People came from all over the province to create and implement a safety alert system, first in Saskatoon Health Region and then in other regions across Saskatchewan.

Saskatoon Regional Health Authority board chair Jim Rhode addresses the crowd on the first day.

Saskatoon Regional Health Authority board chair Jim Rhode addresses the crowd on the first day.

A map of the many methods of safety reporting in Saskatoon Health Region.

A map of the many methods of safety reporting in Saskatoon Health Region.

Patient advisor Myrna Gehl from Cypress Health Region works with her group during a brainstorming session.

Patient advisor Myrna Gehl from Cypress Health Region works with her group during a brainstorming session.

Patient advisor Heather Thiessen talks with Lisa Rock, Quality Improvement Nurse Educator with Prince Albert Parkland Health Region.

Patient advisor Heather Thiessen talks with Lisa Rock, Quality Improvement Nurse Educator with Prince Albert Parkland Health Region.

The group of 60 people met from December 2 to 6. The group included nurses, patient safety specialists, client representatives, patient advisors, union representatives, physicians, senior leaders and board members. The group also included representatives from the Ministry of Health, Saskatchewan Cancer Agency, Health Quality Council, eHealth, 3S Health, long term care and affiliates.

The week was challenging and rewarding as Region representatives shared how safety and incident reporting is performed in their regions and identified the collective flaws in these systems. The group also heard from patient advisor Heather Thiessen who shared her experience of ‘stopping the line’ in her care when she was almost given a drug she was severely allergic to.

Members brainstormed, shared and designed what a dream or ideal future state for a safety alert system would look like and used these attributes to design a process map for reporting, triaging and responding to safety issues and concerns. The final process map identifies four levels of triage, and an appropriate response time for each level with a feedback loop built in to inform and consult the person reporting the incident about what was done to resolve the incident. The team also discussed building mistake proofing into the process to help prevent incidents from happening again. Later in the week, the team ran simulations of safety scenarios that needed reporting, triage and response.

By the end of the week, the team had the final process map and a framework of the work that needed to be done in the next 30, 60, 90 days and up to a year.

Now the Region’s project team has to work on the details and logistics of the process developed during the 3P so that the safety alert system is ready to go live in March 2014.

Teams work through simulations of safety issues, in this case, equipment failure.

Teams work through simulations of safety issues, in this case, equipment failure.

Teams work through simulations of safety issues - a possible medication error.

Teams work through simulations of safety issues – a possible medication error.

Preparing for final report out.

Preparing for final report out.

The team prepares to report out on the final process map.

The team prepares to report out on the final process map.