Bluewater Health participating in voluntary ‘never event’ reporting

Bluewater Health began reporting “never events” to Ontario Health earlier this year.

Article content

Article content

Article content

Never events are incidents resulting in serious patient harm or death and that could be prevented through organizational checks and balances, a new Bluewater Health quality and patient safety plan says.

There have been six in Sarnia-Lambton, said Jane Mathews, Bluewater Health’s clinical support services vice-president, since Bluewater Health answered Ontario Health’s call to start voluntary reporting last January.

“We are pleased to be able to participate,” she said.

Sharing what happened and how the organization fixed the problem, so it doesn’t happen again, also serves as a learning example provincially, she said.

“Recommendations and initiatives are shared back to other organizations for learning,” she said.

Article content

Five of the six events at Bluewater Health since January resulted in no harm to patients, officials said, and there have been none at Bluewater Health in the last two quarters.

“We identify whenever there is a situation that could be a never event, even if there was no harm. . . so that we can put checks and balances in place,” Mathews said.

Never event examples from Ontario Health include improperly sterilizing instruments, administering the wrong gas to patients, infant abductions, a patient leaving high-level observation areas without staff knowledge, or operating on the wrong person, body part, or performing the wrong procedure, she said.

Never-event reporting is one aspect of the hospital corporation’s broader quality and patient safety plan, recently presented to the board.

Article content

The plan places patient safety at the center of everything Bluewater Health does, and backs safety-oriented practices and procedures with things such as the hospital corporation’s strategic plan, patient feedback, a risk management plan, a patient declaration of values, and the corporation’s quality improvement plan.

Safety in the plan applies to safe medical care, safety for patients and staff from violence, and creating a just and trusting culture where people feel safe, Mathews said.

Hospital group programs encourage reporting near misses; there’s a “red rule” that makes sure patients are asked for two pieces of identifying information like their names and birthdays at every interaction; and Bluewater Health employs best practices and has been recognized for that since 2015 as a best-practice spotlight organization by the Registered Nurses’ Association of Ontario, she said.

Article content

The quality and patient safety report is updated annually with new goals, she said.

“Really, it’s to continuously improve safety, quality and health-care experience for everyone in our community,” she said.

Of note, no Bluewater Health staff missed time due to injury in July and August, she said, when there were 28 incidents of workplace violence reported.

There were 62 incidents reported between January and August, resulting in 68 days of lost time, a recent report to the board says.

Mathews credited a hospital group program that’s patient-centered and focuses on prevention, and de-escalation.

[email protected]

Article content