Patients, families and employees to participate in safety alert system development

stop the line 2013-11-08

Petrina McGrath knows the devastation felt by a patient’s family and staff after an incident that called safety into question. “The family members looked at me and asked, ‘How can we be sure that this incident won’t happen again?’ and at that moment, I couldn’t say for sure that it wouldn’t,” she says. McGrath is Saskatoon Health Region’s vice president of Quality and Interprofessional Practice. She’s responsible for the Region’s safety initiatives. McGrath met with the family. Later, staff got another opportunity to debrief and even months later, they were still highly emotional because they were re-living the incident. “They were the second victims because we didn’t have a system to keep them safe either,” says McGrath.

That is why the Region is in the process of developing and implementing a safety alert/stop the line system.

Having a safety alert/stop the line system in place would allow anyone to report a safety concern and receive the appropriate follow up in a timely manner. “Currently we have so many different places, forms and processes to report safety issues which can be confusing and time consuming to figure out,” explains McGrath. “Response times to safety concerns and reports can vary as well and we know this deters people from reporting.”

The goal is to create a single, comprehensive method of reporting that is easily accessed by physicians and staff, as well as by patients and their families.

The project is part of the provincial plan to establish a culture of safety by 2017 with a shared ownership for the elimination of defects for patients and staff. McGrath and Dr. George Pylypchuk, vice president of Practitioner Staff Affairs, are leading this work with help from an advisory group.

“A safety alert system will be a positive step to ensuring that patients get the best and safest care and that the safety of our physicians and staff is protected as well,”

says Pylypchuk. The reporting system would require any employee who encounters a situation that is likely to harm a patient, a staff member or his/herself to make an immediate report and to cease any activity that could cause further harm. This would ‘stop the line.’

To help design this new safety alert system, the region is hosting a 3P (production, preparation, process) event from December 2 to 6, 2013. This process is usually used to design a process or a facility. Physicians, staff and patient advisors from the Region, as well as other health regions and the Ministry of Health will participate.

“I think the most amazing thing about the 3P event is that we have the opportunity to tap into the wisdom of patients, families and leaders from all areas of our organization and the province, from point of care staff and physicians to board members,” says McGrath. “We can tap into the expertise across our Region and across the province and build on best practices that already exist to design this safety alert system.”

The work won’t be easy. “Our biggest challenge will be shifting from a culture of fear, blame or retribution for reporting a safety concern, to a culture of openness and fairness,” says Pylypchuk.

McGrath agrees. “We can’t fix what we don’t know about and I think we have created work-arounds for so many reasons that we sometimes don’t even see things as a safety risk,” she says. “We’ve normalized what shouldn’t be normalized.”

The reaction has been positive. “Many staff members I’ve talked to say that we really need it and that the current processes are too complex,” says McGrath. “Most people see the value, but like anything they want to see it in action to really be able to understand how it will help keep them safe and enable them to provide safe care to the patients, clients and residents we serve.”

Source: The Region Reporter. Click here for full article on website.


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4 Responses to “Patients, families and employees to participate in safety alert system development”

  1. Where's the patient?
    November 12, 2013 at 4:25 pm #

    So where does the patient who spends six days waiting for an urgent cardiac cath land in this plan? Does the line stop and that patient goes to the cath lab? Does the patient who is bumped cause the cord to be pulled again? This system depends on staff who feel confident enough to pull the cord, after they acually recognize this as a patient safety concern. I assume patients can’t stop the line… Until there is a system that runs in some predictable manner there is no point in pulling the cord. It just adds to the chaos.

    • Saskatoon Health Region
      November 12, 2013 at 5:04 pm #


      Those are all really excellent questions and we’ll have some more solid answers about how this will all work once we design the safety alert system using the 3P event. We know that we want patients and families to be able to stop the line and we will have patient and family advisers working with us on the 3P to help us design how to make that happen and what will work best for them.

      Thanks for your questions and comments.

  2. Frank Hector
    November 8, 2013 at 11:52 am #

    I have reviewed both identical posts but still do not know what the grim event that McGrath and Pylypchuck are talking about.! It appears that it had taken place some months previously.I would appreciate a sometime patient.. Without this information the item does not mean anything to me and I suspect others. Am I missing something obvious?. I cannot see how I would fit into the( Inspire O Meter) Regards from a old vet.

    • Saskatoon Health Region
      November 12, 2013 at 4:58 pm #

      Hi Frank Hector,
      We appreciate your comments and can understand your frustration in not knowing the details. However, due to the Health Information Protection Act (HIPA), we cannot include any specific information about the incident as details could identify the patient or family members involved. We were just trying to illustrate that a safety incident can impact all involved – patients and families, as well as physicians and staff.


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