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Patient Safety and Incident Management Physiotherapy Alberta Webinar Sandi Kossey and Ioana Popescu, Canadian Patient Safety Institute October 22, 2015
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Patient Safety and Incident Management - College · Patient Safety & Incident Management Toolkit •Goal: safe care •The need: –Recognize, respond, reduce, learn –Aligned with

Jul 21, 2020

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Page 1: Patient Safety and Incident Management - College · Patient Safety & Incident Management Toolkit •Goal: safe care •The need: –Recognize, respond, reduce, learn –Aligned with

Patient Safety and Incident Management

Physiotherapy Alberta Webinar

Sandi Kossey and Ioana Popescu, Canadian Patient Safety InstituteOctober 22, 2015

Page 2: Patient Safety and Incident Management - College · Patient Safety & Incident Management Toolkit •Goal: safe care •The need: –Recognize, respond, reduce, learn –Aligned with

Overview of Presentation

• About the Canadian Patient Safety Institute

• Patient safety and incident management

– Link to PT

– Concepts

– Toolkit features

• Patients as partners

• Resources

Page 3: Patient Safety and Incident Management - College · Patient Safety & Incident Management Toolkit •Goal: safe care •The need: –Recognize, respond, reduce, learn –Aligned with

WHERE DO YOU WORK?WHAT DO YOU WANT TO KNOW?

Page 4: Patient Safety and Incident Management - College · Patient Safety & Incident Management Toolkit •Goal: safe care •The need: –Recognize, respond, reduce, learn –Aligned with

ABOUT THE CANADIAN PATIENT SAFETY INSTITUTE

Sandi Kossey, Senior Director

Page 5: Patient Safety and Incident Management - College · Patient Safety & Incident Management Toolkit •Goal: safe care •The need: –Recognize, respond, reduce, learn –Aligned with

Our Vision:

Safe healthcare for all Canadians

Our Mission:

To inspire extraordinary improvement in patient safety and quality

Our Main Roles:• We champion the cause of patient safety.• We help create the capacity to improve.• We are integrators; brokers; catalysts; and promoters.• We create resources for the healthcare system, work with partners,

and celebrate successes.• We listen, engage, customize, and spread knowledge.

Canadian Patient Safety Institute

Page 6: Patient Safety and Incident Management - College · Patient Safety & Incident Management Toolkit •Goal: safe care •The need: –Recognize, respond, reduce, learn –Aligned with

Our Mantra

Page 7: Patient Safety and Incident Management - College · Patient Safety & Incident Management Toolkit •Goal: safe care •The need: –Recognize, respond, reduce, learn –Aligned with

PATIENT SAFETY AND PTPatient Safety and Physiotherapy Practice

Page 8: Patient Safety and Incident Management - College · Patient Safety & Incident Management Toolkit •Goal: safe care •The need: –Recognize, respond, reduce, learn –Aligned with

DefinitionsPatient safety – the avoidance, prevention, and amelioration of adverse outcomes or injuries stemming from the processes of health care

Definitions

HarmfulIncidents

Harm – An outcome that negatively affects a patient’s health and/or quality of life.

Patient safety incident – an event or circumstance that could have resulted, or did result, in unnecessary harm to a patient

Healthcare Associated

Harm

Harmful

Incidents

Page 9: Patient Safety and Incident Management - College · Patient Safety & Incident Management Toolkit •Goal: safe care •The need: –Recognize, respond, reduce, learn –Aligned with

WHAT IS YOUR UNDERSTANDING OF PATIENT SAFETY?

Page 10: Patient Safety and Incident Management - College · Patient Safety & Incident Management Toolkit •Goal: safe care •The need: –Recognize, respond, reduce, learn –Aligned with

Our Inspiration

Page 11: Patient Safety and Incident Management - College · Patient Safety & Incident Management Toolkit •Goal: safe care •The need: –Recognize, respond, reduce, learn –Aligned with

Issues Specific to PT Practice

• Rehabilitation settings and services have unique patient safety phenomena

• Patient populations viewed as unique and increasingly complex

• Infection control

• Individual risk vs. patient autonomy– Informed decision-making

– Discharge planning

– Transitions of care

Page 12: Patient Safety and Incident Management - College · Patient Safety & Incident Management Toolkit •Goal: safe care •The need: –Recognize, respond, reduce, learn –Aligned with

Patient Safety Management in PT Practice

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• Enablers of and barriers to patient safety are consistent with those found in other health care settings– Teamwork

– Culture and leadership

– Resources

– Individual and organizational responsibilities

Page 13: Patient Safety and Incident Management - College · Patient Safety & Incident Management Toolkit •Goal: safe care •The need: –Recognize, respond, reduce, learn –Aligned with

PATIENT SAFETY AND INCIDENT MANAGEMENT

Ioana Popescu, Patient Safety Improvement Lead

Page 14: Patient Safety and Incident Management - College · Patient Safety & Incident Management Toolkit •Goal: safe care •The need: –Recognize, respond, reduce, learn –Aligned with

Patient Safety & Incident Management Toolkit

• Goal: safe care

• The need:

– Recognize, respond, reduce, learn

– Aligned with Accreditation

• All sectors, settings

Page 16: Patient Safety and Incident Management - College · Patient Safety & Incident Management Toolkit •Goal: safe care •The need: –Recognize, respond, reduce, learn –Aligned with

Principles

• Patient and family centred care

• Shared responsibility

• Safety culture

• System perspective

Page 17: Patient Safety and Incident Management - College · Patient Safety & Incident Management Toolkit •Goal: safe care •The need: –Recognize, respond, reduce, learn –Aligned with

Patient Safety CULTURE

“Culture is tribal; it lives and breathes at provider level and in middle management level. The reality is that there are significant cultural differences between shifts and even team members. Furthermore, a unit’s culture can be influenced – both negatively and positively – by a single individual.” Hugh MacLeod

Page 18: Patient Safety and Incident Management - College · Patient Safety & Incident Management Toolkit •Goal: safe care •The need: –Recognize, respond, reduce, learn –Aligned with

Before the Incident

• Promote teamwork, build capacity, culture

• Monitor, analyze, prioritize – risks + note strengths

• Implement actions – to mitigate risks, improve safety and quality

• Establish incident management structures– Reporting and learning system

– Plans, processes, resources

– leadership and staff support

Page 19: Patient Safety and Incident Management - College · Patient Safety & Incident Management Toolkit •Goal: safe care •The need: –Recognize, respond, reduce, learn –Aligned with

Incident Management

Page 20: Patient Safety and Incident Management - College · Patient Safety & Incident Management Toolkit •Goal: safe care •The need: –Recognize, respond, reduce, learn –Aligned with

Disclosure

The hardest right thing you will ever have to do

Remember

• Principles

• Values

Page 21: Patient Safety and Incident Management - College · Patient Safety & Incident Management Toolkit •Goal: safe care •The need: –Recognize, respond, reduce, learn –Aligned with

Disclosure Matters

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• Caring for patients– Explanations, expression of regret vs. apology, making sure

it does not happen again

– Longer term support for some

• Supporting staff– Understanding, communication

– Professional and personal support

– Potential long term effects

Page 22: Patient Safety and Incident Management - College · Patient Safety & Incident Management Toolkit •Goal: safe care •The need: –Recognize, respond, reduce, learn –Aligned with

Share Learning

• Close the communication loop

& make system safer

• Patient safety successes &

incidents

• Internally & externally

• Formal & informal

Page 23: Patient Safety and Incident Management - College · Patient Safety & Incident Management Toolkit •Goal: safe care •The need: –Recognize, respond, reduce, learn –Aligned with

System Factors

• Shape and are shaped by PSIM

• System levels

• Actions

– Respond, align, leverage, collaborate

Page 24: Patient Safety and Incident Management - College · Patient Safety & Incident Management Toolkit •Goal: safe care •The need: –Recognize, respond, reduce, learn –Aligned with

Toolkit Adaptation to PT

Page 25: Patient Safety and Incident Management - College · Patient Safety & Incident Management Toolkit •Goal: safe care •The need: –Recognize, respond, reduce, learn –Aligned with

WHAT RESOURCES DO YOU HAVE OR NEED?

Page 26: Patient Safety and Incident Management - College · Patient Safety & Incident Management Toolkit •Goal: safe care •The need: –Recognize, respond, reduce, learn –Aligned with

PATIENTS AS PARTNERS

Page 27: Patient Safety and Incident Management - College · Patient Safety & Incident Management Toolkit •Goal: safe care •The need: –Recognize, respond, reduce, learn –Aligned with

Patient Centred Care

• System changes

o Technology, society, campaigns

• Shift

o Patients: experts, providers: guests

o Doing to doing with

o How can I help what concerns YOU

• Results:– Adherence health savings

Page 28: Patient Safety and Incident Management - College · Patient Safety & Incident Management Toolkit •Goal: safe care •The need: –Recognize, respond, reduce, learn –Aligned with

Patient Engagement

• Patient advisors – former patients

• Represent the patient perspective

– Education

– Policies, procedures

– Decisions

– Improvement projects

Page 29: Patient Safety and Incident Management - College · Patient Safety & Incident Management Toolkit •Goal: safe care •The need: –Recognize, respond, reduce, learn –Aligned with

SUMMARY

Page 30: Patient Safety and Incident Management - College · Patient Safety & Incident Management Toolkit •Goal: safe care •The need: –Recognize, respond, reduce, learn –Aligned with

Everything I need to know about patient safety I learned in kindergarten...

Page 31: Patient Safety and Incident Management - College · Patient Safety & Incident Management Toolkit •Goal: safe care •The need: –Recognize, respond, reduce, learn –Aligned with

Summary

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• Patient safety is everyone’s responsibility

• Understanding the problem is the first step towards improvement

“When errors are viewed as an opportunity for improvement rather than punishment, patients will

benefit.” (Vincent, 1998)

Page 32: Patient Safety and Incident Management - College · Patient Safety & Incident Management Toolkit •Goal: safe care •The need: –Recognize, respond, reduce, learn –Aligned with

Physiotherapy Alberta Resources

Page 33: Patient Safety and Incident Management - College · Patient Safety & Incident Management Toolkit •Goal: safe care •The need: –Recognize, respond, reduce, learn –Aligned with

CPA Risk Management Practice Resource -Apology

Page 34: Patient Safety and Incident Management - College · Patient Safety & Incident Management Toolkit •Goal: safe care •The need: –Recognize, respond, reduce, learn –Aligned with

#asklistentalk

Page 35: Patient Safety and Incident Management - College · Patient Safety & Incident Management Toolkit •Goal: safe care •The need: –Recognize, respond, reduce, learn –Aligned with

DISCUSSION

Page 36: Patient Safety and Incident Management - College · Patient Safety & Incident Management Toolkit •Goal: safe care •The need: –Recognize, respond, reduce, learn –Aligned with

Thank You

Contact us: [email protected]; 1.866.421.6933

www.patientsafetyinstitute.ca

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