Title: Building a Safer System Together: The Role of the Canadian Patient Safety Institute
1Building a Safer System Together The Role of
the Canadian Patient Safety Institute
Presentation to CAPHC November 7, 2004 John Wade,
MD, FRCPC Chair, Board of Directors
2PRESENTATION OVERVIEW
- Understanding and defining patient safety and
adverse events - Background/What we now know
- Baker, R. Norton, P. et al. (2004)
- Forster, J. et al. (2004)
- Canadian Safety Patient Institute
- Mandate and vision
- Workplan
- Future Challenges
3Definitions
- Patient Safety
- The reduction and mitigation of unsafe acts
within the health-care system, as well as through
the use of best practices shown to lead to
optimal patient outcomes. - Canadian Patient Safety Dictionary, 2003
- Adverse Event (Bad outcomes from care)
- An adverse event is an unintended injury or
complication which results in disability, death
or prolonged hospital stay, and is caused by
health-care management. Wilson et al
4Swiss-cheese Model
Reason, J. (2000) Human error models and
management. BMJ 320 (7237) 768-70
5Patient Safety History
- Pioneering work
- Snow to Beecher, Manitoba Outcome Study,
Anesthesia - System-wide/national reviews
- Harvard study
- UK, Australia, NZ
- Baker Norton
6Patient Safety Status in Canada
- Adverse Events in Canadian Hospitals
- (Baker, R. Norton, P. et al. (2004))
- Incidence rate of 7.5 in hospitals (2000)
- 70,000 preventable adverse events (est.)
- 9,000 - 24,000 preventable AE deaths
- 1.1 million additional hospital days
- Comparable to similar health systems
- Ottawa Hospital Patient Safety Study (Forster, J.
et al. 2004) - 61 of adverse events occurred before index
hospitalization - Health Care in Canada 2004 Focus on Safe Care
- (Canadian Institute for Health Information)
7Baker Norton Findings Procedures or events to
which AEs were related, by service most
responsible for delivery of care at time of AE
i Physician reviewers could attribute events to
more than one type of procedure ii AEs not
covered in previous categories i.e. burns,
falls iii System events include AEs that cannot
be attributed to an individual or specific
sources e.g. communication, reporting, lack of
equipment
8Types of Adverse Events
Sharp End Immediate Cause(s)
Sharp End Examples Medication AEs,
Nosocomial Infections
Patient / Health Care Provider / Team / Task and
Environmental Factors
Contributing Factors
Blunt End Underlying Cause(s)
Blunt End Examples Communications Culture
Physical Environment Policies /
Procedures
Management/ Organizational/ Regulatory Factors
Root Cause(s)
Adapted from the NHS Report Doing Less Harm,
2001
9What Needs To Be Done
- Further research
- Types of AEs and contributing factors
- Acute care and beyond
- Greatest gains will come from
- Modifying work environments
- Creating better defenses
- Need
- Leadership to encourage reporting
- Continue to monitor incidences
- Apply new technologies
- Improve communication and coordination
- Ways to monitor for continuous improvement
- Baker, R. Norton, P. et al. (2004)
10Canadian Patient Safety Institute
- Governance
- Mission
- Mandate
- Business Plan
11Board of Directors
- Non-governmental Directors
- John Wade, Chair
- Wendy Nicklin
- James Nininger
- Brian Postl
- Denis Roy
- Bonnie Salsman
- Provincial/Territorial Directors
- Patricia Petryshen
- David Rippey
- George Tilley
12Governance
- Not-for-profit corporation
- Separate legal entity
- Arms length independence consistent
- with mandate and guiding principles
- Fully transparent and accountable
13Limits
- CPSI will not have a role in
- Overseeing, managing or prescribing practices for
delivering health care - Regulating the health professions
- Approving devices, drugs, technologies or
interventions
14Mission
To provide national leadership in building and
advancing a safer Canadian health system.
15Vision
- We envision a Canadian health system where
- Patients, providers, governments and others work
together to build and advance a safer health
system - Providers take pride in their ability to deliver
the safest and highest quality of care possible
and - Every Canadian in need of healthcare can be
confident that the care they receive is the
safest in the world.
16Mandate
- Provide leadership on patient safety issues
- Advise governments, stakeholders and public on
effective strategies - Foster information sharing
- Influence culture change
- Support systems change
- Collaborate with stakeholders in an ongoing
dialogue on patient safety
17What does the Institute mean for the Canadian
health-care system?
Measurement and Evaluation
Legal/Regulatory
System Changes to Create a Culture of Safety
Education and Professional Development
Information and Communication
18Strategic Business Plan
- Theme 1 Define Patient Safety Issues
- Theme 2 Identify Leading Practices and
Effective Interventions - Theme 3 Champion Change
19Theme One Define Patient Safety Issues
- Highlights
- Provincial/Territorial Consultation Workshops
across Canada - Obtain feedback on strategic business plan
- Learn about local patient safety issues and
initiatives - Obtain feedback on recommended priorities for the
Institute.
20Theme One Define Patient Safety Issues
- Highlights (continued)
- Sponsor an annual national conference to discuss
major patient safety issues and the progress made
in addressing them - Platinum sponsor of Halifax 4
- Create a national storehouse of patient safety
information, beginning with environmental scan
and identification of patient safety indicators
21Theme Two Identify Leading Practices and
Effective Interventions
- Highlights
- Increase scope and scale of research
- Promote access to tools for root cause analyses
and case studies - Support learning opportunities
- Develop a standardized and validated patient
safety curriculum - Safety champions
- Leadership development
- Simulation-based, multi-disciplinary training
22Theme Three Champion Change
- Highlights
- Support innovation and technology
- Example Canadian Medication Incident Reporting
and Prevention System - Develop legislative model
- Example Saskatchewan critical incident
legislation and root cause analysis framework. - Increase public awareness
- Develop national policy guidelines regarding
disclosure and patient/provider communications
23Taking Action
- Management team
- Don Schurman, Interim CEO
- Judith Dyck, Consulting Director of
Communications - Joseph Gebran, Director of Corporate Services
- Carolyn Hoffman, Director of Operations -Ontario
to B.C. - Pierrette Leonard, Director of Operations
Quebec and Eastern Canada
24Taking Action (continued)
- Stakeholder Advisory Network
- Establish network of advisory committees,
including - Education/Professional Development
- Health System Innovation
- Legal/Regulatory
- Research/Evaluation
- Information/Communication
- Emphasis on web-based communication
- www.cpsi-icsp.ca
25The Challenge
- Pediatric health centres and CPSI
- Key partners in defining the issues and
collaborating on improvement strategies - Build on the expertise and capacity within your
member organizations to identify and implement
leading practices and share outcomes - Within organizations
- Ensure all members of the health team are
involved - Nurture strong and knowledgeable leadership for
improving patient safety
26Contact Information
- Canadian Patient Safety Institute
- Phone (780) 409-8090 or
- Toll free (866) 421-6933
- Fax (780) 409-8098
- Email info_at_cpsi-icsp.ca
- www.cpsi-icsp.ca
- The Canadian Patient Safety Institute would like
to acknowledge funding support from Health
Canada. The views expressed here do not
necessarily represent the views of Health Canada.