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Showing results for tags 'Canada'.
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Event
ISMP Canada: Incident analysis and proactive risk assessment
Patient Safety Learning posted a calendar event in Community Calendar
untilThis virtual workshop from the Institute for Safe Medication Practices Canada will provide healthcare professionals with background theory and hands-on practice in incident analysis using Root Cause Analysis (RCA) and in proactive risk assessment using Failure Mode and Effects Analysis (FMEA). Register -
Event
ISMP Canada: Incident analysis and proactive risk assessment
Patient Safety Learning posted a calendar event in Community Calendar
untilThis virtual workshop from the Institute for Safe Medication Practices Canada will provide healthcare professionals with background theory and hands-on practice in incident analysis using Root Cause Analysis (RCA) and in proactive risk assessment using Failure Mode and Effects Analysis (FMEA). Register -
Event
ISMP Canada: Incident analysis and proactive risk assessment
Patient Safety Learning posted a calendar event in Community Calendar
untilThis virtual workshop from the Institute for Safe Medication Practices Canada will provide healthcare professionals with background theory and hands-on practice in incident analysis using Root Cause Analysis (RCA) and in proactive risk assessment using Failure Mode and Effects Analysis (FMEA). Register -
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News ArticleGreg Price died of complications after testicular cancer surgery, but a review of his case found missed faxes, follow-ups and botched data-sharing ultimately cost the vibrant 31-year-old Alberta man his life. All the missteps in his case meant it took 407 days from his first complaint for Price — an engineer, pilot, and athlete — to be diagnosed with cancer. He died three months after his doctor said he should see a specialist, and while he was being passed between multiple doctors, his health data often was not. Now, his sister, Teri Price, says too little has changed in medical information-sharing in the decade since her brother's death. This, despite a review of his case — the 2013 Alberta Continuity of Patient Care Study — that recommended life-saving changes to the healthcare system to avoid more experiences like his. So, she's fighting to improve the system that she says not only failed her brother, but keeps failing to change. Price says that Canadians assume that their health information is shared between doctors to keep them safe and studied to improve the system, but often, it's not. And medical front-line staff in Canada say problems persist when it comes to sharing everything from patient information to aggregate medical and staffing data. "Information tends to be broken up between the services that patients attend," said Ewan Affleck, a doctor in the Northwest Territories who has spent his career fighting for better data access, and a member of the expert advisory arm of the Pan-Canadian Health Data Strategy Group. "The cohesion and use of health data in Canada is legislated to fail." Read full story Source: CBC News, 17 November 2022
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Just Culture and incident investigation
Patient Safety Learning posted a calendar event in Community Calendar
untilThis virtual seminar from the Clinical Human Factors Group will be looking at Just Culture and incident investigation and will feature two of the authors, Jan Davies and Carmella Steinke, of the new book 'Fatal Solution' , a book which describes "how a healthcare system used tragedy to transform itself and redefine Just Culture". In this provocative true story of tragedy, the authors recount the journey travelled and what was learned by, at the time, Canada’s largest fully integrated health region. They weave this story together with the theory about why things fall apart and how to put them back together again. Building on the writings and wisdom of James Reason and other experts, the book explores new ways of thinking about Just Culture, and what this would mean for patients and family members, in addition to healthcare providers. With afterwords by two of the major players in this story, the authors make a compelling case that Just Culture is as much about fairness and healing as it is about supporting a safety culture." To accompany this story Ken Catchpole, Professor of Human Factors at Medical University of South Carolina will discuss a variety of enablers and barriers to learning from clinical safety incidents, based on his perspective within the US health system. This will illustrate the format of incident analysis and response at MUSC; legal and regulatory issues; and the role and impact of human factors and systems engineering. He will also comment on the recent RaDonda Vaught case, and what that tells us about how far we still have to go. Jane O’Hara, Professor of Healthcare Quality and Safety in Leeds will adds a UK perspective to this worldwide issue, together with a session focusing on the view from a pharmacy perspective. Register- Posted
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Content ArticleHow to have safety conversations: A resource for healthcare providers How to have safety conversations: A resource for patients and caregivers “What makes you feel safe” posters Presence of Safety - This document describes how Healthcare Excellence Canada is supporting a transformative shift from seeing safety as the absence of harm, to a more holistic approach that fosters safe, inclusive care. Engagement capable environments organizational self-assessment tool A journey we walk together: Strengthening indigenous cultural competency in health organizations Canadian quality and patient safety framework evaluation
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ISMP Canada Safety Bulletins
Patient Safety Learning posted an article in Medication
2022 ISSUE 1 - Anti-rejection medications: Analysis of reported errors ISSUE 2 - Mitigating Risk for Medication Errors Involving Paxlovid ISSUE 3- Heightened Risk of Methotrexate Toxicity in End-Stage Renal Disease ISSUE 4 - ALERT: Multipronged Strategy Required to Manage Shortage of Sterile Water for Injection ISSUE 5 - Pediatric Medication Errors in the Community: A Multi-Incident Analysis ISSUE 6 - ALERT: Substitution Error with Tranexamic Acid during Spinal Anesthesia ISSUE 7 - Emergency Care Plans Can Save Lives ISSUE 8 - ALERT: Infusion Errors Leading to Fatal Overdoses of N-Acetylcysteine ISSUE 9 - Safer Labelling of Repackaged Active Pharmaceutical Ingredients for Pharmacy Compounding ISSUE 10 - Optimizing Medication Safety in Virtual Primary Care -
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Canadian Institute for Health Information
Patient Safety Learning posted an article in International patient safety
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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 ArticleKey findings Patients, their care partners and care providers express that safety is more than the absence of harm. Safe care requires a proactive approach, with ongoing engagement of patients and their care partners. A number of strategies can be used to enable safer care including giving patients and care partners access to information and engaging them in safety discussions (huddles, bedside reporting, etc). Care partners, volunteers, advocates, and/or a point person (provider) is required to improve communication with patients and increase opportunities for them to be meaningfully involved in their care.
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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 -
Event
Towards EVERY PATIENT SAFE – what difference do patients make?
Patient Safety Learning posted a calendar event in Community Calendar
Think back to 2006 and recall what you knew about patient safety, and patients as partners in safety. Now, pause for a second to reflect on where we are now, in 2021. Then, imagine what you want patient safety to look like in 15 years – 2036 to be specific. Join the Canadian Patient Safety Insitute in exploring how patients, families and communities have helped shape patient safety in the past 15 years, and contribute your thoughts on how we can accelerate safety efforts together in the next 15 years. In celebration of Patients for Patient Safety Canada's 15th anniversary, we will share our journey so far, our successes, and our dream: "EVERY PATIENT SAFE". Register -
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Falling through the cracks: Greg’s story
Patient Safety Learning posted an article in Patient stories
