'Training will help build capacity' for safer healthcare system: Hannah
Sessions zero in on understanding root cause of mistakes, taking proactive measures
Friday February 5, 2010 -- Natalie Hamilton
Avoiding storing two medications that are similar in shape, colour and name side-by-side can help prevent a busy nurse from grabbing the wrong medication by mistake.

When looking at the reasons errors occur, healthcare providers can put safeguards in place to make accidents less likely to happen.

Understanding the cause of adverse events and putting preventative measures in place are the intended key learnings from a series of upcoming training sessions in Winnipeg.

The Regional Health Authorities of Manitoba (RHAM) Quality and Risk Network is hosting a provincial initiative that brings the Canadian Patient Safety Institute (CPSI) to the province to provide root cause analysis (RCA) training.

RCA education identifies the factors in healthcare that contribute to errors and the training helps participants identify areas to make system improvements.

Basic training is being held on May 31 and advanced train-the-trainer sessions are lined up for June 1 and 2. The sessions are essentially full.

A recent Canadian study shows that between 9,000 and 24,000 deaths occur due to preventable adverse events, notes Kristine Hannah, regional program director of quality improvement and risk management at the Regional Health Authority-Central Manitoba Inc.

"The goal of conducting a RCA is to identify ways to reduce these risks and prevent medical errors from happening again in the future," Hannah says.

"This is an excellent opportunity for healthcare organizations in Manitoba to broaden their scope and understanding on how to investigate incidents, particularly those with the most significant impacts.

"These are the critical incidents where an unintended event occurred and resulted in a serious and undesired outcome such as death, disability, injury or harm, unplanned admission to a hospital or unusual extension of a hospital stay," Hannah says.

"By looking at the root and contributing factors, strategies can be put in place to prevent similar like situations from happening again. The focus is looking at the sequence of events that led to the incident rather than blaming a person and looking at 'who did it?'"

The train-the-trainer sessions equip participants with the tools to share the knowledge within their respective organizations, Hannah notes. She hopes this will keep up the momentum for RCA and broaden the scope of the impact of the training throughout the province.

"Similar to myself, I think my colleagues would like this training to help strengthen the culture of safety in healthcare," Hannah says.

"We want to learn from our mistakes in healthcare. Good people make mistakes not because they want to but because of poorly-designed systems.

"This training will help build capacity so that we can learn from our mistakes and in turn, take proactive steps which lead to safer environments for patients and clients."

The Healthcare Insurance Reciprocal of Canada (HIROC) is one of the sponsors of the event. Others include the Manitoba Institute for Patient Safety and the regional health authorities.

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