Patient Safety Culture Bundle for CEOs and Senior Leaders.

Senior healthcare leaders are the difference makers as key influencers in ushering in an organizational culture committed to patient safety. Although leaders at all levels are champions of transformation, leaders at the "top" have a unique opportunity - and a responsibility - to foster a culture that supports an organization on its journey to zero harm. Through a literature review of more than 60 resources and validation with thought leaders, national and provincial partners have developed a patient safety culture bundle for CEOs and senior healthcare leaders. The bundle is based on a set of evidence-based practices that must be applied collectively to establish and sustain a culture of quality and safety in order to deliver safe care.

Integrated (Enterprise) Risk Management in Canadian Healthcare Organizations: Common Barriers and a Shared Solution for Effective and Efficient Implementation in Canada.

Healthcare is a complex, high-risk industry as evidenced by frequent accounts of unintended patient and staff harm as well as other disruptions leading to financial, reputational and facility losses. Canadian healthcare organizations have struggled to adopt effective organization-wide risk management programs to reduce the likelihood and impact of these losses. This paper outlines an evidence-based initiative to spread, at scale, an effective and efficient program for integrated risk management. National results and benchmarks from the first three years of implementation are provided.

Questions healthcare boards should ask senior leaders about risk.

Drawing on strong ethical and evidence-based principles, Healthcare Insurance Reciprocal of Canada, in collaboration with healthcare leaders, has developed guiding questions to help boards of healthcare organizations carry out a critical governance function-the oversight of key organizational risks. The resulting list of 21 questions is the first of its kind for healthcare and focuses on the core mandate of healthcare organizations which is providing high-quality care. Recommended practices accompany each question.

Building safer systems through critical occurrence reviews: nine years of learning.

At The Hospital for Sick Children (SickKids), the term critical occurrence was developed to describe any event that results in an actual or potential serious, undesirable and unexpected patient or staff outcome including death or major permanent loss of function, not related to the natural course of the patient's illness or underlying condition. It also includes a breach of legislation including the Personal Health Information Protection Act of Ontario. Although broader in its definition, the term aligns closely with critical incident as defined within the amendments to Regulation 965, under the Public Hospitals Act (Government of Ontario 1990). Critical occurrences may include (but are not limited to) potential or actual adverse outcomes (including death) associated with or resulting from medication errors; a wrong site, patient or procedure performed; contaminated drugs, devices or products; an equipment malfunction; an outbreak or unusual pattern/type of nosocomial infection; employee actual or potentially serious injuries.

Improving communication of critical test results in a pediatric academic setting: key lessons in achieving and sustaining positive outcomes.

By applying the Institute for Healthcare Improvement's framework for strategic change (will, ideas and execution), The Hospital for Sick Children, in Toronto, Ontario, developed processes to improve patient safety through the effective communication of critical test results. In response to an adverse patient event, near misses and accreditation requirements, a task force with representatives from the laboratories and clinical services was established to ensure the timely and reliable communication of critical test results for biochemistry, hematology, coagulation, therapeutic drug monitoring and microbiology. The task force critically assessed processes and best practices, identified practical alternatives, tested changes, codified new processes in a hospital-wide policy and procedure and carried out post-implementation outcome audits. Lessons learned in sustaining improvements included the following: there is value in identifying strategies from a larger system perspective; there exist merits to working collaboratively as an inter-professional team (i.e., laboratory and clinical leaders); there is value in learning from failure; higher-cost but "higher-leverage" approaches can be pivotal; and regular monitoring and vigilance of policy compliance are required.

Compliance with a pediatric clinical practice guideline for intravenous fluid and electrolyte administration.

The occurrence of acute hyponatremia associated with cerebral edema in hospitalized children has been increasingly recognized, with over 50 cases of neurological morbidity and mortality reported in the past decade. This condition most commonly occurs in previously healthy children where maintenance intravenous (IV) fluids have been prescribed in the form of hypotonic saline (e.g., 0.2 or 0.3 NaCl). In response to similar problems at The Hospital for Sick Children (six identified through hospital morbidity and mortality reviews and safety reports prior to fall 2007), an interdisciplinary clinician group from our institution developed a clinical practice guideline (CPG) to guide fluid and electrolyte administration for pediatric patients. This article reviews the evaluation of one patient safety improvement to change the prescribing practice for IV fluids in an acute care pediatric hospital, including the removal of the ability to prescribe hypotonic IV solutions with a sodium concentration of < 75 mmol/L. The evaluation of key components of the CPG included measuring practice and process changes pre- and post-implementation. The evaluation showed that the use of restricted IV fluids was significantly reduced across the organization. Success factors of this safety initiative included the CPG development, forcing functions, reminders, team engagement and support from the hospital leadership. A key learning was that a project leader with considerable dedicated time is required during the implementation to develop change concepts, organize and liaise with stakeholders and measure changes in practice. This project highlights the importance of active implementation for policy and guideline documents.

Lessons learned from a privacy breach at an academic health science centre.

In 2007, the Hospital for Sick Children experienced a serious privacy breach when a laptop computer containing the personal health information of approximately 3,000 patients and research subjects was stolen from a physician-researcher's vehicle. This incident was reported to the information and privacy commissioner of Ontario (IPC). The IPC issued an order that required the hospital to examine and revise its policies, practices and research protocols related to the protection of personal health information and to educate staff on privacy-related matters.

Improving patient safety through a multi-faceted internal surveillance program.

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.

Disclosure of medical errors.

The 1999 release of the Institute of Medicine's document To Err is Human was akin to removing the lid of Pandora's box. Not only were the magnitude and impact of medical errors now apparent to those working in the health care industry, but consumers or health care were alerted to the occurrence of medical events causing harm. One specific solution advocated was the disclosure to patients and their families of adverse events resulting from medical error. Knowledge of the historical perspective, ethical underpinnings, and medico-legal implications gives us a better appreciation of current recommendations for disclosing adverse events resulting from medical error to those affected.

Blueprint for patient safety.

This article outlines a plan called the Blueprint for Patient Safety, which one organization has used to implement a comprehensive patient safety program. The blueprint starts with a graphic that depicts the basic objectives of patient safety and clarifies the sometimes misunderstood relationship between patient safety and more traditional quality-improvement activities. A second schematic outlines the key elements of the plan, including the concepts of continuous learning and the encompassing role of leadership. Finally, the 10 components of the plan and specific elements that could fall under each component are described.