In the midst of Canadian Patient Safety Week (November 1 to 5, 2010) we are reminded that as Saskatoon Health Region staff and physicians, we come to work, dedicated to providing the best possible care and services. Our efforts to provide safe care are helped through the contributions of patients and families. We need to recognize them as active partners in our care teams. This year’s Patient Safety Week theme is the important role patients and families play in helping us provide safer care when they “ask, listen, talk.” and there is good communication among patients, families and care providers.

Quality and patient safety are high priorities for the Health Region. Our strategic plan has an explicit goal – eliminate harm and avoidable death. Every single member of the Saskatoon Health Region team plays an important part in achieving this goal. We have established and invested in several priorities to improve the quality and safety of our care, with a particular focus on preventing infections and falls, enhancing wound care and improving access. All staff are expected to practice good hand hygiene, surgical teams are required to conduct a surgical checklist prior to every surgery, staff double check the identity of patients before administering medications or performing procedures, and care is provided using other evidence-based policies and protocols.

The vast majority of our patients, clients and residents receive excellent care, and they tell us so. But like every other health system, we are not perfect.

Sometimes, mistakes happen, errors occur and patients are harmed. This harm may result from human error, when staff unintentionally and unknowingly do something wrong – to err is human. This may happen because the individual was distracted, fatigued or for other reasons failed to follow expected procedures. Most often, when errors occur, there are other factors which contributed to the error and our checks and balances fail to protect the patient and prevent harm. In the language of patient safety, we often refer to the “Swiss cheese” effect, when an unanticipated series of circumstances line up, creating, in effect, a “hole” that allows harm to occur.

When this happens, we try to learn from our mistakes and take corrective action to avoid the error from reoccurring. Most importantly, when a patient has been harmed we acknowledge our mistake openly and honestly, and apologize. We are committed to developing what is referred to as a “just culture” where patent safety is the organization’s highest priority; we learn and continuously improve by reporting and reviewing critical incidents and errors.

In late November, we will welcome a team of sixteen Accreditation Canada surveyors: peers from across the country who will visit our Health Region, compare how we provide care and services relative to national standards of excellence, and provide feedback on how to improve.
Saskatoon Health Region has made a promise. Every moment is an opportunity to create a positive experience in the way we treat and care for people, in how we work and interact with each other, and in how we deliver quality service. We are committed to providing high quality, safe care. We promise to seize every opportunity to improve.