Breakfast With the Chiefs February 1, 2007 Philip Hassen Chief Executive Officer

1. Patient Safety Past, Present, Future Breakfast With the Chiefs February 1, 2007 Philip Hassen Chief Executive Officer

2. Presentation Overview • Introduction to Patient Safety and CPSI • Nature of the Problem • Evolution of Patient Safety • Systems Approach vs. Medical/Community Approach • Current Activities and Goals • Conclusion

3. Mission To provide national leadership in building and advancing a safer Canadian health system Vision • 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.

4. Definitions 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: 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

5. ‘Will we put the methods of science to work in the evaluation of our practices, or must we admit that no matter how much we read, study, practice and take pains, when it comes to a show-down of the results of our treatment, no one could tell the difference between what we have accomplished and results of some genial charlatan…?”Codman, 1915 Evolution of Patient Safety

6. What Patient Safety Is and Is Not • It is not what most of us were thinking about 10 years ago • It is not what ‘we have always done’ • It is the most significant change in the healthcare system in over a century • It is a new applied science • It has forever changed the face of modern healthcare

8. What We Know Canadian Institute for Health Information (2004) • One in nine adults contract infection in hospital. • One in nine patients receive wrong medication or wrong dose. • More deaths after experiencing adverse events in hospital than deaths from breast cancer, motor vehicle and HIV combined.

9. Milestones of the Modern Era • 1991 Harvard Medical Practice Study • Quality in Australian Health Care Study • 1996 Annenberg conferences begin • 1999 Colorado / Utah Study • 1999 IOM Report:To Err is Human • 2000 BMA/BMJ London Conference on Medical Error • SAEM: San Francisco Conference on EM Error • British study • ______________________________________________ • 2001-3 Halifax Symposia on Medical Error • 2001 RCPSC National Steering Committee on Patient Safety • 2002 RCPSC Report:Building a Safer System • Canadian Patient SafetyInstitute • 2006 6th Canadian Symposium on Patient Safety (Vancouver)

11. Delayed or missed diagnoses Medication errors Wrong side surgery Wrong patient surgery Equipment failure Patient identity Transfusion errors Mislabeled specimen Patient falls Time delay errors Laboratory errors Radiology errors Procedural error Lost, delayed, or failures to follow up reports Retention of foreign object following surgery Contamination of drugs, equipment Intravascular air embolism Failure to treat neonatal hyperbilirubinemia Stage lll or lV pressure ulcers acquired after admission Wrong gas delivery Deaths associated with restraints or bedrails Sexual or physical assault Adverse Events

12. Why Do Adverse Events Happen? • In any system or organization that involves humans, error is inevitable because there is a wide variation in performance both within and between people • Evidence is accumulating that some human dispositions towards error are hard-wired • Only a small proportion of error is egregious • Ambient conditions and systemic design increase the likelihood of error • Error has been described as the ‘essential friction’ within all systems

13. Sources of System Error Adverse Events • Overall culture • Education/Training/Experience • System design / HFE • Resource availability • Demand/Volume • Throughput Impedance • Shift-work/schedules

14. A Culture of Safety 31,033 Pilots, Surgeons, Nurses and Residents Surveyed* *Sexton JB, Thomas EJ, Helmreich RL, Error, stress and teamwork in medicine and aviation: cross sectional surveys. BrMedJour, 3-18-2000.

15. Comparative Reliability Between Industries PPM Difficulty with Referral Mammography Screening 1,000,000 • • • • • Tax Advice (phone-in) (140,000 PPM) • Low Back TX 100,000 10,000 • Airline Baggage Handling Post Heart Attack Medications Medication Accuracy in General 1000 Domestic Airline Flight Fatality Rate (0.43 PPM) 100 10 • 1 DEFECTS 50% 31% 7% 1% 0.02% 0.0003% SIGMA 1 2 3 4 5 6 Sigma Scale of Measure Source: Institute for Healthcare Improvement

16. Imagine: • $15 billion in annual purchases hand-written on slips of paper The Canadian prescription drug industry • 1 billion service events scheduled manually over the phone Annual diagnostic test events in Canada • An industry that does not increase productivity The healthcare industry in Canada comprises almost 10% of the economy • A service industry that injured 7.5% of its customers through preventable errors (30% of injuries resulting in permanent impairment, 5-10% resulting in death) Hospital care in Canada

17. THEN WE HAVE HUMAN FACTORS

18. Human Factors “Health care is the only industry that does not believe that fatigue diminishes performance.” Lucian Leape

19. Human FactorsFatigue • 24 hours without sleep is equivalent to a blood alcohol level of 0.10 – a 30% decrease in cognitive processing • Nurses are 3 times more likely to make mistakes after 12 hours on the job • Interns made 30% more errors in ICU patients when on traditional 24 hour call schedules • The best countermeasure for fatigue is teamwork –more people in the movie • 3 major disasters related to night time workers: Exxon Valdez, Chernobyl, and Three Mile Island. Leonard, Michael MD. (Nov 2005). Safer Healthcare Now Presentation

21. Association Between Evening Admissions and Higher Mortality Rates in the Pediatric Intensive Care UnitYeseli Arias, Doublas S. Taylor, and James P. MarcinPediatrics 2004; 113: 530-534

22. Human FactorsMultitasking, Interruptions, Distractions • Humans are poor multi-taskers • Drivers on cell phones have 50% more accidents, 25% of traffic accidents are “distracted drivers” • Interruptions and distractions increase error rates • Humans need very formal cues to get back on task when interrupted and distracted Leonard, Michael MD. (Nov 2005). Safer Healthcare Now Presentation

23. Human FactorsInherent Human Limitations • Limited memory capacity – 5-7 pieces of information in short term memory • Negative effects of stress – error rates • Tunnel vision • Negative influence of fatigue and other physiological factors • Limited ability to multitask – cell phones and driving Leonard, Michael MD. (Nov 2005). Safer Healthcare Now Presentation

24. Patient Safety: Barriers to Action • Difficulty recognizing errors • Lack of information systems to identify errors • Relationship of trust with providers • Access is more urgent in Canada • Leadership turnover • Fragmentation of care delivery hampers systems • thinking

25. Patient Safety: Barriers to Action • Poor capital investment framework favours short • term needs • Shortages of clinical professionals • Concern about liability • Jurisdictional conflicts • Simplistic approach to building the EHR • Culture of patient safety is lacking

26. Systems Approach to Patient Safety Measurement and Evaluation Legal/Regulatory EHR System Changes to Create a Culture of Safety Education and Professional Development Information and Communication

27. A Systems Approach “The systems approach is not about changing the human condition but rather the conditions under which humans work.” J.T. Reason, 2001

28. Reason’s Swiss Cheese Model

29. CPSI Strategies and Activities • Adverse Event Reporting and Learning System • Root Cause Analysis • National Disclosure Guidelines • Safer Healthcare Now!

30. Development of a Canadian Adverse Events Reporting and Learning System (CAERLS) A major initiative in the 2006/07 CPSI Action Plan is to explore the development of a Canadian Adverse Event Reporting & Learning System to enable a patient safety knowledge base, create a repository and facilitate knowledge transfer to inspire innovation and safety improvement. Activity to date includes: • The synthesis of findings on adverse event reporting and learning systems related to: • international site visits • an extensive literature search and review • a comprehensive review of applicable Canadian legislation and policy. 2. Development and circulation of a consultation paper outlining recommended options for a non-punitive national adverse event reporting and learning system so that the information can be sorted, integrated, evaluated and acted upon in a highly coordinated and timely manner.

31. The Canadian Root Cause Analysis Framework What is Root Cause Analysis? • An analytic tool that can be used to perform a comprehensive, system-system based review of critical incidents. 1 History • In January of 2005 CPSI partnered with ISMP Canada and Saskatchewan Health, to begin work on the development of the Framework. Goals of the partnership • To standardize information and processes related to RCA in Canada. • To utilize those with known expertise in use of the process and knowledge transfer of the tool to assist with the development of the framework. 1 Hoffman, C., Beard P., Greenall,J., U,D., & White, J. (2006). Canadian Root Cause Analysis Framework. Edmonton AB: Canadian Patient Safety Institute

32. National Guidelines for Disclosure of Adverse Events • National Working Group • Project Charter – full endorsement • Background Document • Literature Search and Review • Final Draft – Feb 2007 • Nationwide Consultation – Mar – April 2007 • Nationwide Endorsement – May – Aug 2007 • Publication and Distribution – October 2007 (Halifax 7)

33. Safer Healthcare Now!Interventions • Deploying rapid response teams • Improved care for acute myocardial infarction • Prevention of adverse drug effects • Prevention of central line-associated bloodstream infection • Prevention of surgical site infection • Prevention of ventilator associated Pneumonia Retrieved from www.saferhealthcarenow.ca or www.soinsplussursmaintenant.ca Toll free#: 1-866-421-6933

34. Campaign Structure Campaign Support SHN National Steering Committee Secretariat - CPSI Clinical Support CIHI CCHSA Operations Quebec Node IHI Teams Western Node Atlantic Node Patients Canadian ICU Collaborative Ontario Node Other Canadian Faculty Peer Support Network ISMP Canada Partner Network CAPHC Measurement Working Group & CMT Communication Working Group Education & Resource Working Group

35. *As of January, 2007

36. Teams Continue to Enroll

37. Ventilator Associated Pneumonia (VAP)Calgary Health Region

38. Ventilator Associated Pneumonia (VAP)St. Paul’s Hospital (SK) • 229 days since last reported VAP

39. Preventing Central Line Infections National Nosocomial Infections Surveillance System (NNIS) Rate

40. Rapid Response TeamUniversity of Alberta # Cardiac ICU Arrests ALOS Pre-implementation 7 (4.0 per 100 separations) 10.2 Post-implementation 1 (0.8 per 100 separations) 6.4 Total # calls 24 Source: ICU Collaborative

41. CPSI Strategies and Activities • Research • Professional Development • Simulation • National Hand Hygiene Campaign • Patient Safety Competencies Project • Executive Patient Safety Series • Canadian Patient Safety Officer Course

42. CPSI Strategies and Activities Research - 2005 • With CIHR, CHSRF and safety leaders safety research priorities • Launched 2005 CPSI grants competition • 327 registered projects • 125 full applications received • 57 peer-reviewed • 28 funded ($1.9M) • Co-funded with CHSRF two REISS programs • Pediatric and Adult Acute Care, Family Medicine • Two Projects Funded with CIHR

43. CPSI Strategies and Activities Research - 2006/07 • Launched 2006/07 CPSI grants competition • 64 full applications received • 35 peer-reviewed • 15 funded ($1.4M) • Launched with CIHR a Patient Safety Priority Announcement • Grants • Fellowships • Partner in the “Listening for Direction” health services research priority setting initiative with CHSRF, CIHR, CADTH, CH, CIHI, Health Canada, Statistics Canada • Partnered with CIHR, CADTH, CIHI, Statistics Canada, CHSRF to study post marketing surveillance and effectiveness

44. CPSI Strategies and Activities Professional Development - Leading the Safety Process In partnership with the CMA and the CMPA, CPSI is developing a workshop in which participants will learn: • the key best practice approaches to patient safety • how to build a culture of safety & reporting while maintaining professional accountability • how to disclose adverse events to patients • Participants will also practice the effective communication skills and techniques when confronted with critical incidents

45. CPSI Strategies and Activities Simulation in Canada Goal: To facilitate the development of a national simulation strategy for healthcare Objectives • To create a national vehicle for the promotion and endorsement of simulation including an infrastructure for collaboration • To endorse team – focused simulation education Phases Phase 1: Endorse and Support Phase 2: Educate Phase 3: Evaluate

46. CPSI Strategies and Activities • National Hand Hygiene Campaign • The Canadian Patient Safety Institute, the Canadian Council for Health Services Accreditation, the Public Health Agency of Canada and the Community and Hospital Infection Control Association are working together to support, supplement and integrate existing hand hygiene initiatives locally, regionally and provincially, by developing and implementing a hand hygiene campaign across Canada. • Campaign Goal: • To promote the importance of hand hygiene in reducing the spread of healthcare associated infections in Canada • Campaign Objective: • To respond to the needs of healthcare organizations for capacity building, leadership development, and/or the production of tools to help promote hand hygiene

47. CPSI Strategies and Activities Patient Safety Competencies Project Objectives: • Identify the key knowledge, skills and attitudes related to patient safety competencies for all healthcare workers • Develop a simple, flexible framework that will act as a benchmark for training, educating and assessing healthcare professionals in patient safety • Help make patient safety competencies easy for everyone to understand and apply

48. CPSI Strategies and Activities • Executive Patient Safety Series • Objectives: • Describe how you can better fulfill your responsibilities and accountabilities for patient safety at the Board/Executive level; • Understand the methods to effect a cultural shift in your organization to improve patient safety; • Create and share safety practices that can be adapted and established in your organization; and • Position safety in the context of quality in your organization.

49. CPSI Strategies and Activities Canadian Patient Safety Officer Course With the help of faculty experts, this course will be delivered through interactive workshops, networking and presentations by patient safety leaders for healthcare professionals and leaders involved in patient safety (patient safety officers, clinical managers and physicians) Overall objectives: • Provide the skills to create, implement, and maintain a vigorous and focused patient safety program • Help develop detailed, customized patient safety strategies and implementation plans Dates: September 24-28, 2007 Location: The Kingbridge Centre, Toronto, Ontario

50. Other Important Tools • Resource Crew Management Briefings • S-B-A-R • Situation • Background • Assessment • Recommendation