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A six-year-old boy is lying in a hospital bed unconscious and in pain, surrounded by family. When a nurse comes to administer morphine, the unthinkable happens — the little boy stops breathing after the nurse puts too high a dose into his IV line.
The family panics and the nurse, distraught over her mistake, has to be coached through the steps to get the boy breathing again by a colleague come to help out. Eventually, the boy is saved, but everyone is left shaken by the near brush with tragedy.
Fortunately, in this case, these events weren’t real, but part of a simulation held at St. Paul’s Hospital to showcase a new incident reporting system.
A 24-hour-a-day hotline has been set up to replace 13 different reporting procedures that were used in the past.
Staff, patients or their families can phone 306-655-1600 if they see a safety situation that harms a patient, or even a near-miss.
Petrina McGrath, the health region’s vice-president of People, Practice and Quality, explained that they’ve seen a marked increase in the number of reports since bringing the system online, starting with a pilot project at St. Paul’s in March 2014 and then moving into City Hospital and Royal University Hospital this summer.
“We see about 1,800 reports a moth from our three Saskatoon hospitals. We know that number should be higher,” she said.
McGrath said the number of reports has roughly doubled compared to the tangled web of reporting systems that used to exist. She said they believe this is because the one-stop phone line makes it easier for people to make reports.
McGrath said there would be ongoing work to encourage more reporting. She stressed that the system wasn’t focused on assigning blame, bu rather on identifying issues and getting them fixed as soon as possible. She noted that while about 90 per cent of issues reported are able to be resolved by frontline staff, there are mechanisms in place to send those calls right up the chain to a vice-president such as herself if necessary, at any time of day.
Saskatchewan Health Minister Dustin Duncan was also on hand for the simulation. He praised the work done by the health region to get the system in place and noted that the elimination of errors was obviously beneficial for patients and staff, but would also help keep costs down.
Duncan said they expect similar systems will be rolled out for every health region in the province by March 2018.
