400

[No abstract available for this article.]

Patient Safety Papers: Editorial

Tue, 15 Apr 2008 11:44:35 -0400

Responses to the two previous issues of Patient Safety Papers suggest that there is a large audience for descriptions of effective patient safety practices. While few would argue that Canadian healthcare is measurably safer today than it was five years ago, there are important initiatives that have laid the groundwork for improvements. For example, the Safer Healthcare Now! (SHN) campaign has engaged teams across the country in six critical areas where current performance has lagged behind knowledge of what is needed for safer care. Yet, SHN nicely illustrates the continuing challenges to improve safety. Even with evidence-based bundles of changes, useful metrics to assess improvement and well-orchestrated supports for teams, overall progress in SHN is uneven: some teams have been very successful, but others struggle to make and sustain improvements in their performance.

Improving Patient Safety through Computerized Drug Management: The Devil Is in the Details

Fri, 18 Jan 2008 10:10:43 -0500

Electronic prescribing and computerized drug management can improve the safety, quality and cost-effectiveness of prescribing. However, if the problems that lead to avoidable adverse events are not addressed by information technology, there is a risk of making considerable investment without the expected return of error reduction and improved patient safety. Improving the safety of prescribing is particularly important in ambulatory care, where most drugs are prescribed. To improve patient safety, IT solutions should be developed that provide: (1) access to the list of all currently active drugs, (2) alerts for relevant prescribing problems (therapeutic duplication, excess dose, dose adjustment for weight [children, elderly] and renal impairment, drug-disease, drug-drug, drug-age and drug-allergy contraindications), (3) the capacity to electronically submit medication stop orders to the dispensing pharmacy and (4) integration of electronic prescriptions (e-rx) into pharmacy software to avoid transcription errors. To improve quality of prescribing, IT solutions should be capable of providing physicians with reminders and alerts for evidence-based preventive care and disease management based on patient-specific drug, disease, therapeutic intent and other relevant clinical information. To improve the cost-effectiveness of prescribing, IT solutions should be developed to provide the cost of medication at the time the prescription is written, and evidence-based alerts for drugs of choice recommendations when appropriate.

Electronic Health Records and Patient Safety: What lessons can Canada learn from the experience of others?

Fri, 18 Jan 2008 10:10:25 -0500

It is recognized that the Electronic Health Record (EHR) has significant potential to improve patient safety in Canada. However, the scientific evidence connecting EHRs to improvements in patient safety is incomplete. Additionally, international experience has demonstrated that EHRs trigger profound cultural and organizational changes in healthcare delivery. Consequently, Canada has a unique opportunity to learn from these experiences. A three-way partnership was established between Canada Health Infoway, the Canadian Patient Safety Institute (CPSI), and the Integrated Centre for Care Advancement through Research (iCARE); to explore opportunities for enhancing patient safety through the implementation and use of EHRs.

Thorough Planning and Full Participation by Pharmacists Is Key to MOE/MAR Success

Wed, 15 Nov 2006 11:25:09 -0400

The successful implementation of the University Health Network's (UHN) Medication Order Entry/Medication Administration Record (MOE/MAR) project was dependent on the Pharmacy department working collaboratively with many other stakeholders in the organization. This paper highlights the Pharmacy department's contribution to MOE/MAR by assessing four main areas: (1) the Pharmacy department's role in developing the technical MOE/MAR solution; (2) Pharmacy department staffing challenges; (3) workflow changes and "workarounds"; and (4) clinical practice changes to support the implementation. While some of the patient safety benefits from MOE/MAR will be alluded to in this paper, more detailed analysis of MOE/MAR benefits are found in "The Benefits of the MOE/MAR Implementation: A Quantitative Approach" (see p. 77 in this issue).

Low-Cost Rapid Usability Engineering: Designing and Customizing Usable Healthcare Information Systems

Fri, 15 Sep 2006 11:19:46 -0400

It is essential that the healthcare systems we develop are usable, meet user information needs and are safe. To ensure system usability, a variety of methods have emerged from the area of usability engineering and have been adapted to healthcare. The authors have been applying methods of usability engineering, working with hospitals and companies to develop more usable healthcare information systems for over 15 years. Based on our current work at the University of Victoria, we describe how to set up a low-cost portable laboratory that can rapidly evaluate the usability and safety of healthcare information systems both in artificial mocked-up settings and in real clinical contexts (e.g., in hospital wards).

CIHI Survey: In-Hospital Hip Fractures in Canada: Using Information to Improve Patient Safety

Wed, 15 Sep 2004 11:13:55 -0400

Few people anticipate breaking their hip after being admitted to hospital, yet new data demonstrate the magnitude of this problem in Canadian hospitals. Most hip fractures occur in the community, but nearly one in 1,000 seniors admitted to hospital fracture a hip during their stay. Not surprisingly, patient falls or injuries were the second-most-common patient safety concern identified by Canadian healthcare organizations in a 2002 survey (Baker and Norton 2002). The rate of in-hospital falls for seniors is one of a series of patient safety indicators at the regional, provincial/territorial and national levels, recently developed at the Canadian Institute for Health Information (CIHI). Originally adapted from indicators developed by the U.S. Agency for Health Research and Quality (ARHQ), the CIHI in-hospital hip fracture indicator was tailored for use with Canadian data and in our healthcare system.

Academy of Canadian Executive Nurses Annual Report, 2003-04

Mon, 15 Nov 2004 11:12:56 -0400

The year 2003-04 was characterized by significant expansion of strategic alliances with key national healthcare organizations and government, successful completion of several patient safety and nursing workload initiatives and preparation for the development of a permanent secretariat in Ottawa for the Academy. These were the particular directions chosen for the Academy at the 2003 annual meeting.

University Health Network Achieves Over 85% CPOE with Misys CPR, Improves Accuracy and Saves Time

Wed, 15 Nov 2006 10:39:58 -0400

The implementation of a computerized physician order entry (CPOE) and medication administration system may seem at first glance to be primarily an information technology (IT) challenge. Yet those institutions that have implemented these applications have discovered that success is often more dependent upon behavioural changes in the medical staff. The fact is, putting the world's most advanced technology at a physician's fingertips does not provide any guarantee that he or she will not simply bypass the system by scribbling out a prescription.

CIHR Research: Addressing the Effects of Adverse Events: Study Provides Insights into Patient Safety at Canadian Hospitals

Wed, 15 Sep 2004 10:38:29 -0400

We live in an exciting era, where new therapeutic discoveries move quickly from the research bench to the patient bedside. Yet in implementing these discoveries and providing care, defences sometimes fail, resulting in a preventable adverse event. On May 25, 2004, the first national study to examine the problem of adverse events in Canadian hospitals, led by the authors of this paper and involving researchers from seven Canadian universities, was published in the Canadian Medical Association Journal (CMAJ). Funded by the Canadian Institutes of Health Research (CIHR) and the Canadian Institute for Health Information (CIHI), the Canadian Adverse Events Study found that, in 2000, the overall rate of adverse events was 7.5 per 100 patients admitted, not including pediatric, obstetric and psychiatric admissions. In other words, approximately 185,000 of the 2.5 million similar medical and surgical admissions in Canadian hospitals in 2000 were associated with an adverse event. In the study, we used a definition of adverse event that has been applied to similar studies elsewhere. An adverse event is an "unintended injury or complication resulting in death, disability or prolonged hospital stay caused by healthcare management rather than the patient's underlying condition."

ACAHO/ACEN Comment: Patient Safety Culture and Leadership in Canada's Academic Health Sciences Centres

Sat, 15 Jan 2005 10:33:08 -0400

Over the past few years, the focus on patient safety has emerged as an important policy issues on the national health policy agenda, both nationally and internationally. Given the importance of this issue, and the shared commitment to continuing to improve patient safety, the Academy of Canadian Executive Nurses (ACEN) and the Association of Canadian Academic Healthcare Organizations (ACAHO) have developed a joint policy statement on patient safety cultures and leadership within Canada's Academic Health Sciences Centres.

CHSRF Knowledge Transfer: Broadening the Dialogue to Include Quality

Sun, 15 Apr 2007 10:32:28 -0400

News reports and national polls all point to wait times as the top concern facing our healthcare system, rivalled only by patient safety. Both issues have an impact on a limited number of patients - those waiting beyond wait-time benchmarks and those receiving unsafe care. However, focusing on access and safety does little to solve the broader problem of achieving quality healthcare, which also involves discussions of efficiency, efficacy, equitability and patient-centred care, for example (Canadian Health Services Research Foundation [CHSRF] 2007a; Institute of Medicine 2001). In fact, the attention on access could theoretically be a bad thing for many patients. As Berwick (2006) points out in a recent article, "Invasive Procedures: Less Is More … and Better," less access to care often leads to improved quality of care and outcomes.

Patient Safety Institute: The Patient Safety Journey

Tue, 15 Mar 2005 10:21:28 -0400

In 2004, the collective efforts of many in Canada began to coalesce around the real issues affecting patient safety, leading to heartening advances in building a stronger culture of safety.

Lessons To Be Learned From England About The Potential of GP Computer Systems to Improve Patient Safety

Tue, 15 Jun 2004 10:20:39 -0400

In December 2003, the National Patient Safety Agency in England published a report entitled "Realizing the Potential of GP Computer Systems to Improve Patient Safety." The project team that generated the report was led by Professor Anthony Avery, Head of the Division of Primary Care, School of Community Health Sciences, at the University of Nottingham. The project team also included researchers from the University of Manchester and the University of Edinburgh.

Urban Outpatient Views on Quality and Safety in Primary Care

Tue, 15 Mar 2005 10:10:21 -0400

The Minimizing Errors Maximizing Outcomes Study is designed to examine the effect of workplace conditions on quality of care and medical errors. In the first phase of the study, patients were asked to "tell their stories" via focus groups.

Quality Work Environments for Nurse and Patient Safety

Tue, 15 Mar 2005 10:03:25 -0400

Quality Work Environments for Nurse and Patient Safety is the product of a critical analysis of the literature regarding indicators that can be measured in the work environment of nurses and that can be linked to both nurse and patient safety.

Is Consent Required For Publication of Medical Errors?

Sat, 15 Oct 2005 09:58:44 -0400

Publication of information about medical errors is critical to error prevention and shared learning among health professionals and institutions. While some countries have error reporting systems in place, journal publications are still essential reference tools for learning about error, and editorial policies about when to publish errors are needed, as these provide important guidance to journal editorial boards. While there is a prima facie moral requirement to obtain consent to publish patient information, publication without patient consent may be justified if certain criteria are met. Justification will involve consideration of a variety of principles, rules and conditions grounded in ethics, law and policy. Except in exceptional circumstances of overriding importance to public health, a patient's personal information should not be published over the patient's refusal. But what constitutes "exceptional circumstances of overriding importance to public health"? We argue that medical error is one such circumstance and present an argument in favour of a specific policy stance on publication of medical errors.

The Benefits of the MOE/MAR Implementation: A Quantitative Approach

Wed, 15 Nov 2006 09:57:55 -0400

This article reports on the results of UHN's multi-year study looking at the impact of MOE/MAR. In our overview, we examine such elements as the methodology used as well as the challenges and constraints faced by the team. We also examine the following: the types of lessons learned during MOE/MAR's implementation; the effectiveness of teamwork; and the impact of external resources upon the project.

Project Profile: Canadian Healthcare Excellence in Quality Award (CHEQA)

Sun, 15 Jan 2006 09:55:25 -0400

The Quality Healthcare Network (QHN) in collaboration with rL Solutions, awarded the inaugural Canadian Healthcare Excellence in Quality Award (CHEQA) at a cocktail reception, closing September's QHN Fall Leading Forum. CHEQA was created by QHN to promote and recognize Canadian healthcare organizations that have demonstrated excellence in the areas of patient safety and overall quality of care.

Next Steps for Patient Safety in Canadian Healthcare

Fri, 15 Oct 2004 09:54:10 -0400

Morgan outlines some important elements necessary for improving patient safety in Canadian healthcare. But these steps are likely to require considerable time and resources and may be difficult to implement. In the light of the evidence of adverse events in Canadian hospitals, all Canadian healthcare organizations need to begin to measure the numbers and types of adverse events experienced by their patients and clients. Staff need to learn new skills for investigating and improving care. A variety of tools and resources are available for these tasks. Leadership both in senior management and on the front lines must learn to shift the focus from blaming individuals to improving systems of care. Leaders must also acknowledge that most healthcare organizations have failed to gather the necessary information on adverse events, and they must invest in building knowledge and implementing practices that reduce the current levels of injury.

Envisioning Safer Healthcare

Fri, 15 Oct 2004 09:45:36 -0400

Morgan provides an action plan for safer Canadian healthcare and argues that needed, fundamentally safer healthcare requires commitment to change from policymakers, healthcare leaders and practitioners. He posits that safer healthcare in Canada can be achieved through information technology (IT) and a national patient safety investigative agency.

Improving Patient Safety through Computerized Drug Management: The Devil Is in the Details

Fri, 15 Oct 2004 09:45:01 -0400

The Impact of the Electronic Health Record on Patient Safety: An Alberta Perspective

Fri, 15 Oct 2004 09:44:21 -0400

Alberta is at the leading edge in developing its electronic health record (EHR), a provincial initiative to provide healthcare providers with immediate access to a patient's medication history and laboratory test results, regardless of where they are in the province, or where the patient's drugs or other treatments were ordered. The Alberta EHR was launched in October 2003. So far 6,000 healthcare providers have voluntarily signed on to use it, and benefits to patient safety have been reported. The EHR is an important part of healthcare renewal that is required to improve patient safety; however, it must not be viewed as a stand alone cure-all solution to Canada's patient safety challenge. The EHR will only reach its full potential if it is part of an integrated approach to health renewal that stresses consistency of healthcare, practice and information standards, and consistency and standardization of healthcare data. Without a sector-wide EHR like Alberta's, the proliferation of computerized electronic medical records (EMRs) in hospitals, clinics and pharmacies might create "islands of information" that are not widely compatible. A national EHR approach must acknowledge the importance of improving broadly accepted practice standards and data consistency in order to reduce the islands of information and protect patients from medical errors as they move between them.

The Electronic Health Record: A Leap Forward in Patient Safety

Fri, 15 Oct 2004 09:43:17 -0400

In his review of patient safety issues in the Canadian healthcare system, Dr. Matthew Morgan states that "coordinated national EHR initiatives will cost less, save lives and prevent harm when compared to the status quo." Canada Health Infoway is spearheading this initiative in Canada. Infoway's No. 1 guiding principle for investment is that projects undertaken must "enhance the quality of patient care, healthcare services and patient safety." They must also support the development and adoption of pan-Canadian interoperable EHR solutions. Infoway is working in seven major areas to improve electronic access to accurate and timely health information in order to reduce errors, facilitate accurate diagnoses and speed treatment. These areas include the building blocks of the EHR: infostructure, registries, digital imaging systems, and drug and laboratory information systems. Infoway is also developing and expanding telehealth networks to increase the scope of the Canadian healthcare system. Infoway was recently mandated to develop a public health surveillance system for infectious diseases to give healthcare providers a tool for tracking and managing disease outbreaks in the Canadian population. These systems will improve safety, quality, accessibility, cost-efficiency and the sustainability of the healthcare system. Patient safety is a cornerstone of Infoway's activities.

In Pursuit of a Safe Canadian Healthcare System

Fri, 15 Oct 2004 09:26:20 -0400

This paper provides evidence that Canada's healthcare system is not as safe as it needs to be, and suggests ways to make it safer. Healthcare leaders must recognize that patient safety is indistinguishable from the delivery of high quality, affordable healthcare, and they must become more knowledgeable about the extent of the patient safety problem in Canada. The creation of a Patient Safety Board, modelled after Canada's Transportation Safety Board, will provide the authority healthcare leaders require to reduce medical errors. Without a national Patient Safety Board we cannot efficiently and effectively identify, quantify and address medical errors in Canada. This paper also urges healthcare leaders to recognize that a fundamental tool in improving patient safety is the electronic health record (EHR). Return on investment data for a national EHR strategy are presented. The author focuses on three EHR initiatives: outpatient electronic prescribing; in-patient computerized physician order entry; and home-based diabetes disease management. Potential net savings to Canada from these three EHR initiatives alone approach $2 billion annually. We must accelerate our EHR investment. Coordinated national EHR initiatives will cost less, save lives and prevent harm when compared to the status quo. These initiatives will also provide the foundation for transforming our healthcare system and will assist in building a better-educated, healthier and therefore more economically competitive nation.

Patient Safety to Frame and Reconcile Nursing Issues

Mon, 15 Dec 2003 16:13:21 -0400

Canadian nursing leadership is called to advance a national patient safety agenda for the delivery of safe, quality care in professional practice environments. Yet, the nursing discipline is burdened by issues and challenges related to clinical practice and workplace dilemmas that contribute to barriers and obstacles to safe, quality and humane care. We propose that the many clinical challenges faced by nurses in Canada can be more fully understood when framed by a patient safety perspective. Nurse executive leaders and nurse scientists are called to reform clinical practice and conduct research to reconcile patient care safety issues. This paper applies findings obtained from nurses via focus groups led by the Academy of Canadian Executive Nurses (ACEN) and integrates these findings into a patient safety perspective via a conceptual framework.

Signing on to Sign-out: Creation of a Web-based Patient Sign-out Application

Sat, 15 Oct 2005 16:12:52 -0400

Sunnybrook and Women's College Health Sciences Centre (Sunnybrook and Women's) is the amalgamation of three healthcare organizations, the Orthopaedic and Arthritic Hospital, Sunnybrook Health Science Centre and Women's College Hospital. It was created by a Special Act of Legislation (Bill 51) in June 1998 and is fully affiliated with the University of Toronto. The division of General Internal Medicine within the Department of Medicine consists of four medical teaching teams, each responsible for the care of patients admitted to their medical ward. At the end of each day, the primary inpatient house staff must transfer the care of their patients to the on-call team, a process referred to as "patient sign-out."

IT Solutions for Patient Safety - Best Practices for Successful Implementation in Healthcare

Sun, 15 Jan 2006 16:11:25 -0400

Recent reports in the United States and Canada have suggested that healthcare systems in both countries fall short in delivering high quality and safe patient care (Baker and Norton 2001; Institute of Medicine 1999, 2001). In addition to these reports, empirical studies have stressed the enormity of the problem of adverse events in hospitals in terms of frequency and severity (e.g., Evans et al. 1994; Budnitz et al. 2005; Classen et al. 2005). Investigators in the Harvard Medical Practice Study, for example, found that adverse events occurred in approximately 3.6% of hospitalizations in New York State (Brennan et al. 1991), the majority of which were due to drug complications (Leape et al. 1991). Such adverse events and errors have also been found to be preventable and significantly associated with longer hospital stays, disability and increased healthcare utilization and costs (Bates et al. 1997; Evans et al. 1993; Phillips, Christenfeld and Glynn 1998; Thomas et al. 1999; Classen et al. 2005). The United States incurs an estimated total (direct and indirect) cost of approximately $17 billion to $29 billion in preventable adverse events (Institute of Medicine 2001). Although some errors are attributable to poor performance by individual providers, the majority of preventable errors are a result of systemic and organizational deficiencies of healthcare delivery systems (Ball and Douglas 2002; Leape et al. 1998; Peth 2003).

Transforming Healthcare Organizations

Wed, 15 Nov 2006 16:10:59 -0400

Imagine you are a member of a hospital's executive team, having just left a meeting in which you and other members discussed the possible introduction of an ambitious Computerized Physician Order Entry (CPOE) system. Around the conference table you and others questioned whether CPOE would be the most effective way to realize your hospital's commitment to patient safety. Other issues that were raised included whether clinicians would support or resist the change, whether staff would have sufficient skills, where to begin, affordability and whether to proceed incrementally or with a "big bang." While there was much disagreement with respect to each of the issues, there was near unanimity around two important decisions - CPOE would be implemented and you would be the executive responsible for the system's design and implementation. This article, based on the experiences of a multi-site hospital, and drawing on past research on organizational change, provides a Four-Stage model to help change leaders in healthcare. Although relying on Toronto's University Health Network to illustrate the change model, the model is intended to speak to change leaders implementing various types of complex changes in all healthcare organizations.

Adverse Events in Community Care: Developing a Research Agenda

Tue, 15 May 2007 16:10:30 -0400

Little is known about the extent to which adverse events compromise the quality of community care. This article describes the results of a consensus workshop in which 31 healthcare professionals were asked to identify and rank common adverse events and important research questions relating to community care. Workshop participants were decision-makers and healthcare providers with areas of expertise that included community and home care; acute and primary care; patient safety; medical errors; and health services policy, administration and research. Results include prioritized lists of adverse events, research questions and contributing factors associated with adverse events. Further study should be aimed at defining and implementing research priorities and developing standardized definitions of common adverse events associated with community care.

Quality Improvement Will Require a Major Commitment

Thu, 15 Mar 2001 16:09:28 -0400

The current issue of the Longwoods journal, HealthcarePapers (Vol. 2 No. 1) examines strategies for improving the safety of patients in the healthcare system. The lead paper was written by two Canadian experts, G. Ross Baker at the University of Toronto and Peter Norton at the University of Calgary, who are to be commended for putting the issue forward. In this issue of Hospital Quarterly we are pleased to publish the abstract of their paper. We are fortunate to have a comprehensive response from Australian Ross Wilson who led The Quality in Australian Health Care Study and is considered a world authority on patient safety.

CCHSA Accreditation: A Change Catalyst toward Healthier Work Environments

Mon, 15 Jan 2007 16:08:12 -0400

Canada has made significant progress in research and policy development regarding work environment issues that contribute to the quality of the work environment in health organizations. In order to successfully achieve the outcomes that healthier work environments can have on providers, patients and the system, more definitive action is required now. The Canadian Council on Health Services Accreditation (CCHSA) is a recognized catalyst of change in health organizations and systems in Canada and internationally. This paper reviews CCHSA's role in contributing to the improvement of the health of work environments in order to improve both the well-being of those working in healthcare and the quality of care being provided to their patients or clients.

Patient Safety: Is the Evidence Strong Enough That Information Technology Can Help?

Fri, 15 Oct 2004 16:07:32 -0400

It is not difficult to prepare a commentary on Dr. Morgan's invited essay "In Pursuit of a Safe Canadian Healthcare System" if one agrees with almost everything he reveals and postulates. When a respected young practising physician candidly and forcibly makes a case for the need for significant healthcare system reform, one must sit up and take notice. If nothing else, his statement "outpatient medical errors are the bread and butter of internal medicine hospital admissions" should cause us to be deeply concerned. Dr. Morgan pleads for a number of reforms, such as the creation of a Patient Safety Board akin to Canada's Transportation Safety Board, the demonstration of an ROI for the electronic health record, the introduction of computerized physician order entry, and a number of other suggestions. Due to limitations of time and space, we will react to only a few of his views, mildly disagreeing with some while strongly reinforcing others.

Hippocrates Denied: Why Canada Has Yet to Act on the Patient Safety Imperative

Fri, 15 Oct 2004 16:06:45 -0400

A review of patient safety literature reveals clear documentation of significant patient safety concerns in many countries going back over two decades. However, it was not until the publication of the Institute of Medicine's To Err Is Human about four years ago that widespread attention was at last drawn to this issue. Even with this attention, there has been a very limited response in Canada to the well-documented need for action to address preventable errors. After some reflection, it is clear that a whole series of factors may be conspiring to slow or blunt our response to this issue. This commentary explores these factors and endorses strategies for moving forward.

Patient Safety: Springboard to Nursing Accountability

Mon, 15 Dec 2003 16:05:59 -0400

If any issue should command the attention of every nurse in the country, it is that of patient safety. Think back a few years. If someone asked you to provide safe care, would you not be somewhat insulted? Would you not say, "I want to provide more than just safe care; I want to provide quality care. Quality patient care is more than just safe care." Patient safety is now a talking point in our understanding of how we provide quality nursing care. In my view, it is the bottom rung of the healthcare standards ladder, but it is poised to become the springboard for significant changes in the way we practise. These changes could have significant benefits, both for providers and for consumers of healthcare.

How High Is the Bar?

Mon, 15 Jan 2007 16:05:32 -0400

Gosfield and Reinertsen's paper poses a number of interesting questions that merit examination in the Canadian context. They propose that the widespread adoption of the six streams of evidence-based practices included in the 100,000 Lives Campaign changes the standard to which hospitals will be held liable, regardless of whether they have enrolled in the campaign. They suggest that hospitals now have a legal incentive to ensure adoption of these practices. They propose that, instead of viewing the potential litigation as a threat, hospitals and healthcare leaders should understand and harness these legal forces to help them drive these changes. They go as far as suggesting that malpractice liability could be a positive force for reducing needless deaths.

Collaborating to Embrace Evidence-Informed Management Practices within Canada's Health System

Tue, 15 May 2007 16:04:50 -0400

In late 2005, 11 major national health organizations decided to work together to build healthier workplaces for healthcare providers. To do so, they created a pan-Canadian collaborative of 45 experts and asked them to develop an action strategy to improve healthcare workplaces. One of the first steps taken by members of the collaborative was to adopt the following shared belief statements to guide their thinking: "We believe it is unacceptable to fund, govern, manage, work in or receive care in an unhealthy health workplace," and, "A fundamental way to better healthcare is through healthier healthcare workplaces."

A Dialogue on Quality and Patient Safety with Maureen Bisognano

Wed, 15 Mar 2006 16:03:09 -0400

A dinner for healthcare leaders at the 6th National Conference on Quality featured a conversation with Maureen Bisognano, Executive VP and COO of the Institute for Healthcare Improvement (IHI). IHI is a leading source of innovation in the improvement of healthcare. The conversation was facilitated by G. Ross Baker, professor in the Department of Health Policy, Management and Evaluation at the University of Toronto. Following are highlights from the rich dialogue that evening.

CHSRF Knowledge Transfer: Nurse Staffing and Patient Safety: Ratios and Beyond

Mon, 15 May 2006 16:02:39 -0400

Since the publication of the Canadian Adverse Events Study, quality and safety have never been more prominent on the Canadian health policy agenda. Many voices have weighed in with quite different perspectives on what needs to happen in our healthcare system in order to address the situation

A Conversation about Leadership and Quality with James Reinertsen and G. Ross Baker

Thu, 15 Feb 2007 16:01:23 -0400

James Reinertsen, MD, has worked as a physician, CEO and consultant on leadership, quality improvement and patient safety with leading healthcare systems around the world. What follow are excerpts from a conversation held at a dinner for healthcare leaders during the 7th National Conference on Quality in Toronto this February (2006). Reinertsen is a former CEO of Health System Minnesota and CareGroup, an academic and community hospital system in Boston. He currently heads The Reinertsen Group and leads the Institute for Healthcare Improvement's leadership development sector. The questions are posed by G. Ross Baker, PhD, professor in the Department of Health Policy, Management and Evaluation at the University of Toronto.

Annual Report: September 2004 to November 2005

Thu, 15 Dec 2005 16:00:47 -0400

Because the Annual General Meeting of the Academy of Canadian Executive Nurses (ACEN) was moved to November from September, this report covers a 14-month period. During this time, ACEN has taken on a new identity on the national front. We have implemented the decisions taken at the last annual meeting related to changes in membership categories and fees, establishing a national office and increasing the Academy's visibility. Membership has been expanded to include nursing executive leaders in healthcare delivery, academia, government and professional associations. The response to this change has been positive, and it is anticipated that membership will continue to increase over the next year. A national office has been established in Ottawa.

Commentary: They Must Embrace the Vision

Wed, 15 Nov 2006 15:59:14 -0400

Justifying the expense of health information technology undergoes unparalleled scrutiny. Competing priorities for expenses must be balanced by revenue, all within the confines of the "service" industry. Whether for profit or non-profit, healthcare is ultimately a business.

Case Study: Reconciling the Quality and Safety Gap through Strategic Planning

Mon, 15 May 2006 15:58:31 -0400

An essential outcome of professional practice environments is the provision of high-quality, safe nursing care. To mitigate the quality and safety chasm, nursing leadership at St. Michael's Hospital undertook a strategic plan to enhance the nursing professional practice environment. This case study outlines the development of the strategic planning process: the driving forces (platform); key stakeholders (process and players); vision, guiding principles, strategic directions, framework for action and accountability (plan); lessons learned (pearls); and next steps to moving forward the vision, strategic directions and accountability mechanisms (passion and perseverance).

Recognizing the Importance of Proactive Reporting at a Large Urban Teaching Hospital

Tue, 15 May 2007 15:58:00 -0400

Incident reporting focuses on correcting system and process issues after an incident has occurred. By comparison, near-miss reporting is a means of proactively reporting events that could have resulted in an incident but did not because of timely intervention. Near-miss reporting allows organizations to identify and remedy potential incidents before harm befalls any patients. Recognizing the value of near-miss reporting, University Health Network (UHN) implemented a recognition program to encourage individuals to report near misses. Since the program's implementation in May 2006, near-miss reporting at UHN has increased 38% compared with the same time the previous year.

Grasping the Opportunity to Improve the Safety of Care

Fri, 15 Oct 2004 15:57:08 -0400

Clearly a wakeup call for the healthcare industry, the IOM report of 2000 To Err Is Human now appears to have been a sentinel event, at least in the United States (Institute of Medicine 1999). Given that the practice of medicine in the United States is, in many ways, very similar to that in Canada - for example, our physician trainees are educated and evaluated using similar models - it is unfortunate that the IOM report was not also a wakeup call for Canada. Four years have passed, and apparently Canadians have only recently woke up to front-page newspaper headlines that point out that Canadians, like Americans, are being harmed and killed as a result of medical errors.

Patient Safety Culture and Leadership within Canada's Academic Health Science Centres: Towards the Development of a Collaborative Position Paper

Mon, 15 Mar 2004 15:56:17 -0400

Currently, the Academy of Canadian Executive Nurses (ACEN) is working with the Association of Canadian Academic Healthcare Organizations (ACAHO) to develop a joint position paper on patient safety cultures and leadership within Academic Health Science Centres (AHSCs). Pressures to improve patient safety within our healthcare system are gaining momentum daily. Because AHSCs in Canada are the key organizations that are positioned regionally and nationally, where service delivery is the platform for the education of future healthcare providers, and where the development of new knowledge and innovation through research occurs, leadership for patient safety logically must emanate from them. As a primer, ACEN provides an overview of current patient safety initiatives in AHSCs to date. In addition, the following six key areas for action are identified to ensure that AHSCs continue to be leaders in delivering quality, safe healthcare in Canada. These include: (1) strategic orientation to safety culture and quality improvement, (2) open and transparent disclosure policies, (3) health human resources integral to ensuring patient safety practices, (4) effective linkages between AHSCs and academic institutions, (5) national patient safety accountability initiatives and (6) collaborative team practice.

Current Strategies to Improve Patient Safety in Canada: An Overview of Federal and Provincial Initiatives

Wed, 22 Aug 2007 15:55:49 -0400

This article provides an overview and examples of current initiatives based on reviews of documents and websites, interviews with key informants in several provinces and attendance at patient safety meetings in several cities. As we shall see, although several provinces are beginning to address the patient safety issues, there remain important challenges of leadership, coordination and learning that are essential in gaining public confidence in the safety of our healthcare system.

System Performance Is the Real Problem

Sun, 15 Apr 2001 15:55:14 -0400

Baker and Norton are right in calling for a study of medical error in Canada, and they have provided some very reasonable recommendations for reducing the problem. Medical error, however, is just part of a broader problem of performance quality in healthcare. The healthcare system itself is now being identified as a major cause of illness, death and added costs because of errors, infections, the adverse effects of medications, the underuse of effective interventions and the provision of unnecessary or inappropriate care. For the healthcare system to aspire to the safety level of other modern industries (e.g., airlines) there will be a need for: leadership and vision; better data systems and information on performance; commitment and skills development among providers; and better accountability.

National Agenda: Local Leadership

Sun, 15 Apr 2001 15:54:54 -0400

Cultural change is the first step in addressing the issue of patient safety. Strategies to achieve this must be well thought-out and extremely well-executed. However, action may be constrained by tension between federal and provincial governments. The provincial licensing bodies must be involved in rethinking the approach to error. Local leadership stimulated by a national agenda is the best way to proceed.

Medication Error and Patient Safety

Sun, 15 Apr 2001 15:54:32 -0400

A number of barriers to the enhancement of patient safety through a reduction of medication errors have been identified. These include a blame culture; lack of leadership; lack of peer-review protection; and the absence of a collaborative voluntary national reporting system. The latter would provide oversight and help healthcare providers avoid recurrence of these adverse drug events stemming from human error.

Cutting Healthcare Costs without Preventable Clinical Incidents - Together We Can Improve

Sun, 15 Apr 2001 15:54:10 -0400

Medical errors are receiving increasing attention as research results reveal escalation in their numbers. Three elements of this complex issue are reviewed. A systems approach to reducing the number of errors may be less than effective until the negative connotation associated with the phraseology "medical error" is changed. Healthcare restructuring, which results in the destabilization of teams, is another factor that is related to the increase in medical errors. Stabilization of the healthcare environment and/or stronger support mechanisms during change are essential. Finally, the litigious sensitivity of the public and healthcare systems overall intensifies the "error" element. This element is counter-productive to the openness required for the systems approach.

Improving Patient Safety: Just Do It!

Sun, 15 Apr 2001 15:53:36 -0400

Clinicians must celebrate and study medical errors. The dark culture of blame must be replaced by a scholarly culture of safety. This commentary presents six cases that show what we can learn from errors.

Professionals Must Recognize Personal Responsibility

Sun, 15 Apr 2001 15:52:52 -0400

The recommendations Baker and Norton have developed for reducing error within the healthcare delivery system, with their emphasis on non-punitive reporting of error, are commendable. However, healthcare practitioners must clearly understand that the current medical/legal system has not adopted a similar approach. Courts have long recognized the right of victims to compensation for injury caused by malpractice or negligence. Individuals will be held to the accepted standards of their profession.

Patient Safety: Cultural Changes, Ethical Imperatives

Sun, 15 Apr 2001 15:52:28 -0400

One essential aspect to improve patient safety and reduce medical errors focuses on the need for healthcare organizations to promote a patient-safety culture, and to banish the blame and shame culture and "conspiracy of silence" - traditional approaches within organizations when reacting to medical errors. Culture change arises when physicians, pharmacists, nurses and other self-regulated professionals are encouraged and expected to report errors without fear of retribution. A culture of patient safety will evolve in healthcare organizations and regulatory agencies only if top leaders demonstrate their commitment to change by making this a personal priority by assimilating new knowledge about medical errors and human behavior. Leaders must also promote strategies to integrate patient safety into every process that supports the system of patient-care delivery.

Taking Responsibility for Closing the Holes

Sun, 15 Apr 2001 15:52:06 -0400

Healthcare leaders must assume responsibility for closing the "holes" in their organizations. At the organizational level, this means taking personal responsibility for error, making safety an explicit organizational goal and building an organization with the people, resources and courage to achieve the goal. At the process level, it requires removing unnecessary complexity from processes. At the practitioner level, it means changing the design and administration of individual roles, and the way individuals work in teams.

Better Cooperation and Less Measurement

Sun, 15 Apr 2001 15:51:31 -0400

Baker and Norton offer an analysis for tackling medical error that, while not wrong, is very traditional in the policy solutions it recommends. The research priority should not be better measurement of error, but instead increased international cooperation to find solutions to existing problems. For instance, rather than developing new databases for mapping errors, existing databases should be utilized to create a learning culture that addresses existing problems. Within this, understanding errors in primary care is essential, and thus research should not restrict the study of errors to clinical situations. Changing the culture of medicine is difficult. A model of governance that emphasizes quality and accountability may be a mechanism for developing a culture within medicine that reduces error and improves patient safety.

All Components of the System Must be Aligned

Sun, 15 Apr 2001 15:51:00 -0400

A culture of safety in healthcare will not be achieved until the fragmentation that currently characterizes the delivery system is replaced by an alignment of the many component parts, including providers, patients and their families and front-line workers on the "sharp end" - physicians, nurses and pharmacists. A systemic approach should be introduced that would recognize the interacting nature of the delivery system's component parts, and that a change in one component of the system will provoke a change in another part. Consumers and their families can be empowered through programs that raise awareness, prevent error and mitigate its effect when error does happen. Within the system, the "safety sciences" can provide guides to effective work processes. Finally, it is critical to capture knowledge of what type of error occurs in what place and to elucidate strategies to prevent the error.

Making Patients Safer! Reducing Error in Canadian Healthcare

Sun, 15 Apr 2001 15:49:13 -0400

Media reports of adverse events experienced by patients raise questions about whether these are isolated exceptions or part of a larger problem.There is no reliable Canadian data on medical error; but there is little reason to expect that the situation differs markedly from Australia or the United States which have rigorously studied the problem. Research in Australia has concluded that as many as 16% of hospital patients are injured as a result of their treatment. The Australian study and more recent research in the United States have created widespread concern that an epidemic of error exists in healthcare.

Medication Error and Patient Safety

Wed, 22 Aug 2007 15:48:41 -0400

How can we create a culture of safety within our organization?

Wed, 22 Aug 2007 15:47:30 -0400

Question: How can we create a culture of safety within our organization? And how do we get to understand our staff and physicians?

Top 10 Patient Safety Myths

Wed, 22 Aug 2007 15:46:49 -0400

Many provider CIOs are reevaluating their institutions' processes for insuring patient safety. Some are seeking counsel to help break through the noise of the HIM marketplace. With that in mind, Cap Gemini Ernst & Young Health has compiled the following list of the most dominant patient safety myths, along with tips on how healthcare leaders can counter them.

Commentary: Nursing Perspective: Focus on Clinical Best Practices, Patient Safety and Operational Efficiency

Wed, 15 Nov 2006 14:40:44 -0400

Organizational challenges and struggles with user adoption of computerized clinical applications are common and, as yet, not easily overcome. This case study demonstrates the complexity of the issues and processes that need to be addressed in the implementation of new technologies to support the management of clinical information. These complexities arise in the management of the people, the processes and the technology associated with the change.

High Reliability versus High Autonomy: Dryden, Murphy and Patient Safety

Mon, 15 May 2006 14:39:31 -0400

Healthcare is not a high-reliability industry. The adverse event rate is on the order of 10^-2; industries such as aviation, nuclear power and railways achieve rates of 10^-5 or better. Increasing awareness of this contrast has made "patient safety" a major topic of concern. High reliability in other industries flows from a combination of "engineered safety," tight regulation ("high-level constraints") and the development of a "culture of safety" that recognizes error as a systemic rather than a personal failure. In medicine, achieving such a combination would involve abandoning deeply embedded and centuries-old traditions of individualism, clinical autonomy and personal responsibility. This will not happen. Watch instead for safety concerns to be diverted into activities that do not threaten core values.

Case Study: On the Leading Edge of New Curricula Concepts: Systems and Safety in Nursing Education

Fri, 15 Sep 2006 14:38:28 -0400

The Nursing Division of the Saskatchewan Institute of Applied Science and Technology (SIAST) first included systems and patient safety as a priority in its institutional business and strategic plan in 2003. Three interrelated leading-edge, two-year projects (2004-2006) were launched: Best Practice, Mentorship and Patient Safety, with the intent that each project would enhance the others. This case study focuses on the work of the Patient Safety Project Team. The team developed a project framework and strategic plan, conducted a literature review and identified key concepts related to systems and patient safety. Strategies to integrate these concepts into the school's 15 nursing education programs are being implemented.

CCHSA Client/Patient Safety Culture Assessment Project: Lessons Learned

Sun, 15 Oct 2006 14:37:42 -0400

The Canadian Council on Health Services Accreditation (CCHSA) released its inaugural Patient Safety Goals and Required Organizational Practices to its member organizations and surveyors in December 2004. CCHSA's first patient safety goal is to "Create a culture of safety within the organization." To help support a culture of safety, organizations need to have an understanding of staff and physician perceptions of the current state of client/patient safety culture.

Ensuring Patient Safety

Wed, 22 Aug 2007 14:37:03 -0400

In the last few years, the release of a number of landmark reports including the Baker Norton Report "Patient Safety and Healthcare Error in the Canadian Healthcare System" and the CIHI/CIHR study "Improving the Quality of Healthcare in Canadian Hospitals" has triggered wide spread awareness and discussion about the need to improve patient safety.

Focus on Clinical Best Practices, Patient Safety and Operational Efficiency

Wed, 15 Nov 2006 14:34:07 -0400

The following article explores the MOE/MAR-driven changes from the perspective of nurses. The examination of the collaboration and coordination of the Nursing Informatics (NI) Team with Nursing, the role of Nursing Informatics, the collaboration with the Project Team from Shared Information Management Services (SIMS), the Education Working Group and the Computer User Support Program (CUSP) are features of this journey into the electronic world during the implementation of MOE/MAR.

The Business Case for Patient Safety

Wed, 15 Nov 2006 14:31:04 -0400

Conventional wisdom dictates that hospitals are institutions in which ailing or injured people go for a temporary visit, their discharge ultimately dependent upon either a partial or complete recovery. Unfortunately, the most well-intended acts sometimes result in tragedy. Depending upon the severity of a patient's condition, sometimes a visit to the hospital is a one-way excursion. And in some cases (most would argue in too many cases), the reason a patient dies within the confines of a hospital is due to the lack of a systems approach to patient safety.

Patient Safety Papers - Healthcare Quarterly Vol. 8 Special Issue

Sat, 15 Oct 2005 14:26:57 -0400

This special issue of Healthcare Quarterly reports Canadian experiences in identifying and improving patient safety. The commitment to quality in Canadian healthcare is not new; but the identification of patient safety as a strategic goal is still emerging, and the recognition of the need to master and apply new skills and knowledge has just begun. The papers in this issue bear witness to a growing awareness and accelerating efforts to enhance the reliability of healthcare in our country.

Patient Safety Papers - Healthcare Quarterly Vol. 9 Special Issue

Sun, 15 Oct 2006 14:23:12 -0400

This issue of Healthcare Quarterly provides evidence that safer patient care is achievable. We have gathered papers outlining excellent work across Canada addressing this goal.

Patient Safety Culture Measurement and Improvement: A "How To" Guide

Sat, 15 Oct 2005 11:12:42 -0400

Currently, there is relatively little experience in healthcare of implementing safety culture measurement and improvement initiatives. This lack of experience may increase the risk that safety culture interventions may fail to achieve their objectives. Fortunately, safety culture interventions are commonly used in other industries such as nuclear power and the petrochemical industry. The lessons learned from these industries are summar ized in the 10-step process outlined in the article