I am pleased to welcome a guest writer for this week’s blog, Professor Jennifer Medves, our Vice-Dean and Director of Queen’s School of Nursing. Richard
Patient safety is all of our responsibility as health care providers. We are all concerned about the adverse events that happen in health care every day. The cost to the health care systems is significant; one report estimated the cost in the US is about $17 billion every year in direct and indirect costs (1). Reports such as “To Err is Human: Building a Safer health Care System” (1) and in 2004 a landmark Canadian study by Ross Baker and his colleagues (2) have raised the awareness of patient safety. These, and many other reports and publications have made patient safety a major quality issue for health care. As many as 37% of all adverse events are ‘highly’ preventable, nearly ¼ are related to medication error, and 1 in 13 adults admitted to a Canadian hospital will encounter an adverse event. The onus and responsibility is on all health care providers and administrators to reduce errors, but it is a very complex issue. We have evidence that some practices including surgical check lists, hand washing, and medication reconciliation reduce errors. As health care providers we now need to develop ways to reduce all errors and aim for robust systems that identify potential adverse events before they happen. The first step is to stop blaming and shaming individuals and work together to find system solutions. Once we have better ways to provide care we then must teach it to learners in our education programs.
Queen’s University hosted the first Patient Safety Educators Program (PSEP) – Canada Become a Patient Safety Trainer conference over three days at the beginning of January 2012. The Canadian Patient Safety Institute (3) in partnership with Northwestern University in Chicago has put together a very exciting program to train patient safety trainers for clinical settings. Lead designers were Linda Emanuel (4) and Richard Bell (5), both of whom attended and presented at the conference. Faculty at Queen’s requested that the program be modified to assist university educators to teach patient safety to pre and post registration learners and both CPSI and Northwestern were very keen to train educator. The PSEP program attracted 46 participants with master facilitators including Drs David Goldstein and Roy Ilan from Queen’s brought the number to 60. The PSEP program utilized the David Walker Atrium and three classrooms in the new School of Medicine building, the first time an outside organization has run such a large event.
Although all the participants worked hard we had fun and were able to take lots of pictures including one of the School of Medicine physicians many of whom are Program Directors of their post graduate training programs. We also welcomed colleagues from Renfrew Hospital and hospitals in LHIN 10. This is a first step to develop health care professionals for the future who understand the complexity of patient safety and become advocates for quality care that keeps the safety of patients central to our care. The PSEP conference is the first step in making health care safer for all patients, reducing the cost of error, and helping us understand our responsibility. Next steps are up to us all particularly the 46 who participated. We are looking to everyone to help us.
If you would like more information about the PSEP program the link to CPSI is below, if you would like us to host the program again, or if you have comments please send them to me at email@example.com or drop by my office door is always open – 127 Cataraqui Building.
(1) Kohn L T, Corrigan J M, Donaldson M S. (Eds) (1999). To Err is Human. Washington, DC: Institute of Medicine, The National Academies Press. http://www.nap.edu/openbook.php?isbn=0309068371
(2) Baker, G R, Norton P G, Flintoft, V, Blais, R, Brown, A., Cox, J et al (2004). The Canadian Adverse Events Study: the incidence of adverse events among hospital patients in Canada. CMAJ, 170(11), 1678-1686. http://www.ecmaj.ca/content/170/11/1678.full
(3) Canadian Patient Safety Institute http://www.patientsafetyinstitute.ca/English/Pages/default.aspx
(4) Contact information for Dr Emanuel http://fsmweb.northwestern.edu/faculty/FacultyProfile.cfm?xid=11207
(5) Contact information for Dr Bell http://fsmweb.northwestern.edu/dept-profile/deptFacultyProfile.cfm?xid=10065