Patient safety improvements arise from third party review

Alberta Health Services today released the complete report of the Health Quality Council of Alberta. The report outlines a review of four potentially serious patient care incidents at the Alberta Children’s Hospital in Calgary that has led AHS to take a number of actions.

The Health Quality Council of Alberta (HQCA) conducted an independent review of the incidents at the request of Alberta Health Services.

In all four incidents, staff recognized and reported the errors and immediate action was taken to ensure each child received the appropriate care. Actions resulting from the review are underway at the Alberta Children’s Hospital and throughout AHS. Actions being implemented at the Alberta Children’s Hospital include:

• development of standardized procedures for tracing and labeling all infusion lines
• making equipment adjustments to eliminate the ability to connect gastronomy tube products to intravenous lines
• ensuring Clinical Nurse Educators spend increased time with staff (specifically staff new to an area or unit) to ensure thorough orientation of specific unit routines
• reinforcing existing processes for storing, requesting and feeding expressed breast milk, including the requirement of double-signature (clinician and parent)
• designing nursing care plans tailored particularly for those children with very complex health needs
• implementing safety action teams on each patient care unit which include front line staff members

Related Items

• View Health Quality Council of Alberta Report (PDF)
• View March news release with additional highlights of the report