It’s been anywhere from three to five decades since high-quality evidence demonstrated the pervasiveness of medical error. While discussion of preventable patient harm has become radically more open, there’s been no corresponding radical decrease in its ubiquity. This presentation takes a hard look at why we still kill patients and what needs to change so we don’t.

Learning objectives:
1)  Learn the medical literature on patient safety that predates the 1999 “To Err is Human” report
2) Understand the real-life barriers that have impeded progress towards safe care
3) Learn strategies for breaking through barriers in order to achieve significant progress towards the goal of zero preventable harm.

Provides an overview of the key activity in Clinical Medicine – how we make decisions. The talk is centered on how we make clinical decisions in medicine and how they contribute to diagnostic failure, the most serious threat to patient safety. The argument will be made that current Root Cause Analysis (RCA) typically provides limited insight into how clinical decision making fails – an alternative system is proposed that brings into focus the distal causes of failed clinical decision making.

Learning objectives:
1) To emphasize that along with the acquisition of medical knowledge, it is especially important to consider how we think about that knowledge.
2) To emphasize that the complexity of the diagnostic process requires changes in the way that   clinicians think and make decisions.
3) To reinforce that the development of well-calibrated rationality in clinical reasoning and decision making is the most important of a clinician’s skills

Intellectual humility (a willingness to acknowledge that we might be wrong) is a characteristic and a practice that we see rarely in public life, but research is increasingly suggesting that it may be key to reducing belief in misinformation. It may also facilitate meaningful connections with people who see us as outgroup members, thus opening pathways to future conversations that could promote patient care and positive health outcomes. Especially in a moment when trust in science and medicine is declining, finding ways to engage with patients of various political and social persuasions is necessary to promote public health. This presentation will explore the role of social identity in shaping public misperceptions about health and science, and how intellectual humility might be integrated into patient care in a way that helps to bridge these divides.

Learning objectives:
1) Understand the concept of intellectual humility, what it is and what it looks like.
2) Understand the link between social and political identity and misperceptions in the realms of science and medicine.
3) Acquire specific methods and techniques to integrate intellectual humility and a shared political identity into patient care.

Presentation information pending

Patients and families and partnerships with them are essential to patient safety in all settings where individuals and families receive care and support. Specific examples of patient and family partnerships will be discussed as well key strategies for successful collaboration. The new CMS Patient Safety Structural Measure for many hospitals in the United States will be briefly described.

Learning objectives:
1) Describe the evolution of patient and family partnerships in quality improvement and safety through a succinct history of patient safety.
2) Discuss specific ways to partner with patient and family advisors to enhance safety and reduce harm.
3) Model partnership with a patient/family leader and describe strategies to support successful participation.

What happens when patients and families are invited as full members of patient safety event review committees—including those protected under Section 51? At Provincial Health Service Authority in B.C. (PHSA), we’re piloting a new approach that aims to move beyond consultation toward genuine partnership in safety learning and improvement.

This session will introduce PHSA’s framework for supporting the safe and effective inclusion of patient and family partners (PFPs) in safety event reviews. Designed to meet programs where they are, the framework provides tools, guiding principles, and a phased implementation approach that honours organizational readiness, cultural safety, and legal context.

Learning objectives:
1) Explore how meaningful patient and family partner (PFP) involvement in patient safety event reviews can transform learning, uncover root causes, and drive system-wide safety improvements.
2) Learn how PHSA’s new framework and phased implementation approach support safe, effective, and context-sensitive inclusion of PFPs across programs—regardless of current organizational readiness.
3) Understand how involving PFPs in Section 51*-protected reviews strengthens person-centred partnerships, supports accreditation readiness, and reflects diverse perspectives in safety culture.

* BC’s quality assurance legislation falls under the Ministry of Attorney General’s Evidence Act
[RSBC1996]. Section 51 of the Evidence Act (Section 51); was developed to
promote quality assurance or quality improvement by supporting an environment where health
care providers could speak truthfully about the care they or others provided, without fear that
the information produced during a review could be used as evidence in a legal proceeding.
The legislation articulates a qualifying committee structure and sets out that information
provided to and produced by a qualifying committee is prohibited from being used in legal
proceedings. The intent is to provide a safe space for frank and open discussion amongst health
care professionals. 

RAND is a nonprofit research organization that is leading an AHRQ-funded initiative to enhance diagnostic safety in healthcare and is seeking health care organizations that are interested in implementing one or more resources designed to improve diagnosis-related communication and decision-making: Calibrate Dx: A clinician tool for refining diagnostic reasoning; Measure Dx: A guide for identifying and learning from diagnostic safety events; and Toolkit for Engaging Patients To Improve Diagnostic Safety: Simple interventions to improve exchange of diagnosis-related information in office-based settings. This is a great opportunity for clinics, hospitals, and health systems to be involved in improving diagnostic safety and reducing patient harms at their site.

Learning objectives:
1) Describe the prevalence and impact of diagnostic safety events.
2) Understand the importance and salience of using previously developed resources to improve diagnostic safety in different settings.
3) Identify at least one available resource that could directly improve diagnostic safety at their site.

With supportive culture change enablers, and through significant engagement and many plan-do-study-act-cycles, we developed a process to report and review incidents of Indigenous-specific racism and discrimination (ISRD) that have caused patient harm.  These events are reported directly from patients and families as their lived experience, or from staff witnessing how racism and discrimination is operating in healthcare and contributing to harm.  The focus of this work is to effect system-level change to make improvements in the provision of culturally safe and anti-racist care and use restorative approaches for resolution to rebuild trust with harmed patients, families and communities.  This project is aligned with obligations from the Canadian government and related foundational documents (such as the Declaration of the Rights of Indigenous Peoples Act and the Truth and Reconciliation Commission of Canada’s Calls to Action) and with our Integrated Quality and Safety Strategy goal of achieving a culturally safe and anti-racist environment.  The work included launching Indigenous self-identification in patient safety event reporting, creation of an avenue for staff to report racism and discrimination as a contributing factor to a safety event, formation of an ISRD incident response committee, the development of an ISRD reporting and review protocol with associated tools, templates and resources, and creation of reporting accountability (tracking incident information, resolution approaches and recommendation implementation).  Early findings show increased confidence of leaders in reviewing ISRD and that many events have led to resolution, learning and action.

Learning objectives:
1) Describe the historical and ongoing impacts settler colonialization has on Indigenous-specific racism and discrimination in healthcare, and explain why addressing these harms is essential to ensuring culturally safe, equitable, and high-quality care.   
2) Identify the key enablers of the culture change required to address Indigenous racism and embed cultural safety as a core component of patient safety.   
3) Gain practical skills in how to report and review incidents of patient harm resulting from Indigenous-specific racism and discrimination and explain how a structured reporting and review process enables follow-through on recommendations, fosters accountability at individual and system levels, and supports achieving resolution to restore trust with Indigenous patients and families.

Four healthcare organizations present innovative processes and practices that enhance equity that result in measurable changes in access to, and quality of, care for patients, reductions in patient harm and improved outcomes.

Learning Objectives:
1) Learn innovative practices that address healthcare inequities leading to improved patient safety and outcomes.
2) Understand how different healthcare organizations embed equity principles into best practices.
3) Learn how specific quality improvement activities, that are focused on equity, are implemented in different healthcare environments.

Community engagement is a powerful tool to advance health equity and empower patients. When done well, community engagement builds trust, advances health equity, creates cost-savings and efficiencies for healthcare organizations, and leads to healthy and thriving communities. Unfortunately, too often, well-intentioned community engagement initiatives are limited in diversity, fail to achieve meaningful outcomes, and fall short of authentic power-sharing. INSPIRE (Initiating National Strategies for Partnership, Inclusion, and Real Engagement) is a national partnership project that brings together the Camden Coalition, Community Catalyst, the Center to Advance Consumer Partnership, PFCCpartners, the Institute for Patient-and Family-Centered Care, alongside a team of experts with lived experience. Together we are working to co-design a national strategy to advance meaningful partnerships between healthcare organizations and community members.

Learning objectives:
1) Understand major finding from INSPIRE’s research efforts engaging over 300 healthcare stakeholders and community members from across the country.
2) Learn practical strategies to more meaningfully engage the patient community.
3) Strengthen their ability to make the “business case” for sustained investment in community engagement.

We will share a brief overview of the new B.C. Provincial Health Service Authority’s (PHSA) Patient Engagement Framework which provides a consistent and adaptable approach to engagement across PHSA. This will be expanded by sharing of two examples, and insights from these examples, related to patient and family engagement within the central Quality and Safety Team that incorporate the approaches and best practices of the framework – 1) Patient and Family Partner Engagement within the PHSA Speak Up for Patient Safety Procedure and 2) Patient and Family Partner Inclusion within the new PHSA Integrated Quality & Safety Steering Committee

Learning objectives:
1) Describe the components of the PHSA’s Patient Engagement Framework.
2) Explain how the approaches and best practices of the Speak Up for Patient Safety Procedure contribute to improved patient safety and quality.
3) Explain how the new Integrated Quality & Safety Steering Committee has improved patient and family partner inclusion and led to improved safety and quality.

LGBTQ people and their families have never been safe in the healthcare system. In fact, doctors and nurses have perpetuated some of the worst injustices many LGBTQ people have ever faced. But over the last 25 years great progress has been made to address this history and the pain faced by this growing patient population. Together, we will learn about the past, celebrate the progress, assess the current challenges, and find a path forward to ensure everyone is safe to receive the care they deserve.

Learning objectives:
1) Appreciate the history of medical injustice towards LGBTQ patients.
2) Understand the great changes healthcare systems have made to address LGBTQ patient’s unique needs3
3) Reflect on ways we can continue to move forward with better care for everyone

The public is at greater risk of harm from medical misinformation now more than ever. How can we regain people’s trust and build their skills to navigate the current information landscape?

Learning objectives:
1) Identify where we are and how we got here.
2) Identify some effective communication strategies.
3) Understand the importance of collaborations for amplification (Every single one of us needs every single one of us.)

Description

Learning objectives: