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

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