Safety improvements in health care was a presentation made by Sun Country Health Region’s CEO Marga Cugnet to the board of directors who were meeting in Weyburn on April 27 for a general public business session.
The Never Events presentation, she said, centred on safety improvements by the Canadian Patient Safety Institute.
She said the stories about wrong body parts being surgically removed or repaired, are sometimes true. It is also true that incorrect biological implants, blood products or wrong tissues are sometimes introduced when double checks aren’t made.
She said that is why patients are continually being asked to respond to what may appear to be nonsensical and repetitive questions, especially prior to any surgical procedure.
She said patients, under stress or suffering from temporary or permanent memory loss, may give varied answers or responses whether it be about allergies to medications, that can be misinterpreted, or some other issue.
Leaving foreign objects in a patient following procedures has happened, and they can only be overcome by the surgical teams doing consistent second checks and inventory lists.
She said the length of the packing needs to be recorded on insertion and again with removal with it all being documented and verified.
Improperly sterilized instruments are another area of concern that can haunt a surgical team. She said that is one reason why, in Sun Country, only two locations sterilize the equipment, Estevan and Weyburn, to better keep track of the process and verify that it is being done properly.
Giving the patient the wrong inhalation or insufflation gas have been identified as real problems in the past. She said that is why gas cylinders are now colour-coded using a universal coding system. This monitoring is especially important on maternity wards, she noted.
Pharmaceutical events can lead to other problems, she said, whether it be inadvertent injections of incorrect solutions, intravenous administration of concentrated potassium solution, or overdoses of hydromorphone. She said in Sun Country’s situation, hydromorphone is not stocked and it is only given to specific patients.
There can be problems in dealing with pressure ulcers, accidental burns, patients leaving observation areas or secured facilities or wards without staff knowledge, suicide attempts, or abduction of infants or patients being discharged by the wrong person. These are all situations that can come to haunt a healthcare facility or team of healthcare employees.
That, she said, is why there are continual checks and counter checks and re-checks going on all the time with each patient under care.
Earlier in the meeting, board members and guests received reports on clinical placements both physician and non-physicians.
On the employee front, Sun Country reported they had 2,380 people employed with 1,999 being directly employed by them, another 310 by St. Joseph’s Hospital and another 71 by other affiliated facilities.
Cataract removal services started on April 20 at Weyburn General Hospital, said Cugnet, with Dr. Eidsness from Regina performing the service. Ten cases are booked for each day that is scheduled. She noted that it took over four years of planning and negotiating before the service could be implemented.
She also noted, in reference to the safety presentation, that by early June all intravenous pumps in the region will be replaced with new pumps containing the latest technology for IV administration that includes a built-in drug library that will automatically flag improper dosage or rates. “These pumps will reduce the number of medication errors across the province,” said Cugnet.
