Ont. hospitals to use surgical checklist to improve patient safety starting next year

By Maria Babbage (CP) 
TORONTO — Ontario hospitals will be required to use a surgical safety checklist and report on their compliance starting next spring as part of a government effort to improve patient safety, The Canadian Press has learned.

Hospitals already report on eight indicators of patient safety, such as C. difficile rates and hand washing.
The new rules, to be announced Thursday, will require hospitals to report publicly twice a year on whether they're following the checklist, starting July 31, 2010. However, the first report is expected to include data about operations performed between April 1 and June 30.

The checklist includes 26 common tasks and items that surgeons and staff carry out to ensure patient safety in the province's operating rooms, such as checking equipment, confirming patient information and reviewing resuscitation plans. The checklist is divided into three sections: tasks that must be completed before the anesthesia, before the incision and before the patient leaves the operating room. It even requires surgeons, anesthesiologists and nurses to introduce themselves by name and role before the patient goes under the knife. The checklist will apply to all surgeries and hospitals will have to report on the number of surgeries in which the checklist's tasks were completed.

Government sources say the list, which was developed in consultation with experts and the Ontario Hospital Association, will make the province's patient safety reporting regime the most comprehensive in North America. They cite a study published in the New England Journal of Medicine in January that showed the implementation of surgical checklists helped reduce deaths and complications among patients. The announcement will mark the first anniversary of public reporting of C. difficile rates in Ontario, which have declined by 30 per cent since hospitals started reporting them.

The province extended mandatory reporting of the infection and other hospital-acquired infections in the wake of an outbreak that caused or contributed to dozens of deaths in Ontario hospitals in 2007 and 2008.
In 2007, the Ontario coroner's office determined that C. difficile caused or contributed to 18 deaths at a Sault Ste. Marie hospital and suggested hospital overcrowding and out-of-date facilities may have contributed to the outbreak. A Toronto-area hospital also battled more than a dozen cases that year that were positively identified as the same virulent strain that has claimed some 2,000 lives in Quebec since 2003.

In 2008, Joseph Brant Memorial Hospital in Burlington reported that C. difficile caused 62 patient deaths and 115 other infections between May 2006 and December 2007. C. difficile is one of the most common infections in hospitals and nursing homes. The bacterium, which is found in feces, causes diarrhea and more serious intestinal conditions such as colitis. Seniors and patients requiring prolonged use of antibiotics are at greater risk of infection, which can occur through physical contact after touching a contaminated surface.

Copyright © 2009 The Canadian Press. All rights reserved.

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17 percent of Canadians subject to medical, medication, or laboratory errors. Commonwealth Study

17 percent of Canadians subject to medical, medication, or laboratory errors. Commonwealth Study

20 percent of Americans and Australians report that they were subject to medical, medication, or laboratory errors.

Evidence of patient safety risks and their impact on patients continues to emerge, both in hospitals and community settings.

HEALTHCARE LAGGING IN CREATING EFFECTIVE SAFETY LEARNING SYSTEMS. Seven Country Study

G. Ross Baker, co-author of The (2004) Canadian Adverse Events Study. Can. Med. Assoc. J., May 2004) calls for "deeper capacity" to deal with ongoing changes in healthcare.

In his editorial to the fourth special issue of the journal Healthcare Quarterly dedicated to patient safety, he quotes a colleague's words: "safety is a dynamic and emerging state that is continually renegotiated as things change. And in healthcare everything changes all the time ... so [we need] to develop a deeper capacity to deal with these issues so we can understand the complexity that we are working in."

May 2009 marked the fifth anniversary of the publication of the Canadian Adverse Events Study. He now writes:
• Evidence of risks and their impact on patients continues to emerge, both in hospitals (where the evidence is considerable) and community settings (where it is not).
• New technologies that improve diagnostic capabilities or offer therapeutic benefits often carry risks.
• Even if these risks are carefully calibrated, this knowledge is not always widely shared.
• Methods and tools alone may be insufficient to create an environment supporting safer care.
• Hand hygiene is "widely recognized as a critical practice for reducing healthcare-associated infections, many audits find only modest levels of acceptable practice."

Many experts, he writes, believe that healthcare has lagged in creating the types of effective safety learning systems seen in other high-risk industries.

Full issue available here:
http://www.longwoods.com/home.php?cat=604.

Self reported errors discussed here:
http://www.longwoods.com/product.php?productid=20967&cat=604&page=1

To contact the Editor please write G. Ross Baker (ross.baker@utoronto.ca).

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Zach Dunlap says he feels "pretty good," four months after he was declared brain dead and doctors were about to remove his organs for transplant.

Was this a patient error or adverse event? Would other patients in similar circumstances also been witmess to their declaration of death? Will organ transplant programs re-visit their policies and programs and related issues of medical ethics?

Dunlap, 21, said he has no recollection of his crash.

Dunlap was pronounced dead November 19 at United Regional Healthcare System in Wichita Falls, Texas, after he was injured in an all-terrain vehicle accident. His family approved having his organs harvested.

As family members were paying their last respects, he moved his foot and hand. He reacted to a pocketknife scraped across his foot and to pressure applied under a fingernail. After 48 days in the hospital, he was allowed to return home, where he continues to work on his recovery.

On Monday, he and his family were in New York, appearing on NBC's "Today."

"I feel pretty good. but it's just hard ... just ain't got the patience," Dunlap told NBC.

Dunlap, 21, of Frederick, Oklahoma, said he has no recollection of the crash.

"I remember a little bit that was about an hour before the accident happened. But then about six hours before that, I remember," he said.

Dunlap said one thing he does remember is hearing the doctors pronounce him dead.

"I'm glad I couldn't get up and do what I wanted to do," he said.

Asked if he would have wanted to get up and shake them and say he's alive, Dunlap responded: "Probably would have been a broken window that went out."

His father, Doug, said he saw the results of the brain scan.

"There was no activity at all, no blood flow at all."

Zach's mother, Pam, said that when she discovered he was still alive, "That was the most miraculous feeling."

"We had gone, like I said, from the lowest possible emotion that a parent could feel to the top of the mountains again," she said.

She said her son is doing "amazingly well," but still has problems with his memory as his brain heals from the traumatic injury.

"It may take a year or more ... before he completely recovers," she said. "But that's OK. It doesn't matter how long it takes. We're just all so thankful and blessed that we have him here."

Dunlap now has the pocketknife that was scraped across his foot, causing the first reaction.

"Just makes me thankful, makes me thankful that they didn't give up," he said. "Only the good die young, so I didn't go."

First-ever national guidelines to assist and support healthcare providers in the disclosure of adverse events to patients and their families

March 18, 2008: TORONTO -- The Canadian Patient Safety Institute (CPSI) and the Disclosure Working Group today released the first-ever national guidelines to assist and support healthcare providers in the disclosure of adverse events to patients and their families. Experts from organizations representing physicians, nurses, pharmacists, healthcare providers, patients and others created the Canadian Disclosure Guidelines through nearly two years of collaborative effort.

"A focus on patient safety is now emerging in Canada in an effort to learn from and take coordinated action to reduce preventable harm and death," said CPSI Chief Executive Officer Philip Hassen. "CPSI has been pleased to provide coordination, leadership and funding support to the Disclosure Working Group, whose tireless efforts to develop the guidelines have resulted in an important tool for supporting open and transparent communication between providers and patients."

"The Canadian Disclosure Guidelines are intended to assist and support the development and implementation of disclosure policies, practices and training methods. They represent a commitment to the patient's right to be informed if they are involved in an adverse event, by promoting a clear and consistent approach to disclosure, emphasizing inter-professional teamwork, and supporting learning from adverse events."

"The guidelines build on various patient safety initiatives currently underway across Canada," said Working Group chair Brent Windwick. "Through them, we hope to encourage healthcare providers to develop or enhance their disclosure policies and practices by incorporating the core elements, but in ways that are adapted to their respective needs."

For patients and their families, the guidelines stress the importance of providing an apology, timely information and access to further health care, designating a knowledgeable and familiar staff member to provide practical and emotional support, and assisting patients in accessing additional provider and personal supports.

"Things can happen with any type of treatment or care, but when they do, disclosure is very important," said Working Group member and Patients for Patient Safety Canada member, Katharina Kovacs Burns. "As stressful as this may be for healthcare providers, who are the ones disclosing, as well as the patients and families who get the news, apologies are always appreciated. Apologies are a sign of caring, compassion and empathy, not guilt or blame."

For healthcare providers, the guidelines present clear expectations on what should be done to disclose information and assist patients and their families when harm occurs. The guidelines also promote the adoption of a variety of strategies to make organizational and professional supports available to providers, as well as discourage speculation or attribution of blame.

"Adverse events affect thousands of patients every year in Canada," said Working Group member and registered nurse Carolyn Hoffman. "These guidelines support frontline staff and senior healthcare leaders as they enter into timely disclosure conversations with their patients. Open and honest communication following an adverse event helps everyone to learn what happened and what may prevent the same thing from ever happening again."

"Patients are treated and healed through a relationship with their healthcare providers that is based on trust and respect," said Working Group member Dr. Ward Flemons. "When adverse events occur, that relationship is at risk. Timely, truthful and transparent disclosure can re-establish patient/provider trust and is always the right thing to do."