Medication Safety Self-Assessment for Long-Term Care Pilot Instructions

Instructions for Completing the Self-Assessment

1. Establish an interdisciplinary team similar to the following:

  • Resident/family representative
  • Director of care
  • Medical Director or Physician
  • Pharmacist
  • Pharmacy technician, if applicable
  • Registered Nurse
  • Registered Practical Nurse
  • Personal Support Worker
  • Safety/quality improvement and/or risk management professional(s)

2. Distribute the assessment document before the team meeting so that team members can review and consider the questions in advance.

3. Discuss each assessment item and select the option that represents the team's understanding of the level of implementation of the item.

All assessment items refer to medications prescribed, dispensed, and administered to all residents of the Home/facility unless otherwise noted.

Possible responses:

  1. N Never – This item has not been implemented in our Home/facility
  2. R Rarely – This item is implemented and in practice less than 40% of the time
  3. S Sometimes – This item is implemented and in practice 40-70% of the time
  4. O Often - This item is implemented and in practice 70-90% of the time
  5. A Always - This item is fully implemented and in practice more than 90% of the time
  6. NA Not applicable – Use this option where indicated, if an assessment item does not apply to your Home/facility

For self-assessment items with multiple components, full implementation (score of A) is appropriate only if all components are present.

Homes may want to consider assigning an individual to record any discussion generated around each assessment item and the rationale behind the selected choice. This information, meant for internal use only, can assist the team when reviewing scores for individual items or reassessing the Home at a later date.

For assessment items that are not applicable to your Home/facility:

Some assessment items may not be applicable to all LTC Homes/facilities; criteria for a "not applicable" response have been provided for selected items. For example, some sites may not provide intravenous infusions, therefore, there will be no associated risks.

4. Finalize your assessment.

You will be prompted to save your responses for each section before you proceed to the next section. When all responses have been entered, you will be prompted to "Check MSSA for errors" and then to submit your results.

Once you have submitted your results you cannot edit them. The web-based survey tool will immediately download the information into a secure database maintained solely by ISMP Canada. No data will be maintained on the Internet survey form after it has been submitted. Individual results can be viewed or accessed only by the pharmacy submitting them. Confidentiality is assured.

5. Print/view your completed assessment.

Once your results have been submitted you will be able to print a report summarizing your results.

6. Compare your results to the aggregate.

Once your results have been submitted you will immediately be able to compare your results to the aggregate response. You can compare to the total aggregate or to demographically similar facilities, using the filters provided.

View/print options include:

  • Summary of results ("report card" format)
  • Graphs comparing your Home's/facility's results to the aggregate database for key elements and individual assessment items, including available filters based on demographic information submitted. (To ensure confidentiality, there must be at least 3 respondents in the aggregate to generate graphs.)

7. Using aggregate data

LTC Homes/facilities can freely share their own results internally and externally to the organization as they deem appropriate; however, any comparisons to aggregate data can only be shared externally to the organization with written permission from ISMP Canada. Email mssa@ismpcanada.ca for more information.