Innovative system changes how Saskatoon Health Region responds to safety events


If you want to report a safety event in Saskatoon Health Region, who are you going to call?

Petrina McGrath, Saskatoon Health Region’s Vice-President of People, Practice and Quality, is hoping you’ll call the Region’s Safety Alert System and is encouraging everyone to do so.

Yesterday, the Region hosted a “show and tell” presentation of the Safety Alert System to demonstrate how the single, call-in reporting system works and how we have used simulation training, provided by the Saskatoon Institute for Medical Simulation (SIMS) to help train leaders to respond. Health Minister Dustin Duncan was a keynote speaker and Minister for Rural and Remote Health Greg Ottenbreit was also in attendance.

The SIMS team, with help from patient advisor Dianne Martin, staged a fictional scenario where a 6 year old patient in Acute Care Pediatrics is recovering from an appendectomy surgery and is given too much morphine for pain control while in recovery.

“The scenario portrayed the distress that a family would experience as well as the devastation the nurse felt at making the error,” explained McGrath. The scenario also demonstrated the care team mitigating the situation and the family calling the Safety Alert System to report, not only their concern about their stabilized child but about the distraught nurse as well.

rr-2015-11-13-safetyalertsystem-familyThe family in the Safety Alert System scenario reacts after Cody stabilizes.

After the simulation, McGrath explained the Region’s response process. “Once safety is restored, the response in this type of example would include a review of the incident to understand what happened and how we can improve our processes to prevent harm from hitting the patient,” she said. “This includes meeting or speaking with the family and staff involved.” This review helps the Region develop and improve protocols and procedures to help prevent incidents like this from happening in the future.

“The more we learn, the better support we can provide to those involved, including our patients and families and our employees and physicians.”
(Petrina McGrath, Saskatoon Health Region’s VP of People, Practice and Quality)

“Protecting patients and healthcare workers is a top priority in Saskatchewan, and that is why Safety Alert/Stop the Line is so valuable. It saves lives, prevents harm and creates a safer environment for everyone,” says Health Minister Dustin Duncan. “Saskatoon Health Region has had great success piloting this initiative, and their work will guide the implementation of Safety Alert/Stop the Line in health regions across Saskatchewan.”

rr-2015-11-13-safetyalertsystem-duncanHealth Minister Dustin Duncan reacts to the simulation and discusses the plan to replicate the system province-wide implementation in health regions across Saskatchewan by March 2018.

While the Region is responding to safety concerns in a way it never has before, the system isn’t perfect. “Safety events are typically underreported. We see on average 1,800 reports a month from our three Saskatoon hospitals. We know that number should be higher. Alerts are critical because we can’t fix what we cannot see,” said McGrath.

“We want everyone, whether you’re a patient, a family member, an employee or a physician to feel empowered to report safety issues or concerns,” says McGrath. “The ultimate purpose of the Safety Alert System is to understand how we can continue to reliably deliver safe care and service to our patients, clients and residents while protecting the safety of our staff and physicians.”

rr-2015-11-13-safetyalertsystem-petrinaPeople, Practice and Quality Vice President and Safer Every Day team co-lead Petrina McGrath speaks to media.

The system was first piloted at St. Paul’s Hospital in March 2014. In July and August of this year, the system was implemented at Saskatoon City Hospital and Royal University Hospital. The initial mandate to design and develop a single, comprehensive safety reporting system came from the Ministry of Health in 2013.

Saskatoon Health Region encourages anyone who experiences a safety issue or concern in any of Saskatoon’s three hospitals to report them by calling 306-655-1600. The phone line is open 24 hours a day, 7 days a week.

Saskatoon Health Region is focusing on improving safety through Safer Every Day, a 90 day cycle devoted to achieving breakthrough safety approaches. This 90 day initiative is another phase of a strategy to eliminate preventable harm by 2020.

Photo: In the Safety Alert System scenario, Nurse Lynette (left) is distraught after giving Cody “the patient” too much medication.

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