Search the hub
Showing results for tags 'Canada'.
Found 66 results
-
Content ArticleSafety 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.
-
Content ArticleThis cross-sectional survey in the BMJ Open aimed to examine the sociodemographic characteristics, activities, motivations, experiences, skills and challenges of patient partners working across multiple health system settings in Canada. This survey was the first of its kind to examine the characteristics, experiences and dynamics of a large sample of self-identified patient partners at a population level. Although patient partners who took part were from similar sociodemographic background, the scope, intensity and longevity of their roles varied. Respondents predominantly identified as female (76.6%), white (84%) and university educated (70.2%). Primary motivations for becoming a patient partner were the desire to improve the health system based on either a negative (36.2%) or positive (23.3%) experience. Respondents reported feeling enthusiastic (83.6%), valued (76.9%) and needed (63.3%) always or most of the time. Just under half felt they had always or often been adequately compensated in their role.
-
Content ArticleThe 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.
-
Event
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
- 1 comment
-
- (and 3 more)
-
Content ArticlePatients, 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.
-
Content ArticleAccording to the World Health Organization (WHO), medication harm accounts for 50% of the overall preventable harm in medical care. As well as telling the story of Melissa Sheldrick, who has been campaigning to improve medication safety since her son Andrew died as a result of a medication error, this blog looks at how making it 'safe-to-say' can reduce the risk of medication errors. Healthcare systems need a culture shift that makes it safe-to-say when something has gone wrong, is going wrong, or could go wrong. The authors argue that it is only when errors are appropriately managed, reported, responded to and learned from that we can improve the system as a whole, support people impacted to heal and take informed action to prevent similar incidents from happening in the future.
-
News Article
Why Canada's ERs are struggling to stay open
Patient Safety Learning posted a news article in News
On a Thursday in mid-August, the doors of a hospital's emergency department two hours west of Toronto were shut. A note posted on the front said the ER was closed for the day. It would reopen the following morning at 08:00, but close again for the evening. Patients who needed urgent care were asked to go to nearby hospitals - a 15- to 35-minute drive away. It was the ninth time since April that the Huron Public Healthcare Alliance - a network of four hospitals serving around 150,000 people in western Ontario - had to temporarily close or cut back hours at one of its emergency departments. Canada is one of the richest countries in the world. Its universal publicly funded healthcare system has been touted by progressive politicians in the US, the country's southern neighbour, who see it as a needed alternative to an American system where millions remain uninsured. But in recent months, Canada's system has been described by workers and hospital executives as being in a state of "crisis". That includes struggling emergency rooms. Toronto ER physician Dr Raghu Venugopal said he has seen stretchers lining the hallways, occupied by patients suffering from ailments like a broken hip or abdominal pains. On some days, those patients may wait anywhere from two to four days to be admitted to hospital, all while a team of two nurses tends to a total of 50 to 60 patients on the unit. Other patients are being examined in the waiting room because the lack of staff has forced parts of the ER to close, meaning there is limited space for doctors to see them privately. "We are in a standard-less void where anything goes, and it is shocking," Dr Venugopal said. Read full story Source: BBC News, 2 September 2022 -
Content Article
ISMP Canada Safety Bulletins
Patient Safety Learning posted an article in Medication
The Canadian Institute of Safe Medication Practice's bulletins. Learn about strategies to mitigate harm and to prevent medication errors based on analyses of medication incident reports from Canadian healthcare providers, facilities, pharmacies, organisations and consumers. -
Content ArticleThis 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.
-
Content ArticleRather than measuring how safe care is, the focus is often on measuring levels of harm in healthcare systems. This report by Healthcare Excellence Canada outlines findings from a research study which aimed to answer, “How safe is care from the perspective of patients, families, care partners, and care providers?” Through a literature review, interviews, focus groups and a World Café wthe study aimed to increase understanding of how patients and their care partners view safety. The Measuring and Monitoring of Safety Framework (MMSF) (Vincent et al., 2013b) was used to guide the study. The MMSF offers a broader, more comprehensive and real-time view of patient safety and helps shift away from a focus on past cases of harm towards current performance, future risks and organisational resilience. The report concludes that the MMSF represents a critical shift in how patients can enable safer care. Inviting patients and care partners to contribute meaningfully to safety will enhance healthcare providers’ view of harm and understanding of what it means to feel safe.
-
Content ArticleThis 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.
-
Content ArticleThis 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.
-
News Article
Patient safety incidents are the third leading cause of death in Canada
Patient Safety Learning posted a news article in News
The COVID-19 crisis has both divided and galvanised Canadians on healthcare. While the last three years have presented new challenges to healthcare systems across the country, the pandemic has also exacerbated existing challenges, most notably the high levels of errors and mistreatment documented in Canadian health care. According to a 2019 report from the Canadian Patient Safety Institute, Canada was already facing a public health crisis prior to the pandemic: a crisis of patient safety. As the report details, patient safety incidents are the third leading cause of death in Canada, following cancer and heart disease. Few studies calculate national data on this topic, but a 2013 report found that patient safety events resulted in just under 28,000 deaths. Many Canadians who have experienced these errors have shared their experiences with media in an effort to raise awareness and demand change. The impact of the COVID-19 pandemic has created a moment of dual crises. First, the pre-existing crisis of patient safety, and second, healthcare overall is now at a breaking point after three years of COVID-19, according to healthcare workers. Edmonton physician Dr. Darren Markland, for example, recently closed his kidney specialist practice after making a few "profound mistakes." In an interview with Global News, he explains he could no longer work at the current pace. He is not alone in this decision. Across the country, there have been waves of resignations in health care, leaving some areas struggling with a system that is "degrading, increasingly unsafe, and often without dignity." Read full story Source: MedicalXpress, 17 June 2022 -
Content ArticleThis 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.
-
Content ArticleOne 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.
-
Content ArticleFocused practice is an approach to primary care where a family doctor or GP chooses one or more specific clinical areas as a major part-time or full-time component of their practice. In recent years, there has been a global increase in focused practice and a decline in offering a comprehensive scope of practice in primary care. This Canadian study in the British Journal of General Practice looked at factors influencing family doctors' decisions to work in focused practice. The authors of the study concluded that: both early-career and resident family doctors unanimously saw focused practice as a way to avoid the burnout or exhaustion they associated with comprehensive practice in the current structure of the healthcare system. more research is needed to understand the implications of family physician choices of focused practice within the physician workforce.
-
Content Article
Engage with impact toolkit (October 2021)
Patient-Safety-Learning posted an article in Patient engagement
The Engage with Impact Toolkit was designed to help organisations evaluate the impact of their patient, family and caregiver engagement programs and activities. It was developed in Canada by a Working Group of patient, family and caregiver partners, health system researchers, engagement leads and government personnel, led by Dr Julia Abelson and the Public and Patient Engagement Collaborative at McMaster University. The Toolkit has been developed as a series of five modules, each of which includes background information, tasks to complete, resources and other support. -
Content ArticleIn North America, although pharmacists are obligated to ensure prescribed medications are appropriate, information about a patient’s reason for use is not a required component of a legal prescription. The benefits of prescribers including the reason for use on prescriptions is evident in the current literature. However, it is not standard practice to share this information with pharmacists.The aim of this study was to characterise the research on how including the reason for use on a prescription impacts pharmacists.The results suggest that including the reason for use on a prescription can help the pharmacist catch more errors, reduce the need to contact prescribers, support patient counseling, impact communication, and improve patient safety. Reasons that may prevent prescribers from adding the reason for use information are concerns about workflow and patient privacy.
-
Content ArticleIn this video of a plenary session from the Guidelines International Network (GIN) Conference on 26 October 2021, James McCormack, Professor at the Faculty of Pharmaceutical Science, University of British Columbia, discusses issues with clinical practice guidelines and ways to overcome them.
-
Content ArticleThis study in BMJ Quality & Safety examines how much electronic differential diagnostic support (EDS) systems improve diagnostic accuracy, and whether EDS should be used early or late in the diagnostic process. Using a volunteer sample of medical students and doctors at six Canadian medical schools, the authors compared the rate of correct diagnosis when EDS was used early and late in the diagnostic process. The study found that EDS increased the number of diagnostic hypotheses and the likelihood of correct diagnosis, and that these effects persisted whether EDS was used early or late in the diagnostic process.
-
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. -
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 -
Content ArticleThis article by Lauren McGIll in The Walrus looks at how design changes to the trauma bay at St Michael's Hospital in Toronto are saving lives. Lack of intentional design in hospitals, new technologies and a culture that celebrates adaptability all contribute to what the author describes as "a piecemeal approach" to emergency medicine workspaces. The outcome of this is ultimately higher mortality rates as staff do not have an optimum working environment. The article describes a research project set up in 2015 by doctors Christopher Hicks and Andrew Petrosoniak, which aimed to identify and remove latent hazards and obstacles that cost trauma staff time in emergency situations. They redesigned the trauma bay at St Michael's hospital as a result of their findings, and early reports are that dramatic rescues have been possible thanks to the new layout. Petrosoniak says, “You cannot remove the stress of someone dying in front of you, but we can remove the stress of not being able to find equipment.” Further reading Trauma Resuscitation Using in situ Simulation Team Training (TRUST) study: latent safety threat evaluation using framework analysis and video review (BMJ Quality & Safety) Study protocol for a framework analysis using video review to identify latent safety threats: trauma resuscitation using in situ simulation team training (TRUST) (BMJ Open) Stress Testing the Resuscitation Room: Latent Threats to Patient Safety Identified During Interprofessional In Situ Simulation in a Canadian Academic Emergency Department (AEM Education and Training) Health professionals' experience of teamwork education in acute hospital settings: a systematic review of qualitative literature (JBI Evidence Synthesis)
-
News ArticleLogan 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
-
Content ArticleAfter an investigation of an event, it’s important to touch base with the healthcare team and everyone involved so they can get some closure. This is an important part of the healing process that we have neglected too often. Alberta Health Services provide tips on how to support staff involved in adverse events.
