Patient Safety Indicators

Thunder Bay Regional Health Sciences Centre takes your care and safety very seriously, and we are committed to transparency.

Nine separate indicators will be reported on, including a number of hospital-related infections and the success rates of health care professionals practicing proper hand hygiene to prevent the spread of disease.

The public reporting of safety indicator rates is not intended to serve as a measure for hospitals to compare themselves against other organizations, or for the public to use as a measure of where to seek care. Rates can vary from hospital to hospital, month to month. Some hospitals may experience higher specific rates due to the nature of the care they provide and their patient population, such as those with higher elderly patient populations.

What public reporting adds and ensures is that all hospitals are tracking and counting in the same way. This is not for comparison purposes, but rather for accountability. Our posting the data on our website confirms TBRHSC’s commitment to public accountability and transparency. A further benefit is that hospitals with similar demographics and challenges can more easily share tips and strategies.

Indicator Reporting Period Data Trend

Central-Line Primary Blood Stream Infection (CLI)
Jul – Sep 2018 Rate = 0.00
(per 1000 line days)
# of cases = 0

Clostridium Difficile Infection (CDI)
May 2022 Rate = 0.42 (per 1000 inpatient days)
# of cases = 5

Hand Hygiene Compliance
2021 – 2022 Hand hygiene before initial patient/environment contact = 57.3%

Hand hygiene after patient/environment contact = 69.67%


Hospital Standardized Mortality Ratio (HSMR)
2015/16 – 2019 Q1 ratio of observed to expected deaths: 90 Trend

Hospital-associated Methicillin-resistant Staphylococcus Aureus (MRSA) Bacteraemia (Bloodstream Infection)
Jan-Mar 2022 Rate = 0.00
(per 1000 patient days)
# of cases = 0
Surgical Safety Checklist (SSC) April to September 2018 SSC Rate = 100%

Hip and Knee Replacement Surgical Site Infection (SSI) Prevention
Oct-Dec 2018 SSI Prevention Rate = 99.2% Trend

Hospital-associated Vancomycin-resistant Enterococcus (VRE) Bacteraemia (Bloodstream Infection)
Jan-Mar 2022 Rate = 0.0
(per 1000 patient days)
# of cases = 0

Ventilator-associated Pneumonia (VAP) in the Intensive Care Unit (ICU)
Jul – Sep 2018 Rate = 3.34
(per 1000 vent days)
# of cases = 2