Your voice has the power to save lives.
One in three Canadians has suffered from preventable harm in healthcare, according to a 2018 poll by Ipsos Public Affairs. On average, a patient experiences serious harm every two days at UHN due to preventable errors. And, silence plays a major role.
If something feels wrong, looks wrong, or is wrong, we need to speak up – in the moment.
Speaking up is exactly what Amita Patel, Registered Nurse on the busy Toronto Western Hospital 4B General Internal Medicine unit, did while administering routine medications to her patient.
"I noticed Gravol was ordered for the patient," Amita recalls. "This wasn't a typical medication for the patient, which set off some alarms.
"I knew I must ask a few clarifying questions to ensure the patient would receive the correct medication."
Amita reached out to the pharmacy and medical team to get some answers. By using the SBAR framework (Situation, Background, Assessment, Recommendation), she was able to effectively request assistance and get a prompt response.
Good thing she did: "It turned out the patient should have been prescribed Benadryl," she says.
Speaking up allowed her to get the correct medication for the patient and avoid a potential adverse drug event.
Caring Safely Week at UHN runs Oct. 27 to Nov. 1 and coincides with National Patient Safety Week.
This year, the theme is battling systemic silence, which can exist between patients and providers and between colleagues.
Amita's example is just one of the good catches that occur on 4B.
Jennifer Pittman, Administrative Assistant and Safety Coach on 4B, has been helping create a strong safety culture on the unit, where staff are encouraged to – and thanked for - raising safety issues.
The Safety Coach Program, which is a peer-to-peer coaching initiative aimed at promoting and reinforcing the use of error prevention tools, has helped give staff a platform to promote Quality and Safety initiatives on their unit.
"I wanted to become a Safety Coach because safety is one of our core values at UHN," Jennifer says. "It brings me a great sense of pride in knowing that I am living this value by collaborating with the Caring Safely team, and contributing to the safest environment for staff, patients and visitors."
Good Catch Card Program
Jennifer, who became a Safety Coach last November, encouraged Amita to submit a Good Catch Card after learning about the incident involving the medication.
A Good Catch occurs when the initiating error is caught before it reaches the patient, visitor, or staff through use of an Error Prevention Tool. The Good Catch Program was developed as a way to encourage staff to share stories and learnings of how they are using the tools in practice.
"After events occur, incident reports are submitted and discussed each morning during our safety huddle," Jennifer says. "I encourage staff to complete a Good Catch Card as it helps to further share learnings, connect the Error Prevention Tools, and provides positive reinforcement that they are doing the right thing."
Jennifer says the Good Catch Card Program "has been imperative to the safety" on 4B.
"It provides a sense of 'no blame' and acts as a way for everyone to learn and prevent similar incidents in the future," she says. "Since the good catch cards have been introduced on 4B, staff have been more inclined to come forward with their good catches and share their use of the error prevention toolkit.
"We all learn from one another and we do it in a safe and positive environment."
Jennifer says one of the safety goals on 4B is zero medication errors.
"With the good catches that have been brought forward, especially those involving potential medication errors, I believe it has highlighted the importance of taking a STAR moment and really focusing attention on the task at hand," she says. "We have been able to celebrate 450 days without a Medication Serious Safety Event and received our Patient Safety & Quality Accomplishments board, which has helped keep us motivated!"
The Patient Safety & Quality Accomplishments program recognizes some of the outcome-based milestones UHN teams have reached.