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

The Institute for Safe Medication Practices Canada (ISMP Canada) and the Canadian Patient Safety Institute (CPSI) are pleased to provide this Medication Safety Self-Assessment: Focus on "Never Events" in Community Pharmacy (MSSA-Never Events-Community), developed in collaboration with stakeholders.

This assessment is designed to help community pharmacy teams to identify and address vulnerabilities related to high-risk processes, use of high-alert medications and treatment of vulnerable populations to avoid "never events" – situations known to have previously caused harm to patients, for which safeguards are available.

This program supports community pharmacy teams to:

  • Raise awareness of high-risk situations and "never events" in the community pharmacy setting;
  • Identify high-leverage strategies to reduce the likelihood of harmful medication incidents related to known areas of risk;
  • Create a baseline measurement for the current implementation of recommended strategies to avoid harm events; and,
  • Evaluate progress over time through periodic repeated measurement.

This assessment is intended to represent leading practices and should be considered complementary to national and provincial/territorial standards of practice and regulatory requirements. Items included in this assessment reflect selected vulnerabilities and do not represent all possible risks. In addition to this self-assessment, pharmacy teams are encouraged to complete ISMP Canada's MSSA for Community Pharmacy for a more comprehensive assessment of medication safety practices.

Topics and content for this MSSA have been derived from a variety of sources, including the following:

  • ISMP Canada resources and learning from analysis (e.g., reports to the National Incident Data Repository for Community Pharmacy, Safety Bulletins, other MSSA programs, recommendations from community pharmacy on-site assessments)
  • ISMP (United States) resources (e.g., newsletters, MSSA programs)
  • CPSI resources (e.g., Global Patient Safety Alerts)
  • National Association of Pharmacy Regulatory Authority (NAPRA) model standards of practice for pharmacists and pharmacy technicians

This assessment is aligned with the World Health Organization Global Patient Safety Challenge: Medication Without Harm. It is the third assessment in a series of "never event" assessments, following customized programs for acute care and long-term care.

Development and validation of the assessment content was supported by an expert Advisory Panel which included patient and family advisors, practicing pharmacists and pharmacy technicians and representation from regulatory authorities, academic institutions, a national pharmacy association and a prescriber. In addition, the validation process included a pilot test and consultation with selected stakeholders.

The MSSA-Never Events-Community assessment includes 65 items, divided into 6 sections. The high-level topics are referred to as "Key Elements" and sub-sections are called "Core Characteristics". The first section focuses on general strategies for safety, followed by sections describing considerations for high-alert medications and selected clinical situations. Not all items will be applicable in all settings.

This self-assessment supports continuous quality improvement initiatives in community pharmacies. The value of ongoing evaluation with a self-assessment program was highlighted in a 12-year review of responses to ISMP Canada's MSSA for Long-term Care, which showed that mean total self-assessment scores improved over time.

The MSSA-Never Events-Community and its components are copyrighted by ISMP Canada. The assessment is intended for use as part of ongoing quality improvement activities. Other uses, such as in education presentations external to an individual pharmacy or corporate group require written permission from ISMP Canada.