Hospital Medication Safety Self-Assessment Instructions

Instructions for Completing the Self-Assessment

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

  • Senior leadership representative
  • 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
    • Pharmacist
    • Pharmacy technician
    • Pharmacy assistant, if applicable
    • Physician

Include representation from different services within the hospital.

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

3. Complete the demographic section.

4. Discuss each self-assessment item and evaluate the hospital'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 hospital
  4. D This item is fully implemented for some areas, patients, medications and/or staff in the hospital
  5. E This item is fully implemented throughout the organization
  6. NA (Not applicable) is available as an option for selected items.

Hospitals 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 organization at a later date.

Scoring Guidelines:

For all assessment items:

  • All assessment items refer to medications prescribed, dispensed, and administered to all inpatients and outpatients unless otherwise noted.
  • Choice of E (full implementation) is appropriate only if all components are present in all areas of the hospital, for all patients, 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 hospital, select C or D.

For assessment items with an option of "Not Applicable (NA)":

Criteria for "not applicable (NA)" responses are identified within each item where this selection is available. The scoring for the NA items reflects the impact of the item on overall system safety.

5. 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 organization submitting them. The aggregate findings will be available for viewing by others once a minimum of three organizations have submitted results and may be used by ISMP Canada for research and education purposes only.

6. Print/view your completed assessment.

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

7. 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 organizations using the filters provided.