Driving Quality Improvement Forward UNDERSTANDING PATIENT SAFETY EVENTS WITHIN BC EMERGENCY HEALTH SERVICES

ANNEMARIE TAYLOR, BCPSLS JAN BUTLER, BCEHS

What is a patient safety event for BCEHS? How is BCEHS different?

486,000 ground

events throughout

the province

394,000

pre-hospital (9-1-1)

events

92,000 inter-facility patient transfers

What are the impacts and outcomes?

When is a service issue a patient safety event?

• Timing of event awareness • Electronic access • Availability of patient outcome information • Causal relationship to harm

Vs

Considerations

Event reporting

Other Other Other

+

No relevant data Limited cultural uptake

Other Other Other

+

No relevant data Limited cultural uptake

What’s important to BCEHS? - Interfacility transfer?

- Patient Transfer Network involved?

- Phase of transport or transfer

- Lights and sirens?

- Discussed in safety huddle?

- BCEHS employee injured?

- Device or supply involved?

- Medication, IV, oxygen, blood involved?

- Language barrier a factor?

- Associated with handover?

- Transport or transfer related event?

- Patient handling (e.g. restraint in vehicle)

- Vehicular event (land or air)

- Involvement of second organization

- Patient harmed?

- Potential for severe harm?

- Who’s reporting?

What have we learned?

+300 QPins

Our team Annemarie Taylor, Provincial Director, BC PSLS ataylor@phsa.ca

Janice Butler, Corporate Director, Quality, Safety, Risk Management & Accreditation, BCEHS janice.butler@bcehs.ca

Sandra Christenson, Quality Assurance and Change Management Leader, BCPSLS schristenson@phsa.ca

George Papadopoulos, Director, Patient Safety, Quality & Accreditation, BCEHS george.papadopoulos@bcehs.ca

Emily Hamilton, Leader, Patient Safety, Quality & Accreditation, BCEHS emily.hamilton@bcehs.ca

Mary MacKillop, Director, Patient Care Quality Office, PHSA mmackillop@phsa.ca