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

Instructions for Completing the Self-Assessment

1. Establish an interdisciplinary team consisting of, or similar to, the following:

• Senior leadership representative
• Patient or patient representative/advocate
• Patient safety/quality improvement and/or risk management professional
• Nursing director/manager
• Pharmacy director/manager
• Physician leader (e.g., chief of service)
• Frontline staff (at least one of each of the following):
  • Registered nurse
  • Registered practical nurse
  • Physician
  • Pharmacist
  • Pharmacy technician
  • Pharmacy assistant, if applicable

Include representation from different services within the facility.

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

3. Discuss each self-assessment item and evaluate the facility's current success in implementing the item.

As necessary, investigate and verify the level of implementation for each item with other healthcare practitioners and staff outside the assessment team.

Possible responses:

1. A There has been no activity to implement this item
2. B This item has been formally discussed and considered but not implemented
3. C This item has been partially implemented for some areas, patients, medications and/ or staff in the facility
4. D This item is fully implemented for some areas, patients/residents, medications and/or staff in the facility
5. E This item is fully implemented throughout the facility
6. NA Not applicable - use this option if the assessment criteria does not apply to your facility.

Facilities 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 facility at a later date.

Scoring Guidelines:

For all assessment items:

• All assessment items refer to medications prescribed, dispensed, and administered to all patients/residents in the facility unless otherwise noted.
• Choice of E (full implementation) is appropriate only if all components are present in all areas of the facility, for all patients/residents, all medications, and followed by all personnel. If only one or some of the components of the item have been fully implemented in only some or all areas of the facility, select C or D.

For assessment items that are not applicable to your facility:

Not applicable items fall into two categories:

1. Your facility does not administer medications from the category and therefore there is no associated risk (e.g., paralyzing agents are not used in long-term care and therefore there is no associated risk for these agents in such a facility); or
2. You cannot answer the question because a practice is not in place (e.g., an ambulatory care centre that does not use smart infusion pumps cannot answer questions about how the pumps are utilized).

All items ranked as "not applicable" will receive the same score as a "fully implemented" item for the pilot; scoring may be adjusted in the final version. Additionally, the program functionality will be enhanced in the final version to allow selection of full sections as not applicable.

4. Finalize your self-assessment.

You will be prompted to save your responses for each key element before you proceed to the next key element page. 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. Confidentiality is assured.

Individual results can be viewed or accessed only by the facility submitting them. The aggregate findings will be available for viewing by others once a minimum of three facilities have submitted results.

Aggregate findings may be used by ISMP Canada and the Canadian Patient Safety Institute for research and education purposes.

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.