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 Last modified June 9, 2004  

CNO Launches Examination of Patient Safety Issue

In response to growing concern across Canada regarding preventable adverse events that have injured or claimed the lives of clients, The College of Nurses of Ontario (CNO) formed a Patient Safety Advisory Group in February 2004.

At present, there is very little comprehensive and reliable research about preventable adverse events in Canadian health care facilities. This will be partially remedied by the findings of the Canadian Adverse Events Study. Preliminary findings from the study were published in the May 25th issue of the Canadian Medical Association Journal.

The study was undertaken by the Canadian Institute for Health Information and the Canadian Institutes of Health Research, with an exclusive focus on acute care settings. The definition of an adverse event used by the Canadian researchers is “an unintended injury or complication which results in disability, death or prolonged hospital stay and is caused by health care management.”

Through a systematic review of hospital charts, the researchers hope to determine the extent and nature of adverse events in Canadian hospitals. British Columbia, Alberta, Ontario, Quebec and Nova Scotia are the participating provinces. One teaching hospital, one community hospital and two rural hospitals were randomly selected from each province, and the research teams will have reviewed about 3,700 charts over the course of the study period.

Canada is not the first country to examine the frequency and nature of adverse events. The United Kingdom, the U.S. and Australia have already released reports on patient safety. The U.S. report, entitled To Err is Human (1999), estimated that between 44,000 and 98,000 deaths and more than one million injuries each year are attributable to hospital adverse events. Findings from the Quality in Australian Health Care study (1995) and Adverse events in British hospitals: a preliminary retrospective record review (Vincent, Neale & Woloshynowych, 2001) suggested that between five and 10 percent of hospital admissions lead to adverse events, a third of which lead to disability or death, and half of which were preventable.

CNO, and the nursing profession as a whole, is aware of the potential for preventable adverse events within the health care system.

For example, CNO supported the removal of potassium chloride (KCl) from hospital nursing stations. The Quality Practice Settings Attributes, found in the Practice Setting Consultation Program®, support professional practice and help nurses meet the standards.

CNO’s new Patient Safety Advisory Group has built a base of knowledge about system errors and the actions taken in other jurisdictions. The College is using this information in its response and communication with members and the public. As a first step, CNO has developed a new section on the website related to patient safety. Here, members will find links to further information, as well as responses from CNO on the regulatory issues raised by the Canadian study. In addition, the group is identifying opportunities for partnerships with other health care, academic and government bodies that are addressing patient safety issues.

Developing strategies for the prevention of adverse events is another way in which CNO is working to fulfill its objectives. By to addressing issues raised about patient safety, CNO continues to build confidence in nursing self-regulation.

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