What are the targets for 2014/2015?
All facilities and service areas will have established Daily Visual Management
and a process for multidisciplinary safety huddles and good catches/safety
Staff will be able to identify a stop the line example and will feel supported if
they stop the line
Patients will know who to contact with safety concerns
WHAT ARE THE NEXT STEPS FOR MY AREA/FACILITY?
The Stop the Line Team will be working with all programs and service areas to
implement daily visual management, daily safety huddles, and define stop
the line examples.
A training session for managers will be held in Winter 2014/15.
Before this session is held, please reflect on the needs of your team(s). We
have found that any training on teambuilding, communication and/or
respectful workplace is a great foundation before working with staff to
develop processes for safety huddles and discussing stop the line.
Please consider contacting those listed below for more information about
Type of Training
Root Cause Analysis –
Patient Safety Reporting
Just Culture Training
SAFETY ALERT/STOP-THE-LINE SYSTEM
Building a culture of safety is a provincial priority. Saskatoon Health
Region was chosen as a pilot site to develop a safety alert system
for Saskatchewan. The system will be tested in Saskatoon Health
Region and then replicated across all regions. Sun Country Health
Region is working to build on the safety programs that are in place
and to further develop a safety culture including Stop-the-Line.
This will prepare us to link in to the provincial system as we work
together to prevent harm to patients/residents and staff.
WHY IS A SAFETY ALERT SYSTEM NEEDED?
Patients/residents and staff are being harmed.
Studies show that an estimated 7.5% of patients admitted to acute care hospitals
experience 1 or more safety events. More than 10,000 deaths of acute care patients in
Canada can be prevented.
The healthcare industry has the highest injury rate in the province. Approximately 1 in 7
are injured on the job. All workplace injuries are preventable.
WHAT IS A SAFETY ALERT SYSTEM?
a comprehensive system for safety; builds on work done to date and includes both staff
and patient safety reporting.
fosters a culture where staff members and patients/families always feel supported in
immediately detecting and reporting unsafe situations, incidents and errors.
requires any staff member and invites patients and families who encounter an incident or
situation that is likely to harm staff or patients to make an immediate report and to cease
any activity that would cause harm (Stop-the-Line) e.g. processes or equipment may be
removed until improvements or fixes are made.
encourages “stop and fix”, but allows for escalation or help when needed.
WHAT ARE SOME OF THE GAPS THAT WILL BE ADDRESSED WITH THE DEVELOPMENT OF A
SAFETY ALERT/STOP-THE-LINE SYSTEM?
weak safety culture.
fear of reporting safety incidents and of discussing errors.
feeling that when reporting incidents, the person is being written up, not the problem.
multiple processes for reporting safety incidents.
no capacity or standardized process to analyze events, identify themes or share themes
across Sun Country Health Region or the process.
no feedback loop – staff and/or patients/clients/residents may never find out how the
incidents they reported or that impacted them were resolved.
What does it mean to Stop-the-Line?
Stop-the-Line is the request of any team member
(including patients and families) for
clarification/interruption of a process and action when
there is an immediate risk to patient or staff safety.
Stop-the-Line is ceasing any activity or removing equipment
that could cause further harm.
WHAT IS AN IMMEDIATE RISK TO PATIENT OR STAFF SAFETY?
Any situation in which safety is perceived to be at risk. Examples may include,
but are not limited to:
Missed Hand Hygiene at moment of patient care.
Improper use of Personal Protective Equipment (PPE).
Improper use of Transfer-Lift-Reposition (TLR) procedures and equipment
When patient/family identifies something is wrong – i.e. wrong medication,
Differing views regarding the ability to meet care needs in a safe
environment for a patient (e.g. receiving transfers we are unable to accept).
Omission of care.
Patient assessment reveals risks such as suicide or VTE, but no actions taken
Incomplete process for checklists, procedures or best practice e.g. Surgical
Checklist, Medication Administration, patient Identifiers, Labeling, Physician
A disagreement between members of the care team or between members
of the care team and patients/families regarding the provision of care.
Differing views regarding the ability to provide safe patient care and the
need for alternate care (e.g. different facility).
Equipment malfunctions, unavailability or failure of equipment that could
have or did jeopardize the patient/resident/client and/or staff.
EACH FACILITY OR AREA OF CARE/SERVICE WILL IDENTIFY THEIR OWN STOP-THE-LINE
EXAMPLES FOR EDUCATION OF STAFF AND PATIENTS TO THE UNIT, FACILITY OR SERVICE.
A Good Catch is an event or situation that did not result in patient or
staff injury because the safety issue was identified before harm
malfunctioning lift, unsafe sidewalk, wet floor, error in packaging of
medications, Transfer-Lift-Reposition (TLR) logo incorrect or missing.
REPORT A GOOD CATCH AND DISCUSS AT YOUR DAILY TEAM
to get feedback from others about a safety issue or concern.
to let others know about a concern or action taken.
if it could happen again.
if you need help or support to resolve a concern or take action
Fill out a Patient Safety Occurrence/Employee Incident Report
Form for a Good Catch if:
the safety concern keeps repeating.
it is beneficial to share with other facilities.
there is potential for serious harm.
not getting help/support needed.
Good catches are part of a Stop-the-Line culture where staff members
and patients/families always feel supported in immediately detecting
and reporting unsafe situations, incidents, and errors. As part of this
work, we want to encourage and celebrate Good Catches and most
importantly the immediate action taken and follow up to resolve the