driving quality improvement forward: understanding patient safety events within bc emergency health...

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Driving Quality Improvement Forward UNDERSTANDING PATIENT SAFETY EVENTS WITHIN BC EMERGENCY HEALTH SERVICES ANNEMARIE TAYLOR, BCPSLS JAN BUTLER, BCEHS

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Page 1: Driving Quality Improvement Forward: Understanding Patient Safety Events within BC Emergency Health Services

Driving Quality Improvement Forward UNDERSTANDING PATIENT SAFETY EVENTS WITHIN BC EMERGENCY HEALTH SERVICES

A NNEMA RI E TAYLOR, BCPSLS JA N BUT LER , BCEHS

Page 2: Driving Quality Improvement Forward: Understanding Patient Safety Events within BC Emergency Health Services
Page 3: Driving Quality Improvement Forward: Understanding Patient Safety Events within BC Emergency Health Services
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What is a patient safety event for BCEHS? How is BCEHS different?

Page 5: Driving Quality Improvement Forward: Understanding Patient Safety Events within BC Emergency Health Services

486,000 ground

events throughout

the province

394,000

pre-hospital (9-1-1)

events

92,000 inter-facility patient transfers

Page 6: Driving Quality Improvement Forward: Understanding Patient Safety Events within BC Emergency Health Services

What are the impacts and outcomes?

When is a service issue a patient safety event?

Page 7: Driving Quality Improvement Forward: Understanding Patient Safety Events within BC Emergency Health Services

• Timing of event awareness • Electronic access • Availability of patient outcome information • Causal relationship to harm

Vs

Considerations

Event reporting

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Other Other Other

+

No relevant data Limited cultural uptake

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Other Other Other

+

No relevant data Limited cultural uptake

Page 12: Driving Quality Improvement Forward: Understanding Patient Safety Events within BC Emergency Health Services

What’s important to BCEHS? - Interfacility transfer?

- Patient Transfer Network involved?

- Phase of transport or transfer

- Lights and sirens?

- Discussed in safety huddle?

- BCEHS employee injured?

- Device or supply involved?

- Medication, IV, oxygen, blood involved?

- Language barrier a factor?

- Associated with handover?

- Transport or transfer related event?

- Patient handling (e.g. restraint in vehicle)

- Vehicular event (land or air)

- Involvement of second organization

- Patient harmed?

- Potential for severe harm?

- Who’s reporting?

Page 13: Driving Quality Improvement Forward: Understanding Patient Safety Events within BC Emergency Health Services

What have we learned?

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+300 QPins

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Our team Annemarie Taylor, Provincial Director, BC PSLS [email protected]

Janice Butler, Corporate Director, Quality, Safety, Risk Management & Accreditation, BCEHS [email protected]

Sandra Christenson, Quality Assurance and Change Management Leader, BCPSLS [email protected]

George Papadopoulos, Director, Patient Safety, Quality & Accreditation, BCEHS [email protected]

Emily Hamilton, Leader, Patient Safety, Quality & Accreditation, BCEHS [email protected]

Mary MacKillop, Director, Patient Care Quality Office, PHSA [email protected]