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 (firstname.lastname@example.org).