practice partner
Wendy Yen, a research associate in the Research and
Evaluation department.
And lastly, the College presented findings at CCME
that highlighted the role of CPSO policy in Committee decisions. As part of an internal review of education decision-making, a subset of 380 decisions made
between 2010-2013 were analyzed to better understand policy usage. More than 40% of these decisions
identified policy as a contributor to the Committee
decision or as an educational resource for the physi-
Patient safety
... Continued from pg. 50
In addition, the electronic medication record for “as
needed” medications did not display a long enough
time line for staff administering medications to
notice that there was an increase in the “as needed”
medication use in the latter part of December. Staff
also indicated that they did not suspect a significant
injury as there was no recognized traumatic event.
According to the coroner, it was the opinion of the
orthopedic surgeon that it would not have taken
significant force to cause a fracture in this elderly
woman who was an immobile diabetic with severe
osteoporosis and that the injury could have occurred
during a transfer. The surgeon felt that if an X-ray
had been done when first requested by the family, it
would have resulted in a diagnosis and more timely
care of the patient with analgesics and other measures
to reduce her pain level, such as splinting the left leg
and non-weight bearing during transfers.
The risk management review conducted by the longterm care home also examined communication issues
between the physicians and nursing staff, particularly
over the holiday season.
There was some question as to why the long-term care
home did not transport the patient to the emergency
department at the hospital for an evaluation, particularly when faced with the difficulties of having a physician assessment at the home. There was an indication
that some long-term care homes have felt criticized in
the past for sending too many residents to the emergency department. While the patient did not necessarily
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cian subject to the decision.
The study builds on previous findings presented at
last year’s CCME that tested the usefulness of coding
physician learning needs identified by CPSO committees into CanMEDS roles.
The results of both studies were encouraging, said
Andréa Foti, manager of the College’s Policy department, and will help the College more systematically
track educational requirements by Committees and,
over time, their impact.
Dialogue Issue 2, 2015
require transfer to an emergency department, she did
require an adequate on-site assessment and ordering of
mobile X-rays.
The Regional Supervising Coroner requested a review
of this case. The investigating coroner identified communication between nursing staff and family as well as
the attending physicians, as a root cause of the problem.
An investigation was carried out by the MOHLTC in
which there were two orders and six written notices
directed to the long-term care home.
The Regional Supervising Coroner subsequently had
all deaths in the long-term care home investigated over
a six month period. There were no further quality of
care issues identified.
Recommendations to health-care professionals
1. ealth-care professionals should have a high index of
H
suspicion of fracture or significant injury in frail, immobile seniors even in the absence of known trauma
and the absence of definitive clinical signs of trauma.
2. Long-term care homes should ensure the availability
of clinicians (i.e., physicians or Registered Nurses
– Extended Class) to assess residents on site in the
event of a change in resident status.
3. ong-term care documentation tools should allow staff
L
to identify trends in pain, behaviour or medical care that
might imply a significant change in health status.