Quality & safety in Canadian health care system

Question 1

Safety

Answer 1

• Freedom from accidental injury

* Failure of a planned action to be completed as intended

Question 2

Adverse event

Answer 2

• “an unintended injury or complication that results in disability at the time of discharge, death or prolonged hospital stay that is caused by health care management rather than by the patient’s underlying disease process.”

Question 3

Near miss

Answer 3

• An act of commission or omission that could have harmed a patient but did not as a result of chance, prevention, or mitigation

Question 4

Patient safety

Answer 4

• “the pursuit of the reduction and mitigation of unsafe acts within the healthcare system, as well as the use of best practices shown to lead to optimal patient outcomes.”
• Freedom from accidental or preventable injuries produced by medical error

Question 5

Harvard Medical Practice Study (1991, USA)

Answer 5

Incidence of adverse events and negligence in hospitalized patients
• No harm (13%)
• Minor (57%) event occurred, painful but resolved
• Moderate (14%) was 1-6 months to resolve
• Severe (2%) is permanent disability
• Death (14%)

Question 6

To Err is Human (1999, USA)

Answer 6

• Shift from blame
• Agency for Healthcare Research and Quality (AHRQ)
• Periodic re-licensing
• Institute of Safe Medication Practice (ISMP)
• Reporting of events; mandatory reporting of severe and adverse events, voluntary reporting of minor events
• Safety as an aim; through a lot of movement, nurses as advocates and enable the change

Question 7

Emergency of Patient Safety in Canada: 2004

Answer 7

Canadian Adverse Events Study – Baker et al.
• 7.5% Canadian patients are severely harmed by their health
care
• 37% of normally avoidable events that negatively affect the patient’s health or well-being are considered preventable
• 5.2% of adverse events became permanent disability

Question 8

Emergence of Patient Safety in Canada: 2005

Answer 8

Canadian Council on Health Services Accreditation (CCHSA) Patient Safety Goals
• Auditing organizations; improvements on how to meet standards

Safer Healthcare Now
• Grassroots safety patient campaign
• Change takes time; we need to focus on what we know we can change

Question 9

Emergence of Patient Safety in Canada: 2009

Answer 9

Apology Act (Ontario)
• Apology “means an expression of sympathy or regret, a statement that a person is sorry or any other words or actions indicating contrition or commiseration, whether or not the words or actions admit fault or liability or imply an admission of fault or liability in connection with the matter to which the words or actions relate”
• Expression of sympathy or regret; whether or not the words/actions admit fault or liability or imply an admission of fault or liability
• When you’re patients are frustrated; you apologizing does not mean you are admitting you made a mistake

Question 10

Jeremy Limpens TED Talk

Answer 10

• The courage to say sorry in healthcare
• It’s not easy to be a patient; sometimes you don’t know what you’re asking for, but you know something is not right
• It can be traumatizing to be a patient
• They want to have their story heard

Question 11

Emergency of Patient Safety in Canada: 2010

Answer 11

Excellent Care for All Act (ECFAA)
• Quality committees, which would report to the hospital board of directors on quality- related issues
• Annual quality improvement plans where each hospital would be required to create and publicly post
• Executive compensation which would be required to be linked to achieving improvements set out in the annual quality improvement plan
• Patient relations process to address patient, client and caregiver relations
• Patient/client/caregiver surveys to assess satisfaction
• Staff surveys to assess satisfaction with employment experience and views about the quality of care provided
• Declarations of values that would be developed by health care organizations after public consultation

Question 12

Emergence of Patient Safety in Canada: 2015

Answer 12

Never Events for Hospital Care in Canada (guidelines for things that should never occur)
• National Patient Safety Consortium identified number of priority actions
• Never events are patient safety incidents that result in serious patient harm or death and that are preventable using organizational checks and balances. Never events are not intended to reflect judgment, blame or provide a guarantee; rather, they represent a call-to-action to prevent their occurrence

Question 13

Never Events for Hospital Care in Canada

Answer 13

• Categories: Serious; recurring; identifiable; avoidable
1. Surgery on the wrong body part or the wrong patient, or conducting the wrong procedure
2. Wrong tissue, biological implant or blood product given to a patient
3. Unintended foreign object left in a patient following a procedure
4. Patient death or serious harm arising from the use of improperly sterilized instruments or equipment
5. Patient death or serious harm due to a failure to inquire whether a patient has a known allergy to medication, or due to administration of a medication where a patient’s allergy had been identified
6. Patient death or serious harm due to the administration of the wrong inhalation or insufflation gas
7. Patient death or serious harm as a result specific pharmaceutical events
8. Patient death or serious harm as a result of failure to identify and treat metabolic disturbance
9. Any stage III or stage IV pressure ulcer acquired after admission to hospital
10. Patient death or serious harm due to uncontrolled movement of a ferromagnetic object in an MRI area
11. Patient death or serious harm due to an accidental burn
12. Patient under the highest level of observation leaves a secured facility or ward without staff knowledge
13. Patient suicide, or attempted suicide that resulted in serious harm, in instances where suicide-prevention protocols were to be applied to patients under the highest level of observation
14. Infant abducted, or discharged to the wrong person
15. Patient death or serious harm as a result of transport of a frail patient, or patient with dementia,
where protocols were not followed to ensure the patient was left in a safe space

Question 14

Emergence of Patient Safety in Canada: 2017

Answer 14

The Case of Investing in Patient Safety in Canada
• Over the next 30 years within acute and home care settings, there could be roughly 400,000 average annual cases of patient safety incidents
• One in 18 patients in Canadian Hospitals experience preventable harm

Question 15

Error Types

Answer 15

• Three types

1) Slip; attentional failures (intrusion, omission, reversal, misordering, mistiming)
2) Lapse; memory failure (omitting planned items, place-losing, forgetting intentions)
3) Mistake; rule-based mistakes (misapplication of good rule, application of bad rule) and knowledge-based mistakes (many verbal forms)

Question 16

Unsafe Acts

Answer 16

1) Unintended actions; slips and lapse
2) Intended actions; mistake and violation
• Violation can be a routine, exceptional, or acts of sabotage

Question 17

Understanding error: culture or blame vs discovery

Answer 17

• Blame; Error prevention is focuses on decreases the variability of human error
• Discovery; error prevention is at multiple levels
• Humans are fallible; we are prone to making mistakes and we work with less under a lot of stress, attending to multiple needs, multi-tasking, working 24hrs

Question 18

The human condition and errors

Answer 18

■ Limited memory
■ Affected by fatigue & distraction
■ Required to multi-task
■ Required to perform high risk activities
■ Dealing with complex patients, equipment and processes

Question 19

Swiss Cheese model to errors

Answer 19

■ Two Types of Failures; Active and Latent

• Active errors are the events occurring immediately before an incident or accident. These are the actions of the people on the front line interacting directly with the patient, such as doctors and nurses
• Latent errors are problems lurking within systems, which under certain conditions will contribute to an error occurring. Latent errors may lie dormant in systems for some time, but given a certain set of circumstances become evident
• It is never simply just an action that causes an event; usually a multitude of things put in place that lines up
• All of the holes line up and something slips through

Question 20

Five Levels of Care

Answer 20

1) Optimal care and adherence to standards
2) Compliance with standards; ordinary care with imperfections
3) Unreliable care-poor quality; the patient escapes harm
4) Poor care with probable minor harm but overall benefits
5) Care where harm undermines any benefit obtained

• Levels 1-3 are area of quality
• Level 3 is the “illegal normal” or normalized deviance
• Levels 4-5 are area of safety

Question 21

Three contrasting approaches to safety

Answer 21

1) Ultra adaptive - embracing risk
2) High reliability - managing risk
3) Ultra safe - avoiding risk

Question 22

Ultra adaptive

Answer 22

• Taking risks is the essence of the profession: deep sea diving, military in war time, drilling industry, rare cancer, treatment of trauma
• Power to experts to rely on personal resilience, expertise and technology to survive and prosper in adverse conditions
• Training through peer-to-peer learning shadowing, acquiring professional experience, knowing one’s own limitations
• Priority to adaptation and recovery strategies
• i.e. innovative medicines trauma centres

Question 23

High reliability

Answer 23

• Risk is not sough out but is inherent in the profession: marine, shipping, oil industry, fire-fighters, elective surgery
• Power to the group to organize itself, provide mutual protection, apply procedures, adapt, and make sense of the environment
• Training in teams to prepare and rehearse flexible routines for the management of hazards
• Priority to procedures and adaptation strategies
• i.e. scheduled surgery, chronic care

Question 24

Ultra safe

Answer 24

• Risk is excluded as far as possible: civil aviation, nuclear industry, public transportation, food industry, medical laboratory, blood transfusion
• Power to regulators and supervision of the system to avoid exposing front-line actors to unnecessary risks
• Training in teams to apply procedures for both routine operations and emergencies
• Priority to prevention strategies
• i.e. anaesthesiology, radiotherapy blood transfusion

Question 25

Why patient safety

Answer 25

1. Everyone’s Responsibility
2. Nurse Entry-to-practice competencies
3. Accreditation Canada standard – Essential Element
4. Part of a global goal
5. “Nurses monitor and manage the quality of care delivered in hospitals, outpatient departments, long-term care, and many other settings. Their role includes immediate detection and intervention in practice breakdown to reduce adverse events of patients.”

Question 26

RNAO patient safety position statement

Answer 26

■ Patient safety is a priority in public accountability for individual nurses, administrators, organizations, professional associations and all levels of government
■ RNs protect and enhance the health of patients/clients whether the client is an individual, family, or community
■ Nurses create environments that support patient safety
■ Patient safety is not merely a mandate;
■ RNs view patient safety as a moral and ethical imperative in caring for others

• Quality care & nursing: workload, staff shortage, patient acuity
• Quality work environment: skill mix, safety approaches, error identification, whistleblower protection
• Multi-level accountability: system processes

Question 27

Progress in patient safety over two decades

Answer 27

Where we were (1995)
• Foundations: incident reporting, continuous improvement and development of best practice
• Definition: harm defines from a professional standpoint, rooted in a medico-legal and insurance perspective. Narrow vision of causality, direct association between technical care and harm
• Perimeter of inclusion: dominant technical vision of care, improved clinical protocols as main priority for improving safety
• Measurement: counting incidents and adverse events

Where we are now (2015)
• Foundations: largely unchanged, more translation and use of industrial approaches to safety, increased attention to incident analysis, learning and feedback
• Definition: patient safety linked to a medico-legal perspective. Broader understanding of human error and organizational influences
• Perimeter of inclusion: recognition of the importance of human factors and human sciences, organizational factors and safety cultural are additional priorities for safety
• Measurement: largely unchanged

Question 28

Five safety strategies

Answer 28

1) Safety as best practice: aspire to standards
2) Improving healthcare processes and system
3) Risk control
4) Improving capacity for monitoring, adaptation, and response
5) Mitigation

Question 29

Five principles of high reliability organization

Answer 29

1) Preoccupation with Failure
• Process Failures are Addressed Immediately and Completely

2. Reluctance to Simplify
   • Complex Problems Get Complex Solutions
3. Sensitivity to Operations
   • Every Voice Matters
4. Commitment to Resilience
   • Recovery is Swift
5. Deference to Expertise
   • Experts are Trusted

Question 30

Defining quality

Answer 30

• The degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge
• Patient centred, effective, timely, efficient, equitable, safe

Question 31

RN replacement

Answer 31

■ Following from Minister Hoskin’s Patients First proclamations (2015), the RNAO released Mind the safety gap in health system transformation: Reclaiming the role of the RN focused on 2 priorities:
– Appropriate nurse skill-mix utilization
– Organizational models of nursing care delivery that advance care
– continuity

■ Put forth 8 recommendations for MOHLTC (LHINs) including:
– Develop a provincial evidence-based interprofessional HHR plan to align population health needs and the full and expanded scopes of practice of all regulated health professions with system priorities
– Moratorium on nursing skill mix changes until a comprehensive interprofessional HHR plan is completed
– Legislate an all-RN nursing workforce in acute care effective within two years for tertiary, quaternary and cancer centres and within five years for large community hospitals

Question 32

The Canadian Adverse Events Study: the incidence of adverse events among hospital patients in Canada

Answer 32

■ Landmark national study on “adverse events” in Canada
■ AEs are “unintended injuries or complications resulting in death, disability, or prolonged hospital stay that arise from health care management” (p. 1678)
– A total of 3745 charts in 20 hospitals in 5 provinces reviewed
– AE rate of 7.5 per 100 hospital admissions
– 185,000/2.5 million annual hospital admissions in Canada result in AEs
■ 36.9% of AEs deemed to be highly preventable
■ 5.2% of AEs resulted in permanent disability
■ 20.8% of AEs resulted in death with 9% judged as highly preventable

Question 33

Public Hospitals Act (PHA) Regulation 965

Answer 33

• “a critical incident” means any unintended event that occurs when a patient receives treatment in the hospital,
– That results in death, or serious disability, injury or harm to the patient, and
– Does not result primarily from the patient’s underlying medical condition or from a known risk
inherent in providing the treatment
• PHA critical incident reporting mapped various taxonomies to the WHO classification and noted that critical incident threshold was at the levels of “severe harm” and “death”

Question 34

Culture of safety components

Answer 34

– Atmosphere of trust in which people are encouraged, even rewarded, for providing
essential safety information
– We use the information to help fix the system/process NOT punish the person or assign blame
• just culture, reporting culture, learning culture, improving culture

Question 35

Culture of safety: just culture

Answer 35

An understanding the competent people unwilling make mistakes, often due to system issues, and should receive support not blame

Question 36

Culture of safety: reporting culture

Answer 36

Encouraging, supporting and rewarding the reporting of patient safety incidents and risks. Sharing information from reporting to inform improving

Question 37

Culture of safety: learning culture

Answer 37

Having knowledge of patient safety science and, the skills and resources to address safety issues

Question 38

Culture of safety: improving culture

Answer 38

Commitment to analyzing and addressing safety issues and concerns and sharing the lessons throughout the organization including opportunities for improvement