Developing a Comprehensive Patient Safety Strategy for an Integrated Canadian Healthcare Region

he Calgary Health Region (the Region) is one of the largest completely integrated health regions in Canada, covering an area of 39,260 square kilometres. With four urban hospitals and eight rural hospitals (total of 2,104 acute care beds), the Region provides population health, preventive health, acute care, long-term care and home care services for 1.14 million residents, as well as tertiary care services for residents of southern Alberta, southwestern British Columbia and south-eastern Saskatchewan. In 2004, a batch of citrated renal dialysis solution was mistakenly prepared by the Region’s central pharmacy with potassium chloride rather than sodium chloride. Two patients in our critical care units undergoing continuous renal replacement therapy who were dialyzed with this solution developed severe hyperkalemia and subsequently died. The Region immediately recalled the remaining dialysate solutions and also informed other acute care sites in Canada that produced this type of dialysate about the adverse event. A subsequent internal review led to changes in the storage and labelling of potassium chloride in the central pharmacy and also to the dialysate solution production process. The Region disclosed the details of the adverse events to the families of the involved patients and shortly thereafter, with their permission, the Region informed the public. The Region commissioned a comprehensive external review of its pharmacy services and its organizational approach to patient safety. From this, and through its own internal processes, the Region has developed a comprehensive organizational patient safety strategy. In the last several years, many excellent reports have recommended approaches for improving healthcare safety (Institute of Medicine 2001; National Steering Committee on Patient Safety 2002; Institute of Medicine 2004). However, we were unable to find a report or guide written specifically for large integrated health regions that provided a comprehensive “how to” roadmap to address the complex area of patient safety. The internal and external reviews suggested opportunities that would assist the Region in creating a safer environment for patients. An important outcome of these efforts was the production of a framework that highlighted the key areas that needed to be addressed (Figure 1), and which has also served as the basis for the creation of the Region’s patient safety strategy. We acknowledged that in its broadest context patient safety encompasses occupational safety, environmental safety, physical plant and equipment safety, and business risk management, as well as clinical safety (i.e., the day-to-day practices that directly impact patients). Our patient safety strategy, however, deals only with the narrower context of “clinical safety.” Designing an Agenda for Change

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