Medication Safety Self-Assessment Pilot: Focus on "Never Events" Introduction

Introduction to Pilot Version

ISMP Canada and the Canadian Patient Safety Institute (CPSI) are excited to launch this pilot version of a new Medication Safety Self-Assessment (MSSA) program focusing on "never events".

"Never events are patient safety incidents that result in serious harm or death, and that can be prevented by using organizational checks and balances."

This pilot version provides an opportunity to test the content and provide feedback. A final version will be released in Spring 2019.

The Medication Safety Self-Assessment: Focus on “Never Events” (MSSA – Never Events) was designed to help Canadian healthcare practitioners in hospitals, ambulatory care centres and long-term care homes to identify and address system vulnerabilities underlying critical incidents associated with high-alert medications, with a specific focus on never events.

This assessment is aligned with the World Health Organization Global Patient Safety Challenge: Medication Without Harm.

Content has been derived from previously published material in ISMP Canada Safety Bulletins and MSSA programs for hospitals and long-term care, as well as from the ISMP (US) Medication Safety Self-Assessment for High-Alert Medications , and CPSI’s Global Patient Safety Alerts.

This program is designed to:

  • Heighten awareness of medication-related never events;
  • Identify high-leverage strategies to reduce the likelihood of never events and other critical incidents with high-alert medications; and
  • Create a baseline measurement of current implementation of recommended strategies to avoid never events.

The assessment includes a total of 100 items, divided into 12 sections. Section I focuses on known never events and Section II on general strategies for safety. Sections III-XII focus on selected high-alert medication classes. Not all items will be applicable in all settings and the final version will have improved functionality related to items that are not relevant in some settings (e.g., paralyzing agents are not used in long-term care homes).

The assessment items are presented in an order that reflects the medication use process, beginning with patient/resident engagement and then following the steps in the medication use process: prescribing, order processing, dispensing, administration and monitoring. Not all sections include items from each of these steps.

ISMP Canada and CPSI are not standard-setting organizations and the assessment items in this document are not intended to represent a minimum standard of practice and should not be considered as such. In fact, some of the items represent innovative practices that may not be widely implemented; however, their value in reducing errors is grounded in scientific research and expert analysis of medication errors and their causes.

The MSSA – Never Events and its components are copyrighted by ISMP Canada and may not be used in whole or in part for any other purpose or by any other entity except for self-assessment of medication systems as part of ongoing quality improvement activities.