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Safer patients, better care through never events, research and education central ccac

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  • 1. Safer patients, better care through Never Events research and education Canadian Patient Safety Institute Virtual Forum on Patient Safety and Quality Improvement October 2013 Outstanding care – every person, every day Central CCAC
  • 2. Groundbreaking research: a Canadian first • Central CCAC’s reality: 30,000+ patients a day, 58% from hospital, 69% with high/very high needs • Central CCAC / University of Toronto study - incidents that should never happen when delivering care in the community • Serious, preventable, reportable • Generated recommendations for clinical, administrative and policy strategies • Strengthens accountability through performance measures • Increases transparency through public reporting • Supports Outstanding care – every person, every day Central CCAC 2
  • 3. Key lessons learned • Top four Never Events Central CCAC’s first focus 1. Adverse reaction requiring ED visit or hospitalization due to med-related events 2. Serious injury related to inappropriate service plan 3. New peritoneal dialysis infection 4. Serious event related to care or services contrary to current professional or other practice standards • Complexities of care in community include patients choosing to live at risk and informal caregiver involvement • How to identify events, improve reporting systems and support sustainable change – Everyone has a role! Central CCAC 3
  • 4. Using the research to drive safer patients, better care • Building a shared community sector vision where patients receiving home care never experience a serious, preventable medication-related error • Key steps • Listening to patient and family feedback • Process improvement sessions • Never Events education:  34+ workshops and webinars  500+ frontline staff, service providers  16 service provider organizations • Measurement – Reporting of errors has increased since education Central CCAC 4