Hi Everyone,

This morning's Toronto Star is running a front page story about patient safety http://www.thestar.com/News/article/193502. This article is part of a comprehensive series on patient safety. In this article, there are several references to University Health Network, including a mention of our incident reporting system. We encourage all of our staff to report any adverse events that occur in our hospital, including "near misses" where harm may have occurred without staff being vigilant. These incidents are reviewed monthly at the Quality of Care Committee which I chair. All adverse events and "near misses" are reported over our Intranet using an electronic incident reporting system and when a severe event occurs (that has caused or might cause patient harm) - the event is immediately routed to my desk as well as the Manager's, Director's and Risk Manager's desks so that immediate review can occur if appropriate. Over the past four years that this system has been operational, our staff have become very proficient at investigating and evaluating adverse events and my involvement is rarely necessary- however we think it sends the right message that the CEO reviews all severe events immediately when reported.

In the Star story there is mention of the fact that we expect to report more than 4000 incidents this year at UHN. This number may seem somewhat alarming to Trustees who are not members of the Quality Committee of the Board. Encouraging staff to report incidents has dramatically increased the numbers of events that we review. The vast majority of these events cause no harm to patients. However, by encouraging staff to look for potential risks, we are creating the culture of safety where every staff member feels empowered to report risks and to improve the quality and safety of care at UHN.

Our Board/Management Retreat in April will focus on patient safety and some of the authorities quoted in this Star article will be in attendance. Last week, Cara Flemming, Dr. Michael Baker and I attended the Institute for Healthcare Improvement's Patient Safety Officer Course in Boston. As part of that seminar, we drafted a Patient Safety Plan for UHN which will formalize our safety processes and procedures and establish a strategy for enhancing patient safety over the next few years. We anticipate bringing that Plan to the Quality Committee and then to the full Board for review and approval later this year.

I encourage you to read the Toronto Star series which is available at http://www.thestar.com/News/article/193080


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