The Safety Net
January 2025
| Stay informed with the latest insights, updates, and initiatives dedicated to enhancing patient safety. |
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Remembering David Wells: Improving Safety by Learning from Reporting
David joined PFPSC in April 2012 because his wife had an incident during chemotherapy which left her with ongoing pain. Even before he joined us, he chaired the New Brunswick Surgical Care Network, presented at several conferences, and was part of the Maritime Strategy for Patient-Oriented Research (SPOR) Support Unit. He wanted to make a bigger difference as a member of our group. David was very active as a member of our group as a presenter at many conferences, a member of several committees (primary care, medication packaging and labelling, appropriate care, interoperability, and more). David was also a Co-chair of PFPSC for a few years. He also contributed art to HeART of HealthCARE.
David was also a member of the Canadian Medication Incident Reporting and Prevention System (CMIRPS). At one of the meetings he spoke up hearing us using the automatic “reporting and learning” wording and pushed us to think differently. After we bounced ideas we decided as a group to say “improving safety by learning from reporting” – words that give direction and focus. It was a beautiful moment for all and several of us still use the new wording.
Above all, David had a kind and fun presence, always ready to tell stories from his work and life, constantly smiling and making others smile, spreading a positive and encouraging message to all of us. He lifted us up and we believe we lifted him up too. Thank you David for everything you contributed to patient safety. PFPSC will continue your work and legacy.
Here is a link to David’s obituary. You can add a note to the family at the link or send your note to hello@patients4safety.ca and we will compile all messages and send them to the family.
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On January 22, 2025, PFPSC will celebrate its first year being incorporated as a not-for-profit.
Board and Board Committee development in 2024:
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Our board currently consists of five members:
- Linda Hughes – Treasurer and Chair of Finance, Audit & Resources Committee
- Allison Kooijman – Vice Chair
- Angie Hamson – Member at Large
- Wendy Nicklin - Member at Large and assisting Governance Committee
- Kathy Kovacs Burns – Board Chair and Chair of Governance and Communications Committees.
- We have three board committees:
- Governance: Temporary Chair – Kathy; Board Assistance – Wendy; 5 external members – Maryanne D’Arpino, Joan Fernandez, Pauline Warden, Polly Stevens & advisor as needed – Dave Price
- Communications: Temporary Chair – Kathy; PFPSC member - Melissa Sheldrick; External – Pierre Leonard and Cecilia Bloxom
- Finance/Audit/Resources Committee – Chair – Linda; PFPSC member – Stan Petrov; External members – Jane Kraut, Amardeep Sparks and Yordanos Weldeslassie.
- Plans are to bring on four new board members, and possibly two others for succession planning. We invite PFPSC members for board and committee positions.
- Strategic planning:
- The board lead a strategic planning initiative from September to present.
- Next step will be to populate a draft 3-5 year strategic plan to be shared back with PFPSC members and key partners for review and confirmation. Operational, communication and evaluation plans will be developed in parallel to the strategic plan.
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The board developed a set of policies – available here
Suggestions and thoughts regarding any of the board or other initiatives are welcome.
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Mutual Healing Working Group Update | |
Our members, including Donna Davis (interim chair), Wendy Nicklin, Dale Nixon, Linda Hughes, Laurie Kay, with guest contributors Alice Watt and Amy Nakajima, have been working with consultant Diane Aubin to oversee the development and implementation of a Mutual Healing Program. This program enables open and sincere conversations in a safe environment between patients and their families and healthcare workers to support them in their healing after a harmful incident.
We have recently confirmed that we will be piloting this program with partners in the Winnipeg Regional Health Authority. We are excited to share our knowledge, experience and many resources with a healthcare organization who, like us, believes there is great capacity for healing both the patient/family and the healthcare worker if the two parties hear and listen to each other’s story and perspective through open and genuine communications.
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Knowledge Transfer (KT) Working Group Update | |
The Knowledge Transfer (KT) Group members are a dedicated group who are passionate about sharing patient safety information with PFPSC Members, patients, families, the public generally and healthcare workers. The members of this group are Esha Ray Chaudhuri, Paula Orecklin, Kathy Kovacs Burns, Andrew Milroy and Theresa Malloy-Miller (Chair)
The purpose of the KT Group is to increase PFPSC’s and the public’s awareness and ability to engage in patient safety through participatory approaches and public dialogue to advance PFPSC’s vision and mission.
This was a very busy Fall for the KT group as they contributed to patient safety campaigns about diagnostic safety (World Patient Safety Day), broadening our understanding of healthcare harm (Canadian Patient Safety week), World Antimicrobial Resistance Week and Pressure Injury Prevention day. There are many very helpful resources and PFPSC Members’ lived experiences for these events on the PFPSC website and Youtube page. You can also follow these events on Instagram, LinkedIn and FaceBook.
In January the KT Group will be planning for 2025. Please send us your ideas or even better join the next KT meeting on Thursday January 16/25 (4-5 pm ET).
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Communications Working Group Update | |
The purpose of the CWG is to ensure PFPSC communicates with one voice in advancing our vision and mission. Donna, as the Chair, together with Eileen Chang and Laurie Kay, led the development of PFPSC’s new website with support from Binary Logic – a huge accomplishment. The website will be updated so reach out to share your ideas on how to make this huge asset for PFPSC better. In addition they advised and helped coordinate the internal communication with members as well as external communication about programs and campaigns on social media.
The CWG wants to know what communication needs our members have to help them confidently speak, write, sing and dance (joking) about patient safety. As we promoted the 4 patient safety campaigns in the Fall of 2024, we heard that members would benefit from social media training. To address the need, we contracted experts to provide coaching and support to a first group of 10 members. There are still a few spots left so contact hello@patients4safety.ca if you are interested in this training. The CWG is also looking for one or two PFPSC members to join the group - please send an email to the address above if you are interested, or contact Donna dfddavis3@gmail.com
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Patient Safety & Incident Management | |
Patients for Patient Safety Canada (PFPSC) has been involved since inception in initiatives aiming to advance patient safety (PS) and incident management (IM). This resulted in guidelines, training/ capacity building, programs, policies, and practices that include the patient perspectives, needs and expectations. Also PFPSC members have led webinars and training where their lived experience provided the foundation for safety theory. With these foundational pieces in place, the goal of this program is to develop a capacity building workshop that will help those responsible for PS&IM improve how they practice.
A working group (WG) was established: Donna Davis (Chair), Sabina Robin, Frankie Fombong, and Andrew Milroy who were later joined by Melissa Sheldrick, Teri Price, Kathy Kovacs-Burns, Linda Hughes, Theresa Malloy-Miller, and Dale Nixon. In October-November Donna, Linda, and Kathy delivered a virtual session divided in 3 one hour modules as a proof of concept to Association of Registered Nurses Manitoba. It was very well received. Knowing that the most powerful way to learn is in-person, the WG designed a 4 hour workshop which will be pilot tested on February 4th with a small group of safety mangers and patient partners who are involved in safety and incident management.
Next, we will advertise and make plans to offer 4 in-person workshops/ year. This will be a revenue generating stream for PFPSC. If you are interested in knowing more, becoming a PFPSC facilitator and deliver future sessions, or just help position this project for success contact Donna.
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The Membership Working Group (MWG) is made up of members, Eileen Chang, Donna Davis, Jignesh Padia and Melissa Sheldrick, Chair. We will be focussing on growing our membership this year and maximizing the efficiency of the people who dedicate so much time and energy to this excellent work. The MWG also plays a role in reviewing requests for participation and various other tasks that involve the members of PFPSC. We were pleased to welcome a new member in November, Sanja, to PFPSC. We are always open to ideas and new people joining the MWG and if you would like to contribute in any way, please email Melissa at amsheldrick@gmail.com. | |
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Donna Davis
My name is Donna Davis of Carievale, SK. I retired in 2023 after being a nurse for 47 years. I live in a tiny, really tiny (approx. 200 people) village in SE Sask. 10 minutes from the MB border and 10 minutes from the US border.
My husband of 50 years is Jack; I have three daughters, one deceased son, Vance, and five grandchildren. I love almost all sports (can’t really get into football unless the Sask Roughriders are playing) Hockey is my number one love with baseball and barrel racing a close second and third. I am a voracious reader who can’t be without a book.
With our oldest child being a high-level paraplegic due to Spina Bifida we had many interactions with the health system- some excellent and some not. My husband and I had several instances with the reality that one of our children might die, namely Deidre, with her numerous health issues. We were completely shell shocked and taken off guard when our healthy, hard working 19-year old son died following a single motor vehicle accident because the care given to him, or more accurately, NOT given to him did not give him the best chance of survival. Vance’s was a true example of everything bad in his care lining up (The Swiss Cheese effect) resulting in his death. There was so much that needed to be improved then and still does today.
That is why, as a founding member of PFPSC, I know we can not give up our work to see Every Patient Safe. If not us, who? If not now, when?
I sit on the following PFPSC working groups: Membership Working Group, Co-chair of the Mutual Healing Working Group, Chair of the Communications Working Group, Chair of the Patient Safety/Incident Management Working
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Laurie Kay
I am a retired school social worker who lives in London Ontario. With a special interest in bereavement, I also, through the Canadian Mental Health Association, facilitated bereavement groups for loss due to suicide or homicide. I also spent 8 years in the army reserves, training first as a medic, and later as a medical administrative officer, learning how to set up a field hospital - just like M.A.S.H.!
My husband of 37 years, Sandy, is a retired high school English/Spec Ed teacher; we have one son, Derek, who recently finished a PhD in Philosophy of Science (Biology). My hobbies are painting, gardening, and textile arts, such as hand spinning and weaving. I am a cancer survivor; Robin McGee was my cancer mentor.
I became interested in patient autonomy (patients having final say over everything to do with their care) during my cancer treatment, before I joined PFPSC. After some negative medical encounters, sometimes involving students against my wishes (I was told I had no choice), I researched how other jurisdictions involve patients in medical education. I found that many other developed countries required patient consent before involving students in their care. I was able to convince Dr Peeter Poldre, then President of the College of Physicians and Surgeons of Ontario that Canada (except BC) was lagging behind its peer countries in this aspect, and that patients should have the right to consent - or not consent - to participate in medical education. The College took the concerns seriously, drafted a revised policy and asked for public input on the draft. The Ontario policy now requires consent of the patient before medical students can care for or observe a patient being cared for. All patients in Ontario now have a choice.
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Eileen Chang
My thirty plus years in healthcare included twenty-one years of progressive leadership positions in medical imaging at a leading academic, research and teaching organization, including its amalgamation across three academic health science centres in Toronto, Ontario. Prior to my retirement in 2020, I held positions in risk management, quality and with the primary focus, in patient safety.
I enjoy gardening, ballroom and Latin dancing, skating, skiing and playing the piano.
My son Daniel was an active sports participant in both individual and team sports, and played a few musical instruments. He was recognized as an Ontario scholar upon his high school graduation. However, Daniel felt physically unwell, during and ending his first year at McGill University (yet still achieving an A average). He received a series of travel vaccines to volunteer abroad for the summer. At 19 years old, Daniel was later diagnosed with myalgic encephalomyelitis, ME, a debilitating illness that has no cure.
Daniel met with multiple challenges as he and I navigated the healthcare system, trying to identify a care plan that can address and manage/relieve his relentless and debilitating pain accompanied post-exertional malaise (PEM), symptoms that worsen after physical, mental or emotional effort. He himself engaged in bringing awareness to others such as creating his own You Tube videos, lobbying at Queen’s Park and joining the ME Association of Ontario.
I continue to build on Daniel’s legacy by representing the ‘voice of the patient’. I am hoping that by sharing his lived experiences, there will be opportunities in building partnerships with healthcare providers/practitioners thereby resulting in shared learnings and best practice.
I have been an active member of Patients for Patient Safety Canada (PFPSC) since 2014
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We will feature 2-3 member profiles in each newsletter to get to know each other better. Please send your profile and picture to hello@patients4safety.ca | |
What Our Members Are Up To | |
How Our Members Contribute to Safer Healthcare
Because we can’t include all the contributions submitted by members, the CWG selected, for this newsletter, a few examples that illustrate how our collective work helps advance our vision, mission and goals.
Requests directly to Patients for Patients Safety Canada:
- HIROC Symposia Calgary – presentation by Kathy
- Health Canada Natura Health Products – ongoing participation by Linda and Kathy
- Infection Prevention and Control Canada Board Meeting – presentation by Kathy and Ioana (Kim is a public representative on the board); Kim, Kathy and Ioana submitted an article submitted that was posted in the association newsletter to members
- Canadian Medication Incident Reporting and Prevention System – committee members Melissa and Paula
If you’d like to read the other contributions our members made with other partners, click here.
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July 16, 22nd, 29, and September 19, November 21 Patient Partner, Member of Quality Curriculum, Working Group: IPE (Interprofessional Education) Core Curricular Learning, Senior Level Foundational Activity 2024-2025 Academic Year: Collaborating for Quality
- “Designed to provide foundational knowledge regarding interprofessional quality improvement practices, interactive professional small group discussion/activities with other professions about roles in quality and application through an interprofessional case.”
Eileen C.
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- September 28, 2024, Presentation entitled "Patients as Partners in Shaping Safer Care in Canada", which was really talking about PFPSC, who we are, what we do, and accomplishments over the years in shaping safer care. Presentation was for UK Healthcare Conference.
- November 4, 2024, presentation on "The Importance of Teaching Patients About Safety" - this included work of PFPSC and was presented to over 3000 participants who were part of the Saudi Patient Safety Centre Learning Initiative out of Saudi Arabia and The Emirates.
- April 17, 2024 - Attended Global Patient Safety Leaders Group Secretariat hosted by WHO Patient Safety Alliance and Global Network - designated by Health Canada to attend for Canada along with a HEC representative - this group is a G20 country council that meets twice a year.
Kathy Kovacs Burns
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Both Theresa Malloy-Miller & Joni Magil were judges in the HEC Health Worker Challenge series which started in the fall of 2023 to the fall of 2024. Front line Health Care Workers (HCW) submitted projects which focused on retention, HCW well being and sustainability. It was very encouraging to review these very workable, cost effective plans/ actions which would ultimately increase patient safety.
Theresa & Joni M
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- Pub Rep Canadian Standards Association (CSA) Review of standard on Cleaning and Disinfection Jan/24-current
- Pub Rep Health Standards Association (HSO) and Accreditation Review of standard on Infection Prevention and Control August/24 -current
- Public Rep Patient Safety Executive Committee with the Saskatchewan Health Authority and Ministry of Health in the development and implementation of CI (Critical Incident) reporting policy
Kim N
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- On January 8, 2024 Donna Davis presented “Vance’s Story” to the General Internal Medicine students at the University of Sask. This is an annual request to Donna from this department.
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May 15th, 2024 saw Donna again present “Vance’s Story”. This time at the Saskatchewan Health Authority Emergency Dept. Grand Rounds.
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Donna was a Patient Advisor for Healthcare Excellence Canada planning Canadian Patient Safety Week 2024.
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March 7th: Quality Mental Health Care Network - MHCC
- August 24th: Strengthening Access to Primary Care Advisory Committee - HEC
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October 28th: Guest lecturer on healthcare harm for 4th year nursing students at Mount Royal University
- December 23rd: Interview with Alberta Native News on mental healthcare harm of Indigenous people and need to provide culturally appropriate services
- December 26th: Interview with Indigenous Projects regarding Indigenous therapy, stigma in healthcare, importance of culturally appropriate care.
Samaria
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Do you have contributions you'd like to highlight for the next newsletter? Please reach out to hello@patients4safety.ca | |
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Our first all member meeting this year is on January 28, 2025. We are offering two time slots to accommodate member schedules as best we can: 1000-1100 MT and 5:00-6:00 MT. Join the meeting that works best for your schedule. If you need the invite please contact Tali at hello@patients4safety.ca.
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Many of the articles below came from CBC Health's Second Opinion. If you are interested in seeing more articles like these, open the link and scroll down the page until you come to the CBC Health’s Second Opinion title and click the subscribe button. It is a free Newsletter with lots of facts, information, articles and stories about healthcare in Canada and outside Canada.
These articles speak to the issue of maintaining patient dignity and bodily autonomy:
Family speaks out after Pasqua First Nation man's braids cut off in Edmonton hospital
'Why did they do that to me?': Métis man says ponytail was cut off without consent at Saskatoon hospital
Sikh man was shaved without consent at Brampton hospital: complaint
This article shows us the catastrophic consequences of not verifying patient information before a surgical procedure
Review into amputation underway after patient says wrong leg removed
These articles speak to systemic sexism and racism in healthcare, and how it may result in delayed diagnosis, sometimes with tragic outcomes:
Racism, prejudice contributed to Joyce Echaquan's death in hospital, Quebec coroner's inquiry concludes
Doctors said her gangrenous appendix was just anxiety. She's not alone
Woman living in chronic pain says N.S. health care plagued by sexism, ageism and 'dangerous' apathy
These articles shine a light on how patient safety issues are created by a healthcare system stretched to the limit:
Manitoba woman set to lose right leg after languishing in hospital bed with open wound
Alberta hospital patients waiting to move into continuing care are paying millions in fees
When you see different doctors, is anyone keeping track of your health? Perhaps not:
When you see different doctors, is anyone keeping track of your health? Often no, new report says
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