Central CCAC Outstanding care – every person, every day Safer patients, better care through Never Events research and education Canadian Patient Safety Institute Virtual Forum on Patient Safety and Quality Improvement October 2013
Central CCAC
Outstanding care – every person, every day
Safer patients, better care through Never Events research and
education
Canadian Patient Safety InstituteVirtual Forum on Patient Safety and Quality Improvement
October 2013
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Groundbreaking research:a Canadian first
• Central CCAC’s reality: 30,000+ patients a day, 58% from hospital, 69% with high/very high needs
• Central CCAC / University of Toronto study - incidents that should never happen when delivering care in the community• Serious, preventable, reportable
• Generated recommendations for clinical, administrative and policy strategies • Strengthens accountability through performance measures• Increases transparency through public reporting• Supports Outstanding care – every person, every day
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Key lessons learned
• Top four Never Events1. Adverse reaction requiring ED visit or
hospitalization due to med-related events 2. Serious injury related to inappropriate service plan3. New peritoneal dialysis infection4. Serious event related to care or services contrary to current
professional or other practice standards
• Complexities of care in community include patients choosing to live at risk and informal caregiver involvement
• How to identify events, improve reporting systems and support sustainable change – Everyone has a role!
Central CCAC’s first
focus
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Using the research to drive safer patients, better care
• Building a shared community sector vision where patients receiving home care never experience a serious, preventable medication-related error
• Key steps• Listening to patient and family feedback• Process improvement sessions• Never Events education:
34+ workshops and webinars500+ frontline staff, service providers16 service provider organizations
• Measurement – Reporting of errors has increased since education