CPSI-funded research presentations:

Improving the safety of ambulatory intravenous chemotherapy in Canada
Anthony Easty, Toronto, Ontario

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Safe prescribing, dispensing and administering of opioids to patients with chronic non-malignant pain
Anita Srivastava, Toronto, Ontario

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Using SBAR to communicate falls risk and management in interprofessional rehabilitation teams
Karima Velji, Toronto, Ontario

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Using root cause analysis to reduce adverse events on an acute pain service
James Paul, Hamilton, Ontario

Pat Croskerry, Co-chair, Symposium Organizing Committee, Halifax, Nova Scotia

Kevin McNamara, Deputy Minister of Health, Nova Scotia

The Noughties revisited and a hesitant peek into the 'teens'
Jim Reason, Manchester, United Kingdom

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Jim Reason will provide a decadic retrospective from a human factors point of view, from both sides of the Atlantic. He will show that progress has been and will continue to be slow. That is the nature of the safety time-constant: two steps forward and one step back. But we will get there – eventually.

From tragedy to truth
Margaret Murphy, Cork, Ireland

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Margaret Murphy will describe the circumstances resulting in the needless death of her son Kevin through a series of errors, the unsatisfactory interactions with the healthcare system and with individuals following the event, and the trauma of the litigation process. She will share her insights into the impact of the event on both her family and the healthcare professionals, together with her perceptions of the barriers to open communication and disclosure. She will recount Kevin’s story and her experience with a desire to engage and partner with healthcare professionals in diverse settings at international, national and local levels. Her final appeal is for dialogue – powerful conversation – acknowledging errors and allowing learning to occur.

Better safety needs better measurement
Ross Baker, Toronto, Ontario

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Measurement and reporting have become increasingly important in healthcare safety. But do we have the right measures and how can we use the information we collect in an effective way – to actually improve the safety and quality of care? In this talk Ross Baker will examine the use of measurement for leadership and clinical teams. Current controversies over the quality of measures often fail to examine what measures are needed for what purposes. Senior leaders and clinical teams who understand how to select and use measures are better equipped to improve the safety of healthcare.

Senior leaders - emerging from the safety shadows
Rhona Flin, Old Aberdeen, Scotland

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Rhona Flin will review the role of leadership and how this role has changed over the last decade. By examining the leadership of organizations both in healthcare and other industries, Rhona will discuss how the organizational culture reacts to the model set by those in the lead.

Narcissism and performance variations: applications to the normalization of deviance
John Banja, Lawrenceville, Georgia

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Professionals who perform rule-bound tasks will frequently and intentionally deviate from the standards, rules, regulations, policies and procedures that govern their task performance. In healthcare, these deviations or “process variations” can be very worrisome, as not only can they significantly increase the risk of harm to which patients are exposed, but their repetitions will cause the actions to become “normalized,” such that they are no longer recognized as deviations. John Banja will discuss the “normalization of deviance” and offer strategies on how healthcare systems can better manage this strikingly common, but professionally concerning, situation.

The influence of the working environment
Jacqueline Vischer, Montréal, Québec

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Jacqueline Vischer considers the physical environment of hospitals and other healthcare settings as environments in which people work. This presentation will examine findings from the field of environmental psychology to better understand how people who work in healthcare settings are affected by features of their physical environment. Adverse physical settings can lengthen response time, increase stress and fatigue, and reduce communication effectiveness, possibly leading to errors. Supportive and functionally comfortable physical settings that help people get their work done have beneficial effects for staff and therefore for patient care and safety. Jacqueline will review ways of designing healthcare environments to ensure that they provide supportive workspaces.

Fatigue management
Drew Dawson, Adelaide, Australia

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Drew Dawson will present his new data on what healthcare professionals do to minimize fatigue-related problems by reviewing how individuals can cope with fatigue through different means. Drew will describe how we need to move from the concept of limiting working hours to recognizing that a complex problem cannot be tackled with a simple solution and that, in future, the problem of fatigue management will also include balancing outcomes.

Diagnostic error - back to the future
Mark Graber, Northport, New York

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Diagnostic error was formally introduced to the patient safety community in Halifax almost a decade ago at “The Third Halifax Symposium on Healthcare Safety” in 2003. Mark Graber will discuss the historical importance of that event and how it stimulated the many advances in understanding and preventing diagnostic error that have taken place over the ensuing years. Current initiatives regarding diagnostic error will be reviewed, including decision-support tools, checklists, and relevant features of electronic medical records. Finally, he will look into the future to envision where the field will stand in 2020.

Risk and safety in medicine - revisited
Charles Vincent, London, United Kingdom

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Since the first Halifax Symposium, patient safety has moved from primarily being the province of a few enthusiasts to a world-wide phenomenon. There has been an explosion of studies, reports and initiatives. Are patients any safer? For all the progress and activity, this simple question remains hard to answer. Charles Vincent will address the reasons for this uncertainty and hopes and directions for the future.

The management of risk and safety investigation - the need for an integrated approach
Rob Lee, Melba, Australia

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Rob Lee will speak about the outcomes of systemic safety investigations in all high technology industries that have consistently shown, for almost every accident or serious incident, the main contributing factors were present before the problem occurred. These factors could have, and should have, been identified and rectified through more effective safety information systems, including proactive analyses of risks in a positive organizational safety culture. The risk controls that are in place in high-technology industries, such as equipment and procedures, work effectively most of the time. However, failures of the same sets of controls can result in a multitude of different specific scenarios in the same broad category of occurrence. In the case of incidents, understanding the nature of the failures of preventive controls, which contribute to an incident, and the success of the recovery controls, which stop that incident escalating into an accident, is more critical to the management of safety than the specific details of the event itself. Rob will also highlight the fact that the proactive management of risk and the reactive investigation process are two sides of the same coin. They need to be fully integrated to maximize the overall safety of the system.

Our own stories
Dave Musson, Hamilton, Ontario

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Dave Musson will reflect on the evolution of aviation safety and which concepts / methods aviation has abandoned as not being helpful. He will speak to why we, in healthcare, need to be able to see the big picture, which comes from reviewing the rich stories from our own individual organizations. Finally, focusing on CRM and nontechnical skills and their use as individual competency markers, Dave will speculate about whether or not teaching safety at the individual level is paramount – when the ‘problems’ lie in the system.

The second victim
Albert Wu, Baltimore, Maryland

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Albert Wu will present the 10-year history of the ‘second victim’ in healthcare safety, noting the ways in which few systems were set up to deal with the second victims, let alone recognize them. In the last 10 years, there has been a greater understanding of this phenomena and systems set in place to assist. Albert will speak to the evolution of the system and what the future will bring for this important aspect of healthcare safety.

Medical encounters and everyday life - why apologies heal
Aaron Lazare, Worcester, Massachusetts

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Aaron Lazare will comment on the history, and increasing frequency, of apologies, both in all of civilization and in medicine in particular. He will then present the various healing forces in apologies along with their relative importance, based on research data on 500 subjects from four different populations. Finally, he will speculate on the task of educating medical students and physicians to offer effective apologies.

Why the system can't wait
Jim Hornell, Brantford, Ontario

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Canadians seem to care most about healthcare and hockey. The analogies between healthcare and hockey in Canada provide an interesting dialogue on outcomes, entrenched cultures and why there is urgency to change.

Having worked as a senior leader in three provincial health systems in the past decade, while volunteering at a national level in hockey governance, Jim Hornell will share personal and unique perspectives on our journey toward improved patient safety by focusing on challenges of leadership, governance, public expectations, habits, and personal and professional values. He will also highlight some of the wins and losses as expectations and experiences intersect with systems and provider-centric healthcare.

Why patients can't wait
Deborah Prowse, Calgary, Alberta

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An event leading to harm of a patient often results in an investigation of policies and procedures of a hospital or health region. Deborah Prowse will provide her perspective as a family member involved in such an event, in describing her personal journey from harm to healing. Drawing on her background as a lawyer and social worker, she will trace how extensive the impact of this type of event can be when patients/families and providers work together to make changes in the system. Safety is such common sense - we must ensure it is common practice.

Pat Croskerry, Halifax, Nova Scotia

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In this last presentation, Pat Croskerry will briefly review the history of the Halifax series and then focus on one of the most important aspects of healthcare safety, that of decision making. He will conclude by offering his thoughts and hopes for greater integration of healthcare safety into the undergraduate education of all healthcare providers. He hopes that, in doing so, all healthcare providers will start as they mean to carry on – with all the basic requirements for healthcare safety from the very beginning.