Saskatchewan to track, report on safety incidents involving patients and employees

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In 2004, University of Toronto professor and Health Quality Council (HQC) Board member Ross Baker co-authored a landmark Canadian study that found adverse events causing harm to patients occurred in an estimated 7.5% of all hospitalizations in Canada.

In a follow-up paper, Beyond the Quick Fix: Strategies for Improving Patient Safety (Nov. 2015), Baker reports that “…ten years later, many Canadian healthcare organizations still struggle to address key patient safety issues. Harm experienced by patients, and the impact on families, staff and organizations continues despite better measures of the number and impact of these events, and efforts to change unsafe practices.”

Saskatchewan’s health system leaders are committed to making health care environments safer for everyone and have set a target to eliminate preventable harm to patients and employees province-wide by March 31, 2020.

The province’s health care system will take a significant step toward achieving that in 2016-17, when all health regions and the Saskatchewan Cancer Agency will begin tracking voluntarily reported safety incidents involving both patients and health care workers. The new reporting measure was created by the provincial Safety Alert/Stop the Line team housed at HQC.

By including both patient- and employee-related incidents, Saskatchewan’s new safety measure will help end the traditional approach to thinking about harm to patients and staff separately. For example, by tracking infection rates among both groups it is much easier to establish patterns and assess the impact of efforts to prevent infection. And, since all regions will be reporting, health system leaders will have information about the province as a whole to facilitate targeted safety improvement efforts.

Measuring safety can be challenging – health care environments are complex and no single safety measure is sufficient in itself but this is a great step forward,” says HQC’s Kate Fast, lead on the province’s Safety Alert/Stop the Line initiative.

The measure will be used by health system leaders to assess the collective impact of a number of safety improvement efforts intended to help detect errors in care processes before they can cause harm.

Health regions will report incidents that result in harm, as well as those incidents that had the potential to cause harm. Employees and providers are expected to stop a care process if they recognize a defect (‘stop the line’) and fix it in the moment before it can cause harm. As these behaviours become pervasive, the proportion of reported ‘no harm’ events is expected to increase.

“Most people think safer health care should result in fewer reports of harm and events that could have led to harm,” says Gary Teare, HQC’s Chief Executive Officer. “In fact, a system that actively uses reporting to become safer will see an increase in these reports to begin with. When patients and providers view reporting safety concerns as welcome and helpful, they are encouraged to report. This new common approach to measuring safety is a vital step forward.”

While there are limitations to this measure, Ross Baker applauds Saskatchewan’s work to improve safety measurement as a means to eventually ending harm to patients and health care workers by 2020.

Incident reporting offers important information needed to measure safety and to identify gaps that expose patients and staff to injuries. Collecting and sharing this information across the province will improve learning about relevant risks and the sharing of effective responses,” says Ross Baker.

For more information about the new safety measure or Safety Alert/Stop the Line, contact Kate Fast by telephone (306-668-8810 ext. 138) or by email (kfast@hqc.sk.ca).

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2 Responses to “Saskatchewan to track, report on safety incidents involving patients and employees”

  1. Kate Fast
    January 11, 2016 at 2:01 pm #

    Kim – you are so right. Optimal care depends on the active involvement of patients and families, and the free flow of information. This level of patient engagement is critical for patient safety at every step of their health care journey.

    The goal of the Safety Alert/Stop the Line (SA/STL) initiative is to support patients, families, staff and physicians to become safety inspectors. Patients and families are invited, and staff and physicians are expected, to identify defects in care processes in the moment (‘Safety Alert’). Staff and physicians are expected to ‘Stop the Line,’ assess the situation and fix defects right away. If staff and physicians cannot restore safety, they are expected to escalate the issue and bring in support. Everyone – including patients and families – is encouraged to report safety concerns (both those that have caused harm, but also risks that have the potential to cause harm).

    Regional health authorities across Saskatchewan are in the process of creating the mechanisms that will best support patients, families, staff and physicians to ‘Stop the Line’ and report safety concerns. Patient and Family Advisors are directly involved in the leadership and deployment of this initiative, as members of the Guiding Coalition and the SA/STL Network.

    If you are interested in increasing patient and family involvement in safety, please contact me, Kate Fast, Lead, SA/STL at kfast@hqc.sk.ca or by phone at 306-361-2303.

    Thank you again for your interest in this important issue.

  2. K. Neudorf
    January 8, 2016 at 9:52 pm #

    Patients/families should have the opportunity to use the reporting system. They offer an important perspective and may report events that were not recognized and therefore not reported by the health care professional. The thinking of the day promotes partnership, transparency, involvement. The program will fall short if patients cannot report.

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