SickKids' Patient Safety Symposium: Paediatric Patient Safety Indicators: Moving OUR Dots

Partners in Patient Safety 5th Annual Pediatric Patient Safety Symposium

WHEN - Thursday, June 11, 2009 7:00 AM - 3:30 PM EST

WHERE - Hollywood Theatre at SickKids Hospital

8:00-8:30 Registration and Breakfast

8:30–8:45 Welcome and Introduction

Setting the Stage

8:45- 9:15 Dots are hot. But what are they?
Peter Lachman, MD, FRCP, Consultant Paediatrician, Consultant for Service Redesign and Transformation, Great Ormond Street Hospital for Children NHS Trust, and Royal Free Hospital Hampstead NHS Trust, London, UK

Little Dots ... Indicators:

9:15- 9:35 Dot Talk: The AHRQ’s Paediatric Indicators
Matthew C. Scanlon, MD, Section of Critical Care, Department of Pediatrics, Medical College of Wisconsin, Milwaukee, WI, USA

9:35 – 9:55 Pursuing Canadian Paediatric Patient Safety Indicators
Astrid Guttman, MDCM, MSc, Division of Paediatric Medicine at the Hospital for Sick Children, Assistant Professor of Paediatrics and Health Policy, Management and Evaluation, University of Toronto, Toronto, Canada

9:55 - 10:15 Positive Deviance: A Culture Change Management Approach to Reducing Healthcare Acquired Infections
Michael Gardam, MD, Director of Infectious Disease Prevention and Control , Ontario Agency for Health Protection and Prevention, Toronto, Canada

10:15 - 10:30 Interactive Session/Questions

10:30 - 11:00 Refreshment Break and Poster Session

Bigger Dots ... Serious Adverse Events and Critical Incidents: Two Perspectives

11:00 - 11:20 The Cincinnati Experience
Stephen E. Muething, MD, Director of Clinical Services, Associate Professor of Pediatrics, Division of General and Community Pediatrics, Cincinnati Children’s Hospital Medical Centre, Cincinnati, OH, USA

11:20 - 11:40 The SickKids Experience

11:40 -12:00 Interactive Session and Questions

12:00 -1:00 LUNCH

Biggest Dot ... Mortality

1:00 – 1:30 Lessons in Patient Safety from the Paediatric Death Review Committee
Dr. A.E. Lauwers, MD, CCFP, FCFP, Deputy Chief Coroner, Office of the Chief Coroner for Ontario, Toronto, Canada

1:30 - 1:45 Question Session

1:45 - 2:15 Poster Awards and Presentation Session

2:15- 2:30 Refreshment Break

Are We Making a Difference in Hospital Mortality: Two Perspectives

2:30 – 2:50 The Lucile Packard Experience
Paul Sharek, MD, MPH, Medical Director, Quality Management, Chief Clinical Patient Safety Officer, Lucile Packard Children’s Hospital at Stanford, Palo Alto, CA, USA

2:50 - 3:10 The Melbourne Experience
Karen Dunn, MD, Paediatrician; Emergency Medicine Fellow, Royal Children's Hospital, Melbourne, Senior Lecturer, Department of Paediatrics, University of Melbourne, Royal Children’s Hospital, Melbourne, Australia

3:10 - 3:30 Feasibility of a Paediatric Hospital Standardized Mortality Ratio (HSMR)
Canadian Institute for Health Information

3:30 - 4:00 Combined Panel Discussion and Question Session

Children help children facing death at early age

Children at a church in Toronto wished to help children facing death at a young age and for Lent, with advice from their parents, are supporting the Sasha Bella Fund. Here is the writeup in the church's current newsletter:

THE SASHA BELLA FUND for Family Centered Care was created in menory of a little girl named Sasha Bella. Sasha was born June 6, 2004 with multiple health conditions. After a brave fight, she died with her family at her side. Her family thought it was important for families in similar situations to be able to have their child at home during the last stages of palliative care. They established the fund in her memory. It is difficult to think of any child fighting a prolonged terminal illness and so, the children of PromiseLand, with the input of ideas from their parents, decided they wanted to help those who face death at an early age. We invite you to join us in making a contribution to this fund.... This Lent, let’s all help the children of our city to die with dignity.

We celebrate the children's love and generosity and purity of purpose and thank the parents for their support.

Have you ever been uncomfortable asking care questions?

Joy Bennet at Cincinnati Children's Hospital has setup a one question survey focused on a very important question for parents. Please consider helping gather data by filling in the survey. Joy writes:

I am working on a family-led project to help families feel more comfortable asking questions or even stopping care if they have a serious concern.

We have created a short, one-question survey to gather input on the reasons why families are reluctant to voice their concerns. We would love for each of you to answer the survey based on your personal experience as a parent or family member.

We also ask that you consider emailing this link to your family mailing list so that we can gather data from a broad range of families.

Once we've analyzed the results, we will share them with all of you.

The survey is here

Thank you so much!

Joy Bennett
Parent Coordinator and Co-chair
Family Advisory Council
Cincinnati Children's Hospital Medical Center

Kim Dionne - "Everyday Hero"

Kim Dionne, co-chair of the NICU Family Care Group, and researcher and mentor on collaboration with families was featured as an "Everyday Hero" on Global TV last Friday. All the short clips can be accessed at "Everyday Heroes" and then select "Kim Dionne". The spot also features photos of the the innovative cart that Janis and Diane and NICU created to allow Jonathan Purdy-Flacks to first see sunlight.

Dr Simone Honikman : Perinatal Mental Health Project

Come and listen to Dr Simone Honikman of the Perinatal Mental Health Project talk about her work with young mothers in the communities around Cape Town.

Date: Saturday 7 March 2009
Time: 10.00 am
Venue: Novotel Toronto North York Hotel, 3 Park Home Avenue (off Yonge Street)
Visit for directions.
Price: $25 per person (Cheques made out to "UCT Foundation")
Contact: Diane Stafford 416 637 7981

The Perinatal Mental Health Project (PMHP) addresses the crucial public health problem of mental distress among women living in adversity in South Africa. More than 1 in 3 women in Khayelitsha, Cape Town, experience postnatal depression. Mental health care is a neglected area – even more so in "healthy" pregnant and postnatal women. The focus on the physical to the detriment of the emotional is particularly felt now against the backdrop of HIV and AIDS. The public health service has been unable to address the mental health needs of women from poorer communities - neither within maternity services nor within mental health services. This is despite a wide body of evidence showing that distress in the mother may have long-lasting physical, cognitive and emotional effects on her children.

Dr Honikman will be in Toronto to present two papers at the conference entitled, "Expanding our Horizons: Moving Mental Health and Wellness Promotion in to the Mainstream" .

Through the PMHP, operating from the Mowbray Maternity Hospital since 2002, to date almost 6000 pregnant women have had access to mental health care, free of charge. The alumni breakfast will present the opportunity for Dr Honikman to discuss the advances made within the PMHP over the past few years. Describing her work with empathy and compassion, Dr Honkiman presents a very compelling case in support of her work.

We look forward to seeing you there!
Kind regards

Di Stafford
Regional Director: Alumni Relations & Development
University of Cape Town Foundation (Canada)

New Palliative Care sign a sign of the times

Several weeks ago I noticed the new sign to the Palliative Care Service as you exit the basement elevator in Black Wing. I had often thought how hard it was to find the office and at a meeting I attended last year one staff got lost. So the sign jumped out at me and feels symbolic of the team's wider work to make palliative support more visible to doctors and patients. The hospital's new Interprofessional Practise video starts with a little girl kept alive on a ventilator with her family and several staff interacting; later on the video, a nurse cries as a doctor recounts her end of life at the team meeting. The service is advocating to the Ministry that palliative care be a mandatory rotation for medical students and not an elective. The Team for Research with Adolescents and Children in Palliation and Grief ( is enrolling families, networking with other researchers and undertaking country wide research studies. Parents of children supported by the team have set up a program to support sibling grief, a research innovation fund and a new hospital wide award so the service can recognize staff interprofessional excellence.

News from Sickkids NICU - developmental care room pilot goes ahead

Sickkids Neonatal Intensive Care Unit will build the pilot developmental care room over the next few days. The six bed room will be home during the entire course of stay for babies under 1500 grams or those very susceptible to neural stimulation such as changes in sound and light. Dr Jonathan Hellmann explained that the idea that controlling environmental stimuli is positive for preemies makes common sense and research shows parents are happier and more involved and feeding is more successful; however the full effect on the babies has yet to be thoroughly researched.

Renovating a busy intensive care facility home to very fragile infants is difficult as babies are transferred to other rooms and efforts have to be made to reduce the banging on two walls and its effects on infants in adjoining rooms. Sickkids NICU has been very busy running at capacity for several weeks and have recently gotten busier with the Ministry's addition of three new beds. Three beds doesn't sound like a lot however, in this unit, doing the work it does, just three beds feels like it pulls out the very last bit of flex.

The renovation follows almost exactly a year after the Toronto Star wrote about a pilot developmental care room to be launched by the end of 2008 and focused on NICU parent input: a NICU dad explained their baby started to feed, digest, add weight and sleep better in an isolated and quiet room but after moving to a brighter, noisier bed by a nurses station the baby immediately struggled to thrive. The renovated room provides a central location for a new developmental care program with specialized staff, environmental controls and new continuous monitoring equipment already started elsewhere on the unit. The room was artly supported by two NICU parents' fundraising in July 2007.