Post on 24-Dec-2014
description
transcript
Central CCAC
Outstanding care – every person, every day
Safer patients, better care through Never Events research and
education
Canadian Patient Safety InstituteVirtual Forum on Patient Safety and Quality Improvement
October 2013
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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
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Key lessons learned
• Top four Never Events1. Adverse reaction requiring ED visit or
hospitalization due to med-related events 2. Serious injury related to inappropriate service plan3. New peritoneal dialysis infection4. 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’s first
focus
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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 webinars500+ frontline staff, service providers16 service provider organizations
• Measurement – Reporting of errors has increased since education