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Healthcare Excellence Canada

This site provides promotional materials for an annual awareness campaign on patient safety that takes place in the autumn. The 2022 observance will be held October 24th through 28th.

Judy Smetzer Just Culture Champion Scholarships.

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Institute for Safe Medication Practices.

A Just Culture supports effective reporting and learning from mistakes. This scholarship, inspired by the work and leadership of Judy Smetzer, former editor of the ISMP Medication Safety Alert! newsletter, will support three team or individual certifications in Just Culture practice. The application deadline is July 31, 2022.

Progress achieved: The 2021 John M. Eisenberg Patient Safety and Quality Award Winners.

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Oakbrook Terrace, IL: Joint Commission: April 19, 2022.

The Eisenberg Award recognizes individual and organizational accomplishment toward patient safety and quality improvement. The 2021 honorees are Hardeep Singh, MD, MPH, Prime Healthcare Services, Ontario, California, Kaiser Permanente Northern California, Oakland, California, and Mark R. Chassin, MD, FACP, MPP, MPH. The awards will be presented virtually during the National Quality Forum's annual meeting in July.

Disrespectful Behavior in your workplace.

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Institute for Safe Medication Practices.

Workplace bullying and disrespectful behavior have been shown to negatively affect fall rates, medication errors, and other adverse events. The Institute for Safe Medication Practices is seeking clinician input on and experiences with disrespectful behaviors in the ambulatory care setting (e.g., community, specialty, and long-term care pharmacies, physician practices, and outpatient visits) and how organizations have been working to improve the culture of respect. The survey will be open until May 27, 2022.

Patient Safety Fellowship.

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Health Care Futures. June-July 2022.

Strategies to educate new health professionals in patient safety and quality improvement can ensure commitment to improvement work. This fellowship will help learners understand the evolution of patient safety and develop skills in quality improvement and human factors engineering. The application period is now closed.

Proposed 2022 CDC clinical practice guideline for prescribing opioids. A notice by the Centers for Disease Control and Prevention.

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Fed Register. February 10, 2022;87: 7838-7840.

The 2016 Centers for Disease Control opioid guidelines have raised concerns as to their potential to contribute to patient harm. This announcement calls for comments from the field to inform and update current policy in response to safety issues that emerged as unintended consequences of the 2016 recommendation. Comments are due to be submitted by April 11, 2022.

NAM Scholars in Diagnostic Excellence program.

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National Academy of Medicine.

Diagnostic error reduction is gaining momentum as a primary focus of patient safety achievement. This educational program will draw from the 2015 Institute of Medicine Improving Diagnosis in Health Care report to support a multidisciplinary cohort of scholars to advance diagnostic improvement. The application process for the 2022-2023 class is open until March 3, 2022.

Fellowship in Diagnostic Excellence.

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Society to Improve Diagnosis in Medicine.

Diagnostic error is garnering increased attention as a key area of focus in patient safety improvement. This fellowship program for physicians who have completed their residency will provide the opportunity to build expertise in enhancing diagnostic safety. The application process for the 2022-2023 program is now closed.

Medication safety issues with newly authorized PAXLOVID.

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Institute for Safe Medication Practices. Medication Safety Alerts. January 3, 2022.

Emerging care practices can produce unsafe situations due to the newness of the approaches involved. This alert highlights safety considerations with an oral antiretroviral COVID treatment that include medication administration problems. Safety recommendations are provided for prescribers and pharmacists.

Input for the TeamSTEPPS Curriculum Updates.

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Rockville MD, Agency for Healthcare Quality and Research. December 7, 2021.

The TeamSTEPPS program is an established approach for improving teamwork and communication in health care. This announcement calls for feedback from healthcare teams and team members on how to update the current TeamSTEPPS training curriculum.

Letter to Health Care Providers: Safe Use of Surgical Staplers and Staples.

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US Food and Drug Administration. October 7, 2021.

Errors of commission during complex procedures can contribute to patient harm. Drawing from an analysis of medical device reports submitted to the Food and Drug Administration, this updated announcement seeks to raise awareness of common adverse events associated with surgical staplers and implantable staples. User-related problems include opening of the staple line, misapplied staples, and staple gun difficulties. Recommendations include ensuring availability of various staple sizes and avoiding use of staples on large blood vessels.

FDA Safety Communication: update--robotically-assisted surgical devices in mastectomy.

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MedWatch Safety Alert. Silver Spring, MD: US Food and Drug Administration; August 20, 2021.

This announcement seeks to raise awareness of the potential risks associated with the use of robotic-assisted surgical devices in mastectomies or cancer-related care. Recommendations for patients who may seek to have robotically assisted surgery include asking about their surgeon's experience with these procedures and discussing benefits, risks, and alternatives regarding available treatment options with their health care provider. Suggestions for health care providers include completing specialized training on procedures they perform. A WebM&M commentary described the challenges and benefits associated with robotic surgery.

FDA Safety Communication: flexible bronchoscopes and updated recommendations for reprocessing.

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Silver Springs, MD: US Food and Drug Administration: June 25, 2021.

Incomplete reprocessing of reusable flexible endoscopes can result in nosocomial infection. This announcement highlights recent guidance to improve the safe reuse of bronchoscopes with a focus on scope design, sterile processing, and infection control program management.

Fellowships and Mentorships Program.

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Institute for Safe Medication Practices.

These educational programs with the Institute for Safe Medication Practices (ISMP) are for clinicians who wish to expand their practical knowledge of medication error prevention. The application process for the 2022-2023 fellowships has closed.

Meitheal Pharmaceuticals, Inc. issues voluntary nationwide recall of Cisatracurium Besylate Injection, USP 10mg per 5mL due to mislabeling.

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MedWatch Safety Alert. Silver Spring, MD: US Food and Drug Administration; January 27, 2021.

Labeling mistakes in the pharmaceutical production cycle can remain undetected until the affected medication reaches a patient. This alert reports a recall of a neuromuscular blocker for use in surgery due to it being mislabeled as a medication to increase blood pressure.

FDA updates vinca alkaloid labeling for preparation in intravenous infusion bags only.

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MedWatch Safety Alert. Silver Spring, MD: US Food and Drug Administration; January 15, 2021.

Vinca alkaloid misadministration is a persistent problem that results in patient harm and death. This alert raises awareness of label changes that aim to mitigate accidental spinal administration of the high-alert chemotherapy agent by supporting infusion bag administration only.

Potential for false positive results with antigen tests for rapid detection of SARS-CoV-2--letter to clinical laboratory staff and health care providers.

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US Food and Drug Administration: November 3, 2020.

False-positive results contribute to patient and family discomfort and harm. This announcement shares information for clinicians to improve the reliability of the COVID-19 testing process and highlights government- and staff-level actions to support effective testing.

FDA advises health care professionals and patients about insulin pen packaging and dispensing.

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MedWatch Safety Alert. Silver Spring, MD: US Food and Drug Administration; October 13, 2020.

Insulin use errors are common despite their heightened potential for patient harm. This announcement highlights labeling and storage practices to reduce dispensing and administration errors associated with individual insulin pen use.

Dangerous wrong-route errors with tranexamic acid.

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National Alert Network for Serious Medication Errors. Bethesda, MD: American Society of Health-System Pharmacists and Institute for Safe Medication Practices. National Alert Network. September 9, 2020.

This announcement highlights container confusion as a contributing factor for accidental spinal injection of tranexamic acid. Storage, purchase, and preparation recommendations are shared to minimize errors with this medication.

FDA recommends health care professionals discuss naloxone with all patients when prescribing opioid pain relievers or medicines to treat opioid use disorder.

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MedWatch Safety Alert. Silver Spring, MD: US Food and Drug Administration. July 23, 2020.

Accidental misuse of prescription opiates for pain can result in addiction, overdose and death. This announcement outlines new federal labeling requirements for opiates and treatments for opioid use disorder. The FDA calls for health care professionals to educate patients about naloxone when prescribing opioid medications to improve the safety of patients taking opiates.

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