CAPHC Safety Update

1. CAPHC Safety Update Child Health Lynn Jones, Sheena Mainland, Dianne Benner June 30, 2006

2. 2 Moving Toward a Culture of Safety Laying the Foundation Initiatives Safe Spaces Family Medication Awareness

3. 3 Fatal Adverse Events - Calgary Health Region Feb / March 2004 Batch Preparation of Dialysis Solution for Patients in ICU � Continuous Renal Replacement Therapy Commercial Product not available ? Compounded in Central Pharmacy Substitution Error � A case of KCl used instead of NaCl 35 bags of dialysate Two patients dialyzed

4. 4 A Fatal Dialysis Error in the Calgary Health Region

5. 5 A Fatal Dialysis Error in the  Calgary Health Region

6. 6 External and Internal Reviews Identified: Inconsistent reporting (multiple reporting systems, feedback issues) No clear policy or practice for disclosing No clear policy on informing stakeholders No articulated culture of safety

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8. 8 Just & Trusting Culture Principles For the Organization Emphasis on being proactive Commitment to analyze reported issues Focus on system contributory factors Communicate with patients / families, workforce, the public Learn from reported & identified issues & factors Address system improvements Commit to evaluate progress Commitment to support individual(s)

9. 9 Old Language vs. New Language Incident or Error Good catch, Near miss Whose fault is it? Errors Made Incident Report Adverse Event Hazardous situations What Happened? Lessons Learned Safety Learning Report

10. 10 Patient Safety Policies

11. 11 Just & Trusting Culture Workers know in advance what the probable organizational response will be to errors. Recognizes that punishing staff for errors does not prevent others from making them. Distinguish between Errors Non-compliance Intent to Harm

12. 12 Safe SpacesOur Goal: To develop and test an education and implementation plan designed to enhance and support interprofessional communication and teamwork in the delivery of safe patient care. Project Charter, January 2006

13. 13 Why Focus on Communication? Communication is the basis for all human interaction Cooperative, coordinated action requires effective communication In healthcare, communication is the causal factor in 70% of sentinel events.

14. 14 NICU and Special Care Nurseries Project Safe Spaces through improved communication and enhanced team work

15. 15 Identified strengths & pitfalls NICU & SCN

16. 16 Strengths Valuing the positive: Diversity Humor Making do (particularly when the unit is very busy) High standards of care Provide timely, efficient and effective care Encourage critical thinking

17. 17 Pitfalls Identifying barriers Hierarchy Poor role clarity Poor unit morale Negativity, gossip Rotation of Neonatologists/Fellows & NNP�s through the different sites leads to decreased standardization of care & differing objectives that can lead to confusion/abrupt change in the plan Perceived lack of respect � between and within disciplines Not feeling valued as a member of the team Different communication styles

18. 18 Identified Strategies and Tools Strategies Situational Awareness Appreciative Inquiry Flattening hierarchy Appropriate assertion Tools Modified SBAR Briefing Debriefing Critical language

19. 19 Family Medication Awareness Our Goal� �To enhance Family Centred Care through a practice culture that educates and encourages parental involvement in medication safety within the Child & Women�s Health portfolio.�

20. 20 Safety Statement Protocol Four key points to be included in initial conversations and reinforced in subsequent interactions with families: �I believe in Family Centred Care� which means we are partners.� �I am committed to safety� so I encourage your questions.�

21. 21 Medication Communication Every time medications are being administered we will communicate: 1) Name of medication 2) Purpose of medication (plain language) 3) The amount being administered 4) Frequency of administration 5) The last time it was administered and the next time it is due.

22. 22 The FMA Philosophy� �Another check in the system can only lead to good things� Family �Excellent, informed, involved, comforted and happy to be part of team, included in medical quality assurances� �I felt more informed and better able to deal with my child�s condition emotionally, I was not stuck on the sidelines� Staff �I felt professional and I felt the message was very important in the care of the child, the mother responded positively and thanked me for being so open and helpful� �I feel that the statement is appropriate to say to parents and has the potential to empower and encourage parents to take a more active role in their child�s care� �They felt confident with the care I was providing, and I sensed they were relieved that I was open to questions.� Family �Excellent, informed, involved, comforted and happy to be part of team, included in medical quality assurances� �I felt more informed and better able to deal with my child�s condition emotionally, I was not stuck on the sidelines� Staff �I felt professional and I felt the message was very important in the care of the child, the mother responded positively and thanked me for being so open and helpful� �I feel that the statement is appropriate to say to parents and has the potential to empower and encourage parents to take a more active role in their child�s care� �They felt confident with the care I was providing, and I sensed they were relieved that I was open to questions.�

23. 23 This is not THE END