An adverse event is defined as an incident that has resulted in harm to the patient as a result of care provided in the OHP. What are some specific examples of adverse events that must be reported to CPSO?

A key component of the definition is that the adverse event must be related to the procedure performed in the OHP. Indicators of adverse events generally include complications related to the use of sedation/anesthesia or to the procedure itself. This includes both serious complications, such as:

• Death within the premises;
• Death within 10 days of a procedure performed at the premises;
• Any procedure performed on the wrong patient, site, or side; or
• Transfer of a patient from the premises directly to a hospital for care.

It also includes other quality assurance incidents which are deemed less critical for immediate action, such as:

• Unplanned extended or overnight stays¹;
• Unscheduled treatment of a patient in a hospital within 10 days of a procedure performed at a premises in relation to the procedure;
• Complications such as infection, bleeding, or injury to other body structures;
• Cardiac or respiratory problems during the patient’s stay at the OHP;
• Allergic reactions; or
• Medication-related adverse events.

Patient harm that occurs as a result of an unrelated activity is not considered an adverse event as defined by the Standard and does not need to be reported to CPSO. For example, if a patient has an injury that results in a hospital stay within 10 days of the procedure performed in the OHP but is unrelated to the OHP procedure, this would not be considered an adverse event.

What is the purpose of reporting adverse events to CPSO? What will CPSO do with this information?

CPSO is responsible for the effective oversight of OHPs. Reviewing the severity and frequency of adverse events within each OHP helps CPSO to fulfill this duty by helping to identify any concerning trends. In order to fulfill CPSO’s obligation to monitor for higher risk events, and to fulfill their own obligations, Medical Directors are accountable to CPSO for ensuring that this information is reported and for taking any appropriate corrective action.

CPSO recognizes that adverse events can result from a variety of factors, including risks inherent in the procedure, system failures, or even performance issues with individual physicians, however they offer opportunity for learning and improvement and can offer insight into areas which might benefit from practice improvement or additional safety measures. Depending on the nature and frequency of adverse events, they are not necessarily an indication of poor practice. However, lack of reporting of adverse events may serve as indication that OHPs are failing to comply with their obligations as set out in the Adverse Events Standard.

CPSO is committed to assisting OHPs with improving their practices and collecting information regarding adverse events helps us to do so.

How can I report adverse events and what information needs to be submitted to CPSO?

Adverse events can be reported through the Member Portal on CPSO’s website. Physicians involved in the adverse event are required to report all relevant information and submit relevant medical records, including any referral letters, pre- and post-operative notes and tests, surgical notes, the anesthesia record, and an update of the patient’s outcome.

Why has CPSO moved away from distinguishing between Tier 1 and Tier 2 adverse events?

With the implementation of CPSO’s new Member Portal, you are now required to report all adverse events as they occur, so the distinction between Tier 1 and Tier 2 adverse events no longer serves a purpose. CPSO will continue to review all adverse events that occur within OHPs and respond accordingly. Medical Directors must also review all adverse events and respond accordingly. Investigations and any corresponding actions need to be proportionate to the circumstances and to the adverse event that occurred. More serious adverse events may require a more in-depth investigation and/or more significant corrective actions. 

Where can I learn more about adverse events?

The CMPA’s Good Practices Guide and Learning from adverse events: Fostering a just culture of safety in Canadian hospitals and health care institutions have additional guidance related to adverse events, including the best approach for reviewing these events.

Endnote

^1. An extended or overnight stay is where a patient has not met discharge criteria and is required to stay in the OHP beyond normal operating hours.