Hospital Medication Safety Self-Assessment Frequently Asked Questions

These FAQs are related to the process for completing the self-assessment. FAQs related to the content are provided within the document for selected assessment items.

How many team meetings should we schedule?
We suggest you schedule a series of 3 meetings of 1-2 hours to complete the self-assessment.
Do we need an interdisciplinary team to complete the self-assessment?
Because medication use is a complex, inter-disciplinary process, the value and accuracy of the self-assessment is significantly reduced if it is completed by a single individual or discipline involved in medication use.
Do we need senior leadership representation on our team?
Attendance by an individual from the organization's leadership team is valuable because the assessment contains many items that relate to your organization's overall commitment to patient safety. Furthermore, participation in the self-assessment provides senior leadership staff with insight into areas of risk in the medication use system.
What if an item doesn't apply to the services offered in my hospital?
For certain assessment items, a response of "not applicable" is available. Criteria for "not applicable" responses are included with each assessment item where this is an available response option.
May I make copies of the self-assessment document?
The copyright allows you to make copies of the self-assessment for internal use. You may not modify or alter the content in any way. Furthermore, you may not modify, transmit, post, or use the contents of this document for personal, public, or commercial purposes unless you have obtained written permission from ISMP Canada.
My organization has a number of sites. Do I need a password for each one?
If your facility is homogeneous or is managed as a single entity, then it may be appropriate to conduct a single self-assessment across the entire organization. However, if your sites are relatively autonomous and have different procedures and levels of technology, then separate assessments are probably appropriate. Completing the self-assessment for individual sites also helps to heighten awareness of vulnerabilities in the medication use system across the organization.
How are individual items scored?
The assessment items have been scored as follows:
A=0 There has been no activity to implement this item.
B=1 This item has been formally discussed and considered, but not implemented.
C=2 This item has been partially implemented for some areas, patients, medications and/or staff.
D=3 This item is fully implemented for some areas, patients, medications and/or staff.
E=4 This item is fully implemented throughout the organization for all patients, medications and/or staff.

For items with a "not applicable" scoring option, the score is based on the level of risk associated with the item. For example, if the item is related to care of paediatric patients and your organization never treats children, this item will not present a risk to the organization or the population served. Alternatively, use of smart pumps is a recognized safety strategy; if your organization administers intravenous medications without the benefit of smart pumps, you will be unable to answer the questions, but the patients served are at higher risk of harm related to incorrect or inappropriate infusion rates.
How can I use our self-assessment results?
Once your data has been entered into the web-based program, there are several ways to examine the compiled information. Note that if you have not completed entering your assessment, you will not be able to view or print your results, or generate graphs comparing your results to the aggregate database.

If you have completed more than one assessment, only your most recent assessment is compared to the aggregate database; however, you can track your hospital's progress from one assessment to the next.

View/print options include:
  • Summary of results ("report card" format)
  • Graphs comparing your hospital's results to the aggregate database for key elements, core characteristics 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)
  • Graphs comparing multiple assessments completed by your hospital
Are there situations where the Hospital MSSA is not appropriate for an organization?
This MSSA version is intended for acute care hospitals providing general medical and surgical services for both inpatients and outpatients. As such, all assessment items may not be applicable to specialty facilities.

ISMP Canada has developed several speciality MSSA programs and Medication Safety Checklists for hospitals:
Anticoagulant Safety
Epidural Label Safety Checklist
HYDROmorphone Safety Self-Assessment
Hospital Self-Assessment for Anticoagulant Safety
ISMP International Medication Safety Self-Assessment for Oncology
Operating Room Medication Safety Checklist

The following sector-specific MSSA programs are also available from ISMP Canada:
Community/Ambulatory Pharmacy
Home Care
Home Care Organizations
Personal Support Worker Organizations
Complex Continuing Care and Rehabilitation
Long Term Care

See for more information.