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Acknowledgements, This report greatly benefited from the valuable contributions and insights of several collaborators Anu. MacIntosh Murray helped in interviewing Canadian leaders and patient safety experts analyzing the key issues. in these interviews Christine Shea and Jocelyn Pang did a detailed review and analysis of the published. Canadian literature and grey literature on patient safety from 2004 to 2014 Their contributions helped to. shape the findings of this report,Introduction 1, Patient Safety Changed Perspectives on Healthcare 2. What Are the Results Has Patient Safety Improved 4. Efforts to Improve Patient Safety Better Measurement Better Understanding Improved. Practice But Limited Results 6, Why Are Patient Safety Improvements So Difficult 8. What Does It Take To Create Safer Care 10, Patient Safety Culture and Reliability Breaking the Vicious Cycle 18. Creating Safer Healthcare Environments 21,Conclusion 23.
References 24,Introduction, The Canadian Adverse Events Study CAES published in May 2004 Baker Norton et al 2004. provided one of the most comprehensive pictures of patient safety in Canada to date The CAES. reported that 7 5 of all hospitalizations in Canada had an adverse event that harmed patients. Extrapolating from the 3 745 cases reviewed suggested that around 185 000 hospital admissions during. the study period likely had adverse events of which close to 70 000 were potentially preventable In. the lead up to the release of the CAES the federal government announced the creation of the Canadian. Patient Safety Institute CPSI In the decade since the CAES provinces have invested heavily in patient. safety reporting the CPSI launched Safer Healthcare Now designed to improve the safety of care and. healthcare organizations across Canada have invested considerable energies in measuring and. assessing adverse events identifying ways to reduce such events and investing in training equipment. and reviews of current practice to reduce the likelihood of such events While hospital acquired. infections surgical complications and medication errors have long been seen as important issues the. adverse events study helped to change the perspective on these and other incidents introducing. patient safety as a critical element of healthcare performance and a major focus for improvement. With ten years of activity and easily tens of millions of dollars invested in patient safety we should now. have a much safer healthcare system But do we This report provides an overview of the impact of this. new focus on patient safety and offers an accounting of the progress made and of the challenges that. remain To provide a comprehensive picture of progress on patient safety we reviewed the Canadian. and international literature on improvements in patient safety spoke with international experts and. conducted structured interviews with 15 Canadian patient safety experts and health system leaders. across the country between November 2014 and January 2015 1. What became clear early on in our analysis is that ten years later many Canadian healthcare. organizations still struggle to address key patient safety issues Harm experienced by patients and the. impact on families staff and organizations continues despite better measures of the number and. impact of these events and efforts to change unsafe practices. A full summary of our methods and a bibliography are available on request. Patient Safety Changed Perspectives on,Healthcare, The concept of patient safety incorporates four fundamental propositions that are transforming. mental models conceptions of team and organizational performance and broader expectations of. clinical and system leadership in our healthcare system. Many patient safety problems are preventable Adverse events or patient safety incidents are. negative unintended consequences of care and care settings experienced by patients These. incidents range from infections in the ICU to medication overdoses on a medical surgical unit to falls. in long term care homes Until recently these problems were viewed as unfortunate consequences. of healthcare they are now seen as failures in quality of care many of which are preventable. Moreover these preventable problems are measureable and could now be aggregated into. measures of performance As a result of measuring and aggregating these events it became evident. that the incidence of such events was much larger and more widespread than most observers even. experts and researchers had recognized or even anticipated The classification of many adverse. events as preventable and the publication of remarkably high rates of adverse events served as a call. to action in the healthcare system, Improving safety requires moving from a focus on blame towards a focus on improvement Patient. safety experts offered a new view on human error and its sources Rather than viewing error simply. as a result of poor individual decisions or knowledge patient safety experts created a broader. perspective, Guided by the work of James Reason Reason 1990 Jens Rasmussen Rasmussen 1990 and others. this new view shifted the focus from individual decisions and practice and saw incidents as the result. of both individual and broader system factors including staffing patterns equipment purchases. information systems credentialing decisions and many more organizational issues Patient safety. events were not just the result of poor clinical practice and flawed decisions by individual. practitioners they represented failures by leaders in healthcare organizations to develop broader. strategies and to make investments to ensure safer care Instead of blaming individuals associated. with errors organizations now faced the more difficult challenge of designing systems of care that. made it less likely that patient safety events would occur Finally as a result of the recognition of the. incidence of such events and their source in both organizational and clinical actions governments. accreditors and regulators started to hold governors and leaders accountable for patient safety. performance and improvements to address patient safety issues and other quality of care issues. This whole new range of quality problems has become a concern for organizational leadership and. governance and system performance If safety was indeed a property of healthcare systems then. those responsible for the performance of those systems needed to be held accountable. Improving patient safety is a shared responsibility to design safer systems The new view of error. requires a new interprofessional approach to improvement In the past the widely different types of. adverse events had previously been the purview of different professional groups or teams surgeons. were responsible for surgical complications infection control specialists for nosocomial infections. pharmacists for medication events and nurses for falls and pressure ulcers As already noted the. old view had been that these errors stemmed from poor judgment inattention incorrect diagnoses. or treatment plans or incompetence Healthcare organizations and professions relied on blaming. and shaming to ensure better performance Leape 1994 Dekker 2014 The new view implicated. organizations and leadership in creating or tolerating risky environments setting the scene for. failure New solutions needed to be based not just on changing individuals but changing the. organization of care Team based care and team performance were seen as important strategies for. improving quality of care and patient safety outcomes Weaver Lyons et al 2010 But teamwork. alters existing relationships and practice and many organizations find this difficult For example. efforts to implement a bundle of practice interventions to reduce central line infections in English. ICUs failed in many hospitals where it was difficult to create an interprofessional leadership team to. guide improvement efforts Dixon Woods Leslie et al 2013 Moreover team based efforts to. improve front line care required organizational support and leadership Organizational and clinical. leaders needed to provide resources to redesign care including not just new resources but clear. direction and a focus on the values underlying efforts to promote safer care. Improving safety requires complex interventions not simple solutions Adverse events are a function. of underlying unsafe systems but safer practice is rarely achieved easily One important patient. safety innovation was the development of improvement bundles sets of practices none of which. were sufficient to reduce patient safety events but which together created better outcomes For. example the effective response to clinically well defined problems like ventilator acquired. pneumonias included several changes in clinical practice including elevation of the bed to 45. degrees daily evaluation of readiness to extubate the utilization of endotracheal tubes with. subglottic secretion drainage oral care and decontamination with Chlorhexidine and initiation of. safe enteral nutrition within 24 to 48 hours of ICU admission Canadian Patient Safety Institute. 2012 No single change was sufficient to improve care. Bundled interventions at the clinical micro system level and arguably even at the system level for. example in care transitions have become the standard for improving safety and address the. complexity of care Guerin Wagner et al 2010 Costello Morrow et al 2008 These new changes. included not only standardizing new clinical practices but also new non technical changes such as. interdisciplinary rounds and improved reporting of events. What Are the Results Has Patient Safety, Medical injuries resulting from care have been acknowledged for some time California Medical.
Association 1977 and the potential for error in diagnosis and screening has been recognized for 25. or more years Eddy 1990 Despite the apparent shock of the adverse events study the recognition. of patient safety as an issue for system policy organizational leadership and clinical practice had. been building slowly over nearly twenty five years Lucian Leape Troy Brennan and colleagues. published several high profile publications in the early 1990s that documented the incidence of. patient safety events in New York State Yet these papers had little impact beyond the research. community Full recognition of the scope of the problem occurred only with the publication of the. U S Institute of Medicine s report To Err is Human in 1999 That event unleashed a series of. reactions that galvanized politicians policy makers and healthcare leaders in the US The following. year Liam Donaldson then the Chief Medical Officer of the National Health Service in England. released a parallel report An Organization with a Memory That report had a similar impact on the. health services in the UK stimulating widespread discussion and activity including the development. of a new agency the National Patient Safety Agency NPSA established in 2001 to monitor patient. safety events and to assist the NHS in developing safer care. In contrast with the US and the UK Canada was slow to recognize patient safety as a system issue In. September 2001 the Royal College of Physicians and Surgeons created a Task Force chaired by Dr. John Wade 2 to recommend a pan Canadian strategy for patient safety The Task Force issued a. report in 2002 Building a Safer System A National Integrated Strategy for Improving Patient Safety. in Canadian Health Care The key recommendation in that report was the creation of the Canadian. Patient Safety Institute CPSI CPSI was formally established with funding from the Government of. Canada in late 2003, The Canadian Adverse Events Study CAES represented a critical turning point in recognizing and. addressing patient safety issues in Canada Although the study was published in the Canadian. Medical Association Journal on May 25 2004 the study funders the Canadian Institutes of Health. Research and the Canadian Institute for Health Information had convened a series of roundtable. knowledge translation efforts starting in the spring of 2002 that engaged national policy makers. including leaders from the major healthcare associations Thus when the study was finally released. there had been considerable planning about policy and programmatic responses This planning and. careful media strategy led to considerable media coverage Baker Norton and Flintoft 2006 Among. important follow up efforts was that by Accreditation Canada to create a series of Required. Organizational Practices addressing patient safety issues and the development of a national. campaign by the Canadian Patient Safety Institute Safer Healthcare Now patterned on the. Institute for Healthcare Improvement s 100 000 lives campaign in the US Like the US campaign Safer. Healthcare Now used bundles of interventions to reduce preventable patient safety events. including medication errors and infections in surgical and intensive care patients. Attention to patient safety was also spurred by a greater focus on general quality of care issues and. performance reporting in many provinces New bodies including the Health Quality Council in. Saskatchewan the Cancer Care Ontario Quality Council and the BC Patient Safety and Quality Council. Dr Wade is a prominent physician leader and an anesthesiologist former chair of the board of the Winnipeg Regional. Health Authority and former Deputy Minister of Health for the province of Manitoba. were created to foster improved performance New performance measurement reporting provided. increased transparency of quality of care and patient safety A series of high profile investigations. including the Cameron Commission of Inquiry on Hormone Receptor Testing in Newfoundland and. Labrador Commission of Inquiry on Hormone Receptor Testing 2009 and the Report of the. Manitoba Pediatric Surgery Inquest also drew attention to major quality and safety concerns. However attention to patient safety remained variable across provinces and across healthcare. organizations Somewhat surprisingly despite these activities there was limited understanding of. how or why patient safety was important and the dominant theme of health policy initiatives was. access to care not the safety or quality of care, Canadian patient safety experts and healthcare leaders noted that the Canadian Adverse Events. Study helped to create a more intensive focus on quality of care One Ontario hospital CEO noted. I would tie some pretty big changes system wide to the adverse event study because I. think that study did shine a big light on safety and it opened the doors for all sorts of. important developments like the Canadian disclosure guidelines apology legislation I. think it was understanding and having out there evidence on adverse events that let the. system start talking about things like apology I think it ultimately led us to Excellent. Care For All ECFA in terms of legislation that now requires quality plans a focus on. quality improvement publication of metrics, One provincial organization s leader stated that awareness and the willingness to measure and hold. organizations accountable have increased to the point that his province is in an entirely different. place although he added that it would take more than ten years to solve most of the problems The. system view and need to ensure leadership and governance focus on patient safety is growing He. We didn t actually have at the board level 10 years ago discussion of patient quality at. all other than what happened to be on the front page of the newspaper and most of. those discussions occurred in the washroom So I really think that we are in a different. place We have the measurement tools and we have the directional strategy from the. Ministry of Health to do some of these things That to me is fundamentally different. Recognition that patient safety is an important quality issue has greatly increased but has this. recognition translated into effective efforts to create safer care. Efforts to Improve Patient Safety Better,Measurement Better Understanding. Improved Practice But Limited Results, Following the IOM report in the US there were optimistic projections that concerted efforts could.
reduce the incidence of patient safety events by 50 or more within five years Kohn Corrigan et al. 1999 These US estimates were in line with data that showed a high proportion of adverse events. was preventable as have studies in Canada and elsewhere But performance improvements have. proved to be much more difficult Despite the development of new organizations focused on. supporting patient safety efforts the development of training programs for leaders front line staff. and patient safety officers and substantial funding devoted to patient safety there is limited. evidence of substantial improvement, The impact of the wide range of activities that followed in the wake of the CAES study found wide. reflection in our interviews with healthcare leaders across Canada Many spoke of the light that. had been shone on problems in patient safety of increased awareness and understanding of the. problems in patient safety and a lot more measurement and public reporting of these problems But. the evidence on whether care has actually gotten safer is mixed with closer and more careful. examinations suggesting limited real improvement, Publicly available data on some patient safety measures such as hospital standardized mortality rates. HSMR or potentially inappropriate prescribing in nursing homes do show improvement Although. often contested as a measure of patient safety the overall HSMR has declined by almost 15 per. cent between 2009 and 2013 3 However profound variation across provinces means that hospital. death rates continue to be 4 higher in Newfoundland in 2013 than across Canada in 2009 while. rates are 19 lower in BC in 2013 than across Canada in 2009 Other indicators like inappropriate. prescribing fell by a smaller proportion over the same time period from 32 of all long term care. home admissions to just under 29 Health Quality Ontario 2015. Yet other more rigorous studies in several countries that attempted to measure patient safety. directly showed little real change For example a study of North Carolina hospitals published in. 2010 reviewed a sample of 100 patients admitted to 10 hospitals in that state each quarter from. January 2002 to December 2007 Using methods similar to the national adverse events studies they. identified harm experienced by patients and assessed changes in the incidence and severity of harm. over this period Landrigan Parry et al 2010 Results from their study indicated no significant. changes in harm and little evidence of widespread improvement. An even more stark demonstration of the persistence of harm comes from two studies carried out in. the Netherlands Researchers in that country repeated a large adverse events study to examine the. changes resulting from a national program aimed at improving patient safety in hospitals in the. Netherlands, These researchers used methods similar to the Canadian Adverse Events Study to assess the. incidence of harm in 21 acute care hospitals in 2004 and 20 hospitals in 2008 In their first study they. See the CIHI sponsored report on Hospital Deaths accessed 29 April 2015 at. http yourhealthsystem cihi ca hsp inbrief lang en indicators 005 hospital deaths hsmr mapC1 mapLevel2. found an overall incidence of 4 1 of patients were harmed while in 2008 following concerted. efforts to address patient safety in the Netherlands the incidence showed a statistically significant. increase to 6 2 although the proportion of preventable AEs did not change Moreover with. shorter lengths of stay in 2008 the number of incidents per 1000 patient days showed an even larger. increase Baines and colleagues concluded that patient harm related to healthcare is a persistent. problem that is hard to influence Baines Langelaan et al 2013. The challenges of improving safety for patients in acute care began to draw commentary at the five. year anniversary of the IOM report In a 2006 article several US experts noted specific challenges in. the US measurement of patient safety was difficult there was limited evidence about effective. interventions and policies enacted to improve safety were written without a clear view of whether. they could be understood or used in practice Pronovost Miller et al 2006 Leape and colleagues. Leape Berwick et al 2009 described the problem more broadly Too many healthcare organizations. were hierarchical lacked teamwork transparency and mutual respect These organizations. continued to rely on blaming individuals as a solution for safety issues and lacked the ability to learn. from the incidents that occurred within them, Interestingly our interviews showed the same understanding of progress Healthcare leaders talked. about better attention to and understanding of patient safety issues across Canada Almost all noted. the importance of reporting or new disclosure requirements Several said that government attention. to the issue was helpful in focusing boards and senior leadership on safety and a few talked about. changing culture and acceptance of safety as a key priority But almost all also talked to the fact that. improving patient safety would be a long journey and many questioned whether care was in fact. safer ten years after the CAES It is also important that a few leaders argued that attention from. above that is from policy makers regulators and accreditation bodies could also hold back. innovation and could not substitute for leadership within organizations. Why Are Patient Safety Improvements So, One highly visible patient safety intervention to reduce adverse drug events provides a powerful.
illustration of the challenges of reducing patient safety events Adverse drug events are a major. category of patient safety events and unintended discrepancies between patients medications on. admission to and discharge from hospital are frequent Up to 69 of patients admitted to hospital. have unintended medication discrepancies Tam Knowles et al 2005 Gleason McDaniel et al 2010. and as many as 80 of those discharged from hospital Lehnbom Stewart et al 2014 In many cases. these discrepancies are not clinically significant Cornish Knowles et al 2005 But studies of care. transitions find that medication issues are a common source of problems post discharge including. unplanned readmissions Coleman Smith et al 2005, Medication reconciliation a process of comparing patient medications at key transfer points was. developed as a strategy to reduce medication discrepancies and potential adverse drug events This. process has become a Required Organizational Practice by Accreditation Canada although many. organizations have struggled to implement effective medication reconciliation Recent reviews. suggest that medication reconciliation on its own may not have a large impact on readmissions but. when combined with other interventions they may reduce the likelihood of post discharge hospital. utilization Hansen Young et al 2011 Kwan Lo et al 2013. An equally powerful illustration of the challenges of improving safety is provided by the example of. the safe surgery checklist Surgical checklists were heralded as an important tool for improving the. safety of surgery and a widely heralded study of the use of the surgical checklist in 8 hospitals. including two Canadian facilities found that the safe surgery checklist reduced mortality by almost. 50 and complications by more than one third These results combined with other studies. Treadwell et al 2014 and efforts by the World Health Organization WHO to spur adoption of the. checklist led to its widespread use Accreditation Canada mandated the surgical safety checklist for. hospitals and Ontario began public reporting of completion of surgical safety checklists at the. hospital level resulting in an immediate increase in reporting compliance However an evaluation of. the impact of this reporting in Ontario by Dr David Urbach and colleagues using administrative data. revealed no real improvement in patient outcomes Urbach Govindarajan et al 2014 This result is. at odds with a recent review of the use of checklists to improve safety in operating rooms that found. checklists could improve teamwork and communications and result in a reduction of errors Russ. Rout et al 2013 But as Charles Vincent the English patient safety expert suggests while checklists. are valid and useful we need in the longer term to think more in terms of designing teamwork. Vincent 2010 Lucian Leape was even more direct in an editorial that accompanied the Urbach. article saying the likely reason for the failure of the surgical checklist in Ontario is that it was not. actually used Leape 2014 Despite the failure of checklists in Ontario hospitals to reduce mortality. and morbidity they remain an important tool for team communication Checklists have been shown. to be effective in multiple settings but they are complex interventions Safety and team. performance experts suggest that checklists are most valuable when they are a part of a larger. strategy to improve care and not as an isolated intervention Bosk Dixon Woods et al 2009. Many patient safety interventions add work for clinical teams For example a recent study. estimated that nurses have to spend an extra 115 minutes per patient per day to complete the tasks. in the ventilator associated pneumonia bundle Branch Elliman et al 2013 The willingness of. clinicians to adopt and reliably perform this work relies on their capability to integrate this increased. workload as well as their perceptions that these interventions will improve patient outcomes. reducing the risk of harm Many clinical teams have been asked to adopt numerous patient safety. interventions without a full assessment of the impact of these interventions on their workload. Greater attention to the work resulting from these efforts will help to ensure that teams are capable. of integrating these new routines into daily practice Chris Hayes has analyzed this challenge. suggesting that both workload and the perceived value of new interventions are important. considerations for ensuring their sustainability Improvement efforts that add substantial work are. less likely to be sustainable over time while those that do not add or can reduce workload and. have high perceived value are more likely to be sustainable Hayes 2014. Paradoxically while patient safety experts have extolled the need to focus on a systems view of. safety moving beyond the role and responsibility of individual providers whose actions are. associated with patient harm the growing numbers of patient safety interventions have been added. to the work of front line teams without assessing whether these teams can integrate these new. routines into daily practice Accreditation mandates and greater public reporting of the incidents. they are intended to prevent reinforce these new patient safety practices But stressing the system. to increase safety will not yield sustainable results A broader view is needed to create the. environments that support safer patient care,What Does It Take To Create Safer Care. The challenges of medication reconciliation and the failed broad scale implementation of safe. surgery checklists in Ontario are illustrative of the broader difficulties of improving patient safety. The lessons of the last 10 years suggest that improving safety is more complex than simply. identifying effective interventions and spreading the word to clinicians practicing in relevant areas. Evidence based interventions are critical to safer care but they are insufficient if the environments in. which these interventions are introduced are not receptive In other words efforts to create safer. care need to be broader than identification of what works Rather we need to understand how we. can create supportive environments that enable implementing sustaining and spreading effective. interventions to improve safety This more comprehensive approach requires not only multiple. interventions focused on specific safety events but also a broader sensitivity to operations Weick. and Sutcliffe 2006 Karl Weick Kathleen Sutcliffe and others who have studied high reliability. organizations HROs suggest these organizations perform well because they are attentive to. patterns and problems of work on the front line and cultivate situational awareness that allows. front line workers to make adjustment to prevent errors from leading to events Sensitivity to. operations translates into a concern for anomalous events and clinicians anticipate and act to. contain risks David Woods and Richard Cook in a prescient analysis published in 2001 suggested that. the organizations wanting to develop safer care had to shift from reporting to learning from. incidents from counting events to a search for patterns in these events from looking backward at. events to anticipating future risks and shifting from a focus on error to a focus on complexity Woods. and Cook 2001 Woods and Cook don t discount reporting and learning from patient safety event. But the current approach to these practices may be insufficient to create safer clinical environments. Creating high reliability organizations is not easy they require new ways of thinking and acting and. openness to new ways of working The failure of organizations to be receptive to new practices is a. common theme in the organizational change literature in healthcare and more generally Armenakis. Harris et al 1993 Kotter 1996 Kirch Grigsby et al 2005 One way to frame this issue is to focus on. readiness for change This idea has substantial face validity organizations that are successful in. improving are those whose staff are ready to change Researchers suggest that readiness to change. depends on two factors first the willingness or motivation of staff to undertake the change and. second the capability of the unit or organization to support the change Weiner Amick et al 2008. The capability of a group includes the expertise resources and opportunity possessed by individuals. as well as the support provided by the organization Another more granular perspective on the. factors influencing the success of improvement initiatives is offered by Mary Dixon Woods and. colleagues who reviewed improvement programs funded by the Health Foundation in the UK Dixon. Woods McNicol et al 2012 They identify 10 factors that span the process of implementing. improvement interventions from design stages to sustainability and spread see Table 1 These 10. factors combine the aspects of willingness and motivation with the capability elements included in. readiness for change and draw attention to several key elements that can limit effective. improvement and patient safety initiatives measurement and data clinical and senior leadership. organizational culture and context teamwork and organizational support There has been. considerable research and experience on these issues that bears on the capability to create safer. high quality care which we will explore further below. Creating an environment that supports safer care was a theme that a number of our interviewees. identified One CEO emphasized that clear organizational values were needed to develop a safety. It all comes down to creating a culture that embraces and focuses on safety We. believe very strongly that there is a correlation between culture and safety Culture we. define as the way in which we work on a day to day basis If you say that an. organization has a culture and organizations do have cultures even if they don t. recognize that they have a culture it is important to communicate to team members. what the culture of the organization is So it has to be visible it has to be identifiable so. we say the culture is how we do things on a day to day basis but it is grounded in our. core values, The CEO illustrated the linkage between the core values and safety with the example of. improvements to hand hygiene through positive peer pressure. Take hand hygiene how did we go from roughly 70 to 90 95 we did that by. honouring our commitment so aligning with our core values in the organization is part. of empowering the culture of safety and quality We use data to drive the success and. we do 40 000 manual hand hygiene audits a year and we have auditors out throughout. the hospital I know that there are technologies that can do this but we don t like the. technological solution To us culture is all about people We want to create an. environment where everyone can speak up, Table 1 Strategies for meeting common challenges in improvement work. Design and Planning of Improvement Interventions, 1 Use hard data and stories to convince staff there is a problem.
2 Provide clear evidence that the solution is effective. 3 Invest in data collection and monitoring systems. 4 Set realistic goals and avoid giving the impression that this is only a project. Organizational and Institutional Contexts Professions and Leadership. 5 Make sure the improvement goals are linked to organizational priorities and ensure that staff have sufficient. time and support, 6 Clarify who owns the problem and solution agree on roles and responsibilities work to common goals and. use shared language, 7 Ensure effective leadership Quieter leadership oriented toward gentle explanation and persuasion. may be more effective, 8 Rely on intrinsic motivations but be prepared to use harder measures judiciously to encourage change. Sustainability Spread and Unintended Consequences Design and Planning of Improvement Interventions. 9 Avoid effort that are seen as short term project or those reliant only on particular individuals. 10 Be vigilant in detecting unanticipated consequences and be willing to learn and adapt. Adapted from Dixon Woods McNicol et al 2012,Measurement and Data. Creating and using measures to assess patient safety enables trustees organizational leaders and. staff to gauge current performance and target improvement efforts There are a growing number of. patient measures that have been developed in the last decade but limited guidance is available to. direct the choice of measures at both an organizational level and in front line care At both. organizational and unit levels no single measure of safety is sufficient Big dot measures including. the Hospital Standardized Mortality Ratio HSMR and composite measures of patient safety events. on a monthly or quarterly basis are useful for assessing current levels of safety But front line teams. require more granular measures and more frequent reporting. Measurement for improvement at the front line is both simple and challenging Quality. improvement experts suggest that improvement projects need to collect small samples of process. measures to assess the impact of the changes that teams are testing to improve key processes. Pronovost Nolan et al 2004 Langley Moen et al 2009 This guidance is a core element for safety. improvement efforts in Canada for example in the development of patient safety metrics for each. intervention in Safer Healthcare Now and in patient safety campaigns in the US and the UK But this. approach faces important cultural and logistical barriers Many clinicians have been educated to seek. carefully analyzed evidence to support changes in practice so the apparent reliance on small non. random samples to test new ideas can seem reckless In a study of physician engagement in quality. improvement Parand noted that some doctors were reluctant to become involved in safety and. quality improvement programs because they saw the methods as unscientific they quote one. informant who said that doctors are having heart failure with the idea of quick and dirty. Parand Burnett et al 2010 Just as important as the culture issues are the more tangible resource. questions Many organizations are unprepared to support local measurement Their information. systems are not capable of collecting and reporting data on a weekly basis nor do they have the. personnel to support clinical teams in doing manual collection and reporting The time skills and. knowledge needed to support such measurement are often lacking Burnett Benn et al 2010 At. the same time policy makers may not be sensitive to requests for support for more data because of. poor experiences with eHealth solution implementation. So what does effective measurement for patient safety look like The English expert Charles. Vincent in a recent report Vincent Burnett et al 2014 asserts the need for five dimensions of. patient safety measures for a scorecard on patient safety see Table 2. The dimensions provide information on five fundamental questions. 1 Past harm Has patient care been safe in the past. 2 Reliability Are our clinical systems and processes reliable. 3 Sensitivity to operations Is care safe today, 4 Anticipation and preparedness Will care be safe in the future.
5 Integration and learning Are we responding and improving.

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Electrical Engineering Concepts and Applications S. A. Reza Zekavat Michigan Technological University Upper Saddle River Boston Columbus San Franciso New York Indianapolis London Toronto Sydney Singapore Tokyo Montreal Dubai Madrid Hong Kong Mexico City Munich Paris Amsterdam Cape Town

Detection of Motion-defined form using Night Vision Goggles

Detection of Motion defined form using Night Vision Goggles

Detection of Motion-defined form using Night Vision Goggles Todd Macuda*a, Greg Craiga Robert S. Allisonb, Pearl Gutermanb, Paul Thomasc, Sion Jenningsa a National Research Council, Flight Research Laboratory, Ottawa, Canada K1A 0R6; bYork University, Department of Computer Science, Toronto, Canada, M3J 1P3 cTopaz Technology Inc., Toronto, Canada 1



CORPORATE COMPUTER AND NETWORK SECURITY Raymond R. Panko University of Hawaii Boston Columbus Indianapolis New York San Francisco Upper Saddle River Amsterdam Cape Town Dubai London Madrid Milan Munich Paris Montreal Toronto Delhi Mexico City Sao Paulo Sydney Hong Kong Seoul Singapore Taipei Tokyo



conference on Protection of Materials and Structures from the Low Earth Orbit Space Environment, held in Toronto April 25-26, 1996. The conference was hosted and organized by Integrity Testing Laboratory Inc, (ITL), and held at the University of Toronto's Institute for Aerospace Studies (UTIAS), where ITL is located. Twenty industrial companies ...

Winter 2018 (January - April) - University of Toronto

Winter 2018 January April University of Toronto

Winter 2018 (January - April) ARC357H1S - Environmental History of Landscape Architecture 100 2 100hrs each $43.65 CDN/hr + 4% Vacation Pay January 1, 2018 - April 30, 2018 In this course, TAs will act as facilitators in discussion sections, take attendance, check student work for completeness, administer examinations, and act as

System Theories: An Overview of Various System Theories ...

System Theories An Overview of Various System Theories

System Theories: An Overview of Various System Theories and Its Application in Healthcare Charissa P. Cordon Collaborative Academic Practice, Nursing-New Knowledge and Innovation, University Health Network, Toronto, ON, Canada . Abstract . Throughout the course of human evolution, humans have been solving complex problems. In this paper, various system theories such as General Systems Theory ...

Comments Mallows' c, Statistics And Multicollinearity ...

Comments Mallows c Statistics And Multicollinearity

Cornrnents on Mallows' C, Statistics And Multicollinearity Effects On Predictions Rahim Moineddin Graduate Department of Communiv Health University of Toronto ABSTRACT Selecting a subset of predictors by considering al1 possible combinations of variables with corresponding values of Mallows' Cp , AIC and BIC is discussed. It is shown that

Inductive Data Flow Graphs

Inductive Data Flow Graphs

Inductive Data Flow Graphs Azadeh Farzan Zachary Kincaid University of Toronto Andreas Podelski University of Freiburg Abstract The correctness of a sequential program can be shown by the anno-tation of its control ?ow graph with inductive assertions. We pro-pose inductive data ?ow graphs, data ?ow graphs with incorpo-

chapter 7 2002 - University of Toronto

chapter 7 2002 University of Toronto

will learn the principles of starting a successful new technology business. AER501H1 F Advanced Mechanics of Structures IV-AEESCBASCA 3/1.5/1/0.50 Introduction to the theory of linear elasticity: stress, strain and material constitutive laws. Variational principles and their appli-cation: stationary potential energy, stationary complementary

Historical Politics, Legitimacy Contests, and the (Re ...

Historical Politics Legitimacy Contests and the Re

Historical Politics, Legitimacy Contests, and the (Re)- Construction of Political Communities in Ukraine during the Second World War Oleksandr Melnyk Doctor of Philosophy Department of History University of Toronto 2016 Abstract This doctoral dissertation is a study of historical politics and legitimacy contests in Ukraine during the Second World War. By situating the operations of the Soviet ...

Evaluation of the Clinical Performance of Pedo Jacket ...

Evaluation of the Clinical Performance of Pedo Jacket

Master of Science Graduate Department of Pediatric Dentistry University of Toronto 2014 To assess the clinical performance of Pedo Jacket crowns for the treatment of ECC-affected primary anterior teeth in a prospective longitudinal clinical study and in vitro. Crowns were



CYTOCHROME P450 PEROXIDASEIPEROXYGENASE-DEPENDENT METABOLIC ACTIVATION OF XENOBIOTICS Ph.D., March 1997 Mohammad Reza Anari Faculty of Pharmacy University of Toronto Cytochrome P450 (P450) peroxidase and peroxygenase activities have been well documented with microsomal enzymes and purified P450 preparations,

Introduction to International Political Economy Sixth ...

Introduction to International Political Economy Sixth

Introduction to International Political Economy Sixth Edition David N. Balaam University of Puget Sound University of Washington, Tacoma Bradford Dillman University of Puget Sound PEARSON Boston Columbus Indianapolis New York San Francisco Upper Saddle River Amsterdam Cape Town Dubai London Madrid Milan Munich Paris Montreal Toronto Delhi Mexico City Sao Paulo Sydney Hong Kong Seoul Singapore ...

Human - University of Toronto T-Space

Human University of Toronto T Space

This study has enabied me to unite two areas close to my heart: music and mother- infant relationships. Thanks to my father, mother, and brother for making music, and more specifically singing, such an integral part of my childhood and for al1 of their love and support throughout my studies. Michael, thanks for the constant pride and interest