​​​​Last week Altum Health completed their oral presentation as part of the WSIB's RFP process.  Over 30 people from across the organization took part, including Dr. Mark Bayley, the Chief Medical Officer for Altum, the medical directors - Dr Rajiv Gandhi, Dr Martin Svhira, Dr Herb von Schroeder, Dr Jonathan Gladstone, Dr Johnny Lau, Dr Eric Massicotte, and I also attended to cheer them on.  A great deal of preparation work and dry runs went into the oral presentations and I commend everyone for doing an exemplary job of representing the work that we do and the support available for injured workers at Altum.  For those not familiar with Altum Health, it is the part of UHN which provides service to injured workers and the goal is to help anyone injured on the job to a full recovery with a return to work as soon as possible.  Over the years Altum Health has provided a revenue stream to UHN which supports our publicly funded healthcare system and if you'd like to know more, click here.  My thanks to Eric Simmons, the CEO of Altum Health and Mary Hall, Altum's Executive Director for all their work and for including me.

Below this message I have pasted in an Associated Press story about the series of events and errors which led to someone in Hawaii sending out an alert that a nuclear attack was imminent.  While there are many parts of this scenario that are troubling, I've highlighted the parts which are relevant to our efforts at creating a safety culture through Caring Safely.  It boils down to a common language of safety, tools to ensure a consistent approach across teams and between individuals, and an understanding that anyone and everyone can and should speak up for safety when they feel that something is wrong.  I'd be interested in hearing from you about the lessons the story below can teach about a safety culture.  Just hit Reply to send me a message.

Speaking of safety, we're looking at the results from our third quarter through the lens of Caring Safely, as well as Patient Experience, Operational Excellence, People & Culture and IT Transformation—known as our Foundational Elements. You can read about our progress in these areas by clicking on each link.

Last week saw the launch of Black History Month which is officially held every February in Canada.  UHN has a Black History Month Committee and you can stay up to date with events that are happening here.  We also celebrated over 130 faculty who have volunteered to teach the Caring Safely sessions and thanked them for their efforts which have, to date, allowed over 73% of all UHN staff to take the Safety Behaviour and Error Prevention Tools training.

And finally, you'll notice that today's message is in larger font.  My thanks for the suggestion from a reader and I hope that it makes the message easier to read, although it will also make it appear longer!


Audrey McAvoy


The Associated Press

January 30 Updated

Hawaii emergency management officials knew for years that an employee had problems performing his job. Then, he sent a false alert warning of an imminent missile attack earlier this month.

The worker had mistakenly believed drills for tsunami and fire warnings were actual events, and colleagues were not comfortable working with him, the state said Tuesday. His supervisors counselled him but kept him for a decade in a position that had to be renewed each year.

The problems in the Hawaii Emergency Management Agency went beyond one troubled employee. The agency had a vague checklist for missile alerts, allowing workers to interpret the steps they should follow differently. Managers didn't require a second person to sign off on alerts before they were sent, and the agency lacked any preparation on how to correct a false warning.

Those details emerged Tuesday in federal and state reports investigating how the agency mistakenly blasted cellphones and broadcast stations Jan. 13 with a warning that led hundreds of thousands of people to believe they were about to die in a nuclear attack. It took nearly 40 minutes to retract it.

Hawaii Emergency Management Agency Administrator Vern Miyagi resigned as the reports were released. Officials revealed that the employee who sent the alert was fired Friday. His name has not been revealed. A second worker quit before disciplinary action was taken, and another was being suspended without pay, officials said.

"The protocols were not in place. It was a sense of urgency to put it in place as soon as possible. But those protocols were not developed to the point they should have," retired Brig. Gen. Bruce Oliveira, who wrote the report on Hawaii's internal investigation, said at a news conference.

A Federal Communications Commission report revealed Tuesday that the worker who pushed out the alert thought an actual attack was imminent. It was the first indication the alert was purposely sent, adding another level of confusion to the misstep that created panic at a time of fear over the threat of North Korean missiles.

The worker believed there was a real attack because of a mistake in how the drill was initiated during a shift change, according to the FCC, which regulates the nation's airwaves and sets standards for such emergency alerts. The employee said he didn't hear the word "exercise" repeated six times, though others clearly heard it.

There was no requirement to double-check with a colleague or get a supervisor's approval before sending the warning statewide, the federal agency said.

"There were no procedures in place to prevent a single person from mistakenly sending a missile alert" in Hawaii, said James Wiley, a cybersecurity and communications reliability staffer at the FCC.

Compounding the issue was that the state Emergency Management Agency had no prepared message for a false alarm. The FCC criticized the state's 38-minute delay in correcting it.

In addition, software at the Hawaii agency used the same prompts for both test and actual alerts, and it generally used prepared text that made it easy for a staffer to click through the alerting process without focusing enough on the text of the warning that would be sent.

"The reports from the FCC and the state of Hawaii demonstrate systems and judgment failures on multiple levels, and they reinforce my belief that missile alerts should be handled by the federal government," said U.S. Sen. Brian Schatz, a Democrat from Hawaii, who plans legislation to give federal officials that sole responsibility.

The FCC said the state emergency agency has taken steps to try to avoid a repeat of the false alert, requiring more supervision of drills and alert and test-alert transmissions. It has created a correction template for false alerts and has stopped ballistic missile defence drills for now.

Earlier this month, the worker who sent the alert heard a recorded message that began by saying "exercise, exercise, exercise" – the script for a drill, the FCC said. Then the recording used language that is typically used for a real threat, not a drill: "This is not a drill." The recording ended by saying "exercise, exercise, exercise."

Once the employee sent the false alert, he was directed to send a cancel message but instead "just sat there and didn't respond," the state report said. Later, another employee took over the computer and sent the correction because the worker "seemed confused."

Gov. David Ige was asked why Hawaii didn't reveal details about the employee earlier, and he said it would have been irresponsible to release statements before the investigation was complete.

Ige has asked the Hawaii National Guard's deputy commander to prepare another report on what needs to be changed in the emergency management system overall. The first version of that report is due in two weeks, with a final version due in six weeks.

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