Patient Safety Indicators

When it comes to your health, YOU are the most important advocate. We encourage you to be an active participant in your treatment plan.

Patient safety remains the most important priority for Woodstock Hospital and this involves ensuring that patients are not at risk for contracting healthcare-associated infections.

The Ministry of Health and Long-Term Care identifies a number of safety indicators that all hospitals are required to publicly report their rates. Woodstock Hospital strongly supports these initiatives, as the transparency is believed to encourage improved performance, enhance patient safety and strengthen the public’s confidence in the provincial healthcare system.

Click on Each Safety Indicator below to learn more.

  • Hand Hygiene Compliance

    Hand Hygiene is the single most effective way to prevent the spread of microorganisms (germs) and infections. During your visit to the hospital, effective hand hygiene practices play a key role in improving patient and healthcare provider safety. At Woodstock Hospital, we have a comprehensive hand hygiene program in place.

    Hand hygiene involves everyone in the hospital, including patients and visitors. We encourage patients play an active role in their care by engaging in hand hygiene practices.

    The 4 Moments of Hand Hygiene

    1. Before initial patient / patient environment contact.
    2. Before aseptic procedure.
    3. After body fluid exposure risk.
    4. After patient / patient environment contact.

    The Ministry of Health and Long-Term Care requires Ontario hospitals to annually report their hand hygiene compliance rates using the following formula:

    # of times hand hygiene performed  x 100
    # of hand hygiene observations

    Quarter 2024 Rate 2025 Rate
    Q1 Apr. – June 96% 97%
    Q2 July – Sept. 97% 97%
    Q3 Oct. – Dec. 97% 96%
    Q4 Jan-Mar 97% 93%
    Fiscal Year Total (to-date) 96.5% 95.5%
  • Surgical Site Infection (SSI) Prevention and Reporting

    Our hospital is committed to keeping patients safe and reducing the risk of surgical site infections (SSIs). An SSI occurs at the site of a surgical incision. Germs can get into the incision area and cause an infection. It can develop within 30 days of an operation, or sometimes even up to one year if an implant (such as a knee or hip joint implant) is used. Infections can be minor, or occasionally they can increase complications that result in a longer length of stay in the hospital, or an increased readmission rate for patients. Sometimes when patients are admitted to the hospital, they can get infections. These are called health care-associated infections. Post-operative SSIs are the most common health care-associated infections in surgical patients. If you have any questions about our hospital’s infection prevention and control program, please contact us.

    One of the most important ways we prevent infection is by giving patients antibiotics at the right time before surgery. This is called timely antibiotic prophylaxis, and it helps protect patients during and after their procedure. Ontario hospitals are required to publicly report timely antibiotic administration rates for hip and knee replacement surgeries. This supports transparency, accountability, and quality improvement across the healthcare system. Our Infection Prevention and Control (IPAC) team internally monitors tracks infection rates for all:

    • Total hip replacement surgeries
    • Total knee replacement surgeries
    • Total shoulder replacement surgeries
    • Caesarean sections (C-sections)
    • Hysterectomies
    Percentage of patients with antibiotic administration within the appropriate time (timely prophylaxis rate)
    Quarter 2024-2025 2025-2026
    Q1 Apr. – June 100% 100%
    Q2 July – Sept. 99.3% 100%
    Q3 Oct. – Dec. 100% 99.1%
    Q4 Jan. – Mar. 100%
    Fiscal Year Total (to-date) 99.85% 99.7%
  • C.Difficile Rates

    Clostridioides difficile (C. difficile) is a type of bacteria that can live in the bowel. About 1–3% of people carry these bacteria without symptoms. However, when someone takes antibiotics, the normal balance of bacteria in the gut can be disrupted, which can allow C. difficile to grow and cause diarrhea and other intestinal symptoms.

    Our hospital monitors C. difficile infection rates as part of our commitment to patient safety, infection prevention, and transparency. Tracking these rates helps us identify trends, improve care practices, and reduce the risk of infection for patients.

    Quarter 2024 Rate (# of cases) 2025 Rate (# of cases)
    Q1 Apr. – June 0 0
    Q2 July – Sept. 0 0.13 (2 cases)
    Q3 Oct. – Dec. 0 0.26 (4 cases)
    Q4 Jan. – Mar. 0.14 % (2 cases) 0.06 (1 case)
    Fiscal Year Total (to-date) 0.04 (2 cases) 0.12 (7 cases)
  • Central Line Associated Bloodstream Infections (CLI/CLABSI)

    When a patient requires long-term access to medication or fluids through an IV, a central line is put in place. A central line associated blood stream infection (CLI or CLABSI) occurs when a pathogen enters the blood stream through the central lines.

    All hospitals with Critical Care Units are required to report into the Critical Care Information System (CCIS) – a centralized data collection system where hospitals report a variety of information. This information is used to calculate the CLI/CLABSI rate data that must be publicly reported.

    Patients can reduce the chance of infection by following instructions given to them by their healthcare team. Appropriate hand hygiene practice is another way to prevent the spread of infection.

    Quarter 2024 Rate (# of cases) 2025 Rate (# of cases)
    Q1 Apr. – June 0 0
    Q2 July – Sept. 0 0
    Q3 Oct. – Dec. 0 0
    Q4 Jan. – Mar. 0 0.02 (1 case)
    Fiscal Year Total (to-date) 0 0.002 (1 case)
  • MRSA/VRE Bacteremia Rates

    Methicillin-resistant Staphylococcus aureus (MRSA) and vancomycin-resistant Enterococcus (VRE) are types of bacteria that are resistant to certain antibiotics. Because they are harder to treat, infections caused by these bacteria require careful monitoring and prevention.

    When these bacteria enter the bloodstream, it is called a bacteremia or bloodstream infection. These infections can be serious, especially for people who are already unwell or have weakened immune systems.

    Hospitals closely track MRSA and VRE bloodstream infections as important indicators of patient safety and quality of care. Monitoring these rates helps hospitals identify trends, improve infection prevention practices, and reduce the risk of infections spreading within the healthcare setting.

    Quarter 2024 (# of cases) 2025 (# of cases)
    MRSA VRE MRSA VRE
    Q1 Apr. – June 0 0 0 0
    Q2 July – Sept 0 0 0 0
    Q3 Oct. – Dec. 0 0 0 0
    Q4 Jan. – Mar. 0 0 0 0
    Fiscal Year Total(to-date) 0 0 0 0
  • Ventilator Associated Pneumonia

    Ventilator-associated pneumonia (VAP) is a lung infection that can develop in patients who are receiving breathing support from a ventilator in a Critical Care Unit (CCU). A ventilator is a machine that helps a patient breathe when they are unable to do so on their own.

    Because patients on ventilators cannot breathe, cough, or clear their lungs normally, bacteria can sometimes enter the lungs and cause infection. Hospitals use strict infection prevention practices to reduce this risk, including proper hand hygiene, equipment cleaning, and patient positioning.

    All hospitals with CCUs are required to report VAP data to the Critical Care Information System (CCIS), a provincial data system. This information is used to calculate and publicly report VAP rates, supporting transparency, patient safety, and quality improvement.

    Quarter 2024 Rate (# of cases) 2025 Rate (# of cases)
    Q1 Apr. – June 0 0
    Q2 July – Sept. 0 0
    Q3 Oct. – Dec. 0 0
    Q4 Jan. – Mar. 0 0
    Fiscal Year Total (to-date) 0 0
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