Patient Safety Indicators

Publicly Reported Safety Indicators

The Ontario Ministry of Health and Long Term Care has established a number of safety indicators that all hospitals are required to publicly report. We encourage you to review our results through the tabs above.

Nosocomial antibiotic resistant bloodstream infection rates

Methicillin-resistant Staphylococcus aureus (MRSA) and Vancomycin-resistant Enterococci (VRE) Bloodstream Infections (BSIs) are Antibiotic Resistant Organisms (AROs) that can lead to serious infections in hospitalized patients. The most severe among these are bloodstream infections (BSIs), which occur when bacteria enter the bloodstream. These infections, when acquired during a hospital stay, are referred to as nosocomial infections.

Monthly C. difficile rates

Clostridioides difficile is a bacterium that causes infection of the colon and can result in serious health outcomes, including hospitalization, admission to critical care, need for surgical intervention (colectomy), and even death. The use of antibiotics increases the risk of developing C. difficile infection (CDI), and outbreaks may occur in hospitals when multiple patients acquire the infection or are exposed to antibiotics.

Nosocomial CDI—meaning infection acquired during a hospital stay—is an important indicator of hospital quality and infection prevention performance. Monitoring these infections supports improvements in patient safety and care practices.

Hand Hygiene Compliance (Fiscal Year 2024/25)

Hand hygiene is the most effective way to reduce the spread of health care-associated infections (HAIs), which are commonly transmitted by the hands of healthcare workers. Monitoring hand hygiene and providing regular feedback are essential for improving compliance and protecting patients. Information regarding Sunnybrook patient safety indicator data related to hand hygiene is available on the HQO website.

How We Measure

At Sunnybrook, hand hygiene is tracked through:

• Electronic Monitoring: Several inpatient units use a sensor-based system that counts dispenser activations and compares them to expected hand hygiene opportunities.
• Covert Audits: Where electronic systems are not in place, trained observers anonymously assess hand hygiene practices.

Electronic monitoring offers more consistent, real-time data and minimizes bias associated with direct observation.

Compliance Rates – Fiscal Year 2024/25

Hospital Standardized Mortality Ratio (HSMR)

The Hospital Standardized Mortality Ratio (HSMR) is a measurement that compares a hospital’s mortality rate with the overall national average rate. While this indicator provides a measure of overall mortality, it should be considered alongside other indicators when assessing the quality of care provided.

A ratio that is greater than the annual national average suggests that the hospital’s mortality rate is higher than the average rate. A ratio that is below the annual national average suggests that the hospital’s mortality rate is lower than the average rate.

How do we measure this?

Surgical Safety Checklist Compliance

It has been proven that the use of a surgical checklist helps to reduce the rates of death and major complications after surgery. By using a surgical checklist, the surgical team is able to confirm important information about the patient and to ensure that the necessary steps have been taken prior and will be taken during the procedure to ensure safe patient care.

This indicator refers to the percentage of surgeries in which a three-phase surgical safety checklist was performed.

How do we measure this?

Surgical Site Infection Prevention

Surgical site infections (SSI) are the second leading type of healthcare-associated infection. Timely administration of prophylactic antibiotics is a key infection prevention strategy for hip and knee replacement surgeries. The greatest benefits are seen when antibiotics are administered within 60 minutes prior to skin incision. The following data shows the percentage of times we were able to administer the appropriate antibiotic within the recommended timeframe.

How do we measure this?

Timely Administration Rate of Prophylactic Antibiotics - All Sites

Chart not available.

Hips	Q3 2023/24	Q4 2023/24	Q1 2024/25	Q2 2024/25
Within time frame	83	78	76	91
Total cases	84	80	79	93
Percentage	97.8	97.8	97.8	97.8

Knees	Q3 2023/24	Q4 2023/24	Q1 2024/25	Q2 2024/25
Within time frame	463	475	518	432
Total cases	468	478	525	438
Percentage	98.6	98.6	98.6	98.6