Petrina McGrath knows the devastation felt by a patient’s family and staff after an incident that called safety into question. “The family members looked at me and asked, ‘How can we be sure that this incident won’t happen again?’ and at that moment, I couldn’t say for sure that it wouldn’t,” she says. McGrath is Saskatoon Health Region’s vice president of Quality and Interprofessional Practice. She’s responsible for the Region’s safety initiatives. McGrath met with the family. Later, staff got another opportunity to debrief and even months later, they were still highly emotional because they were re-living the incident. “They were the second victims because we didn’t have a system to keep them safe either,” says McGrath.

That is why the Region is in the process of developing and implementing a safety alert/stop the line system. Nov_06_stoptheline

Having a safety alert/stop the line system in place would allow anyone to report a safety concern and receive the appropriate follow up in a timely manner. “Currently we have so many different places, forms and processes to report safety issues which can be confusing and time consuming to figure out,” explains McGrath. “Response times to safety concerns and reports can vary as well and we know this deters people from reporting.”

The goal is to create a single, comprehensive method of reporting that is easily accessed by physicians and staff, as well as by patients and their families.

The project is part of the provincial plan to establish a culture of safety by 2017 with a shared ownership for the elimination of defects for patients and staff. McGrath and Dr. George Pylypchuk, vice president of Practitioner Staff Affairs, are leading this work with help from an advisory group.

“A safety alert system will be a positive step to ensuring that patients get the best and safest care and that the safety of our physicians and staff is protected as well,” says Pylypchuk. The reporting system would require any employee who encounters a situation that is likely to harm a patient, a staff member or his/herself to make an immediate report and to cease any activity that could cause further harm. This would ‘stop the line.’

To help design this new safety alert system, the region is hosting a 3P (production, preparation, process) event from December 2 to 6, 2013. This process is usually used to design a process or a facility. Physicians, staff and patient advisors from the Region, as well as other health regions and the Ministry of Health will participate.

“I think the most amazing thing about the 3P event is that we have the opportunity to tap into the wisdom of patients, families and leaders from all areas of our organization and the province, from point of care staff and physicians to board members,” says McGrath. “We can tap into the expertise across our Region and across the province and build on best practices that already exist to design this safety alert system.”

The work won’t be easy. “Our biggest challenge will be shifting from a culture of fear, blame or retribution for reporting a safety concern, to a culture of openness and fairness,” says Pylypchuk.

McGrath agrees. “We can’t fix what we don’t know about and I think we have created work-arounds for so many reasons that we sometimes don’t even see things as a safety risk,” she says. “We’ve normalized what shouldn’t be normalized.”

The reaction has been positive. “Many staff members I’ve talked to say that we really need it and that the current processes are too complex,” says McGrath. “Most people see the value, but like anything they want to see it in action to really be able to understand how it will help keep them safe and enable them to provide safe care to the patients, clients and residents we serve.”