Beyond the Quick Fix: Strategies for Improving Patient Safety

Introduction

The Canadian Adverse Events Study (CAES) – published in May 2004 (Baker, Norton et al. 2004) – provided one of the most comprehensive pictures of patient safety in Canada to date. The CAES reported that 7.5% of all hospitalizations in Canada had an adverse event that harmed patients. Extrapolating from the 3,745 cases reviewed suggested that around 185,000 hospital admissions during the study period likely had adverse events of which close to 70,000 were potentially preventable. In the lead up to the release of the CAES, the federal government announced the creation of the Canadian Patient Safety Institute (CPSI). In the decade since the CAES, provinces have invested heavily in patient safety reporting, the CPSI launched Safer Healthcare Now! designed to improve the safety of care, and healthcare organizations across Canada have invested considerable energies in measuring and assessing adverse events, identifying ways to reduce such events, and investing in training, equipment, and reviews of current practice to reduce the likelihood of such events. While hospital acquired infections, surgical complications and medication errors have long been seen as important issues, the adverse events study helped to change the perspective on these and other incidents, introducing “patient safety” as a critical element of healthcare performance and a major focus for improvement work. With ten years of activity and easily tens of millions of dollars invested in patient safety we should now have a much safer healthcare system. But do we? This report provides an overview of the impact of this new focus on patient safety, and offers an accounting of the progress made and of the challenges that remain. To provide a comprehensive picture of progress on patient safety we reviewed the Canadian and international literature on improvements in patient safety, spoke with international experts, and conducted structured interviews with 15 Canadian patient safety experts and health system leaders across the country between November 2014 and January 2015. What became clear early on in our analysis is that ten years later, many Canadian healthcare organizations still struggle to address key patient safety issues. Harm experienced by patients, and the impact on families, staff and organizations continues despite better measures of the number and impact of these events, and efforts to change unsafe practices. This report was developed with support from KPMG LLP (Georgina Black, KPMG LLP) in partnership with the Institute of Health Policy, Management and Evaluation (G. Ross Baker) at the University of Toronto.